Vancomycin-Soaked ACL Grafts Cut Already-Low Infection Rates
The word “infection” contains 9 letters, but it’s a four-letter word for orthopaedic surgeons. Postoperative infections are complications that we all deal with, but we try hard to avoid them. Infections after elective sports surgeries can have especially devastating long-term consequences. Thankfully, scientific advances such as improved sterile techniques and more powerful prophylactic antibiotics have helped us decrease the rates of perioperative infections. But more can always be done in this arena.
Baron et al. discuss one additional infection-fighting approach in the December 18, 2019 issue of JBJS, where they report on findings from a retrospective cohort study that looked at 90-day infection rates after >1,600 anterior cruciate ligament (ACL) reconstructions. Specifically, they investigated whether the rates of infection differed when the ACL grafts were prepared with or without a vancomycin irrigant. The average patient age was 27 years old, and all the surgeries (84.1% of which were primary reconstructions) were performed by 1 of 6 fellowship-trained surgeons. The graft was soaked in vancomycin solution in 798 cases (48.7%), while the remaining 51.3% did not use vancomycin.
Baron et al. found that 11 of the reconstructions were complicated by infection within 90 days, but only 1 of those 11 infections occurred in the vancomycin group (p=0.032). After controlling for various confounding factors, the authors found that increased body mass index and increased operative time were also significantly associated with postoperative infection, while age, sex, smoking, surgeon, and insurance type were not.
These results reveal an 89.4% relative risk reduction in postoperative infections after ACL reconstructions when grafts are bathed in vancomycin solution, although the absolute rate of infection among non-soaked grafts (1.2%) was still quite low. Time and more rigorous study designs will tell us whether this is a big step forward in the evolution of infection prevention, but these results should at least prompt further investigation.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
ACL Grafts: Diameter Does Matter, Sort Of
Clinical failure of anterior cruciate ligament (ACL) reconstructions continues to be a too-common scenario. The increasing incidence of ACL revision is due to a variety of factors, including greater intensity of postsurgical physical activity, technical issues, and anatomical influences of the proximal tibia and distal femur. Registries are important sources of data for ACL-related investigations, but I think they are most useful in clarifying experimental designs for more sophisticated clinical research.
In a cohort study in the October 16, 2019 issue of The Journal, Snaebjornsson et al. examined the influence of ACL graft diameter on the risk of revision surgery over 2 years in >18,000 subjects whose data resided in the national knee ligament registries of Sweden and Norway. The vast majority of those patients (92.8%) received a hamstring autograft, with 7.2% receiving a patellar tendon autograft. Overall, the 2-year rate of ACL revision was 2.63% for patellar tendon autografts and 2.08% for hamstring autografts, a statistically nonsignificant difference in relative risk.
However, the authors found an important correlation between graft diameter in the hamstring tendon cohort, with autografts <8 mm in diameter being associated with a higher risk of revision, compared with larger-diameter hamstring autografts. Additionally, patients treated with hamstring graft diameters of ≥9 mm or ≥10 mm had a lower risk of ACL revision surgery than those treated with patellar tendon grafts of any size.
One key limitation that should influence our interpretation of this study is a lack of detail regarding how compliant surgeons were intraoperatively with the use of the measurement device that is depicted in the manuscript and shown above. In addition, the limitations of registry data did not permit the authors to adjust for postsurgical exposures, such as return to sport, the increasing intensity of which makes rerupture more likely. Additional relevant information that would have aided interpretation of the findings includes the relative size of the tibia and femur, lateral condyle size and shape, and proximal tibial slope.
Despite these limitations, this study should prompt further research that uses robust clinical designs to more fully investigate the impact of graft diameter on ACL rerupture rates.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Sports Medicine 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Albert Gee, MD, a co-author of the April 17, 2019 “What’s New in Sports Medicine,” selected the five most clinically compelling findings from among the 30 noteworthy studies summarized in the article.
Anterior Cruciate Ligament (ACL) Reconstruction
–Norwegian researchers randomized 120 patients to undergo either single-bundle or double-bundle ACL reconstruction and followed them for 2 years.1 They found no difference between the 2 techniques in any patient-reported outcome, knee laxity measurements, or activity levels. These results, along with the preponderance of evidence from other comparative trials over the last 5 years, strongly suggest that routine use of 2 bundles to primarily reconstruct a torn ACL adds no clinical benefit over a well-positioned single-bundle reconstruction.
Knee Cartilage Repair
–A randomized study compared long-term patient outcomes after knee cartilage repair using microfracture versus mosaicplasty.2 Included patients had 1 or 2 focal femoral lesions measuring between 2 and 6 cm2. Better outcomes after a minimum of 15 years of follow-up were found in the mosaicplasty group. Although there were only 20 patients in each arm, the Lysholm-score differences between the groups were both clinically important and statistically significant. More patients in the mosaicplasty group than in the microfracture group said they would have the surgery again, knowing their 15-year outcome.
Rotator Cuff
–UK researchers randomized 313 patients with ≥3 months of subacromial pain and an intact rotator cuff who had completed a nonoperative program of physical therapy and injection to 1 of 3 groups: arthroscopic subacromial decompression, diagnostic arthroscopy (“sham” surgery), or no intervention.3 At 6 months and 1 year, all groups demonstrated statistically significant and clinically important improvement, but patient-reported outcome scores were significantly better in both surgical groups compared with the no-treatment group. The data suggest that patients such as these improve over time, regardless of management, but that surgical decompression may offer a slight benefit over nonoperative management because of the placebo effect.
–A randomized controlled trial investigated the effect of a formal preoperative education program (2-minute video plus handout)4 about postoperative narcotic use, side effects, dependence risk, and addiction potential among >130 patients undergoing arthroscopic rotator cuff repair surgery. The education group consumed 33% less narcotic medication at 6 weeks and 42% less at 12 weeks compared with the control group. Among the more than one-quarter of the patients who had used opioids prior to surgery, those randomized to the education group were 6.8 times more likely than controls to discontinue narcotic use during the study period.
Hip Arthroscopy
–A randomized controlled trial of >300 patients compared hip arthroscopy and “best conservative care” for treating femoroacetabular impingement (FAI).5 Only 8% of patients crossed over from conservative care to the surgical group. The mean adjusted difference in iHOT-33 scores at 1 year was 6.8, in favor of hip arthroscopy. However, adverse events were more frequent in the arthroscopy cohort, and a within-trial economic evaluation suggested that hip arthroscopy was not cost-effective compared with conservative care during the 1-year trial period.
References
- Aga C, Risberg MA, Fagerland MW, Johansen S, Trøan I, Heir S, Engebretsen L. No difference in the KOOS Quality of Life Subscore between anatomic double-bundle and anatomic single-bundle anterior cruciate ligament reconstruction of the knee: a prospective randomized controlled trial with 2 years’ follow-up. Am J Sports Med.2018 Aug;46(10):2341-54. Epub 2018 Jul 18.
- Solheim E, Hegna J, Strand T, Harlem T, Inderhaug E. Randomized study of long-term (15-17 years) outcome after microfracture versus mosaicplasty in knee articular cartilage defects. Am J Sports Med.2018 Mar;46(4):826-31. Epub 2017 Dec 18.
- Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J,Moser J, Gray A, Jepson M, Tracey I, Judge A, Wartolowska K, Carr AJ; CSAW Study Group. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018 Jan 27;391(10118):329-38. Epub 2017 Nov 20.
- Syed UAM, Aleem AW, Wowkanech C, Weekes D, Freedman M, Tjoumakaris F, Abboud JA, Austin LS. Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. J Shoulder Elbow Surg.2018 Jun;27(6):962-7. Epub 2018 Mar 26.
- Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M,Parsons NR, Petrou S, Realpe A, Smith J, Foster NE; FASHIoN Study Group. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018 Jun 2;391(10136):2225-35. Epub 2018 Jun 1.
What’s New in Pediatric Orthopaedics 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.
This month, Kelly L. VanderHave, MD, co-author of the February 20, 2019 “What’s New in Pediatric Orthopaedics,” selected the five most compelling findings from among the more than 50 noteworthy studies summarized in the article.
Pediatric Trauma
—A before-and-after comparison found that, after implementation of a dedicated, weekday operating room reserved for pediatric trauma, length of stay for 5 common pediatric orthopaedic fractures was reduced by >5 hours. In addition, cost was reduced by about $1,200 per patient; complication rates improved slightly; frequency of after-hours surgery decreased by 48%; and wait times for surgery were significantly reduced.
—Forty-two patients with a distal radial buckle fracture received a removable wrist brace during an initial clinic visit, along with instructions to wear it for 3 to 4 weeks. No follow-up was scheduled, but the family was contacted at 1 week and at 5 to 10 months following treatment. No complications or refractures occurred; 100% of respondents said they would select the same treatment.1
Pediatric Sports Medicine
—Among a continuous cohort of 85 patients (mean age 13.9 years) who underwent primary ACL reconstruction (77% with open physes at time of surgery) and who were followed for a minimum of 2 years, overall prevalence of a second ACL surgery was 32%, including 16 ACL graft ruptures and 11 contralateral ACL tears. A slower return to sport was found to be protective against a second ACL injury.
Infection and Scoliosis Surgery
—A preliminary study of 36 pediatric patients who underwent a total of 191 procedures for early-onset scoliosis found that the use of vancomycin powder during closure significantly decreased the rate of surgical site infection (13.8% per procedure in the control group versus 4.8% per procedure in the vancomycin group).
Clubfoot
—A retrospective review of >1,100 clubfeet that were presumed to be idiopathic upon presentation found that the condition in 112 feet (8.9%) was later determined to be associated with neurological, syndromic, chromosomal, or spinal abnormalities—and therefore nonidiopathic.2 The nonidiopathic group was less likely to have a good result at the 2- and 5-year follow-up, and more likely to require surgery. The authors conclude, however, that surgery is avoidable for most patients with nonidiopathic clubfoot.
References
- Kuba MHM, Izuka BH. One brace: one visit: treatment of pediatric distal radius fractures with a removable wrist brace and no follow-up visit. J Pediatr Orthop.2018 Jul;38(6):e338-42.
- Richards BS, Faulks S. Clubfoot infants initially thought to be idiopathic, but later found not to be. How do they do with nonoperative treatment?J Pediatr Orthop. 2017 Apr 10. [Epub ahead of print].
JBJS 100: Gait Initiation, ACL Replacement
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Initiation of Gait
R A Mann, J L Hagy, V White, D Liddell: JBJS, 1979 March; 61 (2): 232
Using electromyography and force-plate data, this study of 10 healthy men and women revealed that the deceptively simple motion of taking the first step from a standing position is initiated by the unbalanced body harnessing complex neural mechanisms, muscular activity, and biomechanical forces. The findings can inform today’s efforts to prevent falls among the elderly.
Replacement of the Anterior Cruciate Ligament using a Patellar Tendon Allograft
S P Arnoczky, R F Warren, M A Ashlock: JBJS, 1986 January; 68 (3): 376
Fresh or deep-frozen? That was the question researchers asked in this study of 25 dogs whose patellar tendons were replaced with one of these two types of allografts. The fresh allografts incited a marked inflammatory and rejection response, while the deep-frozen allografts appeared to be benign and behaved comparably to autogenous patellar tendon grafts. In the 30-plus years since this 1986 study, we have learned a lot about the immunogenicity and biologic character of transplanted allografts, and this important research continues.
JBJS 100: ACL Grafts and Wrist Instability
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Biomechanical Analysis of Human Ligament Grafts Used in Knee-Ligament Repairs and Reconstructions
F R Noyes, D L Butler, E S Grood, R F Zernicke, M S Hefzy: JBJS, 1984 March; 66 (3): 344
This article set the stage for critically analyzing ACL graft choices based on mechanical properties. Several of the grafts these authors studied had poor strength and are no longer used. Subsequent studies now suggest that several grafts are stronger and stiffer than the native ACL, including bone-patellar tendon-bone grafts. While many other aspects of ACL reconstruction continue to be debated, graft strength and stiffness remain a key consideration.
Traumatic Instability of the Wrist
R L Linscheid, J H Dobyns, J W Beabout, R S Bryan: JBJS, 1972 December; 54 (8): 1612
At a time when orthopaedists were focused primarily on osseous anatomy of the wrist, this article emphasized the importance of assessing carpal alignment and realizing the consequences of disrupted carpal ligaments. Most of the parameters for radiographic assessment of carpal alignment in the article are still relevant today.
Generalized Joint Laxity—A Risk Factor for Poor Outcomes After ACL Reconstruction
Sometimes, being too flexible is not a good thing. In the February 21, 2018 edition of The Journal of Bone & Joint Surgery, Kim et al. show that patients with generalized joint laxity—those who can hyperextend their knees and elbows beyond 10°, for example—tend to have poorer knee-stability and functional outcomes after anterior cruciate ligament (ACL) reconstruction than those who have normal joint flexibility.
The authors studied 8-year outcomes among 163 patients who underwent a unilateral ACL reconstruction. In all cases, the same surgeon performed the same procedure (bone-patellar tendon-bone autograft), and all patients went through the same rehab program.
In terms of graft-rupture rates and contralateral ACL rupture rates over the study period, the authors found no statistically significant differences between the 122 patients without laxity and the 41 patients who were determined preoperatively to have generalized joint laxity. However, at the 8-year follow-up, the patients with laxity had less knee stability (as measured with Lachman and pivot-shift tests and an arthrometer) and worse knee function (as measured with the Lysholm and IKDC scales) than patients without laxity.
Taken together, these findings lead Kim et al. to conclude that “generalized joint laxity should be considered a risk factor for poor outcomes after ACL reconstruction.” We also noted that JBJS Deputy Editor Robert Marx, MD (@drrmarx) remarked on Twitter that “adding lateral ITB [iliotibial band] tenodesis may be helpful for more severe cases with significant knee hyperextension.”
Click here for a two-minute video summary of this study.
Webinar on Dec. 13—Patient Satisfaction After ACL Surgery
An estimated 300,000 ACL surgeries are performed in the US annually, at an estimated cost of up to $1 billion, but we still have many unanswered questions about patient satisfaction after these procedures. Among them:
- Does the cost of postoperative physical therapy affect patient satisfaction?
- What are the rates and predictors of return to play after ACL reconstruction? Does graft choice play a role?
- What is the relationship between return to play and patient satisfaction?
On Wednesday, December 13, 2017 at 8:00 PM EST, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary* LIVE webinar that addresses these and other important questions.
JOSPT co-author Caitlin J. Miller, PT, DPT and JBJS co-author Benedict U. Nwachukwu, MD, MBA, will discuss findings from their respective studies, and the webinar will include additional insights from Mark V. Paterno, PT, PhD, MBA, SCS, ATC, and Elizabeth Matzkin, MD. Moderated by Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA, the webinar will conclude with a live Q&A session between the audience and panelists.
Seats are limited so REGISTER NOW.
*All registrants will have free access to the webinar for 24 hours following the live broadcast.
Patient Satisfaction After ACL Reconstruction—Dec. 13 Webinar
We still have many unanswered questions about patient satisfaction after anterior cruciate ligament (ACL) reconstruction.
- Do specific patient populations benefit from more or fewer physical therapy (PT) visits?
- Does the cost of PT affect patient satisfaction?
- Should patients be classified by factors beyond their medical diagnoses to achieve the best outcomes while minimizing costs?
- What are the rates and predictors of return to play after ACL reconstruction? Does graft choice play a role?
- What is the relationship between return to play and patient satisfaction?
On Wednesday, December 13, 2017 at 8:00 PM EST, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary* LIVE webinar that addresses these important and clinically applicable questions.
JOSPT co-author Caitlin J. Miller, PT, DPT, will share the results of a retrospective cohort study examining the relationship between patient demographics, number of physical therapy visits, and the cost of postoperative interventions with revision rates and patient-reported outcomes following primary ACL reconstruction.
JBJS co-author Benedict U. Nawachukwu, MD, MBA, will discuss findings from a study of return to play and patient satisfaction among athletes following ACL reconstruction. This study also explores the efficacy of patellar tendon autografts and the preinjury impact of certain sports.
Moderated by Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA, a leading authority on the spine and the knee, the webinar will include additional insights from expert commentators Mark V. Paterno, PT, PhD, MBA, SCS, ATC, and Elizabeth Matzkin, MD. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.
Seats are limited so REGISTER NOW.
*All registrants will have free access to the webinar for 24 hours following the live broadcast.
High Rates of Return to Play and Patient Satisfaction after ACL Reconstruction
The estimated annual cost of surgical treatment for anterior cruciate ligament (ACL) ruptures in the US is $2 billion. Are ACL surgery patients—and the health care system—getting significant value for all that money spent?
In the May 3, 2017 issue of The Journal of Bone & Joint Surgery, Nwachukwu et al. set out to answer that question by retrospectively analyzing rates of return to play and satisfaction among 231 ACL-surgery patients (mean age of 27 years) who were followed for a mean of 3.7 years. The authors found that:
- 87% had returned to play at a mean of 10 months after surgery.
- 89% of the 171 athletes eligible to return to their prior level of competition did so.
- 85% said they were “very satisfied” with the outcome, and 98% stated they would have the surgery again.
Not surprisingly, patients were more likely to say they were “very satisfied” if they had returned to play.
The authors also found that the use of patellar tendon autograft increased the chance of returning to play, while preoperative participation in soccer or lacrosse decreased the likelihood of returning to play. Those who participated in basketball, football, skiing, and tennis had higher return-to-play rates than those who participated in the two aforementioned sports.
In addition, Nwachukwu et al. found that one-third of those who did not return to sports reported fear of reinjury as the reason. The authors encourage surgeons to understand that “psychological readiness, fear of reinjury, and mental resiliency influence the probability of an athlete returning to play.”
In her commentary, Elizabeth Matzkin, MD cautions readers to interpret the Level IV study’s findings cautiously. She calls for “better prospective, homogeneous studies” to more accurately assess which surgical graft types and specific sports are more or less likely to result in patients returning to play. Nevertheless, the study, she says, “forces us to look at the big picture: What can we do to make ACL [reconstruction] better for our patients?”
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