Prevention of Infection in the Hamstring ACL Reconstruction

Article by Chadwick Prodromos, MD

The bottom line is that soaking a Hamstring graft during surgery in a Vancomycin saline solution (500mg Vancomycin in 100cc NS) has been shown to completely eradicate HS ACLR infection.  There are 4 relevant recent papers on this point below. The abstracts are linked below.

1. Ristic et al found that HS grafts had a 1.52% infection rate vs 1.03% for BTB grafts. This half percent difference is obviously quite small but has caused some to avoid HS grafts
2. Vertullo et al in 2012 found that soaking the grafts in Vancomycin during surgery eliminated infections, whereas without Vancomycin the infection rate was 1.4%. Phegan et al from this same group in Australia published a larger follow-up study in 2017 with essentially identical results
3. Alomar et al found that 22% of grafts were culture positive.

In my own practice I adopted the practice of soaking grafts in Vancomycin after reading the study by Vertullo in 2012 and have had no deep infections (quite rare previously anyway) or superficial cellulitis since then.   I leave the graft in a small basin in the solution rather than in a wet lap or sponge to maximize Vancomycin contact with the graft.  I also leave some of the Vancomycin solution in the small incisions after irrigation with Saline before closing and inject some into the knee joint as well.

I use four strand hamstring grafts exclusively for all primary and revision cases.  It is the strongest graft with the lowest donor site morbidity.  The only reasons not to use it or lack of familiarity by the surgeon in harvesting techniques – and the slightly higher infection rate.  By soaking in Vancomycin even this half percent higher infection rate can be eliminated.  Regarding the harvest I developed a posterior mini-incsion approach 25 years published in 2005 here with an accompanying video available online here.  Using this technique there should be essentially no chance of harvesting an inadequate graft.

Chadwick Prodromos, MD is the author of The Anterior Cruciate Ligament, 2nd Edition. Click here to download a free chapter.