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C OPYRIGHT Ó 2019 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Graft Preparation with Intraoperative Vancomycin

Decreases Infection After ACL Reconstruction
A Review of 1,640 Cases
J.E. Baron, BA, A.G. Shamrock, MD, W.T. Cates, BS, R.A. Cates, DO, Q. An, MPH, B.R. Wolf, MD, MS,
M.J. Bollier, MD, K.R. Duchman, MD, and R.W. Westermann, MD

Investigation performed at the Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa

Background: Reported infection rates following anterior cruciate ligament (ACL) reconstruction are low, but infections
are associated with high morbidity including reoperations and inferior clinical outcomes. The purpose of the current study
was to investigate the rate of infection after ACL reconstruction with and without graft preparation with a vancomycin
irrigant.
Methods: All ACL reconstructions performed between May 2009 and August 2018 at a single academic institution were
reviewed and categorized based on vancomycin use. Patients with <90-day follow-up, intraoperative graft preparation with
an antibiotic other than vancomycin, or previous ipsilateral knee infection were excluded. Infection was defined as a return
to the operating room for irrigation and debridement within 90 days after ACL reconstruction. Descriptive and inferential
statistical analysis using t tests and Poisson regression were performed, with significance defined as p < 0.05.
Results: In total, 1,640 patients (952 males; 58.0%) with a mean age (and standard deviation) of 27.7 ± 11.4 years
underwent ACL reconstruction (1,379 primary procedures; 84.1%) and were included for analysis. Intraoperative van-
comycin was used in 798 cases (48.7%), whereas 842 ACL reconstructions (51.3%) were performed without intra-
operative vancomycin. In total, 11 reconstructions (0.7%) were followed by infection, which occurred in 10 (1.2%) of the
patients in whom the graft was not soaked in vancomycin and in 1 (0.1%) of the patients in whom the graft was soaked in
vancomycin (p = 0.032). Age (p = 0.571), sex (p = 0.707), smoking (p = 0.407), surgeon (p = 0.124), and insurance type
(p = 0.616) were not associated with postoperative infection risk. Autograft use was associated with decreased infections
(p = 0.045). There was an 89.4% relative risk reduction with the use of intraoperative vancomycin. An increased body
mass index (BMI) (p = 0.029), increased operative time (p = 0.001), and the absence of ACL graft preparation with
vancomycin (p = 0.032) independently predicted postoperative infection.
Conclusions: The use of vancomycin-soaked grafts was associated with a 10-fold reduction in infection after ACL
reconstruction (0.1% versus 1.2%; p = 0.032). Other risk factors for infection after ACL reconstruction included increased
BMI and increased operative time.
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

T
he anterior cruciate ligament (ACL) is commonly
injured1, with an incidence of 43.5 injuries per 100,000
person-years2,3. ACL reconstruction is an effective method
of restoring stability to the knee after ACL rupture4. Although
infrequent, infection after ACL reconstruction does occur4, with
rates between 0.14% and 1.7% reported in the literature4-11. Septic
arthritis after ACL reconstruction may require several reoperations
for irrigation and debridement (I&D), prolonged oral and intra-
venous (IV) antibiotic therapy, potential graft removal, and
occasionally graft revision4,6,9,12,13. Furthermore, infection may
result in worse clinical outcomes, including reduced function,
increased pain, early osteoarthritis, and premature graft failure4,14,15.
The risk factors for deep infection following ACL re-
construction have been examined in multiple studies7,14,16,17. It

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest
forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial
relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F578).

J Bone Joint Surg Am. 2019;101:2187-93 d http://dx.doi.org/10.2106/JBJS.19.00270

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TABLE I Demographics of the Study Groups

Vancomycin Use
Yes (N = 798; 48.7%) No (N = 842; 51.3%) P Value

Age* (yr) 27.9 ± 11.7 27.6 ± 11.0 0.965

Male† 468 (58.6%) 484 (57.5%) 0.668
BMI* (kg/m2) 27.3 ± 6.1 27.8 ± 6.4 0.112
Diabetes† 13 (1.6%) 12 (1.4%) 0.736
Smoking† 119 (14.9%) 170 (20.2%) 0.005‡
Private insurance† 720 (90.2%) 754 (89.7%) 0.701
Caucasian† 651 (83.6%) 694 (88.0%) 0.220

*The values are given as the mean and standard deviation. †The values are given as the number of patients, with the percentage in parentheses.
Self-reported data were not available for private insurance for 1 patient in the no-vancomycin group and for race for 53 participants. ‡Significant.

has been hypothesized that intraoperative graft contamination
with skin flora may contribute to postoperative infection4. IV
antibiotics are given prior to surgical incision; however, the
poor vascularity of tendons used as grafts may lead to insuffi-
cient intratendinous antibiotic levels. Local antibiotic applica-
tion may increase graft antibiotic levels above the minimum
inhibitory concentration for common bacteria such as staph-
ylococcal and streptococcal species.
The purpose of the present study was to determine the
rate of infection after ACL reconstruction with and without
intraoperative graft preparation with vancomycin. We hypoth-
esized that intraoperative graft preparation with vancomycin
would be associated with a decreased rate of infection following
ACL reconstruction, in both the primary and the revision setting
and irrespective of graft type.
Materials and Methods
fellowship-trained orthopaedic surgeons. Eligible patients were
identified using Current Procedural Terminology (CPT) codes
for ACL reconstruction. All patients who were followed for at
least 90 days after ACL reconstruction were included in the
analysis. Patients were excluded if they had intraoperative graft
preparation with an antibiotic other than vancomycin (85 patients
who underwent concomitant intraoperative neomycin adminis-
tration), a history of an ipsilateral knee infection (1 patient), or an
operative time exceeding 300 minutes (1 patient). Patient charts
were reviewed to identify patient demographics, including age,
sex, body mass index (BMI), smoking status, and preexisting
diabetes. A nonsmoker was defined as a patient with no history of
smoking or who had completely ceased smoking at least 6 months
prior to surgery. Operative variables captured included preoper-
ative IV antibiotic administration, graft type, intraoperative van-
comycin use, postoperative infection, operative time, and
concomitant procedures including lateral extra-articular tenode-

A retrospective analysis of all patients who had undergone

primary or revision ACL reconstruction was performed at
a single large academic institution from May 2009 to August
2018. All procedures were performed by 1 of 6 sports medicine
sis, repair/reconstruction of other ligamentous structures, and
additional meniscal repair/transplantation. Infection was defined
as a return to the operating room for I&D within 90 days after the
ACL reconstruction. Variables collected regarding confirmed

TABLE II Operative Variables of the Study Groups

Vancomycin Use
Yes (N = 798; 48.7%) No (N = 842; 51.3%) P Value

Operative time* (min) 98.6 ± 42.3 130.5 ± 54.3 <0.001†

Autograft‡ 580 (72.7%) 535 (63.5%) <0.001†
Allograft‡ 210 (26.3%) 237 (28.1%) 0.436
Hybrid autograft/allograft‡ 8 (1.0%) 70 (8.30%) <0.001†
Revision ACL‡ 128 (16.0%) 133 (15.8%) 0.901
Other ligamentous procedure‡ 90 (11.3%) 61 (7.2%) 0.005†
Perioperative cefazolin‡ 716 (89.7%) 747 (88.7%) 0.511

*The values are given as the mean and standard deviation. †Significant. ‡The values are given as the number of patients, with the percentage in
parentheses.
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TABLE III Demographic and Operative Variables of Patients with and without Infection*

Infection
Yes (N = 11; 0.7%) No (N = 1,629; 99.3%) IRR (95% CI) P Value

Age* (yr) 30.0 ± 14.0 27.7 ± 11.3 — 0.571

Male† 7 (63.6%) 945 (58.0%) 1.266 (0.371-4.342) 0.707
BMI* (kg/m2) 33.9 ± 10.0 27.5 ± 6.2 — 0.029‡
BMI >30 kg/m2† 7 (63.6%) 438 (26.9%) 4.699 (1.376-16.050) 0.014‡
Diabetes† 0 (0%) 25 (1.5%) — 1.000
Smoking† 3 (27.3%) 286 (17.6%) 1.753 (0.465-6.608) 0.407
Private insurance† 11 (100%) 1,466 (90.0%) — 0.616
Caucasian† 8 (72.7%) 1,337 (82.1%) 2.076 (0.551-7.824) 0.281
Operative time* (min) 125.6 ± 48.5 114.9 ± 51.4 — 0.001‡
Tourniquet use† 9 (81.8%) 1,378 (84.6%) — 0.800
Postoperative aspirin† 10 (90.9%) 1,450 (89.0%) — 0.841
Vancomycin† 1 (9.1%) 797 (48.9%) 0.106 (0.014-0.824) 0.032‡
Autograft† 4 (36.4%) 1,112 (68.3%) 0.289 (0.079-0.919) 0.045‡
Hamstring autograft† 3 (27.3%) 761 (46.7%) 0.431 (0.114-1.623) 0.213
Quadriceps autograft† 1 (9.1%) 35 (2.1%) 4.456 (0.570-34.806) 0.154
Hybrid autograft/allograft† 1 (9.1%) 77 (4.7%) 2.003 (0.256-15.644) 0.508
Revision ACL 2 (18.2%) 259 (15.9%) 1.320 (0.280-6.216) 0.665

*The values are given as the mean and standard deviation. †The values are given as the number of patients, with the percentage in parentheses.
Grafts represented in this dataset: 1,116 autografts, 446 allografts, and 78 autograft/allograft hybrids. The autografts consisted of 764
hamstring autografts, 36 quadricep autografts, 315 bone-patellar tendon-bone autografts, and 1 hybrid hamstring/patellar autograft. There
were no infections detected in the bone-patellar tendon-bone or hybrid hamstring/patellar tendon autograft groups. ‡Significant. The data set
was not normally distributed.

infections included the time from the initial procedure to operation, autografts were harvested or allografts were thawed
arthroscopic I&D and organism(s) grown on culture. on confirmation of ACL rupture or deficiency. Grafts were
The choices between allograft and autograft tissue and soaked in 500 mL of 1-mg/mL solution of vancomycin for an
about the specific graft type were made individually by the average of 10 minutes and were then wrapped in vancomycin-
treating surgeon. The individual surgeons chose nonsurgical or soaked gauze sponge after graft preparation and prior to graft
surgical treatment and the timing of the operation according to
the needs of the individual patient. The utilization of
vancomycin-soaked grafts was instituted in each participating TABLE IV Results of Multivariate Analysis Assessing the
surgeon’s practice on the basis of their preference. While each Association of Vancomycin-Prepared Grafts with
Infection*
surgeon began using intraoperative vancomycin at different
time points, all implemented this technique by 2014. One Variable Controlled For IRR (95% CI) P Value
surgeon briefly used neomycin before switching to the van-
comycin protocol, which had become standard practice at our Revision 0.117 (0.015-0.923) 0.042†
institution. Preoperative antibiotic prophylaxis, with cefazolin Other ligamentous procedure 0.100 (0.013-0.782) 0.028†
administered to all patients without a documented cephalo- BMI 0.109 (0.014-0.856) 0.035†
sporin allergy, was used for each patient undergoing ACL Operative time 0.179 (0.021-0.450) 0.011†
reconstruction. Patients with a documented allergy to a ceph- Autograft 0.119 (0.015-0.931) 0.042†
alosporin received clindamycin for intraoperative antibiotic
Hybrid autograft/allograft 0.107 (0.014-0.843) 0.034†
prophylaxis (n = 177). Per standard practice, IV antibiotics
were administered within 1 hour before the skin incision. No *Multiple models were created to evaluate the effect of
patient had a reported allergy to vancomycin. Additionally, all vancomycin ACL graft preparation on postoperative infection while
patients were screened preoperatively for skin lesions, rashes, controlling for a single variable to prevent overfitting. Vancomycin
or infection, and surgery was postponed if necessary. Intra- use remained associated with decreased postoperative infection
rates in each model. †Significant. The data set was not normally
operative graft preparation with vancomycin solution was re- distributed.
corded in the operative record. At the beginning of the
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Fig. 1
Kaplan-Meier curve depicting time to infection (days), including deep and superficial infections, following the ACL reconstruction procedure. Survival
probability (percentage) denotes the absence of diagnosed infection.
passage. Patients were routinely seen in the clinic at 2 weeks, 6
weeks, and 3 months postoperatively.
Descriptive and inferential statistical analyses were con-
ducted. Chi-square and Fisher exact tests were utilized for
comparison of categorical variables. Student t and Wilcoxon
rank sum tests were performed for continuous variables. We
used Poisson regression analysis to calculate incidence rate
ratios (IRRs) with a 95% confidence interval (CI), after adjusting
for confounding. Because of concerns about overfitting the
multivariate model given the low infection rate, no more than 2
variables of interest were examined at a given time. Multiple
models were created to evaluate the effect of ACL graft prepa-
ration with vancomycin on the postoperative infection rate while
controlling for a single variable (revision, other ligamentous
procedure, BMI, operative time, or graft type). Univariate and
multivariate analyses were performed using SAS 9.4 software
(SAS Institute). Significance was defined as p < 0.05.
Results
I n total, 1,640 patients (952 males; 58.0%) with a mean age
(and standard deviation) of 27.7 ± 11.4 years and a mean BMI
of 27.5 ± 6.2 kg/m2 underwent primary (n = 1,379; 84.1%) or
revision (n = 261; 15.9%) ACL reconstruction. The ACL graft
source was most frequently autogenous (n = 1,116; 68.0%).
Twenty-five patients (1.5%) had diabetes, with an average
hemoglobin A1c (HgA1c) of 7.4% ± 1.2%, and there were 289
current smokers (17.6%). Intraoperative vancomycin was used in
798 cases (48.7%) whereas 842 ACL reconstructions (51.3%)
were performed without intraoperative vancomycin graft prep-
aration. There was no significant difference in age (p = 0.965), sex
G R A F T P R E PA R AT I O N W I T H I N T R A O P E R AT I V E VA N C O M YC I N
D E C R E A S E S I N F E C T I O N A F T E R ACL R E C O N S T R U C T I O N
(p = 0.668), or BMI (p = 0.112) between the 2 groups (Table I).
Although a higher percentage of the vancomycin group had
concomitant ligamentous procedures (11.3% versus 7.2%; p =
0.005), that group had a significantly shorter operative time (98.6
versus 130.5 minutes; p < 0.001). Additionally, a significantly
higher percentage of patients in the vancomycin group received
an autograft (72.7% versus 63.5%; p < 0.001); however, there was
no difference in the proportion of allografts (p = 0.436) or
revision cases (p = 0.901) between the 2 groups (Table II).
There were a total of 11 infections (0.7%), which
developed in 10 (1.2%) of the patients without a vancomycin-
soaked graft and 1 (0.1%) of those in whom vancomycin was
used (p = 0.032) (Table III). Intraoperative vancomycin use
significantly decreased the rate of infection following ACL
reconstruction (0.1% versus 1.2%; p = 0.032; IRR = 0.106; 95%
CI = 0.014 to 0.824; 89.4% relative risk reduction), with a
number needed to treat (NNT) of 95. In contrast, obesity (p =
0.014; IRR = 4.699; 95% CI = 1.376 to 16.050) and increased
operative time (p = 0.001) were associated with an increased
risk of postoperative infection. Autograft tendon (p = 0.045;
IRR = 0.289; 95% CI = 0.079 to 0.919) was associated with a
decreased risk of postoperative infection. Revision cases (p =
0.665; IRR = 1.320; 95% CI = 0.280 to 6.216), tourniquet use (p
= 0.800), postoperative use of aspirin (p = 0.841), and surgeon
(p = 0.124) were not associated with the risk of infection. The
results of the multivariate analyses, in which potential con-
founders (revision, other ligamentous procedure, BMI, oper-
ative time, and graft type) were investigated and controlled for,
are shown in Table IV. The protective effect of graft preparation
with vancomycin on postoperative infection was observed after
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controlling for each variable individually (Table IV). There
were no cases of synovitis, stiffness, or early graft failure sec-
ondary to vancomycin use. One patient for whom the graft was
not soaked in vancomycin required a manipulation under
anesthesia to address stiffness.
The average time from ACL reconstruction until post-
operative infection diagnosis was 17.3 ± 18.5 days (Fig. 1). Of
the patients who developed an infection, 8 received periop-
erative IV cefazolin and 3 were given clindamycin because of a
patient-reported penicillin allergy. Responsible microorgan-
isms included Staphylococcus aureus (n = 4), coagulase-
negative Staphylococcus (n = 2), Enterobacter cloacae (n = 1),
and Propionibacteriaceae (n = 1). In 2 cases, no organisms were
grown on culture of specimens from the suspected site of
infection; in another case, gram-positive rods suggestive of
diphtheria were isolated. One patient with a negative culture
presented with a fever and an elevated erythrocyte sedimentation
rate (ESR) of 61 mm/hr and C-reactive protein (CRP) level of
22.2 mg/dL. Knee aspirate demonstrated a total nucleated cell
count of 46,698/mL with 88% neutrophils and no crystals. The
other patient presented similarly, with laboratory studies notable
for a white blood-cell (WBC) count of 32,498/mL, an ESR of 26
mm/hr, and a CRP level of 4.4 mg/dL. Knee aspirate from this
patient demonstrated a total nucleated cell count of 21,546/mL
with 94% neutrophils. The knee aspirate was negative for
crystalline arthropathy. If these culture-negative infections were
excluded, vancomycin use still significantly decreased the risk of
postoperative infection following ACL reconstruction (vanco-
mycin-presoaked graft versus preparation without vancomycin,
0.1% versus 0.95%; p = 0.039).
Discussion
I n our retrospective cohort study of 1,640 ACL reconstruc-
tions, there was a 10-fold decrease (0.1% versus 1.2%) in
postoperative infections in patients who had received an ACL
graft soaked intraoperatively in a vancomycin solution com-
pared with those in whom the graft was not so treated. Other
independent predictors of infection included increased oper-
ative time and increased BMI.
Use of a diluted vancomycin solution was associated with
a decrease in the rate of postoperative infection from 1.2% to
0.1%. Only a few studies have examined preventive strategies to
limit infection following ACL reconstruction4,18,19. In one such
TABLE V Infections, Total Cases, and Cases with Vancomycin-Prepared Grafts According to Treating Surgeon
Infections (no.) Total Cases (no.)
Surgeon 1 3 198
Surgeon 2 4 243
Surgeon 3 1 552
Surgeon 4 0 125
Surgeon 5 0 30
Surgeon 6 3 492
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study, a retrospective analysis of 1,135 patients who had under-
gone ACL reconstruction, Vertullo et al. reported a single sur-
geon’s experience using vancomycin-soaked sterile gauze wrapped
around a harvested hamstring autograft intraoperatively20. Similar
to our study, they demonstrated a reduction in the infection
rate, from 1.4% of 285 cases to 0% of 870 cases. Another study
assessing 1,544 ACL reconstructions demonstrated that the
intraoperative utilization of vancomycin reduced the infection
rate from 1.9% to 0%21. Offerhaus et al. most recently performed
a retrospective review of 1,779 patients who had undergone ACL
reconstruction and reported that soaking of autografts in van-
comycin reduced the rate of deep postoperative infections, as
compared with systemic antibiotic prophylaxis alone, from 2.4%
to 0% after 28 months of postoperative follow-up22. They also
reported that the utilization of a vancomycin-soaked graft did
not affect postoperative clinical outcomes, including Interna-
tional Knee Documentation Committee (IKDC) or Tegner
scores, and may have clinical utility in reducing rates of post-
operative graft rupture22. These findings as well as the results
from the present study suggest that strong consideration
should be given to routine intraoperative vancomycin prepa-
ration of ACL grafts.
Vancomycin is an attractive option for intra-articular
application as in vitro studies have demonstrated relatively
low chondrotoxicity compared with other antibiotics23,24. In a
cadaveric animal study, Grayson et al. demonstrated that col-
lagen fibers of bovine tendons absorb and slowly release van-
comycin over a 24-hour period25. The required duration of
local antimicrobial therapy in ACL reconstruction is poorly
understood; however, there are data in the field of arthroplasty
that suggest that intra-articular vancomycin may be effective
against infection for up to 7 days26. Due to the poor vascularity
of tendons, antibiotic tissue levels above the minimum inhib-
itory concentration have not been established in the graft via
isolated IV administration22,27. Our results and the findings
reported by Vertullo et al.20 suggest that vancomycin graft
preparation represents a promising avenue for preventing
postoperative infection following ACL reconstruction, with
authors of previous studies reporting little concern about local
tissue or graft morbidity with its use22.
The greatest number of cases of septic arthritis in our series
were caused by S. aureus, followed by coagulase-negative staphy-
lococcal species. In 2 cases, a causative organism was not identified.
Vancomycin-Prepared Grafts (no. [%]) Infection Rate
4 (2.0%) 1.5%
2 (0.8%) 1.6%
435 (78.8%) 0.2%
1 (0.8%) 0%
29 (96.7%) 0%
327 (66.5%) 0.6%
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This is consistent with previous literature on infection following
ACL reconstruction, with staphylococcal species most frequently
identified4,28,29. In the study by Vertullo et al., 3 infections were
attributed to S. epidermidis, with the fourth infection due to an
unidentified organism20. Offerhaus et al. reported that, of 22
infections, 16 (73%) were attributed to coagulase-negative Staph-
ylococcus and 2 cases (9%) resulted from S. aureus22. One gram-
negative bacterial species (E. cloacae) was isolated in our cohort.
Vancomycin is typically used to treat gram-positive bacteria and
will consistently provide adequate coverage for staphylococcal
species as well as Enterococcus and Propionibacteriaceae, the
main organisms causing postoperative ACL infections in the
current study as well as previous investigations4,30,31.
Previous studies have identified risk factors for infection
after ACL reconstruction, including diabetes32, graft choice6,13,32,
previous knee surgery33, additional knee procedures, and tobacco
use34. Increased operative time, larger incisions, increased tour-
niquet inflation time, and use of intra-articular drains may also
affect postoperative infection rates6,12,14,16,35. In our study, age, sex,
race, and insurance status were not associated with postoperative
infection. No definitive associations between these demographic
variables and infection following ACL reconstruction have been
established34,36. Additionally, diabetes and tobacco use within 6
months before ACL reconstruction were not found to be associ-
ated with infection in the present analysis. This finding is con-
tradicted by the conclusion that tobacco use was a risk factor for
postoperative infection in a large database study of 13,358 patients
treated with ACL reconstruction37. Due to the relatively small
number of active smokers, the current study may not have been
powered to allow adequate detection of the association between
smoking and infection after ACL reconstruction. Brophy et al. also
suggested that diabetes is an independent risk factor for infection
after ACL reconstruction32. None of the patients with diabetes in
the present study developed a postoperative ACL infection. The
mean HgA1c was 7.4% ± 1.2%, suggesting that the diabetics in
our cohort had relatively good glycemic control.
Previous studies have demonstrated an increased risk of
infection with use of hamstring autografts as compared with
bone-tendon-bone autografts or allografts4,6,9,32. A recent meta-
analysis by Bansal et al. demonstrated a significantly lower
incidence of infection using bone-tendon-bone autografts
compared with hamstring autografts and all other graft types2.
There is no current consensus on the relationship between graft
type and predisposition to infection, with many orthopaedic
surgeons using a particular graft on the basis of anecdotal evi-
dence4,6,13. The current study demonstrated a decreased risk of
infection with autografts; however, our low infection rate may
predispose this finding to type-I error. Of note, vancomycin use
remained associated with a decreased postoperative infection
rate after controlling for graft type in multivariate analysis. Only
1 of the 11 infected ACL grafts was a revision ACL reconstruction
graft, which had not been soaked in vancomycin intra-
operatively. Because of the overall low number of infections in
the present study, primary and revision ACL procedures were
analyzed together and our results indicated that revision ACL
reconstruction does not appear to contribute to subsequent
G R A F T P R E PA R AT I O N W I T H I N T R A O P E R AT I V E VA N C O M YC I N
D E C R E A S E S I N F E C T I O N A F T E R ACL R E C O N S T R U C T I O N
infection. In the current cohort, patients who received a
vancomycin-prepared graft had significantly more concomitant
ligamentous procedures yet shorter operative times. This is likely
secondary to surgeon learning curves and variability in operating
styles. Importantly, no association was observed between sur-
geon and infection.
Limitations
The current study does have several limitations. It is retrospective
in nature and not randomized. Patients in the vancomycin-treated
group received surgery later in the study period, which introduces
the likelihood of both performance bias as the treating surgeons
gained surgical experience and improved their technique over
time as well as chronological bias because other elements of the
overall preoperative and postoperative care of the patient may
have improved and impacted the risk of infection. Additionally,
patients with postoperative infection may have presented to
another hospital for care and may not have been represented in
our analysis. Also, patients were not observed for more than the
90-day period as defined in the inclusion criteria. Late-presenting
postoperative infections may have been missed, introducing
detection bias. Additionally, although we observed no associa-
tion between the treating surgeon and postoperative infection,
we were unable to analyze this relationship using multivariate
analysis because of the wide variability in vancomycin use among
surgeons (Table V). Finally, the low number of infections in each
study group limited extensive statistical analyses and may mean
the study was underpowered to detect differences.
Conclusions
The use of vancomycin-soaked grafts was associated with a 10-
fold reduction in the rate of postoperative infection after ACL
reconstruction. Other risk factors for postoperative infection
after ACL reconstruction included increased BMI and increased
operative time. n
J.E. Baron, BA1
A.G. Shamrock, MD1
W.T. Cates, BS1
R.A. Cates, DO1
Q. An, MPH1
B.R. Wolf, MD, MS1
M.J. Bollier, MD1
K.R. Duchman, MD1
R.W. Westermann, MD1
1Department of Orthopedics and Rehabilitation, University of Iowa,
Iowa City, Iowa
Email address for R.W. Westermann: robert-westermann@uiowa.edu
ORCID iD for J.E. Baron: 0000-0002-2678-0506
ORCID iD for A.G. Shamrock: 0000-0003-3038-3391
ORCID iD for W.T. Cates: 0000-0001-7790-0953
ORCID iD for R.A. Cates: 0000-0003-0786-1586
ORCID iD for Q. An: 0000-0002-1717-5232
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ORCID iD for B.R. Wolf: 0000-0002-2529-8056
ORCID iD for M.J. Bollier: 0000-0002-2612-1367
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