Protocol For The Systematic Review Of Return-To-Activity Criteria In Adolescent Patients Following An Anterior Cruciate Ligament Reconstruction

Abstract Background Anterior cruciate ligament (ACL) rupture is a debilitating knee injury associated with sequela such as joint instability and progressive degeneration. Unfortunately, following surgical ACL reconstruction in adolescents the rates of either ACL graft failure or contralateral ACL rupture ranges from 17–30%. A contributing factor to the high re-injury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return-to-activities (RTA) post-operatively. Several systematic reviews have already sought to develop a consensus on what criteria should be utilized for releasing patients to unrestricted sports activities; however, these reviews have focused on adult populations, a group at much lower risk for re-injury. Our objective is to systematically examine the literature and identify the criteria used in existing research when determining unrestricted RTA following an ACL reconstruction in an adolescent population. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search will be performed of the Medline/PubMed, Cochrane, Embase, CINAHL, and SPORTDiscus electronic database. Searches will be conducted from January 1st, 2000 until submission of the final review. Studies will be identified that include adolescent patients (≤ 18 years old) undergoing a primary ACL reconstruction, and which have specified the criteria used to determine RTA. Each article will be independently screened by two reviewers. To supplement the electronic database search, citations within all included studies will be manually reviewed. Reviewers will record the RTA assessment utilized and the rates of ACL re-injury through a standardized data extraction sheet. Reviewers will resolve full-text screening and data extraction disagreements through discussion. Synthesis of the collected data will focus on compiling and mapping the most commonly used types of RTA criteria. Discussion This systematic review will clarify the existing evidence on RTA in adolescent patients post-ACL reconstruction. This will help future interventions build more effective adolescent-specific RTA assessments through the validation of current RTA criteria as well as the implementation of new criteria according to the identified literature gaps.

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Comparison of Blood Flow Restriction Training versus Non-Occlusive Training in Patients with Anterior Cruciate Ligament Reconstruction or Knee Osteoarthritis: A Systematic Review

Journal of Clinical Medicine ◽

10.3390/jcm10010068 ◽

2020 ◽

Vol 10 (1) ◽

pp. 68

Author(s):

Cristina Bobes Álvarez ◽

Paloma Issa-Khozouz Santamaría ◽

Rubén Fernández-Matías ◽

Daniel Pecos-Martín ◽

Alexander Achalandabaso-Ochoa ◽

...

Keyword(s):

Quality Of Life ◽

Systematic Review ◽

Blood Flow ◽

Anterior Cruciate Ligament ◽

Knee Osteoarthritis ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Flow Restriction ◽

Anterior Cruciate

Patients undergoing anterior cruciate ligament (ACL) reconstruction and patients suffering from knee osteoarthritis (KOA) have been shown to have quadriceps muscle weakness and/or atrophy in common. The physiological mechanisms of blood flow restriction (BFR) training could facilitate muscle hypertrophy. The purpose of this systematic review is to investigate the effects of BFR training on quadriceps cross-sectional area (CSA), pain perception, function and quality of life on these patients compared to a non-BFR training. A literature research was performed using Web of Science, PEDro, Scopus, MEDLINE, Dialnet, CINAHL and The Cochrane Library databases. The main inclusion criteria were that papers were English or Spanish language reports of randomized controlled trials involving patients with ACL reconstruction or suffering from KOA. The initial research identified 159 publications from all databases; 10 articles were finally included. The search was conducted from April to June 2020. Four of these studies found a significant improvement in strength. A significant increase in CSA was found in two studies. Pain significantly improved in four studies and only one study showed a significant improvement in functionality/quality of life. Low-load training with BFR may be an effective option treatment for increasing quadriceps strength and CSA, but more research is needed.

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Twenty-Year Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Prospectively Collected Data

The American Journal of Sports Medicine ◽

10.1177/03635465211027302 ◽

2021 ◽

pp. 036354652110273

Author(s):

Joshua S. Everhart ◽

Sercan Yalcin ◽

Kurt P. Spindler

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Knee Function ◽

Increased Risk ◽

Patient Reported ◽

The Mean ◽

Anterior Cruciate

Background: Several long-term (≥20 years) follow-up studies after anterior cruciate ligament (ACL) reconstruction have been published in recent years, allowing for a systematic evaluation of outcomes. Purpose: To summarize outcomes at ≥20 years after ACL reconstruction and identify patient and surgical factors that affect these results. Study Design: Systematic review; Level of evidence, 4. Methods: Prospective studies of primary ACL reconstructions with hamstring or bone–patellar tendon—bone (BTB) autograft via an arthroscopic or a mini-open technique and with a mean follow-up of ≥20 years were identified. When possible, the mean scores for each outcome measure were calculated. Factors identified in individual studies as predictive of outcomes were described. Results: Five studies met the inclusion and exclusion criteria with a total of 2012 patients. The pooled mean follow-up for patient-reported outcome measures was 44.2% (range, 29.6%-92.7%) and in-person evaluation was 33.2% (range, 29.6%-48.9%). Four studies (n = 584) reported graft tears at a mean rate of 11.8% (range, 2%-18.5%) and 4 studies (n = 773) reported a contralateral ACL injury rate of 12.2% (range, 5.8%-30%). Repeat non-ACL arthroscopic surgery (4 studies; n = 177) to the ipsilateral knee occurred in 10.4% (range, 9.5%-18.3%) and knee arthroplasty (1 study; n = 217) in 5%. The pooled mean of the International Knee Documentation Committee subjective knee function (IKDC) score was 79.1 (SD, 21.8 [3 studies; n = 644]). In 2 studies (n?= 221), 57.5% of patients continued to participate in strenuous activities. The IKDC-objective score was normal or nearly normal in 82.3% (n = 496; 3 studies), with low rates of clinically significant residual laxity. Moderate-severe radiographic osteoarthritis (OA) (IKDC grade C or D) was present in 25.9% of patients (n = 605; 3 studies). Medial meniscectomy is associated with increased risk of radiographic OA. Radiographic OA severity is associated with worse patient-reported knee function, but the association with knee pain is unclear. Conclusion: Currently available prospective evidence for ACL reconstruction with hamstring or BTB autograft provides several insights into outcomes at 20 years. The rates of follow-up at 20 years range from 30% to 93%. IKDC-objective scores were normal or nearly normal in 82% and the mean IKDC-subjective score was 79 points.

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Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546518803365 ◽

2018 ◽

Vol 47 (10) ◽

pp. 2501-2509 ◽

Cited By ~ 3

Author(s):

Avinesh Agarwalla ◽

Richard N. Puzzitiello ◽

Joseph N. Liu ◽

Gregory L. Cvetanovich ◽

Anirudh K. Gowd ◽

...

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Clinical Significance ◽

Cruciate Ligament ◽

Return To Sport ◽

Pubmed Database ◽

Patient Reported ◽

Clinically Significant ◽

Anterior Cruciate

Background: Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics. Purpose: To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs). Study Design: Systematic review. Methods: A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference. Results: This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that. Conclusion: After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm. Clinical Relevance: After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

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Anterior Cruciate Ligament Rupture and Osteoarthritis Progression

The Open Orthopaedics Journal ◽

10.2174/1874325001206010295 ◽

2012 ◽

Vol 6 (1) ◽

pp. 295-300 ◽

Cited By ~ 20

Author(s):

James Min-Leong Wong ◽

Tanvir Khan ◽

Chethan S Jayadev ◽

Wasim Khan ◽

David Johnstone

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Degenerative Change ◽

Acl Rupture ◽

Osteoarthritis Progression ◽

Anterior Cruciate ◽

The Relationship ◽

Meniscal Damage ◽

Acl Deficient

Anterior Cruciate Ligament (ACL) rupture is a common sporting injury that frequently affects young, athletic patients. Apart from the functional problems of instability, patients with ACL deficient knees also develop osteoarthritis. Although this is frequently cited as an indication for ACL reconstruction, the relationship between ACL rupture, reconstruction and the instigation and progression of articular cartilage degenerative change is controversial. The purpose of this paper is to review the published literature with regards ACL rupture and the multifactorial causes for osteoarthritis progression, and whether or not this is slowed or stopped by ACL reconstruction. There is no evidence in the published literature to support the view that ACL reconstruction prevents osteoarthritis, although it may prevent further meniscal damage. It must be recognised that this conclusion is based on the current literature which has substantial methodological limitations.

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Surgical Management of Simultaneous Anterior Cruciate Ligament and Patellar Tendon Ruptures: A Systematic Review

The Journal of Knee Surgery ◽

10.1055/s-0037-1615814 ◽

2017 ◽

Vol 31 (09) ◽

pp. 875-883 ◽

Cited By ~ 2

Author(s):

Carlos Meheux ◽

Robert Jack ◽

Patrick McCulloch ◽

David Lintner ◽

Joshua Harris

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Activity Level ◽

Two Stage ◽

One Stage ◽

Significant Difference ◽

Anterior Cruciate ◽

The One

AbstractThis study performs a systematic review to determine (1) if a significant difference exists in return to preinjury activity level between one- and two-stage treatment of combined anterior cruciate ligament (ACL) and patellar tendon (PT) tears; and (2) if a significant difference exists in the number of postoperative complications between the two differing surgical treatment approaches. A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on PROSPERO. MEDLINE, Cochrane Central Register of Controlled Trials, SCOPUS, and Sport Discus were searched for English language level I–IV evidence studies on either one- (simultaneous) or two-stage (sequential) surgical treatment of simultaneously sustained ipsilateral ACL and PT tears. The approach to initial evaluation, diagnosis, treatment, and outcomes were qualitatively analyzed. Methodological quality assessment of all included studies was completed using the Methodological Index for Non-randomized Studies (MINORS). The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool was used to assess quality of evidence and provide strength of recommendation. Statistical analyses were done using Fischer's exact test. Eleven articles (18 patients; 83% males; mean age, 31.1 ± 10.1 years; mean follow-up, 2.2 ± 1.7 years; and mean MINORS 7.8/16) were analyzed. Eight patients had a one-stage procedure (primary PT repair and ACL reconstruction), and 10 patients underwent a two-stage procedure (primary PT repair first followed by ACL reconstruction) with mean 28 ± 45.7 weeks (5 weeks–3 years) between surgeries. The rate for return to preinjury activity level after surgery was not significantly different between one- (88%) and two-stage (100%) (p = 0.444). There was a significantly higher complication rate (p = 0.023) in the one-stage (stiffness, instability, and patella baja) versus two-stage surgery (no complications). There was no significant difference in return to preinjury activity level between one- and two-stage PT repair and ACL reconstruction. However, the one-stage combined surgery had a significantly higher complication rate compared with two-stage surgery. The level of evidence is IV.

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Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02872-x ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Rohan Bhimani ◽

Reza Shahriarirad ◽

Keivan Ranjbar ◽

Amirhossein Erfani ◽

Soheil Ashkani-Esfahani

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Future Application ◽

Complication Rates ◽

Bony Tissue ◽

Surgical Technical ◽

Anterior Cruciate ◽

Semitendinosus Graft

Abstract Background Transportal (TP) and all-inside techniques (AIT) are the most commonly used anterior cruciate ligament (ACL) reconstruction procedures in current clinical practice. However, there is an ongoing debate over which procedure is superior. Therefore, the purpose of this systematic review was to evaluate and compare the clinical outcomes and complications of these two techniques to propose recommendations for future application. Our primary hypothesis was that AIT is a superior ACLR technique compared to TP. Methods A systematic literature review, using PRISMA guidelines, was conducted using PubMed, Medline, Google Scholar, and EMBASE, up to February 2021 to identify studies focusing on AIT and TP techniques of ACL reconstruction. We excluded animal experiments, cadaveric studies, retrospective studies, case reports, technical notes, and studies without quantitative data. Patients’ characteristics, surgical technical features, along with postoperative follow-up and complications were extracted and reported accordingly. Methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS). Results A total of 44 studies were selected for this review, of which four were comparative studies. A total of 923 patients underwent AIT and 1678 patients underwent the TP technique for ACLR. A single semitendinosus graft was commonly used in the AIT compard to combined semitendinosus and gracilis graft in the TP group. The postoperative increase in International Knee Documentation Committee (IKDC), Lysholm, KT-1000, and Short Form-12 (physical and mental) scores were similar in the AIT group and the TP group. Contrastingly, the VAS pain score was significantly lower in the AIT group compared to the TP group. Furthermore, the pooled complication rates from all studies were similar between the two groups (AIT: 54 patients, 8.26% vs. PT: 55 patients, 6.62%). However, the four studies that prospectively compared AIT and TP techniques showed lesser complications in the AIT group than the TP group. Conclusion Since the future trend in orthopedic surgery is toward less invasive and patients’ satisfaction with good outcomes, AIT is a good alternative method considering preserving bony tissue and gracilis tendon with less post-operative pain, along with more knee flexor strength and equal outcomes compared to conventional ACL reconstruction surgery. Level of Evidence II.

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Physical prognostic factors predicting outcome following anterior cruciate ligament reconstruction: protocol for a systematic review

BMJ Open ◽

10.1136/bmjopen-2019-033429 ◽

2020 ◽

Vol 10 (3) ◽

pp. e033429

Author(s):

Andrew Middlebrook ◽

Sheree Bekker ◽

Nicola Middlebrook ◽

Alison B Rushton

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Prognostic Factors ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Risk Of Bias ◽

Predicting Outcome ◽

Anterior Cruciate

IntroductionInjuries of the anterior cruciate ligament (ACL) are a common musculoskeletal complication and can cause significant reduction in patient function and quality of life. Many undergo ACL reconstruction, with high-quality rehabilitation key to successful outcome. Knowledge of physical prognostic factors, such as quadriceps strength, is crucial to inform rehabilitation and has important implications for outcome following ACL reconstruction. However, these factors predicting outcome are poorly defined. Therefore, the aim of this systematic review is to establish physical prognostic factors predictive of outcome in adults following ACL reconstruction. Outcome will be subdivided into two groups of outcome measures, patient-reported and performance-based. Physical prognostic factors of interest will reflect a range of domains and may be modifiable/non-modifiable. Results will help decide most appropriate management and assist in planning and tailoring preoperative and postoperative rehabilitation.Methods and analysisThis systematic review protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. MEDLINE, CINAHL and EMBASE databases, key journals and grey literature will be searched from inception to July 2019. Prospective cohort studies including participants aged ≥16 years who have undergone ACL reconstruction will be included, with articles focusing on multi-ligament reconstructions and ACL repair surgery, or not published in English excluded. Two independent reviewers will conduct searches, assess study eligibility, extract data, assess risk of bias (Quality in Prognostic Studies tool) and quantify overall quality of evidence (modified Grading of Recommendations, Assessment, Development and Evaluation guidelines). If possible, a meta-analysis will be conducted, otherwise a narrative synthesis will ensue focusing on prognostic factors, risk of bias of included studies and strength of association with outcomes.Ethics and disseminationFindings will be published in a peer-reviewed journal, presented at conferences and locally to physiotherapy departments. Ethical approval is not required for this systematic review.PROSPERO registration numberCRD42019127732.

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SINGLE-LEG HOP TESTING AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IS NOT PREDICTIVE OF GRAFT RUPTURE IN ADOLESCENT PATIENTS

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00153 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0015

Author(s):

Jie J Yao ◽

Jordan Snetselaar ◽

Gregory A. Schmale ◽

Michael Saper

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

High Risk Population ◽

Entire Cohort ◽

Hop Tests ◽

Graft Rupture ◽

Adolescent Patients ◽

The Mean ◽

Anterior Cruciate

Background: Safe return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction is difficult to determine in adolescent patients. Return of strength and dynamic knee stability can be assessed with functional single-leg hop testing as part of a formal RTS assessment. However, it is unclear whether performance during single-leg hop testing can predict future ACL graft rupture. Hypothesis/Purpose: To investigate differences in single-leg hop testing between adolescent patients who experienced a graft rupture after ACL reconstruction and those that did not. Methods: A retrospective review of adolescent patients whom underwent primary ACL reconstruction with a hamstring (HS) autograft identified 16 patients (10 girls, 6 boys) with single-leg hop testing data prior to graft failure. A nearest neighbor match algorithm was used to age-, sex-, surgeon-, and graft-match 16 patients without graft rupture. All patients followed a standardized rehabilitation protocol following surgery. As part of a formal RTS test, assessment of function and dynamic strength/stability was performed using 4 different single-leg hop tests: single hop for distance, triple hop for distance, triple crossover hop for distance, and timed hop. The recovery of muscle strength was defined by a limb symmetry index (LSI) ≥ 90%. Bivariate analyses were performed to compare the two groups. Results: The mean age of the entire cohort at the time of surgery was 14.6 ± 1.5 years. Patients completed their RTS test at 29.0 ± 5.4 weeks. There were no statistically significant differences in demographics, graft size, or time to RTS test between groups. There were no statistically significant differences in LSIs on the single hop (p=0.90), triple hop (p=0.36), crossover hop (p=0.41), or timed hop (p=0.48). The mean LSIs on each of the four hop tests were 92.3 ± 14.7, 95.1 ± 6.1, 95.8 ± 7.1, and 98.6 ± 7.9, respectively. Passing rates were similar between groups (p=0.54). Conclusion: Performance on single-leg hop tests 6 months after surgery is not predictive of graft rupture following ACL reconstruction with HS autograft in adolescent patients. Further investigation of alternative RTS measures and different time frames for testing in this high-risk population is needed.

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Efficacy of Nonaugmented, Static Augmented, and Dynamic Augmented Suture Repair of the Ruptured Anterior Cruciate Ligament: A Systematic Review of the Literature

The American Journal of Sports Medicine ◽

10.1177/0363546520904690 ◽

2020 ◽

Vol 48 (14) ◽

pp. 3626-3637 ◽

Cited By ~ 4

Author(s):

Roy A.G. Hoogeslag ◽

Reinoud W. Brouwer ◽

Astrid J. de Vries ◽

Barbara C. Boer ◽

Rianne Huis in ‘t Veld

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Failure Rate ◽

Patient Reported Outcomes ◽

Cruciate Ligament ◽

Acl Rupture ◽

Suture Repair ◽

High Quality ◽

Patient Reported ◽

Anterior Cruciate

Background: Anterior cruciate ligament suture repair (ACLSR) was abandoned late last century in favor of anterior cruciate ligament (ACL) reconstruction (ACLR) because of overall disappointing results. However, in recent years there has been renewed and increasing interest in ACLSR for treatment of ACL ruptures. Several contemporary ACLSR techniques are being used, but any difference in effectiveness is unclear. Hypothesis: Contemporary nonaugmented (NA), static augmented (SA), and dynamic augmented (DA) ACLSR leads to (1) comparable outcomes overall and (2) comparable outcomes between proximal third, middle third, and combined ACL rupture locations (a) within and (b) between ACLSR technique categories. Study Design: Systematic review. Methods: An electronic search was performed in the MEDLINE and Embase databases for the period between January 1, 2010, and August 7, 2019. All articles describing clinical and patient-reported outcomes for ACLSR were identified and included, and outcomes for NA, SA, and DA ACLSR categories were compared. Results: A total of 31 articles and 2422 patients were included. The majority of articles (65%) and patients (89%) reported outcomes of DA ACLSR. Overall, there was high heterogeneity in study characteristics and level as well as quality of evidence (19 level 4; 7 level 3; 3 level 2; and 2 level 1). Most studies indicated excellent patient-reported outcomes. Overall, the variability in (and the maximum of) the reported failure rate was high within all ACLSR categories. The variability in (and the maximum of) the reported rate of all other complications was highest for DA ACLSR. Regarding ACL rupture location, the failure rate was highest in proximal ACL ruptures within the SA and DA ACLSR categories; rates of all other reported complications were highest in combined ACL ruptures within the DA ACLSR category. However, no studies in the NA category and only 1 study in the SA ACLSR category evaluated combined ACL ruptures. The majority of studies comparing ACLSR and ACLR found no differences in outcomes. Conclusion: The amount of high-quality evidence for contemporary ACLSR is poor. This makes it difficult to interpret differences among ACLSR categories and among ACL rupture locations and, though promising, to establish the role of ACLSR in the treatment of ACL ruptures. More high-quality large randomized clinical trials with longer follow-up comparing ACLSR and ACLR are needed.

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Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

HSS Journal ® ◽

10.1177/15563316211011682 ◽

2021 ◽

pp. 155633162110116

Author(s):

Francisco Figueroa ◽

David Figueroa ◽

Rafael Calvo ◽

Alex Vaisman ◽

Marilaura Nuñez ◽

...

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Case Series ◽

Control Group ◽

Infection Rates ◽

Reconstruction Methods ◽

Anterior Cruciate

Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%–1.000% CI). The overall RR obtained was 0.07 (0.03–0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence.

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