Journal of Orthopaedic Surgery 2014;22(1):111-7
Graft infection following arthroscopic anterior cruciate ligament reconstruction: a report of four cases James Wee, Keng Thiam Lee
Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
INTRODUCTION ABSTRACT Septic arthritis following arthroscopic anterior cruciate ligament reconstruction (ACL) is a rare complication and associated with severe morbidity. Its risk factors include (1) concomitant procedures during the reconstruction, (2) previous knee surgery, (3) allograft usage, (4) peri-operative wound contamination, and (5) presence of intra-articular foreign bodies. We present a series of 3 men and one woman aged 22 to 35 years who developed septic arthritis following ACL reconstruction. The risk factors identified were local infection (n=2), previous ipsilateral knee surgery (n=2), and the use of an allograft (n=1). All patients underwent emergency knee washout and debridement with graft retention within 24 hours, together with a course of intravenous antibiotic therapy. All the patients achieved eradication of their infections (with intact ACL grafts) and satisfactory functional outcome at a mean follow-up of 32 (range, 25–45) months. Key words: anterior cruciate ligament reconstruction; arthritis, infectious; infection
Septic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction is rare and may result in severe morbidity, prolonged hospitalisation, and poor clinical outcome.1 Its incidence is 0.3 to 1.7%,2–6 whereas the postoperative intra-articular infection rate is 1.5%.7 Early diagnosis and aggressive treatment minimises the risks of graft failure, damage to intraarticular hyaline cartilage, and arthrofibrosis,8–10 and thus is vital in eradicating the infection, preserving the graft, and achieving good functional outcomes. Delay in treatment can lead to osteomyelitis, diffuse chondral thinning, full-thickness osteochondral defects, and rapid degenerative osteoarthritis.7,11,12 We report on 4 patients who developed septic arthritis following arthroscopic ACL reconstruction. CASE REPORTS Records of 3 men and one woman aged 22 to 35 years who developed acute (100 mg/l) at presentation. Patients with persistently elevated CRP levels (patients 1 and 3) had repeat washouts, whereas those with rapidly declining CRP levels following the first washout (patients 2 and 4) did not undergo further washout. The ESR response often lagged clinical improvement and the decline of CRP levels by days to weeks; sometimes the ESR even rose temporarily. Three of the 4 patients had normal WBC count on admission and throughout the treatment period. Only patient 2 had a mildly elevated WBC count of 12.2 x109/l on admission. Thus, the WBC count is not sensitive enough for early diagnosis of postoperative septic arthritis and for monitoring the clinical course. The CRP level, together with inspection of the knee aspirate, is the most sensitive marker for detecting postoperative infection and for monitoring the response to treatment.
Treatment Treatment options include long-term intravenous antibiotics, arthroscopic or open washout and debridement, constant joint irrigation, and graft retention or removal with or without reimplantation.13 The most frequently used treatment is joint irrigation and debridement with graft retention.5,15,21–24 Immediate removal of the infected ACL graft is
CONCLUSION Aggressive early knee washout and debridement with graft retention, and a prolonged course of intravenous antibiotic therapy are recommended for treatment of graft infection following arthroscopic ACL reconstruction. The CRP level is the most
Vol. 22 No. 1, April 2014
sensitive inflammatory marker for detecting postoperative infection. All our patients recovered well with reasonably good functional outcomes.
Graft infection following arthroscopic ACL reconstruction 117
DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Kohn D. Unsuccessful arthroscopic treatment of pyarthrosis following anterior cruciate ligament reconstruction. Arthroscopy 1988;4:287–9. 2. Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med 2003;31:414–8. 3. Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2002;398:182–8. 4. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med 1999;27:562–70. 5. Viola R, Marzano N, Vianello R. An unusual epidemic of Staphylococcus-negative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function. Arthroscopy 2000;16:173–7. 6. Williams RJ 3rd, Laurencin CT, Warren RF, Speciale AC, Brause BD, O’Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med 1997;25:261–7. 7. Fong SY, Tan JL. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Ann Acad Med Singapore 2004;33:228–34. 8. Binnet MS, Basarir K. Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques. Arthroscopy 2007;23:862–8. 9. Hogan CJ, Fang GD, Scheld WM, Linden J, Diduch DR. Inhibiting the inflammatory response in joint sepsis. Arthroscopy 2001;17:311–5. 10. Kelly PJ, Martin WJ, Coventry MB. Bacterial (suppurative) arthritis in the adult. J Bone Joint Surg Am 1970;52:1595–602. 11. Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 2006;22:375–84. 12. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med 1999;27:562–70. 13. Schollin-Borg M, Michaelsson K, Rahme H. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy 2003;19:941–7. 14. Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med 2007;35:1059–63. 15. Schulz AP, Gotze S, Schmidt HG, Jurgens C, Faschingbauer M. Septic arthritis of the knee after anterior cruciate ligament surgery: a stage-adapted treatment regimen. Am J Sports Med 2007;35:1064–9. 16. Crawford C, Kainer M, Jernigan D, Banerjee S, Friedman C, Ahmed F, et al. Investigation of postoperative allograft-associated infections in patients who underwent musculoskeletal allograft implantation. Clin Infect Dis 2005;41:195–200. 17. Romanini E, D’Angelo F, De Masi S, Adriani E, Magaletti M, Lacorte E, et al. Graft selection in arthroscopic anterior cruciate ligament reconstruction. J Orthop Traumatol 2010;11:211–9. 18. Greenberg DD, Robertson M, Vallurupalli S, White RA, Allen WC. Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2010;92:2402–8. 19. Musso AD, McCormack RG. Infection after ACL reconstruction: what happens when cultures are negative? Clin J Sport Med 2005;15:381–4. 20. Blevins FT, Salgado J, Wascher DC, Koster F. Septic arthritis following arthroscopic meniscus repair: a cluster of three cases. Arthroscopy 1999;15:35–40. 21. Matava MJ, Evans TA, Wright RW, Shively RA. Septic arthritis of the knee following anterior cruciate ligament reconstruction: results of a surgery of sports medicine fellowship directors. Arthroscopy 1998;14:717–25. 22. Hefti F, Muller W, Jakobs RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1:226–34. 23. Allianatos PG, Tilentzoglou AC, Koutsoukou AD. Septic arthritis caused by Erysipelothrix rhusiopathiae infection after arthroscopically assisted anterior cruciate ligament reconstruction. Arthroscopy 2003;19:E26. 24. Nassif J, Nyland J, Johnson DL. Septic knee arthritis secondary to a functional brace after ACL reconstruction. Am J Knee Surg 1998;11:233–5. 25. Zalavras CG, Patzakis MJ, Tibone J, Weisman N, Holtom P. Treatment of persistent infection after anterior cruciate ligament surgery. Clin Orthop Relat Res 2005;439:52–5. 26. Burke WV, Zych GA. Fungal infection following replacement of the anterior cruciate ligament: a case report. J Bone Joint Surg Am 2002;84:449–53.
Graft infection following arthroscopic anterior cruciate ligament reconstruction: a report of four cases James Wee, Keng Thiam Lee
Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
INTRODUCTION ABSTRACT Septic arthritis following arthroscopic anterior cruciate ligament reconstruction (ACL) is a rare complication and associated with severe morbidity. Its risk factors include (1) concomitant procedures during the reconstruction, (2) previous knee surgery, (3) allograft usage, (4) peri-operative wound contamination, and (5) presence of intra-articular foreign bodies. We present a series of 3 men and one woman aged 22 to 35 years who developed septic arthritis following ACL reconstruction. The risk factors identified were local infection (n=2), previous ipsilateral knee surgery (n=2), and the use of an allograft (n=1). All patients underwent emergency knee washout and debridement with graft retention within 24 hours, together with a course of intravenous antibiotic therapy. All the patients achieved eradication of their infections (with intact ACL grafts) and satisfactory functional outcome at a mean follow-up of 32 (range, 25–45) months. Key words: anterior cruciate ligament reconstruction; arthritis, infectious; infection
Septic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction is rare and may result in severe morbidity, prolonged hospitalisation, and poor clinical outcome.1 Its incidence is 0.3 to 1.7%,2–6 whereas the postoperative intra-articular infection rate is 1.5%.7 Early diagnosis and aggressive treatment minimises the risks of graft failure, damage to intraarticular hyaline cartilage, and arthrofibrosis,8–10 and thus is vital in eradicating the infection, preserving the graft, and achieving good functional outcomes. Delay in treatment can lead to osteomyelitis, diffuse chondral thinning, full-thickness osteochondral defects, and rapid degenerative osteoarthritis.7,11,12 We report on 4 patients who developed septic arthritis following arthroscopic ACL reconstruction. CASE REPORTS Records of 3 men and one woman aged 22 to 35 years who developed acute (100 mg/l) at presentation. Patients with persistently elevated CRP levels (patients 1 and 3) had repeat washouts, whereas those with rapidly declining CRP levels following the first washout (patients 2 and 4) did not undergo further washout. The ESR response often lagged clinical improvement and the decline of CRP levels by days to weeks; sometimes the ESR even rose temporarily. Three of the 4 patients had normal WBC count on admission and throughout the treatment period. Only patient 2 had a mildly elevated WBC count of 12.2 x109/l on admission. Thus, the WBC count is not sensitive enough for early diagnosis of postoperative septic arthritis and for monitoring the clinical course. The CRP level, together with inspection of the knee aspirate, is the most sensitive marker for detecting postoperative infection and for monitoring the response to treatment.
Treatment Treatment options include long-term intravenous antibiotics, arthroscopic or open washout and debridement, constant joint irrigation, and graft retention or removal with or without reimplantation.13 The most frequently used treatment is joint irrigation and debridement with graft retention.5,15,21–24 Immediate removal of the infected ACL graft is
CONCLUSION Aggressive early knee washout and debridement with graft retention, and a prolonged course of intravenous antibiotic therapy are recommended for treatment of graft infection following arthroscopic ACL reconstruction. The CRP level is the most
Vol. 22 No. 1, April 2014
sensitive inflammatory marker for detecting postoperative infection. All our patients recovered well with reasonably good functional outcomes.
Graft infection following arthroscopic ACL reconstruction 117
DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Kohn D. Unsuccessful arthroscopic treatment of pyarthrosis following anterior cruciate ligament reconstruction. Arthroscopy 1988;4:287–9. 2. Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med 2003;31:414–8. 3. Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2002;398:182–8. 4. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med 1999;27:562–70. 5. Viola R, Marzano N, Vianello R. An unusual epidemic of Staphylococcus-negative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function. Arthroscopy 2000;16:173–7. 6. Williams RJ 3rd, Laurencin CT, Warren RF, Speciale AC, Brause BD, O’Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med 1997;25:261–7. 7. Fong SY, Tan JL. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Ann Acad Med Singapore 2004;33:228–34. 8. Binnet MS, Basarir K. Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques. Arthroscopy 2007;23:862–8. 9. Hogan CJ, Fang GD, Scheld WM, Linden J, Diduch DR. Inhibiting the inflammatory response in joint sepsis. Arthroscopy 2001;17:311–5. 10. Kelly PJ, Martin WJ, Coventry MB. Bacterial (suppurative) arthritis in the adult. J Bone Joint Surg Am 1970;52:1595–602. 11. Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 2006;22:375–84. 12. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med 1999;27:562–70. 13. Schollin-Borg M, Michaelsson K, Rahme H. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy 2003;19:941–7. 14. Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med 2007;35:1059–63. 15. Schulz AP, Gotze S, Schmidt HG, Jurgens C, Faschingbauer M. Septic arthritis of the knee after anterior cruciate ligament surgery: a stage-adapted treatment regimen. Am J Sports Med 2007;35:1064–9. 16. Crawford C, Kainer M, Jernigan D, Banerjee S, Friedman C, Ahmed F, et al. Investigation of postoperative allograft-associated infections in patients who underwent musculoskeletal allograft implantation. Clin Infect Dis 2005;41:195–200. 17. Romanini E, D’Angelo F, De Masi S, Adriani E, Magaletti M, Lacorte E, et al. Graft selection in arthroscopic anterior cruciate ligament reconstruction. J Orthop Traumatol 2010;11:211–9. 18. Greenberg DD, Robertson M, Vallurupalli S, White RA, Allen WC. Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2010;92:2402–8. 19. Musso AD, McCormack RG. Infection after ACL reconstruction: what happens when cultures are negative? Clin J Sport Med 2005;15:381–4. 20. Blevins FT, Salgado J, Wascher DC, Koster F. Septic arthritis following arthroscopic meniscus repair: a cluster of three cases. Arthroscopy 1999;15:35–40. 21. Matava MJ, Evans TA, Wright RW, Shively RA. Septic arthritis of the knee following anterior cruciate ligament reconstruction: results of a surgery of sports medicine fellowship directors. Arthroscopy 1998;14:717–25. 22. Hefti F, Muller W, Jakobs RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1:226–34. 23. Allianatos PG, Tilentzoglou AC, Koutsoukou AD. Septic arthritis caused by Erysipelothrix rhusiopathiae infection after arthroscopically assisted anterior cruciate ligament reconstruction. Arthroscopy 2003;19:E26. 24. Nassif J, Nyland J, Johnson DL. Septic knee arthritis secondary to a functional brace after ACL reconstruction. Am J Knee Surg 1998;11:233–5. 25. Zalavras CG, Patzakis MJ, Tibone J, Weisman N, Holtom P. Treatment of persistent infection after anterior cruciate ligament surgery. Clin Orthop Relat Res 2005;439:52–5. 26. Burke WV, Zych GA. Fungal infection following replacement of the anterior cruciate ligament: a case report. J Bone Joint Surg Am 2002;84:449–53.
