Risk factors for postoperative surgical site infections after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature

Infection is an uncommon side effect of arthroscopic surgery, and this percentage is higher in anterior cruciate ligament reconstruction (ACLR) surgery, where graft and fixation devices are used. Infections can not only lead to high re-admission rates and poor functional recovery of the knee but can also have a significant negative impact on the patient's psychological and economic health, especially in athletes, as it can affect their sports career. It is important to be aware of the many risk factors, especially the manifestation of symptoms. These may sometimes be non-specific to the infectious pathology and common to other situations, such as the presence of a significant intra-articular hematoma. Septic arthritis after ACLR can occur at any time after surgery but typically presents acutely, while late manifestation is relatively rare. Diagnosis of infection is based on patient history, physical examination, laboratory parameters, and analysis of synovial fluid after joint aspiration, which is the gold standard for diagnosing post-operative infection. Once symptoms appear and the diagnosis seems certain, it is necessary to intervene quickly with arthroscopic debridement and long-term antibiotic treatment to try to save the graft and resolve the infectious situation to avoid graft failure and arthrofibrotic sequelae. The aim of this paper is to provide an overview of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic evaluation, and current treatment guidelines of septic arthritis after ACLR surgery by analyzing recent literature, in particular meta-analyses and systematic reviews.

Risk factors for venous thromboembolism following knee arthroscopy: A systematic review and meta-analysis of observational studies

Objectives

To evaluate the risk factors for increased risk of venous thrombosis after arthroscopic knee surgery.

Methods

PubMed, EMBASE and Cochrane Library were searched from their inception to April 4, 2023. Observational studies investigated venous thrombosis following arthroscopic knee surgery were included. The Newcastle Ottawa Scale (NOS) was used to evaluate the methodological quality of included studies. The odd ratios (ORs) and 95% confidence intervals (CIs) pertaining to each risk factor were synthesized through a random effects model by STATA 14 software.

Results

The protocol this meta-analysis has been registered on PROSPERO (CRD42023410283). A total of 22 observational studies were included in the systematic review, all of which were of moderate or high methodological quality. The results of the meta-analysis revealed that several factors were significantly associated with an elevated risk of venous thrombosis following arthroscopic knee surgery. These factors included age (mean age ≥30 years) [OR = 1.08, 95%CI (1.04, 1.13), P = 0.001], overweight or obesity [OR = 1.31, 95%CI (1.13, 1.52), P＜0.001], oral contraceptive use [OR = 1.90, 95%CI (1.52, 2.37), P＜0.001], and smoking history [OR = 1.35, 95%CI (1.06, 1.71), P = 0.014]. Furthermore, the subgroup analysis indicated that patients with an average age over 50 years [OR = 3.18, 95%CI (1.17, 8.66), P = 0.001] and those who underwent surgery with a tourniquet for ≥90 min [OR = 4.79, 95%CI (1.55, 14.81), P = 0.007] were at a significantly increased risk of venous thrombosis after knee arthroscopy.

Conclusion

Age, obesity, oral contraceptives, smoking history, and prolonged tourniquet use may increase the risk of venous thrombosis after arthroscopic knee surgery. The incidence of venous thrombosis after knee arthroscopy is on a downward trend, but due to its severity, increasing awareness of risk factors and implementing effective prophylaxis are important tasks for clinicians to prevent the risk of venous thrombosis after knee arthroscopy.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery.

METHODS

A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index.

RESULTS

Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore.

CONCLUSIONS

Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients.

CLINICAL RELEVANCE

Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.

Patellar Tendon Reconstruction After Failed Primary Repair of Bilateral Ruptures: A Case Report

CASE

A 29-year-old man sustained a bilateral acute patellar tendon rupture (PTR) while jumping on a trampoline. He was initially treated with bilateral transosseous patellar tendon repairs. Bilateral rerupture occurred during a fall 10 weeks after. He subsequently underwent staged bilateral patellar tendon reconstructions using an Achilles tendon allograft. At 3-year follow-up, he has maintained full range of motion and leg strength without rerupture or other complications.

CONCLUSION

The use of Achilles tendon allograft in the presence of inadequate and poor-quality tendon tissue for reconstruction of the patellar tendon in the revision setting is a viable and effective treatment option.

A meta-analysis of the risk factors of surgical site infection after hysterectomy for endometrial cancer

Surgical Site Infection (SSI) is one of the common postoperative complications after hysterectomy for endometrial cancer (EC). Previous studies have investigated the risk factors for SSI in patients with EC. However, big differences in research results exist, and the correlation coefficients of different research results are quite different. A meta-analysis was conducted to examine the risk factors related to SSI in patients with EC. We searched English databases to collect case-control studies or cohort studies published before July 20, 2023, including PubMed, Web of Science, Embase and ScienceDirect. The risk of bias in the included studies was assessed via Newcastle-Ottawa Scale. The analysis was performed using RevMan 5.4.1 tool. A total of 6 articles (n = 3647) were selected in this meta-analysis. The following risk factors were presented to be significantly correlated with SSI in EC: laparotomy (OR = 2.66, 95% CI [1.57, 4.54]), postoperative blood sugar ≥10 mmol/L (OR = 4.38, 95% CI [2.83, 6.78]), Federation International of Gynaecology and Obstetrics (FIGO) stage-III or IV (OR = 2.27, 95% CI [1.49, 3.46]). The occurrence of SSI is influenced by a variety of factors. Thus, we should pay close attention to high-risk subjects and take crucial targeted interventions to lower the SSI risk after hysterectomy. Owing to the limited quality and quantity of the included studies, more rigorous studies with adequate sample sizes are needed to verify the conclusion.

Deep Infection After Anterior Cruciate Ligament Reconstruction Diagnosed by Intratunnel Suspensory Fixation Device Migration: A Case Report

CASE

A 43-year-old woman sustained an anterior cruciate ligament injury while kickboxing and underwent anterior cruciate ligament reconstruction with hamstring autograft with suspensory fixation. Lateral thigh wound was superficially infected at 2 weeks postoperatively with resolution of signs and symptoms after debridement. Three months later, posterolateral knee pain developed and radiographs revealed intratunnel migration of the device. That observation with abnormal magnetic resonance imaging and serology results led to the diagnosis of deep infection. Immediate device removal and debridement were performed. Consequently, the grafts were preserved, and the patient could perform kickboxing 2 years thereafter.

CONCLUSIONS

Intratunnel migration of suspensory fixation devices can support a diagnosis of infection.