Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction

Incidence, Common Pathogens, and Risk Factors for Infection after Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis, and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction.

Comparison of Impairments, Activity Limitations, Balance, and Quality of Life between Patients with and without Meniscus Repair or Partial Meniscectomy Post-ACL Reconstruction

(1) Background: The anterior cruciate ligament (ACL) is a crucial ligament in the knee joint. This study compares the differences in knee range of motion (ROM), knee proprioception error, balance, function, and quality of life (QOL) among participants with and without meniscus repair or partial meniscectomy nine months post ACL reconstruction. (2) Methods: In this cross-sectional study, 57 male participants were selected through convenience sampling from a tertiary care hospital. Knee flexion and extension ROM were assessed using a digital goniometer; a digital inclinometer was used to assess knee proprioception error; the Y balance test was used to evaluate balance; the lower extremity functional scale (LEFS) was used to assess activity; and QOL was assessed using the ACLQOL questionnaire. (3) Results: There were no significant differences in outcomes except balance. The YB composite score had a moderate negative correlation with knee proprioception error with an R-value of -0.372 **. (4) Conclusions: Nine to 12 months post ACL reconstruction, the isolated ACL reconstruction participants had better lower-quarter single-leg balance than those who underwent ACL reconstruction and meniscal repair or partial meniscectomy. The remaining parameters, like knee ROM, knee proprioception error, LEFS score, and ACLQOL scores, were similar between these two groups.

ESSKA and EBJIS recommendations for the management of infections after anterior cruciate ligament reconstruction (ACL-R): prevention, surgical treatment and rehabilitation

PURPOSE

Infection after anterior cruciate ligament reconstruction (ACL-R) is a rare but severe complication. Despite an increase in articles published on this topic over the last decade, solid data to optimized diagnostic and therapeutic measures are scarce. For this reason, the European Bone and Joint Infection Society (EBJIS) and the European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) collaborated in order to develop recommendations for the diagnosis and management of infections after ACL-R. The aim of the workgroup was to perform a review of the literature and provide practical guidance to healthcare professionals involved in the management of infections after ACL-R.

METHODS

An international workgroup was recruited to provide recommendations for predefined clinical dilemmas regarding the management of infections after ACL-R. MEDLINE, EMBASE, Cochrane Library and Scopus databases were searched for evidence to support the recommended answers to each dilemma.

RESULTS

The recommendations were divided into two articles. The first covers etiology, prevention, diagnosis and antimicrobial treatment of septic arthritis following ACL-R and is primarily aimed at infectious disease specialists. This article includes the second part of the recommendations and covers prevention of infections after ACL-R, surgical treatment of septic arthritis following ACL-R and subsequent postoperative rehabilitation. It is aimed not only at orthopedic surgeons, but at all healthcare professionals dealing with patients suffering from infections after ACL-R.

CONCLUSION

These recommendations guide clinicians in achieving timely and accurate diagnosis as well as providing optimal management, both of which are paramount to prevent loss of function and other devastating sequelae of infection in the knee joint.

LEVEL OF EVIDENCE

V.

Weight Is a Predictor of Delayed Operation Time in Primary Isolated Anterior Cruciate Ligament Reconstruction

BACKGROUND

Few studies have evaluated the impact of obesity on operation time in patients with ACL reconstruction. The purpose of this study was to understand the effect of obesity on operation time in patients with arthroscopic anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 103 patients were included. The mean pure operation time was 45.9 ± 13.4 min. Considering that 15 min incremental increases in operation time are an independent risk factor for complications, all patients were classified into two groups according to operation time: more or less than 61 min. Demographic data were compared between both groups. Pure operation time was defined as operative time without suture time (pure operation time = suture start time - operation start time). Correlation analysis between demographic data and pure operation time was performed, and multiple linear regression analysis was used to identify the predictors of pure operation time.

RESULTS

The pure operation time ≥61 min group (n = 34) had a 14.7 kg higher weight and 4.5 kg/m2 higher body mass index (BMI) than those with pure operation time < 61 min (n = 69). Weight (r = 0.635, p < 0.001) and BMI (r = 0.584, p < 0.001) were positively correlated with operation time. Multiple linear regression analysis showed that weight (β = 0.635, p < 0.001) was the only predictor of operation time. A weight of 74.25 kg was a cut-off value for a pure operation time of >61 min.

CONCLUSIONS

The weight and BMI of the group with pure operation time of ≥61 min were 14.7 kg and 4.5 kg/m2 higher, respectively. The weight of patients with ACL tears was a factor affecting delay in the operation time. Patients weighing over 74.25 kg were more likely to delay ACL reconstruction.

Vancomycin Presoaking of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction Is Associated With Higher Magnetic Resonance Imaging Graft Signal Without Influencing Clinical Outcome

PURPOSE

To present the clinical and imaging results of a series of patients undergoing anterior cruciate ligament reconstruction with vancomycin presoaking of the hamstring autograft compared with patients in the immediate period prior, when no vancomycin was used.

METHODS

This was a retrospective sequential series of patients with anterior cruciate ligament reconstruction using either a graft protocol with no vancomycin presoaking (group 1, January 2013 to October 2015) or a graft protocol with vancomycin presoaking (group 2, November 2015 to December 2018). Lysholm and International Knee Documentation Committee scores were obtained at a minimum 24-month follow-up. Graft ruptures were recorded. Between 6 and 12 months' follow-up, magnetic resonance imaging (MRI) was obtained to evaluate graft healing and integration.

RESULTS

There were 102 patients (72% male patients), with 40 in group 1 (mean age, 32.2 years) and 62 in group 2 (mean age, 32.3 years). A graft rupture occurred in 5 patients (13%) in group 1 and 6 patients (10%) in group 2 (P = .65). The median Lysholm score was 95 points (interquartile range [IQR], 86-100 points) in group 1 and 95 points (IQR, 90-100 points) in group 2 (P = .37). The median International Knee Documentation Committee score was 93 points (IQR, 82-99 points) in group 1 and 94 points (IQR, 86-99 points) in group 2 (P = .22). MRI evaluation of integration showed that 87 patients (90%) had no synovial fluid at the tunnel-graft interface, without a difference between groups (P = .24). On the basis of graft signal appearance, hyperintense grafts were found in 45 patients (46%); isointense, 45 (46%); and hypointense, 7 (7%). Group 1 had a higher prevalence of hypointense grafts, whereas group 2 had a higher prevalence of hyperintense and isointense grafts (P = .003).

CONCLUSIONS

Vancomycin presoaking of hamstring grafts increased the number of hyperintense and isointense grafts on MRI. Additionally, more hypointense grafts were noted when vancomycin was not used, suggesting the presence of more mature grafts in the non-vancomycin group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

Male Sex, Cartilage Surgery, Tobacco Use, and Opioid Disorders are Associated with an Increased Risk of Infection After Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify patient-related risk factors for infection following anterior cruciate ligament reconstruction (ACLR).

METHODS

The Mariner database within PearlDiver was queried for patients from 2010 to 2019 undergoing primary arthroscopic ACLR. Patients undergoing ACLR with concomitant open surgery or additional ligament reconstructions were excluded. Postoperative diagnoses or procedures for superficial or deep infection within 6 months were assessed. A multivariable logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

In total, 217,541 patients underwent ACLR and 1779 (0.8%) patients had a postoperative infection within 6 months. Significant independent risk factors included male sex (OR 1.58, 95% CI 1.43-1.75, P < .001), obesity (OR 1.22, 95% CI 1.05-1.43, P = .020), morbid obesity (OR 2.54, 95% CI 2.11-3.06, P = .002), tobacco use (OR 1.36, 95% CI 1.19-1.55, P < .001), age younger than 40 years (OR 1.21, 95% CI 1.07-1.37, P = .033), depression (OR 1.18, 95% CI 1.04-1.34, P = .012), opioid disorder (OR 1.50, 95% CI 1.22-1.85, P < .001), concomitant simple cartilage surgery (OR 1.63, 95% CI 1.43-1.86, P < .001), and complex cartilage surgery (OR 1.67, 95% CI 1.20-2.32, P = .002). Partial meniscectomy and meniscal repair at the time of ACLR were not associated with an increased risk of infection.

CONCLUSIONS

In a large national sample, male sex, obesity, tobacco use, older age, depression, opioid disorders and concomitant cartilage surgery were significant risk factors for infection following ACLR.

LEVEL OF EVIDENCE

Therapeutic Level IV, retrospective case series.

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

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.

[Management algorithm for septic arthritis after anterior cruciate ligament reconstruction]

OBJECTIVE

To summarize the experience in the diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction.

METHODS

A retrospective review was conducted of all the arthroscopic anterior cruciate ligament reconstructions performed at Department of Sports Medicine, Peking University Third Hospital between January 2001 and December 2020. In the study, 65 of 27 867 patients experienced postoperative septic arthritis. The incidence, presentation, laboratory results, treatment, and outcome of all the infected patients were analyzed. The experiences of diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction were summarized.

RESULTS

A total of 27 867 anterior cruciate ligament reconstructions were performed at our department between January 2001 and December 2020. In the study, 65 (0.23%) patients were identified with postoperative septic arthritis. The most common symptoms of the infected patients were fever (38.7±0.5) ℃, knee swelling, pain, and restricted motion. The mean peripheral white blood cell count (WBC) was (9.2±2.6)×10⁹/L (range 4.2×10⁹/L-19.4×10⁹/L), with (72.5±6.3) % (range 54.9%-85.1%) polymorphonuclear neutrophils (N). The mean erythrocyte sedimentation rate (ESR) was (59.9±24.1) mm/h (range 9-108 mm/h), C-reactive protein (CRP) was (10.9±5.7) mg/dL (range 1.2-30.8 mg/dL), and fibrinogen (FIB) level was (7.0±1.6) g/L (range 3.7-10.8 g/L). All of the laboratory results were statistically higher in the infection group compared with the normal postoperative group (P＜0.001). The synovial white blood cell count (SWBC) of aspirated knee joint fluid was (45.0±29.8)×10⁹/L (range 7.1×10⁹-76.5×10⁹/L). Polymorphonuclear cell percentage (PMNC) was (90.27±7.86) % (range 60%-97%). In the study, 45 patients (69.2%) had positive aspirate cultures. Microbiology showed coagulase-negative Staphylococcus (CNS) and Staphylococcus aureus (SA) were the most common bacterium (34 cases and 7 cases, individually). There were 26 methicillin-resistant Staphylococcus. Both conservative (16 patients) and operative (49 patients) treatments were effective, but conservative group had a longer recovery time (5.6 d vs. 1.6 d, P=0.042).

CONCLUSION

Septic arthritis after arthroscopic anterior cruciate ligament reconstruction is a rare but potentially devastating complication. The correct diagnosis relies on synovial fluid analysis and bacterial culture. Our proposed treatment protocol is arthroscopic debridement and antibiotic therapy as quickly as possible.

Surgeon practice patterns for pre-soaking ACL tendon grafts in vancomycin: a survey of the ACL study group

PURPOSE

To survey members of The ACL study group to determine the current practice patterns surrounding the technique of pre-soaking ACL grafts in vancomycin.

METHODS

A web-based questionnaire was distributed to members of the ACL Study Group. Questions included the use of vancomycin solution for graft soaking during ACL reconstruction, their protocol for soaking the graft, vancomycin concentration utilized, graft choices, and concerns with the technique.

RESULTS

Sixty-six (57%) ACL surgeons completed the survey. Approximately one-third (37.9%) of respondents currently pre-soak their ACL grafts in vancomycin prior to implantation, with 60% of these surgeons being from Europe. Seventy-six percent have adopted this practice within the past 5 years. The majority of surgeons wrap the graft in a vancomycin-soaked gauze prior to implantation (56%), soak for a variable amount of time before implantation (56%), use a concentration of 5 mg/mL (68%), and soak hamstring grafts (92%). Concerns included the mechanical properties of the graft (35%), cost of vancomycin (23%), availability (12%), and antibiotic resistance (9%).

CONCLUSION

This survey demonstrates that 37.9% of ACL study group members currently utilize vancomycin to pre-soak ACL tendon grafts as a means to decrease post-operative infection risk, with the majority of surgeons having implemented this practice within the past 5 years. The biggest concern towards using vancomycin was the mechanical properties of the graft after soaking.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Synovial Fluid White Blood Cell Is the Gold Standard to Detect Infection After Anterior Cruciate Ligament Reconstruction: Don't Hesitate to Aspirate

Infection after anterior cruciate ligament reconstruction can have devastating consequences, including potential graft loss, arthrofibrosis, chondral destruction or chondrolysis, and secondary osteoarthritis. Early detection and aggressive management are imperative to improve the chances of infection eradication, graft retention, and to decrease the risk of chondral loss. One must have a high index of suspicion and not shy away from working up a possible infection. Synovial fluid aspiration and cell count, specifically white blood cell count, is the gold standard to diagnose postoperative infection.

Significantly Lower Infection Risk for Anterior Cruciate Ligament Grafts Presoaked in Vancomycin Compared With Unsoaked Grafts: A Systematic Review and Meta-analysis

PURPOSE

To compare postoperative infection rates following ACL reconstruction performed with grafts presoaked in vancomycin versus those without vancomycin.

METHODS

A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I to III studies that compared outcomes of presoaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and included studies documented infection with a minimum follow-up of 30 days. Postoperative infection rates and knee-specific patient-reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and retear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an α level of 0.05 set as significant.

RESULTS

The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects [7,507 vancomycin and 13,861 no vancomycin], 67% males, mean ± standard deviation age 29.5 ± 1.5 years) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% versus 0.77%; odds ratio 0.07; 95% confidence interval 0.03, 0.18; P < .001). Only 2 studies included patient-reported outcomes, and both demonstrated no difference in International Knee Documentation Committee scores 1 year after surgery for patients with grafts presoaked in vancomycin versus without vancomycin.

CONCLUSIONS

Soaking ACL tendon grafts with vancomycin before implantation is associated with a nearly 15 times decrease in odds of infection compared with grafts not soaked in vancomycin. Few studies investigated patient-reported outcomes and retear rates after soaking ACL grafts in vancomycin.

LEVEL OF EVIDENCE

III, systematic review of level III studies.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons

AIM

Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology.

MATERIALS AND METHODS

22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics.

RESULTS

Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection.

CONCLUSIONS

A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Soaking of autografts with vancomycin is highly effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts

PURPOSE

To evaluate the impact of local soaking of the autografts with vancomycin during anterior cruciate ligament (ACL) reconstruction on postoperative infection rates.

METHODS

Between 2003 and 2014 (first study period), 1,242 patients underwent ACL reconstruction using autografts, without soaking them in vancomycin solution, while between 2014 and 2019 (second study period) all ACL autografts in 593 patients were soaked in a 5-mg/ml vancomycin solution, in a territory University Hospital. The same standard treatment of perioperative IV antibiotics was applied in both groups.

RESULTS

Postoperative septic arthritis occurred in seven out of 1,242 patients (0.56%) during the first study period. Bone patellar tendon bone autograft was used in 311 (25%) patients, and hamstring tendon autograft was used in the rest 931 (75%) of the study population during this period. All infected cases were male and had a hamstrings graft implanted. There were no postoperative infections (0%) in 593 ACL reconstructions during the second study period. Bone patellar tendon bone autograft was used in 178 (30%) patients while hamstring tendon autograft was used in the rest 415 (70%) of the study population, during this period. Statistical analysis revealed a significantly reduced postoperative infection rate (p = 0.018) between the two reported periods, with the main impact referring to the use of hamstrings autograft (p = 0.031) for the first study period.

CONCLUSIONS

Septic arthritis following ACL reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting of hamstring tendon autograft use, since the risk of postoperative knee infection is significantly higher when this type of graft is used.

Vancomycin presoaking of hamstring autografts to prevent infection in anterior cruciate ligament reconstruction: a narrative review

Hamstring autograft use has been linked to an increased risk of infection after anterior cruciate (ACL) reconstruction compared to other grafts. The absolute reason for this remains unclear, with contamination after harvesting and preparation of the graft being the most accepted hypothesis.

Using the rationale that a contaminated graft could be the main factor in postoperative septic arthritis and in an effort to maximize the antibiotic efficacy of the graft, the Vancomycin presoaking technique was developed. It has shown success in decreasing the infection rate in ACL reconstruction. In recent years, an important number of research articles using this protocol have appeared, but the technique is still not widely implemented.

Recent literature shows that Vancomycin presoaking of the graft has shown a successful decrease in the infection rate after hamstring autograft ACL reconstruction. It has also shown efficacy decreasing the infection rate in other types of grafts (patellar tendon, quadriceps tendon, allograft) and also in patients with concomitant ligament procedures or open surgeries.

Despite the positive effects of Vancomycin presoaking reducing the infection rate after ACL reconstruction, the lack of prospective randomized control trials and the heterogeneity of the different studies mean it is not feasible to recommend Vancomycin presoaking of the graft universally for every ACL reconstruction patient.

Cite this article: EFORT Open Rev 2021;6:211-216. DOI: 10.1302/2058-5241.6.200059

Graft-Preserving Arthroscopic Debridement With Hardware Removal Is Effective for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Clinical, Arthrometric, and Magnetic Resonance Imaging Evaluation

BACKGROUND

Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability.

PURPOSE/HYPOTHESIS

The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis.

RESULTS

Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases.

CONCLUSION

Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis.

Can infection after anterior cruciate ligament surgery be prevented by inserting a Hemovac drain into graft donor site?

Objectives

This study aims to investigate the effect of Hemovac drainage placed in graft harvesting area on preventing deep surgical site infection (SSI) and/or septic arthritis through draining the hematoma formed in the graft area in arthroscopic primary anterior cruciate ligament (ACL) reconstruction surgery using hamstring autograft.

Patients and methods

This retrospective study was conducted between January 2008 and March 2019. A total of 819 patients (769 males, 50 females; mean age 33.7 years; range, 25 to 41 years) who underwent arthroscopic primary ACL reconstruction surgery using hamstring autograft were divided into two groups based on whether a Hemovac drain was also placed at the hamstring graft harvested area. Both groups were compared in terms of the presence of deep SSI and/or development of septic arthritis.

Results

In the non-drained group (group 1, n=401), 16 patients (3.9%) had septic arthritis, four (0.9%) had deep SSI, and two (0.49%) had both wound and joint infections. Septic arthritis was identified in only one patient (0.2%) in the drained group (group 2, n=418). In group 2, the mean amount of blood coming from the drain at the graft harvesting region was 36.85 mL (range, 20-50 mL).

Conclusion

In arthroscopic primary ACL reconstruction surgery using hamstring tendon autograft, we concluded that the use of a Hemovac drain could be effective in preventing deep SSI through reducing the hematoma occurring in this region. However, future studies are needed to validate the effect of Hemovac drain on preventing the septic arthritis.

Screw and Sheath Tibial Fixation Associated With a Higher Likelihood of Deep Infection After Hamstring Graft Anterior Cruciate Ligament Reconstruction

BACKGROUND

Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone-patellar tendon-bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation.

PURPOSE

To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated.

RESULTS

Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Staphylococcus aureus for the BPTB group and Staphylococcus epidermidis in both hamstring groups were the most common infecting organisms. HS with screw and sheath had a higher likelihood of 90-day deep infection compared with BPTB ACLR (odds ratio [OR], 2.87; 95% CI, 1.29-6.38). We failed to observe a difference for HS without screw and sheath compared with BPTB ACLR (OR, 1.23; 95% CI, 0.54-2.77). The NNE was 330 and 2701 for HS with and HS without screw and sheath, respectively.

CONCLUSION

Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed.

Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction

PURPOSE

The purpose was to characterize the independent effect of procedure length on the rates of 30-day perioperative complications, hospital readmissions, and overnight hospital stay in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). We hypothesized that longer procedure length in primary ACLR increases the risk for post-operative complications.

METHODS

Primary ACLR cases from 2005 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Patients were categorized into two cohorts based on procedure length, either less than or greater than 90 min. Two equal-sized propensity-matched cohorts were generated to account for differences in baseline and operative characteristics. Thirty-day clinical outcomes were compared using bivariate analyses between propensity-matched groups that controlled for patient-specific factors and concurrent meniscal repair. Multivariate logistic regression models were used to identify independent predictors of hospital readmission and overnight hospital stay.

RESULTS

In total, 12,077 ACLR cases were identified. The rate of any 30-day complication was increased in longer procedures relative to shorter procedures (1.6% vs 0.9%, p = 0.006), as were the rates of returning to the operating room (0.6% vs 0.3%, p = 0.03), hospital readmission (1.0% vs 0.3%, p = 0.001), and overnight hospital stay (16.2% vs 6.0%, p < 0.001). Obesity was a risk factor for both hospital readmission and overnight hospital stay, while hypertension, diabetes, chronic obstructive pulmonary disease, and a smoking history were associated with increased rates of overnight hospital stay. The most common reasons for hospital readmission were deep vein thrombosis or pulmonary embolism (25.0% of all readmitted patients), surgical site infection (25.0%), and post-operative pain (14.1%).

CONCLUSIONS

In this propensity-matched analysis adjusting for baseline patient characteristics and operative factors, procedure length of greater than or equal to 90 min in ACLR was independently associated with an increased risk of hospital readmission and overnight hospital stay. As a surrogate measure of surgical complexity, operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling.

LEVEL OF EVIDENCE

III.

Graft Preparation with Intraoperative Vancomycin Decreases Infection After ACL Reconstruction: A Review of 1,640 Cases

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 vancomycin was used in 798 cases (48.7%), whereas 842 ACL reconstructions (51.3%) were performed without intraoperative 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.

Value of antibiotic prophylaxis in routine knee arthroscopy : A retrospective study

OBJECTIVE

Prophylactic antibiotic use prior to routine knee arthroscopy remains controversial. It is important to know whether antibiotics help decrease the surgical site infection (SSI) rate. Our aims were to assess the efficacy of antibiotic prophylaxis in preventing SSI and to identify risk factors for SSI following routine knee arthroscopy without an implant.

METHODS

A retrospective study was conducted using the electronic medical records at the authors' hospital to identify patients that underwent routine knee arthroscopy without an implant between October 2010 and October 2016. Data on demographics, clinical characteristics and antibiotic administration were extracted. Arthroscopic diagnosis, debridement, partial or complete meniscectomy, arthroscopic shaving and microfracture, removal of loose bodies, synovectomy and lateral retinacular release were included. Complex knee arthroscopy with an implant was excluded. Patients were divided into evaluation (with prophylactic antibiotics) and control (no antibiotic treatment) groups. Continuous variables between groups were compared using the Student's t-test. Data were analyzed using the Chi-squared test for percentages between groups. Multivariate logistic regression was used to identify independent risk factors of SSI.

RESULTS

Of 1326 patients, 614 (46.3%) received prophylactic antibiotics, while 712 (53.7%) did not. There were seven (0.53%) SSIs. The SSI rate did not differ significantly between patients receiving antibiotics (0.49%, three) and those not (0.56%, four). Five patients (0.37%) had superficial infections, two (0.33%) were in the prophylactic antibiotic group and three (0.42%) were in the other group. Deep infections occurred in two patients (0.15%), one (0.16%) in the prophylactic antibiotic group and one (0.14%) in the other group. The difference between the two groups was not statistically significant (P = 1.0). Age over 50 years was associated with an increased risk of SSI (relative ratio [RR] = 1.469, 95% confidence interval [CI] 1.09-2.13, P = 0.009).

CONCLUSIONS

Prophylactic antibiotic use in routine knee arthroscopy without an implant may not be necessary. Age over 50 years was associated with an increased risk of SSI.

Recurrent surgical site infection after anterior cruciate ligament reconstruction: A case report

BACKGROUND

Surgical site infections following anterior cruciate ligament (ACL) reconstruction are an uncommon but potentially devastating complication. In this study, we present an unusual case of recurrent infection of the knee after an ACL reconstruction, and discuss the importance of accurate diagnosis and appropriate management, including the issue of graft preservation versus removal.

CASE SUMMARY

A 33-year-old gentleman underwent ACL reconstruction using a hamstring tendon autograft with suspensory Endobutton fixation to the distal femur and an interference screw fixation to the proximal tibia. Four years after ACL reconstruction, he developed an abscess over the proximal tibia and underwent incision and drainage. Remnant suture material was found at the base of the abscess and was removed. Five years later, he re-presented with a lateral distal thigh abscess that encroached the femoral tunnel. He underwent incision and drainage of the abscess which was later complicated by a chronic discharging sinus. Repeated magnetic resonance imaging revealed a fistulous communication between the lateral thigh wound extending toward the femoral tunnel with suggestion of osteomyelitis. Decision was made for a second surgery and the patient was counselled about the need for graft removal should there be intra-articular involvement. Knee arthroscopy revealed the graft to be intact with no evidence of intra-articular involvement. As such, the decision was made to retain the ACL graft. Re-debridement, excision of the sinus tract and removal of Endobutton was also performed in the same setting. Joint fluid cultures did not grow bacteria. However, tissue cultures from the femoral tunnel abscess grew Enterobacter cloacae complex, similar to what grew in tissue cultures from the tibial abscess five years earlier. In view of the recurrent and indolent nature of the infection, antibiotic therapy was escalated from Clindamycin to Ertapenem. He completed a six-week course of intravenous antibiotics and has been well for six months since surgery, with excellent knee function and no evidence of any further infection.

CONCLUSION

Prompt and accurate diagnosis of surgical site infection following ACL reconstruction, including the exclusion of intra-articular involvement, is important for timely and appropriate treatment. Arthroscopic debridement and removal of implant with graft preservation, together with a course of antibiotics, is a suitable treatment option for extra-articular knee infections following ACL reconstruction.

The incidence of infection in routine knee arthroscopy without the use of prophylactic antibiotics is low

Background:

The use of prophylactic antibiotics in routine knee arthroscopy remains prevalent despite previous evidence suggesting that it may not be necessary, and may indeed carry more risks than benefits. This study aims to determine the incidence of surgical site infections in patients undergoing routine knee arthroscopy without prophylactic antibiotics.

Methods:

This is a retrospective review of 553 consecutive patients who underwent routine knee arthroscopy from 2004 to 2013 by a single fellowship-trained sports surgeon in a single institution. The spectrum of cases included arthroscopic meniscectomy, meniscal repair, microfracture, chondroplasty, removal of loose bodies and lateral retinacular release. No patient received any prophylactic antibiotics. Patient demographics and comorbidities were reviewed and all patients were followed up postoperatively for a minimum of two years. All postoperative complications were recorded.

Results:

There were 349 male and 204 female patients. The mean age was 41.8 years (SD 14.8) and mean operative time was 30.4 minutes (SD 12.3). Two healthy young patients developed postoperative superficial wound infection within one week after surgery, but recovered with outpatient oral antibiotic treatment. The overall infection rate was 0.36%. No cases of deep infection were reported.

Conclusion:

This study showed a very low rate of surgical site infections, comparable with known rates following such operations. This suggests that prophylactic antibiotics are not necessary and avoids the known risks associated with their use.

Professional Athletes Are Not at a Higher Risk of Infections After Anterior Cruciate Ligament Reconstruction: Incidence of Septic Arthritis, Additional Costs, and Clinical Outcomes From the French Prospective Anterior Cruciate Ligament Study (FAST) Cohort

BACKGROUND

The rate of septic arthritis in the knee after anterior cruciate ligament (ACL) reconstruction varies in the literature but is generally less than 1%. It has been reported to be higher in professional athletes (5.7%).

PURPOSE

The primary goal was to evaluate the rate of septic arthritis after ACL reconstruction in professional athletes compared with other patients. The secondary goals were to analyze the risk factors; increased cost of infections; return to sport, satisfaction, and functional results at 1-year follow-up; and resolution rate of infections at final follow-up.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This retrospective analysis of prospective data included a continuous series of patients who underwent isolated ACL reconstruction between 2012 and 2016. The main outcome criterion was the development of intra-articular infections in the operated knee. An infection was suggested clinically (knee pain with fever and/or chills) and confirmed bacteriologically in deep tissue samples obtained during revision surgery. All infected patients underwent an emergency reoperation with lavage and debridement along with dual antibiotic therapy first by an intravenous route and then orally for 6 weeks.

RESULTS

A total of 1809 of 1859 patients included in the cohort during this period fulfilled inclusion criteria; there were 1632 (90.2%) who underwent primary reconstruction and 177 (9.8%) who underwent revision. The series included 1249 (69%) men and 560 (31%) women, with a mean age of 29.1 ± 9.8 years. Ninety-eight percent of the patients participated in a sport, including 90 (5.0%) at a professional level and 712 (39.4%) competitively. Septic arthritis of the knee developed after a mean 15.7 ± 5.5 days in 7 (0.38%) patients: 5 of 1632 (0.31%) who underwent primary reconstruction and 2 of 177 (1.13%) who underwent revision. Septic arthritis did not develop in any professional or competitive athletes; all affected patients were recreational athletes ( P = .02). The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery (odds ratio [OR], 15; P = .002) and hemarthrosis during the immediate postoperative period (OR, 127.2; P = .002). There were no recurrent infections after a mean follow-up of 2.8 ± 1.2 years.

CONCLUSION

None of the professional athletes in this cohort had septic arthritis after ACL reconstruction. There are no particular precautions to be taken in this population. The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery and hemarthrosis during the immediate postoperative period. Similar to all studies published on the subject, there were very few infected patients, which limits the identification of risk factors.

REGISTRATION

NCT02511158 (ClinicalTrials.gov identifier).

Biomechanical and microbiological effects of local vancomycin in anterior cruciate ligament (ACL) reconstruction: a porcine tendon model

INTRODUCTION

Although there is increasing evidence for the successful use of local vancomycin applied by soaked compresses during ACL reconstruction, there are still little data on its microbiological and biomechanical effects. Furthermore, exact dosage of vancomycin with respect to tendon stability and microbiological effectivity is still unknown.

MATERIALS AND METHODS

63 porcine flexor digitorum profundus tendons were harvested under sterile conditions from fresh cadaver legs. After contamination with Staphylococcus epidermidis (S. epidermidis), tendons were wrapped into sterile compresses moistened with different concentrations of vancomycin for 10 or 20 min. Sterile sodium chloride was used for control. After treatment, tendons were rolled onto blood-agar plates to test for residual bacterial contamination and tested for maximum load and stiffness using a uniaxial testing device with cryo-clamps for tendon fixation. Agar plates were checked after 1 week of culture at 36 °C for signs of bacterial growth.

RESULTS

When applying vancomycin for only 10 min, bacterial contamination was found in all dosage groups ranging from 28.6% contamination (n = 2 of 7 tendons) when using 10 mg/ml up to 85.7% (n = 6 of 7 tendons) when using 1 mg/ml. Applying vancomycin-soaked compresses for 20 min, bacterial contamination was still found in the groups using 1 mg/ml and 2.5 mg/ml (contamination rate 85.7 and 42.9% respectively). When using 5 mg/ml and 10 mg/ml, no bacterial contamination could be perceived after 7 days of culture. With regard to biomechanical properties, no differences were found regarding maximum load or Young's modulus between groups.

CONCLUSIONS

This study showed no signs of biomechanical impairment of porcine flexor tendons after the use of vancomycin wraps with concentration ranging from 1 to 10 mg/ml for 10 or 20 min at a time zero testing. Contamination with S. epidermidis was cleansed in 100% of tendons when using at least 5 mg/ml of vancomycin for 20 min.

Septic arthritis after arthroscopic posterior cruciate ligament and multi-ligament reconstructions is rare and can be successfully treated with arthroscopic irrigation and debridement: analysis of 866 reconstructions

PURPOSE

The purpose of this study was to determine the incidence of septic arthritis following arthroscopic posterior cruciate ligament (PCL) and multi-ligament reconstructions, and to evaluate a treatment regime with sequential arthroscopic irrigation and debridement procedures combined with antibiotic therapy that is focused on retention of the graft.

METHODS

Between 2004 and 2016 a total of 866 PCL reconstructions and multi-ligament reconstructions were performed at our institution (408 isolated PCL reconstructions, 458 combined reconstructions). Medical charts of all cases were retrospectively reviewed with regard to the occurrence of septic complications. These cases were analysed with special focus on clinical management, number of reoperations and if the grafts were retained. Further, microbiological findings, postoperative clinical course and available clinical outcome data were evaluated.

RESULTS

Four cases of septic arthritis (0.5%) were identified (follow-up rate 96.5%): two following isolated PCL reconstruction (0.5%), and two following multi-ligament reconstruction (0.4%), respectively. Septic arthritis was successfully treated in all cases with a mean of 2.5 ± 2.4 irrigation and debridement procedures (1-6). In one case of isolated PCL reconstruction, the graft was resected within the fifth irrigation and debridement due to septic loosing of the femoral fixation. All other grafts were retained. With regard to the outcome, all patients were subjectively satisfied with good stability (stress radiographs) in cases of retained grafts.

CONCLUSION

Postoperative septic arthritis after arthroscopic PCL and complex knee ligament reconstructions is a rare but serious complication. Arthroscopic graft-retaining treatment is recommended, as it is established in ACL surgery. Graft retention can be expected in the majority of the cases.

LEVEL OF EVIDENCE

Case series, Level 4.

Bacterial Contamination of a Marking Pen in Anterior Cruciate Ligament Reconstruction

Background:

A sterile surgical marking pen is commonly used during anterior cruciate ligament reconstruction (ACLR) to outline the proposed skin incision and then to mark the graft during preparation. Once in contact with the skin, the pen is a potential source of bacterial transmission and subsequent infections after ACLR.

Purpose/Hypothesis:

The purpose of this study was to assess whether the skin marking pen is a fomite for contamination during arthroscopic ACLR. We hypothesized that there would be a difference in the rate of culture-positive pens between control pens and the study pens used to delineate the proposed skin incision.

Study Design:

Controlled laboratory study.

Methods:

Twenty surgical marking pens were collected prospectively from patients undergoing ACLR over a 12-month period. All patients underwent standard preoperative sterile preparation and draping procedures. Proposed incisions were marked with a new sterile pen, and the pen tip was immediately sent for a 5-day inoculation in broth and agar. Negative controls (unopened new pen) and positive controls (used to mark the skin incisions preoperatively) were also cultured. Additionally, blank culture dishes were observed during the growth process. All pens were removed from the surgical field before incision, and new marking pens were used when needed during the procedure.

Results:

Three of the 20 study pens (15%) demonstrated positive growth. All 3 pens grew species of Staphylococcus. None of the negative controls demonstrated growth, 6 of the 12 positive controls showed growth, and none of the blank dishes exhibited growth.

Conclusion:

This study found a 15% rate of surgical marking pen contamination by Staphylococcus during ACLR. It is recommended that the skin marking pen not be used for any further steps of the surgical case and be discarded once used.

Clinical Relevance:

Infections after ACLR are rare but may result in significant morbidity, and all measures to reduce them should be pursued. Surgeons performing ACLR should dispose of the surgical marking pen after skin marking and before intraoperative use such as graft markup.

Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis

PURPOSE

To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis.

METHODS

A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias.

RESULTS

Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy.

CONCLUSIONS

This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention.

LEVEL OF EVIDENCE

Level IV, systematic review and decision analysis.

Septic Arthritis After Anterior Cruciate Ligament Reconstruction: Clinical and Functional Outcomes Based on Graft Retention or Removal

Background:

There remains a debate over whether to retain the index anterior cruciate ligament (ACL) graft in the setting of septic arthritis.

Purpose:

To evaluate and compare clinical outcomes for the treatment of septic arthritis after ACL reconstruction (ACLR) in those with and without early graft retention.

Study Design:

Case series; Level of evidence, 4.

Methods:

The Military Health System was queried for all ACLR procedures performed between 2007 and 2013. Inclusion criteria required active military status, primary ACLR with secondary septic arthritis, and minimum 24-month surveillance. Demographic, clinical, and surgical variables were evaluated using descriptive statistics and regression analysis for factors influencing selected outcomes.

Results:

Of 9511 ACLR procedures, 31 (0.32%) were identified as having secondary septic arthritis requiring urgent arthroscopic irrigation and debridement and intravenous antibiotics (mean, 6.3 weeks). The majority (62%) were treated in the subacute (2 weeks to 2 months) setting. Index ACLR was performed with a hamstring autograft (n = 17, 55%), soft tissue allograft (n = 11, 35%), and patellar tendon autograft (n = 3, 10%). The graft was retained in 71% (n = 22) of patients, while 29% (n = 9) underwent early graft debridement. At a mean 26.9-month follow-up, 48% of patients (n = 15) had returned to the military. Graft removal was not predictive of return to active duty (P = .29). The presence of postoperative complications, including symptomatic postinfection arthritis (22.6%) and arthrofibrosis (9.7%), was the only variable predictive of inability to return to duty (odds ratio, 27.5 [95% CI, 3.24-233.47]; P = .002). Seven of 9 patients who underwent graft debridement underwent revision ACLR, and all 7 had stable knees at final follow-up compared with 68% (15/22) in the graft retention group.

Conclusion:

Arthroscopic debridement with early graft removal and staged revision ACLR remains a viable option for restoring knee stability (100%), although the rate of return to active duty was low in the graft resection group (33%). The risk of knee laxity did not differ based on early graft retention. Time to presentation with graft retention was not associated with a decreased rate of graft laxity.

Risk of Infection After Allograft Anterior Cruciate Ligament Reconstruction: Are Nonprocessed Allografts More Likely to Get Infected? A Cohort Study of Over 10,000 Allografts

BACKGROUND

Allograft tissue is frequently used in anterior cruciate ligament reconstruction (ACLR). It is often irradiated and/or chemically processed to decrease the risk of disease transmission, but some tissue is aseptically harvested without further processing. Irradiated and chemically processed allograft tissue appears to have a higher risk of revision, but whether this processing decreases the risk of infection is not clear.

PURPOSE

To determine the incidence of deep surgical site infection after ACLR with allograft in a large community-based sample and to evaluate the association of allograft processing and the risk of deep infection.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors conducted a cohort study using the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Primary isolated unilateral ACLR with allograft were identified from February 1, 2005 to September 30, 2015. Ninety-day postoperative deep infections were identified via an electronic screening algorithm and then validated through chart review. Logistic regression was used to evaluate the likelihood of 90-day postoperative deep infection per allograft processing method: processed (graft treated chemically and/or irradiated) or nonprocessed (graft not irradiated or chemically processed).

RESULTS

Of 10,190 allograft cases, 8425 (82.7%) received a processed allograft, and 1765 (17.3%) received a nonprocessed allograft. There were 15 (0.15%) deep infections during the study period: 4 (26.7%) coagulase-negative Staphylococcus, 4 (26.7%) methicillin-sensitive Staphylococcus aureus, 1 (6.7%) Peptostreptococcus micros, and 6 (40.0%) with no growth. There was no difference in the likelihood for 90-day deep infection for processed versus nonprocessed allografts (odds ratio = 1.36, 95% CI = 0.31-6.04).

CONCLUSION

The overall incidence of deep infection after ACLR with allograft tissue was very low (0.15%), suggesting that the methods currently employed by tissue banks to minimize the risk of infection are effective. In this cohort, no difference in the likelihood of infection between processed and nonprocessed allografts could be identified.

Incidence, Risk Factors, and Management of Infection Following Anterior Cruciate Ligament Reconstruction Surgery

BACKGROUND

Infection after anterior cruciate ligament reconstruction surgery (ACLRS) is a rare complication. Although there are number of studies from various Caucasian population but only few studies are available from Asian population. The aim of the study is to assess the incidence, risk factors and, clinical outcome using our treatment protocol.

MATERIALS AND METHODS

Out of 1468 arthroscopic ACLRS, 26 patients with clinical suspicion of infection were critically analysed in terms of laboratory reports of arthrocentesis, erythrocyte sedimentation rate, C-reactive protein and risk factors such as the type of graft, gender, diabetes mellitus, smoking, intraarticular steroid injection, and obesity. At final followup, all these patients were evaluated using visual analog scale (VAS), Lysholm knee score, and Tegner activity level.

RESULTS

In nine patients, culture did not show any growth and they showed improvement with arthrocentesis and oral antibiotics. These patients were labeled as suffering from aseptic effusion. In the remaining 17 patients, there was no clinical improvement or instead worsening of symptoms after arthrocentesis and oral antibiotics. These patients were labeled as suffering from an infection and underwent surgical debridement along with administration of injectable antibiotics. The history of intraarticular steroid injection before ACLRS was a significant risk factor for developing infection (P = 0.001). At mean followup of 2.8 years, mean VAS improved to 1.18 ± 0.99 from 6.2 ± 2.3. The mean Lysholm knee score and Tegner's activity level at the final followup were 79.2 ± 10.52 and 4.8 ± 2.30, respectively.

CONCLUSION

The incidence of infection was 1.2% (17/1468). The step-ladder approach of differentiating between aseptic effusion and infection and accordingly, following a treatment protocol, i.e., oral antibiotics alone or surgical debridement along with injectable antibiotics or additional debridement of graft in refractory patients, yielded satisfactory results.

Incidence, management and outcome assessment of post operative infection following single bundle and double bundle acl reconstruction

INTRODUCTION

Post-operative infection is a dreadful complication of ACL reconstruction with gray zone over management guidelines. We aimed to establish commonest etiology, assess incidence of infection and effect on outcome, individually for single and double bundle ACL reconstruction techniques, so as to formulate appropriate management guidelines.

METHODS

Our prospective study involved 1152 patients operated for ACL reconstruction (437- DBACL, 715- SBACL) from 2010-2013. Post-operative infection was diagnosed clinically supported by positive gram stain/ culture and increased cell count in knee aspirate. All patients were started on empirical antibiotics and arthroscopic lavage and debridement was done. Graft was retained if it was stable and intact. Data recorded at follow up was analysed statistically.

RESULTS

In SBACL infection rate was 0.84% while in DBACL it was 2.52%. All patients with infection presented with pain, effusion, fever and increased WBC, ESR & CRP. Average time of presentation after the surgery was 2.27 weeks for DBACL and 2.16 weeks for SBACL. In both groups, S.aureus followed by S. epidermidis were commonest isolates. Patients were given IV antibiotics for 2 weeks and oral for further 4 weeks.

DISCUSSION

Incidence of infection is higher with the double bundle technique, however, the functional outcome is not affected (p value 0.231). Joint aspirate is the gold standard diagnostic test for infection. CRP and ESR are the next dependable tests with high sensitivity but their specificity is low. A thorough debridement is necessary apart from recommended antibiotic cover of 2 weeks IV followed by 4 weeks oral antibiotics.

Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature

Osteomyelitis following arthroscopically assisted anterior cruciate ligament (ACL) reconstruction has rarely been reported in the literature. We report a case of a 20-year-old female who had delayed tibial osteomyelitis and a pretibial cyst with culture-positive, oxacillin sensitive Staphylococcus epidermidis 15 months after an ACL reconstruction with hamstring autograft. Soft tissue fixation within the tibial tunnel was with a poly-L-D-lactic acid (PLDLA) bioabsorbable interference screw. The patient underwent surgical treatment with curettage, debridement, hardware removal, and bone grafting of the tibial tunnel followed by a course of intravenous antibiotics. Arthroscopic evaluation demonstrated an intact ACL graft without any evidence of intra-articular infection. The patient returned to collegiate athletics without any complications. While the most common biologic complications include pretibial cysts, granuloma formation, tunnel widening, and inflammatory reactions, infection is exceedingly rare. Late infection and osteomyelitis are also rare but can occur and should be considered in the differential diagnosis.

Prolonged infection at the tibial bone tunnel after anterior cruciate ligament reconstruction

A 24-year-old man with severe atopic dermatitis underwent anterior cruciate ligament (ACL) reconstruction of the right knee seven years earlier but developed a surgical site infection. The infection did not heal after removal of the metal implants, and a fistula eventually developed. This condition was left untreated for six years before he was referred to our hospital. Magnetic resonance imaging showed fluid in the tibial bone tunnel and extensive bone marrow edema surrounding the bone tunnel. Based on these findings, abscess formation within the tibial bone tunnel and osteomyelitis spreading to the proximal tibia were suspected. During the surgery, a portion of artificial ligament and non-absorbable suture were observed in the bone tunnel, and the infection healed immediately after removal of this complex. When surgical site infection occurs after ACL reconstruction, it is important to completely remove all artificial materials as early as possible.

Management of septic arthritis after arthroscopic anterior cruciate ligament reconstruction using a standard surgical protocol

BACKGROUND

To report the incidence of septic arthritis after anterior cruciate ligament (ACL) reconstruction and management of this complication using a specific treatment protocol.

METHODS

All primary ACL reconstructions performed in our institution between January 2002 and January 2014 were included in this study. Time to presentation, clinical symptoms, and culture results of all infected patients were analyzed. According to our protocol, an arthroscopic debridement and irrigation of the knee joint was performed immediately after a diagnosis of infection was made. In case of recurrence, knee irrigation with hardware and graft removal and later re-implantation was performed. Patients were evaluated with the Lysholm knee score, International Knee Documentation Committee (IKDC) Form, KT 1000 arthrometer and radiographic evaluation.

RESULTS

Postoperative septic arthritis occurred in seven of 1242 patients (0.56%). After initial arthroscopic debridement, infection recurred in six out of seven cases (85%). Graft and hardware removal was performed in these patients. Graft re-implantation was performed in four patients at an average five months after infection. At the final follow-up (mean 6.3years) all patients had full range of motion, while in patients with graft re-implantation the mean Lysholm score was 92, and the mean IKDC score was 87. Radiographs demonstrated that three patients had normal knees and one patient had a grade one, knee arthritis according to Kellgren-Lawrence classification.

CONCLUSIONS

Management of septic arthritis after ACL reconstruction using a specific surgical protocol which includes graft removal in case of infection recurrence with later re-implantation, can provide good and excellent results.

LEVEL OF EVIDENCE

Level IV, case series.

Primary anterior cruciate ligament reconstruction: perioperative considerations and complications

Anterior cruciate ligament (ACL) injuries are among the most commonly studied orthopaedic injuries. Despite having an excellent prognosis, complications do occur. The timely recognition and management of complications is imperative to ensure the success of reconstruction. Avoiding such complications requires thorough preoperative planning, proficient technical skills to properly manage intraoperative complications, and an extensive knowledge of possible postoperative complications.

Anterior Cruciate Ligament Injury, Reconstruction, and the Optimization of Outcome

Anterior cruciate ligament reconstruction (ACLR) provides an established surgical intervention to control pathological tibiofemoral translational and rotational movement. ACLR is a safe and reproducible intervention, but there remains an underlying rate of failure to return to preinjury sporting activity levels. Postoperative pathological laxity and graft reinjury remain concerns. Previously, unrecognized meniscal lesions, disruption of the lateral capsule, and extracapsular structures offer potential avenues to treat and to therefore improve kinematic outcome and functional results, following reconstruction. Addressing laterally based injuries may also improve the durability of intraarticular ACLR. Improving the anterior cruciate ligament (ACL) graft replication of the normal ACL attachment points on the femur and the tibia, using either double bundle or anatomical single bundle techniques, improves kinematics, which may benefit outcome and functionality, following reconstruction.

Postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following arthroscopic anterior cruciate ligament reconstruction in an adolescent: A case report and review of the literature

We present a case of postoperative septic arthritis with Eikenella corrodens and Streptococcus mitis following an arthroscopic anterior cruciate ligament reconstruction in an adolescent male with no pertinent medical history. The patient presented to the emergency department nine days after the operation with fever, an elevated white blood cell count, knee pain, and effusion. Arthrocentesis of the knee yielded purulent fluid that tested positive for S. mitis. Repeat intraoperative cultures revealed E. corrodens. In addition to antibiotics, the patient's treatment course included arthroscopic irrigation and debridement in the operating room as well as removal of graft material and fixation devices. To our knowledge, this is the first case of a polymicrobial infection of E. corrodens and S. mitis causing septic arthritis in a teenager following arthroscopic anterior cruciate ligament reconstruction.

Infected shoulder joint with loose Suture Anchor in the joint after Bankart's Repair- A Case Report

Introduction:

The glenoid labrum is frequently torn in traumatic glenohumeral dislocation; arthroscopic repair is the standard method of treatment. The complications associated with this repair are pulling out of metal suture anchors, chondrolysis and joint infection. The infection of joint after arthroscopy is less than 1%. Staphylococcus is most common organism and rarely followed by Pseudomonas aeruginosa. We report a case of infected shoulder with chondrolysis of the joint and pulled out metal suture anchor lying inside the joint after Bankart’s repair.

Case Report:

A 22-year-old gentleman came to us with complaints of shoulder joint pain & gross restriction of movements for one year, with history of intermittent fever and treatment in nearby hospital. He also gives past history of recurrent dislocation of shoulder with last episode 18 months back, which was diagnosed as Bankart’s lesion and arthroscopic Bankart’s repair was done 15 months back. He was evaluated at our institute and suspected to have infection of shoulder joint with pulled out metal suture anchor inside the joint. Arthroscopic removal of suture anchor and debridement of shoulder joint was done, Culture was obtained and culture specific antibiotics were given for six weeks, and significant improvement was observed with this line of treatment. At lyear follow up, the patient was able to perform his daily activities with terminal restriction of range of motion.

Conclusions:

Shoulder joint infection is rare after Bankart’s repair and required a high degree of suspicion. Any foreign materials inside the joint should be taken out & followed with aggressive treatment by debridement, irrigation and culture specific antibiotics. Suppression of joint infection with antibiotics should be avoided specially when there is foreign body inside the joint.

No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts

PURPOSE

To investigate the pre-soaking of hamstring grafts in topical vancomycin, in addition to IV prophylaxis, during anterior cruciate ligament (ACL) reconstruction to reduce the incidence of post-operative infection, and to describe an evidence-based diagnostic and treatment algorithm to facilitate early diagnosis and appropriate management of possible knee sepsis post-operatively after ACL reconstruction.

METHODS

This study is a controlled observational series comprising of 1585 individuals who underwent ACL reconstruction over a 13-year period. All surgeries were performed by a single surgeon at the same hospital. Group 1 consisted of 285 patients who received pre-operative IV antibiotics without topical graft pre-soaking. Group 2 consisted of 1300 individuals who received IV antibiotics and graft pre-soaking in a vancomycin solution of 5 mg/mL.

RESULTS

In group 1, a total of four patients suffered a post-operative joint infection (1.4 %). Three out of the four were culture positive for Staphylococcus species. The fourth was culture negative but was managed as an acute infection. Group 2 suffered no post-operative infections (0 %). Statistical analysis of the vancomycin pre-soak with IV antibiotics group, compared with IV antibiotics-alone group, revealed a significantly reduced post-operative infection rate using a Fisher's exact test (P = 0.0011) and Chi-square test with Yates' correction (P = 0.0003).

CONCLUSIONS

Pre-soaking of hamstrings grafts with topical vancomycin reduced the rate of post-operative infection when compared to IV antibiotics alone. This technique should be utilised by surgeons to reduce the overall incidence of knee sepsis post-ACL reconstruction.

LEVEL OF EVIDENCE

III.

Graft salvage following infected anterior cruciate ligament reconstruction

Aims

To examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes.

Materials and Methods

A search was performed without language restriction on PubMed, EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials (CENTRAL) databases from their inception to April 2015. We identified 147 infected hamstring grafts across 16 included studies. Meta-analysis was performed using a random-effects model to estimate the overall graft salvage rate, incorporating two different definitions of graft salvage.

Results

The graft salvage rate was 86% (95% confidence intervals (CI) 73% to 93%; heterogeneity: tau2 = 1.047, I2 = 40.51%, Q = 25.2, df = 15, p < 0.001), excluding ACL re-ruptures. Including re-ruptures as failures, the graft salvage rate was 85% (95% CI 76% to 91%; heterogeneity: tau2 = 0.099, I2 = 8.15%, Q = 14.15, df = 13, p = 0.36).

Conclusions

Arthroscopic debridement combined with antibiotic treatment can lead to successful eradication of infection and graft salvage, with satisfactory functional outcomes in many cases of septic arthritis following ACL reconstruction. Persistent infection despite repeat arthroscopic debridements requires graft removal with the intention of revision ACL surgery at a later stage. Take home message: Arthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608–15.

Tobacco Use Is Associated With Increased Complications After Anterior Cruciate Ligament Reconstruction

BACKGROUND

The use of tobacco is a well-established cause of preventable morbidity and mortality. There have been few studies examining the effect of tobacco use on outcomes and complications after arthroscopic knee procedures such as anterior cruciate ligament (ACL) reconstruction.

PURPOSE

To investigate the relationship between tobacco use and rates of postoperative infection, venous thromboembolism (VTE), arthrofibrosis, and subsequent ACL reconstruction after primary ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A national insurance database was queried for patients who underwent arthroscopic-assisted ACL reconstruction using Current Procedural Terminology code 29888. Patients underage for tobacco use in all regions of the United States (age <20 years), those with prior ACL reconstruction, and those with the following concomitant procedures were excluded: open cruciate or collateral ligament reconstruction, open or arthroscopic cartilage procedures, patellar stabilization, extra-articular ligamentous reconstruction, and posterior cruciate ligament reconstruction. Tobacco use and non-tobacco use cohorts were queried using International Classification of Diseases-9th Revision coding. The non-tobacco use patients were then matched to the patients with coded tobacco use by age, sex, obesity, diabetes, meniscal repair, and meniscectomy. Complications within 90 days postoperatively were assessed for both cohorts, including infection, VTE, arthrofibrosis, and subsequent ipsilateral or contralateral ACL reconstruction after the index procedure.

RESULTS

A total of 13,358 patients who underwent ACL reconstruction met inclusion and exclusion criteria, including 1659 patients with documented tobacco use and 11,699 matched controls. The incidence of infection was significantly higher in patients who use tobacco (2.0%) versus matched controls (0.9%; odds ratio [OR], 2.3; P < .0001). The rate of VTE was also significantly higher in patients who use tobacco (1.0%) compared with matched controls (0.5%; OR, 1.9; P = .035). The rate of subsequent ACL reconstruction was significantly higher in the tobacco use cohort (12.6%) compared with matched controls (7.8%; OR, 1.7; P < .0001). There was no significant difference in the rate of postoperative stiffness after ACL reconstruction between patients who use tobacco (2.0%) and matched controls (2.3%; OR, 0.9; P = .656).

CONCLUSION

ACL reconstruction in patients who use tobacco is associated with significantly increased rates of infection, VTE, and subsequent ACL reconstruction compared with controls. There was no association between tobacco use and postoperative arthrofibrosis after primary ACL reconstruction.