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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. Knee Surg Sports Traumatol Arthrosc 2018; 26:3029-3038. [PMID: 29556890 DOI: 10.1007/s00167-018-4902-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
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.
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DiBartola AC, Swank KR, Flanigan DC. Anterior cruciate ligament reconstruction complicated by Propionibacterium acnes infection: case series. PHYSICIAN SPORTSMED 2018; 46:273-278. [PMID: 29634385 DOI: 10.1080/00913847.2018.1463062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic procedures. While generally successful, failure resulting in revision surgery is reported to be between 1.9 - 4.9%. However, when not related to traumatic re-injury, failure mechanism is poorly understood. One potential but understudied mechanism of ACL reconstruction failure is infection. We describe three patients with previous ACL reconstructions who later developed infection with Propionibacterium acnes. Two cases presented with knee pain and swelling, and one presented with instability. While only two of the three cases received antibiotic treatment, all three cases were free of knee and infectious symptomatology at most recent follow-up. P. acnes infection may represent one potential mechanism for biologic failure of ACL reconstruction and anaerobic operative cultures may be used to identify its presence.
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Affiliation(s)
- Alex C DiBartola
- a Department of Orthopaedics , The Ohio State University , Columbus , OH , USA
| | | | - David C Flanigan
- a Department of Orthopaedics , The Ohio State University , Columbus , OH , USA.,c Team Physician and Director of the Cartilage Restoration Program, Department of Orthopaedics , The Ohio State University , Columbus , OH , USA
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Pogorzelski J, Themessl A, Achtnich A, Fritz EM, Wörtler K, Imhoff AB, Beitzel K, Buchmann S. Septic Arthritis After Anterior Cruciate Ligament Reconstruction: How Important Is Graft Salvage? Am J Sports Med 2018; 46:2376-2383. [PMID: 30010396 DOI: 10.1177/0363546518782433] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary. PURPOSE To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging. RESULTS Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm ( P = .007), IKDC subjective ( P = .011), and WOMAC ( P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected ( P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention. CONCLUSION Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.
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Affiliation(s)
- Jonas Pogorzelski
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Themessl
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andrea Achtnich
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Erik M Fritz
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany.,University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Klaus Wörtler
- Department of Radiology, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefan Buchmann
- Department of Orthopaedic Sports Medicine, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany.,Orthopädisches Fachzentrum, Weilheim-Garmisch-Starnberg-Penzberg-Murnau, Germany
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Meniscus repairs can be saved in the event of postoperative septic arthritis. Knee Surg Sports Traumatol Arthrosc 2018; 26:2289-2296. [PMID: 29511817 DOI: 10.1007/s00167-018-4890-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/28/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE No systematic studies on optimal treatment of postoperative septic arthritis following arthroscopic meniscus repair are available. The purpose of this study was to retrospectively evaluate the fate of repaired menisci in cases of postoperative septic arthritis, with treatment for infection focused on arthroscopic irrigation and debridement (I&D) and intention to maintain the meniscus. METHODS Data of two sports orthopedics centers of the last 10 years were pooled (approximately 25,000 arthroscopic procedures of the knee). All cases of septic arthritis following arthroscopic meniscus repair were identified. These cases were retrospectively evaluated with regard to clinical course and management, especially the number of necessary I&Ds, if eradication was achieved, and if the repaired meniscus was retained or a partial resection was necessary ('early failure'). Patients with initially maintained meniscus repairs were contacted if further meniscus surgery was performed in further follow-up ('late failure'). RESULTS 20 patients with 23 repaired menisci were included. In 65% (13 cases), a concomitant anterior cruciate ligament reconstruction was performed. A mean of 2.0 ± 1.0 (1-4) arthroscopic I&Ds were performed in the treatment of septic arthritis. In two cases, additional open surgery was performed (after outside-in sutures). Eradication was achieved in all cases. Four repaired menisci (17.4%) showed loosened fixation or substantial degradation and were consequently partially resected within treatment for septic arthritis (early failures). The follow-up rate for the 19 initially maintained menisci was 94.7% after 3.0 ± 2.2 years (median 2.8, 0.4-7.8). Three of these underwent further partial resection (13.0%). Cumulative 3-year survival rate (Kaplan-Meier method) of all repairs was 70.7% (95% CI 50.3-91.1%), and for the subgroup of initially maintained menisci 85.6% (95% CI 67.0-100.0%), respectively. CONCLUSION Septic arthritis following meniscus repair can be successfully treated with (sequential) arthroscopic I&Ds. There is a considerable rate of early failures, however, in a mid-term follow-up the failure rate of initially retained menisci is low and comparable to what we know from the literature for cases without infection. Therefore, it is generally recommended to try to save the repaired menisci in these cases. LEVEL OF EVIDENCE IV, therapeutic case series.
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Cote MP. Editorial Commentary: Graft Removal Versus Retention for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: Accounting for Patient Preference Flips the Script on Current Practice. Arthroscopy 2018; 34:976-978. [PMID: 29502709 DOI: 10.1016/j.arthro.2017.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 02/02/2023]
Abstract
Septic arthritis is a rare but potentially devastating complication after anterior cruciate ligament (ACL) reconstruction. Studies examining surgical treatment options including graft retention and removal are largely inconclusive. Although the literature indicated that 43.8% of patients who have the graft removed later go on to have a revision ACL reconstruction compared with only 6.5% among those whose graft is retained, this expected-value decision analysis found removal to be the optimal treatment for patients with septic arthritis after ACL reconstruction. This is largely based on patient preference to avoid a late reoperation for residual knee infection. These findings support the concept of utility when considering treatment options for patients with a septic knee. For some, avoiding a late reoperation for a persistent infection is the most important factor and as such graft removal may be the most appropriate treatment to produce a positive outcome among these patients despite the fact that currently, an attempt at graft retention could represent the generally preferred treatment option among practicing surgeons.
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Kusnezov N, Eisenstein ED, Dunn JC, Wey AJ, Peterson DR, Waterman BR. Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis. Arthroscopy 2018; 34:967-975. [PMID: 29122433 DOI: 10.1016/j.arthro.2017.08.246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Nicholas Kusnezov
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A
| | - Emmanuel D Eisenstein
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A
| | - John C Dunn
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A
| | - Aaron J Wey
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A
| | - David R Peterson
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A..
| | - Brian R Waterman
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A
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Waterman BR, Arroyo W, Cotter EJ, Zacchilli MA, Garcia EJ, Owens BD. Septic Arthritis After Anterior Cruciate Ligament Reconstruction: Clinical and Functional Outcomes Based on Graft Retention or Removal. Orthop J Sports Med 2018; 6:2325967118758626. [PMID: 29552571 PMCID: PMC5846937 DOI: 10.1177/2325967118758626] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - William Arroyo
- Department of Orthopedic Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Eric J Cotter
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - E'Stephan J Garcia
- Department of Orthopedic Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Gobbi A, Karnatzikos G, Chaurasia S, Abhishek M, Bulgherhoni E, Lane J. Postoperative Infection After Anterior Cruciate Ligament Reconstruction. Sports Health 2016; 8:187-9. [PMID: 26603553 PMCID: PMC4789929 DOI: 10.1177/1941738115618638] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Context: Infection after anterior cruciate ligament reconstruction (ACLR) is uncommon; if it occurs, it can lead to disastrous complications. Objective: To analyze post-ACLR infections and identify related complications to provide the most effective treatment protocol. Study Design: Clinical review. Level of Evidence: Level 4. Results: Among approximately 1850 ACLRs performed by a single surgeon over the past 20 years, 7 cases of post-ACLR infection were identified (incidence, 0.37%). Five patients presenting with low-severity infection were successfully treated without any complication or residual functional disability. The remaining 2 patients, although successfully treated, presented with minor residual limitations. From a literature review, 16 studies including 246 cases of infection were reported among 35,795 ACLRs, making the rate of infection 0.68% (range, 0.14%-2.6%). Conclusion: With proper treatment protocols, post-ACLR infection is rare but can compromise outcomes.
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Affiliation(s)
- Alberto Gobbi
- Orthopaedic Arthroscopic Surgery International (O.A.S.I.) Bioresearch Foundation, Milan, Italy
- Alberto Gobbi, MD, Orthopaedic Arthroscopic Surgery International (O.A.S.I.) Bioresearch Foundation, Via Amadeo 24, 20133 Milan, Italy ()
| | - Georgios Karnatzikos
- Orthopaedic Arthroscopic Surgery International (O.A.S.I.) Bioresearch Foundation, Milan, Italy
| | - Sanyam Chaurasia
- Orthopaedic Arthroscopic Surgery International (O.A.S.I.) Bioresearch Foundation, Milan, Italy
| | - Mudhigere Abhishek
- Orthopaedic Arthroscopic Surgery International (O.A.S.I.) Bioresearch Foundation, Milan, Italy
| | | | - John Lane
- The Coast Surgical Center, San Diego, California
- Department of Orthopaedic Surgery, University of California, San Diego, California
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Short-interval two-stage approach to primary total knee arthroplasty for acutely septic osteoarthritic knees. Knee Surg Sports Traumatol Arthrosc 2016; 24:3115-3121. [PMID: 26768607 DOI: 10.1007/s00167-016-3982-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/05/2016] [Indexed: 01/27/2023]
Abstract
Treatment strategies for advanced knee osteoarthritis with coexistent joint infection are not well established. While in periprosthetic joint infection the two-stage approach has been studied extensively, only few case reports on two-stage total knee arthroplasty (TKA) for knee osteoarthritis with coexistent joint infection have been published. The purpose of this paper was to report on our method of implementing a two-stage TKA with intervening antibiotic-loaded articulating cement spacers and a short interval between first- and second-stage procedures to treat two patients with Staphylococcus aureus-infected end-stage knee osteoarthritis. Consistent infection eradication was found at a 1-year follow-up with postoperative range of motion and knee scores comparing favourably with those of other case series. Level of evidence V.
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Pérez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TMA, Pelfort X, Monllau JC. Autograft soaking in vancomycin reduces the risk of infection after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2016; 24:2724-2728. [PMID: 25416672 DOI: 10.1007/s00167-014-3438-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/11/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine whether the bathing of an anterior cruciate ligament (ACL) autograft in vancomycin reduces the rate of infection following an ACL reconstruction. METHODS Retrospective analysis of all ACL reconstructions over an 8-year period in two University Hospitals. In the initial 4-year period, all patients were operated on under classical antibiotic intravenous prophylaxis (group 1). Over the last 4-year period, this prophylaxis was supplemented with presoaking of the autograft (group 2). Presoaking was performed with sterile gauze previously saturated with a vancomycin solution (5 mg/ml). RESULTS There were 810 and 734 patients in group 1 and 2, respectively. Fifteen cases of knee joint infections were identified in the series (0.97 %). All of these infections occurred in group 1, representing a rate of infection of 1.85 % in comparison with 0 % in group 2 (p < 0.001). CONCLUSIONS Autograft presoaking with vancomycin in combination with classical intravenous antibiotic prophylaxis reduced the rate of knee joint infection following an ACLR in comparison with antibiotic prophylaxis alone. This technique could be of relevance in daily clinical practice to prevent infection after ACLR. LEVEL OF EVIDENCE Case control study, retrospective comparative study, Level III.
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Affiliation(s)
- Daniel Pérez-Prieto
- Department of Orthopaedic Surgery and Traumatology, Consorci Parc de Salut Mar, Universitat Autònoma de Barcelona, Passeig Marítim, 25, Barcelona, Spain.
| | - Raúl Torres-Claramunt
- Department of Orthopaedic Surgery and Traumatology, Consorci Parc de Salut Mar, Universitat Autònoma de Barcelona, Passeig Marítim, 25, Barcelona, Spain
| | - Pablo E Gelber
- ICATME - Hospital Universitari Quirón-Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Xavier Pelfort
- Department of Orthopaedic Surgery and Traumatology, Consorci Parc de Salut Mar, Universitat Autònoma de Barcelona, Passeig Marítim, 25, Barcelona, Spain
- ICATME - Hospital Universitari Quirón-Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Carles Monllau
- Department of Orthopaedic Surgery and Traumatology, Consorci Parc de Salut Mar, Universitat Autònoma de Barcelona, Passeig Marítim, 25, Barcelona, Spain
- ICATME - Hospital Universitari Quirón-Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
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Phegan M, Grayson JE, Vertullo CJ. No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts. Knee Surg Sports Traumatol Arthrosc 2016; 24:2729-2735. [PMID: 25771788 DOI: 10.1007/s00167-015-3558-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 02/25/2015] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Michael Phegan
- Department of Orthopaedics, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Gold Coast, QLD, 4215, Australia.
| | - Jane E Grayson
- Department of Kinesiology and Health Sciences, Stephen F. Austin State University, Nacogdoches, TX, USA
| | - Christopher J Vertullo
- Knee Research Australia, Centre for Musculoskeletal Research, Griffith University, Gold Coast, QLD, Australia
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Complications and Adverse Events of a Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction. Clin J Sport Med 2016; 26:182-9. [PMID: 25881568 DOI: 10.1097/jsm.0000000000000202] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Complications/adverse events of anterior cruciate ligament (ACL) surgery are underreported, despite pooled level 1 data in systematic reviews. All adverse events/complications occurring within a 2-year postoperative period after primary ACL reconstruction, as part of a large randomized clinical trial (RCT), were identified and described. DESIGN Prospective, double-blind randomized clinical trial. Patients and the independent trained examiner were blinded to treatment allocation. SETTING University-based orthopedic referral practice. PATIENTS Three hundred thirty patients (14-50 years; 183 males) with isolated ACL deficiency were intraoperatively randomized to ACL reconstruction with 1 autograft type. Graft harvest and arthroscopic portal incisions were identical. INTERVENTION Patients were equally distributed to patellar tendon (PT), quadruple-stranded hamstring tendon (HT), and double-bundle (DB) hamstring autograft ACL reconstruction. MAIN OUTCOME MEASURES Adverse events/complications were patient reported, documented, and diagnoses confirmed. RESULTS Two major complications occurred: pulmonary embolism and septic arthritis. Twenty-four patients (7.3%) required repeat surgery, including 25 separate operations: PT = 7 (6.4%), HT = 9 (8.2%), and DB = 8 (7.3%). Repeat surgery was performed for meniscal tears (3.6%; n = 12), intra-articular scarring (2.7%; n = 9), chondral pathology (0.6%; n = 2), and wound dehiscence (0.3%; n = 1). Other complications included wound problems, sensory nerve damage, muscle tendon injury, tibial periostitis, and suspected meniscal tears and chondral lesions. Overall, more complications occurred in the HT/DB groups (PT = 24; HT = 31; DB = 45), but more PT patients complained of moderate or severe kneeling pain (PT = 17; HT = 9; DB = 4) at 2 years. CONCLUSIONS Overall, ACL reconstructive surgery is safe. Major complications were uncommon. Secondary surgery was necessary 7.3% of the time for complications/adverse events (excluding graft reinjury or revisions) within the first 2 years. LEVEL OF EVIDENCE Level 1 (therapeutic studies). CLINICAL RELEVANCE This article reports on the complications/adverse events that were prospectively identified up to 2 years postoperatively, in a defined patient population participating in a large double-blind randomized clinical trial comparing PT, single-bundle hamstring, and DB hamstring reconstructions for ACL rupture.
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Kuršumović K, Charalambous CP. Graft salvage following infected anterior cruciate ligament reconstruction. Bone Joint J 2016; 98-B:608-15. [DOI: 10.1302/0301-620x.98b5.35990] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 01/13/2016] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- K. Kuršumović
- Blackpool Victoria Hospital, 38
Whinney Heys Road Blackpool, Lancashire, FY3
8NR, UK
| | - C. P. Charalambous
- Blackpool Victoria Hospital, 38 Whinney
Heys Road, Blackpool, FY3 8NR, and Honorary
Professor, School of Medicine, University
of Central Lancashire, Preston, PR1
2HE, Lancashire, UK
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Anderson MJ, Browning WM, Urband CE, Kluczynski MA, Bisson LJ. A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthop J Sports Med 2016; 4:2325967116634074. [PMID: 27047983 PMCID: PMC4794976 DOI: 10.1177/2325967116634074] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL). PURPOSE To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded. RESULTS A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous. CONCLUSION A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.
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Affiliation(s)
| | | | | | | | - Leslie J. Bisson
- The State University of New York at Buffalo, Buffalo, New York, USA
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Reruptures, Reinjuries, and Revisions at a Minimum 2-Year Follow-up: A Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction. Clin J Sport Med 2016; 26:96-107. [PMID: 26164058 DOI: 10.1097/jsm.0000000000000209] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the predictive factors for traumatic rerupture, reinjury, and atraumatic graft failure of anterior cruciate ligament (ACL) reconstruction at a minimum 2-year follow-up. DESIGN Double-blind randomized clinical trial (RCT) with intraoperative computer-generated allocation. SETTING University-based orthopedic referral practice. PATIENTS Three hundred thirty patients with isolated ACL deficiency were equally randomized to (1) patellar tendon (PT; mean, 29.2 years), (2) quadruple-stranded hamstring tendon (HT; mean, 29.0 years), and (3) double bundle using HT (DB; mean, 28.8 years). Three hundred twenty-two patients completed 2-year follow-up. INTERVENTIONS Anatomically positioned primary ACL reconstruction with PT, HT, and DB autografts. MAIN OUTCOME MEASURES Proportions of complete traumatic reruptures, traumatic reinjuries (complete reruptures and partial tears), atraumatic graft failures, and contralateral ACL tears. Logistic regression assessed 5 a priori determined independent predictors: chronicity, graft type, age, sex, and Tegner level. RESULTS More complete traumatic reruptures occurred in the HT and DB groups: PT = 3; HT = 7; DB = 7 (P = 0.37). Traumatic reinjuries statistically favored PT reconstructions: (PT = 3; HT = 12; DB = 11; P = 0.05). Atraumatic graft failures were not different: PT = 16; HT = 17; DB = 20 (P = 0.75). Younger age was a significant predictor of complete traumatic reruptures and traumatic reinjuries (P < 0.01). Higher activity level, males, and patients with HT, DB, and acute reconstructions had greater odds of reinjury. None of these factors reached statistical significance. Contralateral ACL tears were not different between groups, but trends suggested that younger females were more likely to have a contralateral ACL tear. CONCLUSIONS More traumatic reinjuries occurred with HT and DB grafts. Younger age was a predictor of complete traumatic rerupture and traumatic reinjury, irrespective of graft type. LEVEL OF EVIDENCE Level 1 (Therapeutic Studies). CLINICAL RELEVANCE This article describes the complete traumatic graft rerupture, partial traumatic ACL tear, atraumatic graft failure, and contralateral ACL tear rates observed at 2 years postoperatively in a large double-blind RCT comparing PT, single-bundle hamstring, and double-bundle hamstring ACL reconstructions. The odds and predictive factors of traumatic rerupture and reinjury are also evaluated.
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Schuster P, Schulz M, Immendoerfer M, Mayer P, Schlumberger M, Richter J. Septic Arthritis After Arthroscopic Anterior Cruciate Ligament Reconstruction: Evaluation of an Arthroscopic Graft-Retaining Treatment Protocol. Am J Sports Med 2015; 43:3005-12. [PMID: 26403209 DOI: 10.1177/0363546515603054] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Septic arthritis after anterior cruciate ligament (ACL) reconstruction is a rare but severe complication. Treatment regimens differ, and optimal management has not been established. PURPOSE To determine the incidence of postoperative infections after ACL reconstruction, to identify the microbiological spectrum, and to evaluate a standardized graft-retaining treatment protocol consisting of sequential arthroscopic irrigation and debridement (I&D) procedures and antibiotic therapy until C-reactive protein levels are within normal range. STUDY DESIGN Case series; Level of evidence, 4. METHODS From January 2004 to June 2014, a total of 7096 consecutive arthroscopic ACL reconstructions were performed at a single institution (5907 primary and 1189 revision reconstructions). Thirty-six cases with postoperative septic arthritis were identified and retrospectively analyzed with regard to incidence, clinical presentation, time to and number of arthroscopic reoperations, and microbiological findings. The follow-up examination consisted of a clinical examination, instrumeted measurement of laxity (KT-1000 arthrometer), classification according to objective and subjective International Knee Documentation Committee (IKDC) scores, and radiological evaluation. RESULTS The incidence of septic arthritis was 0.51% (n = 36), with 0.41% (n = 24) in primary and 1.01% (n = 12) in revision reconstructions (odds ratio, 2.5; P = .008). The first I&D was performed a mean (± SD) of 19.6 ± 10.6 days after the index procedure. Eradication was achieved in all patients after a mean of 2.25 ± 1.22 procedures, with graft retention in all but 1 patient (97.2%). The mean duration of antibiotic treatment was 5.4 ± 2.3 weeks (range, 2.1-12.9 weeks) and ≤ 4 weeks in 13 patients (36%). No recurrence of infections was seen. Coagulase-negative staphylococci (62.5%) and Staphylococcus aureus (21.9%) were the most frequent pathogens. Twenty-nine patients were available for follow-up (80.6%) after a mean 4.7 ± 3.2 years (range, 0.7-11.2 years). Two patients suffered recurrent nontraumatic ACL insufficiency (6.9%), and all others (93.1%) had an intact graft, with a mean KT-1000 arthrometer side-to-side difference of 1.4 ± 0.9 mm. The mean subjective IKDC score was 80.4 ± 11.2. No emergence or deterioration of osteoarthritis related to infections was seen. CONCLUSION Postoperative septic arthritis is rare but serious after arthroscopic ACL reconstruction. Graft retention and good to excellent clinical results can be obtained with an arthroscopic treatment protocol. The duration of antibiotic therapy should be based on the individual course.
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Affiliation(s)
- Philipp Schuster
- Centre for Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Martin Schulz
- Centre for Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Micha Immendoerfer
- Centre for Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Philipp Mayer
- Centre for Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Michael Schlumberger
- Centre for Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
| | - Joerg Richter
- Centre for Arthroscopy and Sports Medicine, Orthopedic Hospital Markgroeningen, Markgroeningen, Germany
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Post-arthroscopy septic arthritis: Current data and practical recommendations. Orthop Traumatol Surg Res 2015; 101:S347-50. [PMID: 26412207 DOI: 10.1016/j.otsr.2015.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/30/2015] [Indexed: 02/02/2023]
Abstract
Septic arthritis develops after less than 1% of all arthroscopy procedures. The clinical symptoms may resemble those seen after uncomplicated arthroscopy, raising diagnostic challenges. The diagnosis rests on emergent joint aspiration with microscopic smear examination and prolonged culturing on specific media. Urgent therapeutic measures must be taken, including abundant arthroscopic lavage, synovectomy, and the concomitant administration of two effective antibiotics for at least 6 weeks. Preservation of implants or transplants is increasingly accepted, and repeated joint lavage is a component of the treatment strategy. After knee arthroscopy, infection is the most common complication; most cases occur after cruciate ligament reconstruction, and staphylococci are the predominant causative organisms. Emergent synovectomy with transplant preservation and appropriate antibiotic therapy ensures eradication of the infection in 85% of cases, with no adverse effect on final functional outcomes. After shoulder arthroscopy, infection is 10 times less common than neurological complications and occurs mainly after rotator cuff repair procedures; the diagnosis may be difficult and delayed if Propionibacterium acnes is the causative organism. The update presented here is based on both a literature review and a practice survey. The findings have been used to develop practical recommendations aimed at improving the management of post-arthroscopy infections, which are exceedingly rare but can induce devastating functional impairments.
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Torres-Claramunt R, Gelber P, Pelfort X, Hinarejos P, Leal-Blanquet J, Pérez-Prieto D, Monllau JC. Managing septic arthritis after knee ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2015; 40:607-14. [PMID: 26239533 DOI: 10.1007/s00264-015-2884-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/08/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE Joint infection after anterior cruciate ligament (ACL) reconstruction is uncommon but has potentially serious consequences for the graft and articular cartilage. Most recently published series are in agreement that an urgent arthroscopic washout and antibiotic treatment are mandatory to preserve both graft and cartilage. However, several questions have not as yet been touched upon. METHODS We performed a literature review to assess the most interesting series published about this issue. RESULTS In this review, a management protocol is first presented that discusses the different diagnostic parameters to consider and surgical and antibiotic treatment suggested according to the literature. Outcomes published in different series are also discussed.
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Affiliation(s)
- Raúl Torres-Claramunt
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain. .,IMIM Hospital del Mar Medical Research Institute, Barcelona, Spain.
| | - Pablo Gelber
- Orthopaedic Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Xavier Pelfort
- Orthopaedic Department, Consorci Sanitari de l'Anoia, Avinguda Catalunya 11, 08700, Igualada, Barcelona, Spain
| | - Pedro Hinarejos
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain.,IMIM Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Joan Leal-Blanquet
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Daniel Pérez-Prieto
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Joan C Monllau
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain.,IMIM Hospital del Mar Medical Research Institute, Barcelona, Spain
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Makhni EC, Steinhaus ME, Mehran N, Schulz BS, Ahmad CS. Functional Outcome and Graft Retention in Patients With Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2015; 31:1392-401. [PMID: 25727493 DOI: 10.1016/j.arthro.2014.12.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/30/2014] [Accepted: 12/30/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide a comprehensive review of clinical and functional outcomes after treatment for septic arthritis after anterior cruciate ligament reconstruction. METHODS A systematic review of the literature was performed. Two reviewers assessed and confirmed the methodologic quality of each study. Studies that met the inclusion criteria were assessed for pertinent data, and when available, similar outcomes were combined to generate frequency-weighted means. RESULTS Nineteen studies met the inclusion and exclusion criteria for this review, reporting on a total of 203 infected knees. The mean age was 27.5 years and the mean length of follow-up was 44.2 months, with male patients comprising 88% of the population. Hamstring and bone-patellar tendon-bone autografts were used in 63% and 33% of patients, respectively, with 78% of patients retaining their grafts. The studies reported mean flexion and extension deficits of 5.8° and 1.0°, respectively, and laxity testing showed a mean difference of 1.9 mm. The studies reported mean Lysholm, International Knee Documentation Committee, and Tegner scores of 82.1, 68.2, and 5.6, respectively. Of the patients, 83% reported an ability to return to activities of daily living whereas 67% reported a return to their preinjury level of athletics. Evidence of new degenerative changes was seen in 22% of patients. CONCLUSIONS Septic arthritis after anterior cruciate ligament reconstruction remains a very infrequent event, affecting 0.5% of patients. On average, outcomes in these patients are comparable with those in patients in whom infection does not develop, including postoperative range of motion, residual instability, Lysholm scores, and return to preinjury level of activity. These patients do exhibit decreased International Knee Documentation Committee scores compared with patients without septic arthritis, however. The impact of this differential is not clear, but this scoring difference suggests that septic arthritis may be associated with more severe symptoms and reduced functional outcomes. In addition, there is limited evidence suggesting that septic arthritis leads to early degenerative changes found on imaging. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Affiliation(s)
- Eric C Makhni
- Columbia University Medical Center, New York, New York, U.S.A
| | | | - Nima Mehran
- Henry Ford Hospital, Wayne State University, Detroit, Michigan, U.S.A
| | - Brian S Schulz
- Kerlan-Jobe Orthopedic Clinic, Los Angeles, California, U.S.A
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Aïm F, Delambre J, Bauer T, Hardy P. Efficacy of arthroscopic treatment for resolving infection in septic arthritis of native joints. Orthop Traumatol Surg Res 2015; 101:61-4. [PMID: 25623272 DOI: 10.1016/j.otsr.2014.11.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 11/02/2014] [Accepted: 11/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Septic arthritis is a diagnostic and therapeutic emergency that threatens both life and function. The primary objective of this study was to assess the efficacy on the infectious process of arthroscopic treatment in patients with septic arthritis of native joints. The secondary objective was to identify factors predicting failure to achieve infection resolution after arthroscopic treatment. We hypothesised that arthroscopy was the appropriate treatment strategy. MATERIAL AND METHODS Forty-six cases of septic arthritis in 46 patients with a mean age of 46 years (range, 18-72 years) were retrospectively reviewed. The cause of the septic arthritis was haematogenous dissemination in 39.1% of patients, surgery in 34.8%, a local injection in 19.6%, and trauma in 6.5%. The involved joint was the knee in 32 patients, the shoulder in 6, the hip in 3, the ankle in 3, and the elbow in 2. All patients underwent arthroscopic joint lavage, with or without synovectomy depending on the Gächter stage. Dual antibiotic therapy was given routinely after the procedure. For each patient, we assessed time to treatment, intraoperative findings according to the Gächter classification, cultures of drainage-fluids, and whether repeat arthroscopic lavage was required. Recovery of the infection was defined as absence of clinical or laboratory signs of infection at last follow-up. RESULTS Mean follow-up was 42 months (range, 1-120). Mean time from symptom onset to arthroscopic treatment was 7.5 days. Full recovery of the infection was achieved in 93% of patients, although 25% required more than one arthroscopic lavage. Factors significantly associated with arthroscopic treatment failure were Gächter stage III or IV and positive drainage-fluid cultures after 24h. CONCLUSION Arthroscopic treatment is indicated in all patients with septic arthritis on native joints. The procedure should be repeated if the initial course is unfavourable. LEVEL OF EVIDENCE IV. Retrospective study.
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Affiliation(s)
- F Aïm
- Service de chirurgie orthopédique et traumatologique, hôpital Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
| | - J Delambre
- Service de chirurgie orthopédique et traumatologique, hôpital Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - T Bauer
- Service de chirurgie orthopédique et traumatologique, hôpital Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - P Hardy
- Service de chirurgie orthopédique et traumatologique, hôpital Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
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Boström Windhamre H, Mikkelsen C, Forssblad M, Willberg L. Postoperative septic arthritis after anterior cruciate ligament reconstruction: does it affect the outcome? A retrospective controlled study. Arthroscopy 2014; 30:1100-9. [PMID: 24836173 DOI: 10.1016/j.arthro.2014.03.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 03/20/2014] [Accepted: 03/21/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the outcome after septic arthritis after anterior cruciate ligament reconstruction (ACLR) is inferior compared with uncomplicated ACLR when treated promptly by use of a standard protocol. METHODS At Capio Artro Clinic, 4,384 primary ACLRs were performed during 2001-2009. All patients with postoperative septic arthritis were retrospectively reviewed, and 43 met the inclusion criteria. Twenty-seven patients agreed to re-examination (infection group) and were compared with 27 matched patients with uncomplicated ACLR (control group). The mean follow-up period was 60 months and 66 months in the infection group and control group, respectively. Re-examination included objective (radiographs, physical examination, functional testing, range of motion, strength, stability, International Knee Documentation Committee questionnaire) and subjective (Knee Injury and Osteoarthritis Outcome Score, Tegner score, Lysholm score, European Quality of Life-5 Dimensions, subjective satisfaction questions, Single Assessment Numeric Evaluation of knee function, visual analog scale pain rating) evaluation. RESULTS There were no significant differences in objective knee function between the groups at follow-up. For subjective knee function, no significant differences between the groups were detected with the Single Assessment Numeric Evaluation score, pain during activity, or Lysholm score. The infection group scored lower on 4 of 5 Knee Injury and Osteoarthritis Outcome Score subscales: pain (P = .014), function in daily living (P = .008), sports/recreation (P = .015), and quality of life (P = .007). The infection group scored lower versus control patients on the Tegner score (P = .001) and European Quality of Life-5 Dimensions scores (P = .004). Both groups improved over time, but the control group scored better only on the Tegner score (P = .004). CONCLUSIONS Septic arthritis after ACLR did not result in inferior objective knee function compared with uncomplicated ACLR. Subjectively, infection patients were as satisfied as non-infection patients, but rehabilitation took longer and fewer patients returned to sports. The findings of this study suggest that anterior cruciate ligament grafts may be retained with prompt, thorough arthroscopic lavage and debridement; correct antibiotics according to cultures; and repeated arthroscopy if necessary. LEVEL OF EVIDENCE Level III, retrospective case-control therapeutic study.
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Affiliation(s)
- Helena Boström Windhamre
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Orthopedic Surgery, Capio St Gorans Hospital, Stockholm, Sweden.
| | - Christina Mikkelsen
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Forssblad
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lotta Willberg
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Saper M, Stephenson K, Heisey M. Arthroscopic irrigation and debridement in the treatment of septic arthritis after anterior cruciate ligament reconstruction. Arthroscopy 2014; 30:747-54. [PMID: 24680320 DOI: 10.1016/j.arthro.2014.02.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/23/2014] [Accepted: 02/05/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature and characterize the success and failure rates of arthroscopic irrigation and debridement (I & D) in the treatment of septic arthritis after anterior cruciate ligament (ACL) reconstructions. We also aimed to identify which variables affected the failure rate. METHODS Five databases (MEDLINE, Ovid, Medscape, Web of Science, and Google Scholar) were screened for clinical studies involving the treatment of septic arthritis after ACL reconstruction with arthroscopic I & D. A full-text review of eligible studies was conducted. Inclusion and exclusion criteria were applied to the searched studies. Failure of I & D was defined as the need for graft removal or revision ACL reconstructive surgery because of infection. Data from the selected studies were combined for statistical analyses to elucidate factors associated with the success or failure. RESULTS We identified 11 eligible studies involving 90 patients. These studies described the results of 90 arthroscopic I & D procedures with an overall success rate of 85.6%. Repeated I & D was necessary in 34.5% of patients. Removal of the graft with or without subsequent revision ACL reconstruction was reported in 13 (14.4%) cases. Statistical analysis showed that cases involving Staphylococcus aureus (P = .053), 2 or more I & D procedures (P = .029), and allografts (P < .0001) were at greater risk of failure. CONCLUSIONS Arthroscopic I & D with graft retention is an effective treatment for patients with septic arthritis after ACL reconstruction. Factors affecting the failure rate may include graft choice and organism virulence. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Michael Saper
- Department of Osteopathic Surgical Specialties, Michigan State University, East Lansing, Michigan, U.S.A.; Mid-Michigan Orthopaedic Institute, East Lansing, Michigan, U.S.A..
| | - Kyle Stephenson
- Department of Osteopathic Surgical Specialties, Michigan State University, East Lansing, Michigan, U.S.A.; Mid-Michigan Orthopaedic Institute, East Lansing, Michigan, U.S.A
| | - Meredith Heisey
- Mid-Michigan Orthopaedic Institute, East Lansing, Michigan, U.S.A.; Department of Orthopaedic Surgery, McLaren Greater Lansing, Lansing, Michigan, U.S.A
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Management of the contaminated anterior cruciate ligament graft. Arthroscopy 2014; 30:236-44. [PMID: 24485117 DOI: 10.1016/j.arthro.2013.10.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 10/15/2013] [Accepted: 10/29/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE This systematic review explores management strategies for intraoperative anterior cruciate ligament (ACL) graft contamination. METHODS Two databases (Medline and EMBASE) were screened for studies involving ACL graft contamination published between 1946 and April 2013. We included studies evaluating the management of a contaminated graft and excluded small case-series studies. We conducted a full-text review of eligible studies, and the references were searched for additional eligible studies. Inclusion and exclusion criteria were applied to the searched studies. RESULTS Our search yielded 6 laboratory investigations with a total of 495 graft samples used. These samples were contaminated and cleansed by various methods. The most successful sterilization protocols used chlorhexidine or mechanical agitation with a polymyxin B-bacitracin solution to achieve sterility in 100% of their respective experimental graft tissues. A chlorhexidine soak and plain bacitracin soak were also effective, at 97.5% and 97%, respectively. Povidone-iodine and an antibiotic soak of polymyxin-bacitracin were the least effective, with sterility rates of 48% and 57%, respectively. CONCLUSIONS The results of this review suggest that the optimal agent for sterilizing a dropped graft is chlorhexidine. A protocol of mechanical agitation and serial dilution with a polymyxin B-bacitracin solution was also highly effective; however, the sample size was too small to realistically recommend its use. Bacitracin alone was also found to be an effective sterilization agent, as was a combined solution of neomycin and polymyxin B. Pooled results showed that normal saline solution, povidone-iodine, and a polymyxin B-bacitracin solution all yielded suboptimal sterilization. The available evidence, however, is laboratory based and may not accurately reflect clinical conditions; moreover, there is a lack of biomechanical studies evaluating sterilized grafts. As a result, the findings should be interpreted with caution. LEVEL OF EVIDENCE Level IV, systematic review of basic science studies.
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