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Rougereau G, Hassan SK, Valentin E, Jehan S, Bauer T, Baudrier N, Hardy A. Incidence of Septic Arthritis After Vancomycin Soaking of the Graft During Arthroscopic Anatomic Anterior Talofibular Ligament and Calcaneofibular Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241228276. [PMID: 38444570 PMCID: PMC10913514 DOI: 10.1177/23259671241228276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/10/2023] [Indexed: 03/07/2024] Open
Abstract
Background Vancomycin soaking of the graft during arthroscopic anterior cruciate ligament reconstruction has been shown to be effective in reducing the rate of postoperative infection. Purpose/Hypothesis The present study aimed to (1) analyze the effect of vancomycin-soaked grafts during arthroscopic anatomic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) on the incidence of infection and (2) evaluate the influence of infection on functional outcomes and identify the risk factors of infection. It was hypothesized that vancomycin soaking of the graft would reduce the postoperative infection rate. Study Design Cohort study; Level of evidence, 3. Methods Consecutive patients at 2 centers who underwent ATFL/CFL reconstruction between December 2011 and July 2022 were included. All patients had undergone anterolateral arthroscopic debridement of the ankle and anatomic ATFL/CFL reconstruction with a gracilis tendon autograft. Vancomycin soaking of the graft was begun in both centers in January 2021. Complications, functional scores, return to sports (RTS) rates, and the level of return were compared between patients with and without vancomycin-soaked grafts and between patients with and without infection. Results Overall, 182 patients (48% men; mean age, 34 ± 11.9 years) were included, with a mean follow-up of 23 ± 16.1 months. The rate of postoperative infection was significantly lower in the group with vancomycin soaking versus without (0/92 [0%] vs 8/90 [8.9%]; P = .001). At the final follow-up, there were 26 complications (14.3%): 8 infections, 6 recurrent tears, and 12 peripheral neuropathies. The infections developed after a mean of 17 ± 11 days. The functional scores were excellent at the final follow-up (American Orthopaedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Score, 86.5 ± 18.7; Karlsson score, 85 ± 18.3). Patients with infection had significantly decreased AOFAS scores (52.8 ± 27.6 vs 83.3 ± 21.5; P = .003), Karlsson scores (57 ± 27.7 vs 83.6 ± 20; P = .006), and RTS rates (25% vs 77%; P = .005) versus patients without infection. Conclusion Vancomycin-soaked grafts for arthroscopic anatomic ATFL/CFL reconstruction decreased the rate of postoperative infection. Infection led to a deterioration in results. Vancomycin-soaking of the graft did not have a negative effect on functional results.
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Affiliation(s)
- Grégoire Rougereau
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
- Hospital Pitie Salpetriere, APHP, Paris, France
| | - Sammy Kassab Hassan
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
- Hospital Pitie Salpetriere, APHP, Paris, France
| | | | - Sacha Jehan
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
| | - Thomas Bauer
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
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Schmitz JK, Omar O, Nordkvist A, Hedevik H, Janarv PM, Stålman A. Poorer patient-reported outcome and increased risk of revision at a 5-year follow-up among patients with septic arthritis following anterior cruciate ligament reconstruction: a register-based cohort study of 23,075 primary anterior cruciate ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2023; 31:4090-4098. [PMID: 37395807 PMCID: PMC10471654 DOI: 10.1007/s00167-023-07498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE The primary aim of this study is to analyse the patient-reported outcomes after ACLR complicated by septic arthritis. The secondary aim is to examine the 5-year risk of revision surgery after primary ACLR complicated by septic arthritis. The hypothesis was that patients with septic arthritis after ACLR are more likely to have lower PROMs scores and an increased risk of revision, compared with patients without septic arthritis. MATERIALS AND METHODS All primary ACLRs, with a hamstring or patellar tendon autograft (n = 23,075), in the Swedish Knee Ligament Register (SKLR) between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare to identify patients with postoperative septic arthritis. These patients were verified in a nationwide medical records analysis and compared with patients without infection in the SKLR. The patient-reported outcome was measured using the Knee injury and Osteoarthritis Index Score (KOOS) and the European Quality of Life Five Dimensions Index (EQ-5D) at 1, 2 and 5 years postoperatively and the 5-year risk of revision surgery was calculated. RESULTS There were 268 events of septic arthritis (1.2%). The mean scores on the KOOS and EQ-5D index were significantly lower for patients with septic arthritis on all subscales on all follow-up occasions compared with patients without septic arthritis. Patients with septic arthritis had a revision rate of 8.2% compared with 4.2% in patients without septic arthritis (adjusted hazard ratio 2.04; confidence interval 1.34-3.12). CONCLUSION Patients suffering from septic arthritis following ACLR are associated with poorer patient-reported outcomes at 1-, 2- and 5-year follow-ups compared with patients without septic arthritis. The risk of revision ACL reconstruction within 5 years of the primary operation for patients with septic arthritis following ACLR is almost twice as high, compared with patients without septic arthritis. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jesper Kraus Schmitz
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Osama Omar
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Vo Ortopedi, Södersjukhuset, Sjukhusbacken 10, 11883, Stockholm, Sweden.
| | - Adam Nordkvist
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Hedevik
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Per-Mats Janarv
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Stålman
- Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Zhang L, Yang R, Mao Y, Fu W. A Systematic Review and Meta-analysis of Risk Factors for an Infection After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2023; 11:23259671231200822. [PMID: 37846316 PMCID: PMC10576935 DOI: 10.1177/23259671231200822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 10/18/2023] Open
Abstract
Background Identifying risk factors for an infection after anterior cruciate ligament reconstruction (ACLR) and following targeted preventive strategies can effectively reduce this potentially serious complication. Purpose To perform a systematic review and meta-analysis to identify the risk factors for an infection after ACLR. Study Design Systematic review; Level of evidence, 4. Methods The PubMed, Embase, and Web of Science databases were searched from inception to September 1, 2022, for prospective and retrospective studies investigating risk factors for any type of infection after ACLR. Odds ratios (ORs) or mean differences were calculated for potential risk factors if ≥2 studies assessed the same risk factor. A qualitative analysis of variables was performed if a meta-analysis could not be conducted. Results A total of 17 studies with 141,991 patients were included in this review. The overall pooled infection rate was 0.86% (range, 0.24%-5.50%). There were 20 risk factors identified for analysis. Of these, 7 variables independently increased the odds of an infection after ACLR: (1) male sex (OR, 1.90 [95% CI, 1.33-2.73]), (2) diabetes (OR, 2.69 [95% CI, 1.66-4.35]), (3) hamstring tendon autograft (OR, 2.51 [95% CI, 2.03-3.10]), (4) revision ACLR (OR, 2.31 [95% CI, 1.22-4.37]), (5) professional athlete status (OR, 6.21 [95% CI, 1.03-37.38]), (6) lateral tenodesis (OR, 3.45 [95% CI, 1.63-7.28]), and (7) corticosteroid use (OR, 7.83 [95% CI, 3.68-16.63]). No significant associations were found between postoperative infections and age, body mass index, smoking, meniscal repair, or outpatient surgery. Conclusion This review revealed that an increased risk of infections after ACLR was associated with male sex, diabetes, hamstring tendon autograft, revision surgery, professional athlete status, lateral tenodesis, and steroid use. Knowledge of the risk factors associated with an infection after ACLR may facilitate the identification of high-risk cases and the implementation of preventive measures to mitigate the serious consequences of this complication.
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Affiliation(s)
- Lei Zhang
- Orthopedics Research Institute, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Runze Yang
- Orthopedics Research Institute, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yunhe Mao
- Orthopedics Research Institute, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Fu
- Orthopedics Research Institute, Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Pérez-Prieto D, Totlis T, Madjarevic T, Becker R, Ravn C, Monllau JC, Renz N. ESSKA and EBJIS recommendations for the management of infections after anterior cruciate ligament reconstruction (ACL-R): prevention, surgical treatment and rehabilitation. Knee Surg Sports Traumatol Arthrosc 2023; 31:4204-4212. [PMID: 37243789 PMCID: PMC10471731 DOI: 10.1007/s00167-023-07463-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
- Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar, Barcelona, Spain
- IcatKNEE, Hospital Universitari Dexeus - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Trifon Totlis
- Thessaloniki Minimally Invasive Surgery (The-MIS) Orthopaedic Centre, St. Luke's Hospital, Thessaloniki, Greece.
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Tomislav Madjarevic
- University Hospital for Orthopaedic Surgery Lovran, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Roland Becker
- Centre of Orthopaedics and Traumatology, University of Brandenburg Theodor Fontane, Brandenburg, Germany
| | - Christen Ravn
- Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Juan C Monllau
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar, Barcelona, Spain
- IcatKNEE, Hospital Universitari Dexeus - Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Nora Renz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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Özbek EA, Dadoo S, Chang A, Simonian L, Sebastiani R, Herman Z, Runer A, Poploski KM, Smith CN, Irrgang JJ, Musahl V. Rates of Septic Arthritis After ACL Reconstruction: A Single-Center Analysis Highlighting Quadriceps Tendon Grafts. Am J Sports Med 2023:3635465231165509. [PMID: 37092731 DOI: 10.1177/03635465231165509] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Although the infection rates for bone-patellar tendon-bone autograft (BTB), hamstring tendon autograft (HT), and allograft have been reported previously, there are limited data available for a large cohort of individuals undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) using quadriceps tendon autograft (QT). PURPOSE The aims of this study are (1) to compare rates of septic arthritis after primary and revision ACLR with QT, BTB, HT, and allograft and (2) to evaluate the association between an infection after ACLR and potential risk factors in a large single-system analysis. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All ACLR cases performed by 10 high-volume sports medicine fellowship-trained ACL surgeons between January 2000 and January 2022 were retrospectively analyzed. Minimum follow-up was 90 days after ACLR, and all multiligament reconstructions were excluded. Demographic information, surgical variables, infection characteristics, and rate of ACL graft retention were collected for all included patients. Independent samples t test, chi-square test, or Fisher exact tests with adjusted Benjamini-Hochberg post hoc procedure were used for group comparisons. RESULTS In total, 6652 patients were included in this study. The most commonly used graft was allograft (n = 2491; 37.4%), followed by HT (n = 1743; 26.2%), BTB (n = 1478; 22.2%), and QT (n = 940; 14.1%). The overall postoperative rate of septic arthritis was 0.34% (n = 23). Septic arthritis rates based on graft type were 0.74% (n = 13) for HT, 0.24% (n = 6) for allograft, 0.20% (n = 3) for BTB, and 0.10% (n = 1) for QT. While a statistically significant difference with regard to graft type (P = .01) was observed, no significant relationships were found between postoperative septic arthritis and age, sex, revision ACLR, ACLR surgical technique, and accompanying intra-articular procedures for all septic arthritis patients (P > .05). The average time from the onset of the symptoms of infection to surgical irrigation and debridement (I&D) was 2 days (minimum, 0; maximum, 6). ACL grafts were retained during I&D procedures in all patients with postoperative septic arthritis. CONCLUSION The postoperative rate of septic arthritis was 0.1% after use of the QT autograft. While graft choice may affect rates of septic arthritis after ACLR, patient characteristics, ACLR technique, revision ACLR, and accompanying intra-articular procedures during ACLR were not associated with postoperative septic arthritis with the numbers available for analysis.
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Affiliation(s)
- Emre Anil Özbek
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Sahil Dadoo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Audrey Chang
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren Simonian
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Romano Sebastiani
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zachary Herman
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Armin Runer
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kathleen M Poploski
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clair N Smith
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Hu M, Zhang Y, Shang G, Guo J, Xu H, Ma X, Yang X, Xiang S. Vancomycin presoak reduces infection in anterior cruciate ligament reconstruction: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:267. [PMID: 37020216 PMCID: PMC10074692 DOI: 10.1186/s12891-023-06331-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/16/2023] [Indexed: 04/07/2023] Open
Abstract
PURPOSE To compare the effect of vancomycin presoak treatment of grafts during anterior cruciate ligament reconstruction on the incidence of postoperative infection or septic arthritis. METHODS Studies published before May 3, 2022 investigating vancomycin presoak of grafts during anterior cruciate ligament reconstruction were searched in the PubMed and Cochrane Central Register of Controlled Trials. Studies were screened, and data on the incidence of postoperative infection or septic arthritis were extracted and included in the analysis. RESULTS Thirteen studies were included for analysis after search screening, yielding a total of 31,150 participants for analysis, of whom 11,437 received graft vancomycin presoak treatment, and 19,713 did not receive treatment. Participants who received vancomycin treatment had significantly lower infection rates (0.09% versus 0.74%; OR 0.17; 95% CI 0.10, 0.30; P < 0.00001). CONCLUSION Pre-soaking of the graft with vancomycin during ACL reconstruction reduced the incidence of postoperative infection and septic arthritis.
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Affiliation(s)
- Mingwei Hu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Yifan Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Guangqian Shang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Jianjun Guo
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Hao Xu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Xue Ma
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Xue Yang
- Operation Room, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Shuai Xiang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China.
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A Review of Evidence for Infection Reduction With Vancomycin-treated Anterior Cruciate Ligament Grafts. J Am Acad Orthop Surg 2022; 30:e1571-e1579. [PMID: 36476465 DOI: 10.5435/jaaos-d-22-00463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/10/2022] [Indexed: 12/13/2022] Open
Abstract
Septic arthritis after anterior cruciate ligament (ACL) reconstruction is a rare but devastating complication. Several risk factors and known sources of infection have been identified in the literature. There is growing interest and supportive evidence for a targeted invention aimed at graft decontamination, which has led some surgeons to adopt the use of antibiotic solution soaks and/or wraps applied to ACL grafts before graft implantation in an attempt to reduce the risk of postoperative infection. Despite this, adoption of this technique remains relatively low among surgeons because of a variety of factors: (1) lack of awareness, (2) confusion over optimal protocols, (3) concern for graft viability and clinical outcomes, and (4) efforts to minimize the cost of surgery. However, recently published literature demonstrates notable risk reduction for infection, acceptable safety, no detrimental effect on clinical outcomes, and overall cost-effectiveness with the use of vancomycin graft soaks and wraps. Currently, there is a lack of consensus for clinical protocols, and the protocol that is most efficacious remains unclear. The purpose of this review article was to present the current evidence for ACL graft treatment with vancomycin for the prevention of postoperative infection.
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Komnos GA, Chalatsis G, Mitrousias V, Hantes ME. Postoperative Infection after Anterior Cruciate Ligament Reconstruction: Prevention and Management. Microorganisms 2022; 10:microorganisms10122349. [PMID: 36557602 PMCID: PMC9781783 DOI: 10.3390/microorganisms10122349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/12/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Infection following anterior cruciate ligament (ACL) reconstruction can be one of the most debilitating complications following ACL reconstruction. Its reported incidence is around 1%. Utilization of vancomycin for presoaking the graft is considered an established method for infection prevention. The role of other agents, such as gentamycin needs further investigation. Staphylococci are the predominant causative pathogens, while particular attention should be paid to fungal infections due to their long-standing, occult process. Recent data demonstrate that hamstrings autograft may be at an elevated risk of being contaminated leading to subsequent septic arthritis. Diagnosis is set by clinical and laboratory findings and is usually confirmed by intraoperative cultures. Treatment varies, mainly depending on the intraoperative assessment. Satisfactory outcomes have been reported with both graft retaining and removal, and the decision is made upon the arthroscopic appearance of the graft and the characteristics of the infection. Of note, early management seems to lead to superior results, while persistent infection should be managed with graft removal in an attempt to protect the articular cartilage and the knee function.
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El-Kady RAEH, ElGuindy AMF. Septic Arthritis Complicating Arthroscopic Anterior Cruciate Ligament Reconstruction: An Experience from a Tertiary-Care Hospital. Infect Drug Resist 2022; 15:3779-3789. [PMID: 35859912 PMCID: PMC9289172 DOI: 10.2147/idr.s369240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background Septic arthritis (SA) of the knee following anterior cruciate ligament reconstruction (ACLR) is considered a catastrophic complication in terms of reduced or loss function of the involved joint. The aims of this study were to gauge the incidence, risk factors, and causative organisms of SA after ACLR. Methods We conducted a retrospective review of 836 patients who underwent primary ACLR at our institution from October 2018 to September 2021. Patients’ demographics, onset of presentation, clinical symptoms, laboratory findings, and management details were obtained from patients’ electronic medical records. Results Out of the 836 primary ACLRs, 12 were complicated with SA (1.43%). Independent risk factors associated with SA included age (OR; 11.12, 95% CI; 1.3–94.97), obesity (OR; 8.51, 95% CI; 1.02–71.13), and diabetes mellitus (OR; 12.58, 95% CI; 2.39–66.3). Staphylococcus aureus was the most frequent culprit organism (66.7%), followed by Streptococcus species (25%), and Pseudomonas aeruginosa (8.3%). No fungal, mycobacterial, or polymicrobial growth were recovered from synovial fluid cultures. All of the infected cases underwent arthroscopic joint lavage and debridement in the operating room followed by intravenous antibiotics. Graft removal was not done in any of the involved patients, with eradication of infection in all cases. Conclusion SA after ACLR is uncommon, with S. aureus identified in about two-thirds of the patients. Prompt diagnosis and treatment are crucial to avoid graft loss and arthritis-associated joint damage. Orthopedic surgeons should consider rigorous implementation of infection control strategies to minimize the incidence of this devastating morbidity.
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Affiliation(s)
- Rania Abd El-Hamid El-Kady
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Department of Pathological Sciences, Fakeeh College for Medical Sciences, Jeddah, Kingdom of Saudi Arabia
| | - Ahmed Mahmoud Fouad ElGuindy
- Department of Orthopedic Surgery, Faculty of Medicine, Fayoum University, Fayoum, Egypt.,Department of Orthopedic and Spine Surgery, Dr. Soliman Fakeeh Hospital, Jeddah, Kingdom of Saudi Arabia
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Arakgi ME, Burkhart TA, Hoshino T, Degen R, Getgood A. Biomechanical Comparison of Three Suspensory Techniques for all Soft Tissue Central Quadriceps Tendon Graft Fixation. Arthrosc Sports Med Rehabil 2022; 4:e843-e851. [PMID: 35747631 PMCID: PMC9210367 DOI: 10.1016/j.asmr.2021.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 12/01/2021] [Indexed: 10/27/2022] Open
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Evaluation of Experimental and Clinical Efficacy on Surgical Debridement and Systemic Antibiotics Treatment for Early Knee Infection after Anterior Cruciate Ligament Reconstruction. Antimicrob Agents Chemother 2022; 66:e0011222. [PMID: 35499314 DOI: 10.1128/aac.00112-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Deep knee infection (DKI) after anterior cruciate ligament reconstruction (ACLR) is rare and challenging. The optimal treatment strategy for infection after ACLR remains controversial. This study aimed to investigate the optimal treatment for early infection after ACLR surgery. Rats with unilateral ACLR were injected with 3.0 × 105 colony forming units (CFU) of Staphylococcus aureus in the knee joint for 7 days. Next, with surgical debridement (SD) and/or 21 days of antimicrobial (systemic vancomycin and oral rifampicin [SVR]) therapy, rats were euthanatized and samples harvested. We evaluated signs of infection by general postoperative conditions, serum inflammatory markers, microbiological counting, knee radiographs, micro-computed tomography (micro-CT), histologic staining, and scanning electron microscopy (SEM). Clinically, the data from 12 patients who suffered from DKI after ACLR were analyzed retrospectively. The DKI rats treated with SVR showed better outcomes in general postoperative conditions, serum inflammatory markers, microbiological counting, biofilm on the interference screw and graft, radiographic signs of periarticular osseous destruction, and inflammatory reaction in the joint tissues than those with SD treatment, while the DKI rats with SD and SVR administration showed the best outcomes. Rats which received SD and SVR administration had their S. aureus contamination completely eradicated. All patients treated with SD & SVR or SVR alone had effectively controlled knee infections and achieved good knee function outcomes in the 6 months after treatment, but one patient developed more serious knee infections. Therefore, surgical debridement combined with systemic antibiotics treatment could effectively eliminate S. aureus contamination in the DKI rat model and in patients after ACLR without affecting knee function. Treatment with systemic antibiotics could also control early DKI, which would be especially applicable in patients who could not tolerate surgery.
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Marom N, Kapadia M, Nguyen JT, Ammerman B, Boyle C, Wolfe I, Halvorsen KC, Miller AO, Henry MW, Brause BD, Hannafin JA, Marx RG, Ranawat AS. Factors Associated With an Intra-articular Infection After Anterior Cruciate Ligament Reconstruction: A Large Single-Institution Cohort Study. Am J Sports Med 2022; 50:1229-1236. [PMID: 35286225 DOI: 10.1177/03635465221078311] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An intra-articular infection after anterior cruciate ligament (ACL) reconstruction (ACLR) is a rare complication but one with potentially devastating consequences. The rare nature of this complication raises difficulties in detecting risk factors associated with it and with worse outcomes after one has occurred. PURPOSE To (1) evaluate the association between an infection after ACLR and potential risk factors in a large single-center cohort of patients who had undergone ACLR and (2) assess the factors associated with ACL graft retention versus removal. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS All ACLR procedures performed at our institution between January 2010 and December 2018 were reviewed; a total of 11,451 procedures were identified. A retrospective medical record review was performed to determine the incidence of infections, patient and procedure characteristics associated with an infection, infection characteristics, incidence of ACL graft retention, and factors associated with the retention versus removal of an ACL graft. Multivariable logistic regression analysis was used to identify potential risk factors for an infection after ACLR. RESULTS Of the 11,451 ACLR procedures, 48 infections were identified (0.42%). Multivariable logistic regression analysis revealed revision ACLR (odds ratio [OR], 3.13 [95% CI, 1.55-6.32]; P = .001) and younger age (OR, 1.06 [95% CI, 1.02-1.10]; P = .001) as risk factors for an infection. Compared with bone-patellar tendon-bone autografts, both hamstring tendon autografts (OR, 4.39 [95% CI, 2.15-8.96]; P < .001) and allografts (OR, 5.27 [95% CI, 1.81-15.35]; P = .002) were independently associated with an increased risk of infections. Overall, 15 ACL grafts were removed (31.3%). No statistically significant differences besides the number of irrigation and debridement procedures were found for retained versus removed grafts, although some trends were identified (P = .054). CONCLUSION In a large single-center cohort of patients who had undergone ACLR and those with an infection after ACLR, patients with revision cases and younger patients were found to have a higher incidence of infection. The use of bone-patellar tendon-bone autografts was found to be associated with the lowest risk of infection after ACLR compared with both hamstring tendon autografts and allografts. Larger cohorts with a larger number of infection cases are needed to determine the factors associated with graft retention versus removal.
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Affiliation(s)
- Niv Marom
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Milan Kapadia
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Joseph T Nguyen
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Brittany Ammerman
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Caroline Boyle
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Isabel Wolfe
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Kristin C Halvorsen
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Andy O Miller
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Michael W Henry
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Barry D Brause
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Jo A Hannafin
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Robert G Marx
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Anil S Ranawat
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
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13
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Truong AP, Pérez-Prieto D, Byrnes J, Monllau JC, Vertullo CJ. Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study. Am J Sports Med 2022; 50:922-931. [PMID: 35180008 DOI: 10.1177/03635465211073338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although presoaking grafts in vancomycin has been demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. PURPOSE To 1) determine the cost-effectiveness of vancomycin presoaking during primary ACLR to prevent postoperative joint infections and 2) to establish the break-even cost-effectiveness threshold of the technique and determine its cost-effectiveness across various international health care settings. STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS A Markov model was used to determine cost-effectiveness and the incremental cost-effectiveness ratio of additional vancomycin presoaking compared with intravenous antibiotic prophylaxis alone. A repeated search of the PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials databases, using the same criteria as a recent meta-analysis, was completed. A repeated meta-analysis of 9 cohort studies (level 3 evidence) was completed to determine the odds ratio of infection with vancomycin presoaking compared with intravenous antibiotics alone. Estimated costs of the vancomycin technique, treatment of infection, and further surgery were sourced from local hospitals and literature. Transitional probabilities for further surgery, including revision reconstruction and primary arthroplasty, were obtained from the literature. Probabilistic sensitivity analyses and a 1-way sensitivity analysis were performed to evaluate the ACLR infection rate break-even threshold for which the vancomycin technique would be no longer cost-effective. RESULTS The vancomycin soaking technique provides expected cost savings of $660 (USA), A$581 (Australia), and €226 (Spain) per patient. There was an improvement in the quality-adjusted life-years of 0.007 compared with intravenous antibiotic prophylaxis alone (4.297 vs 4.290). If the infection rate is below 0.014% with intravenous antibiotics alone, the vancomycin wrap would no longer be cost-effective. CONCLUSION The vancomycin presoaking technique is a highly cost-effective method to prevent postoperative septic arthritis after primary ACLR.
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Affiliation(s)
- Anthony P Truong
- Department of Orthopaedics, Toowoomba Base Hospital & Gold Coast University Hospital, Toowoomba, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Daniel Pérez-Prieto
- ICATKNEE, Hospital Universitari Dexeus, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Joshua Byrnes
- Centre for Applied Health Economics, Menzies Health Institute Queensland, School of Medicine and Dentistry, Griffith University, Brisbane, Queensland, Australia
| | - Joan C Monllau
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Department of Orthopaedic Surgery and Traumatology, Hospital del Mar ICATKNEE, Hospital Universitari Dexeus, Barcelona, Spain
| | - Christopher J Vertullo
- Orthopaedic Surgery & Sports Medicine Centre, Gold Coast, Queensland, Australia.,Knee Research Australia, Gold Coast, Queensland, Australia.,Menzies Health, Griffith University, Brisbane, Queensland, Australia.,Australian Knee Society.,Australian Orthopaedic Association.,AOA Continuing Orthopaedic Education
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14
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Carrozzo A, Saithna A, Ferreira A, Guy S, Chadli L, Monaco E, Pérez-Prieto D, Bohu Y, Vieira TD, Sonnery-Cottet B. Presoaking ACL Grafts in Vancomycin Decreases the Frequency of Postoperative Septic Arthritis: A Cohort Study of 29,659 Patients, Systematic Review, and Meta-analysis From the SANTI Study Group. Orthop J Sports Med 2022; 10:23259671211073928. [PMID: 35155711 PMCID: PMC8832611 DOI: 10.1177/23259671211073928] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 02/03/2023] Open
Abstract
Background: Presoaking anterior cruciate ligament (ACL) grafts in vancomycin has been reported to reduce the occurrence of septic arthritis (SA). However, strong recommendations for its universal use have been precluded by concerns regarding the fragility of previous meta-analyses. Purpose: The primary objective was to investigate whether presoaking ACL grafts in vancomycin was associated with a reduction in the rate of SA in a large series of patients. The secondary objective was to perform an updated systematic review and meta-analysis to determine the efficacy of vancomycin in reducing the rate of SA. Study Design: Cohort study and systematic review; Level of evidence, 3. Methods: A retrospective analysis of patients who underwent primary ACL reconstruction (ACLR) at our institution was undertaken. Rates of postoperative SA were determined and analyzed according to whether patients had received grafts presoaked in vancomycin. A systematic review of the literature and meta-analysis was performed. Odds ratios (ORs) for the risk of SA were calculated according to the inverse variance approach. Results were presented using forest plots, funnel plots, and the fragility index. Results: A total of 5300 patients underwent primary ACLR during the study period. The rate of SA was 0.34% (11/3228) in the control group and 0.05% (1/2072) in the presoaked group. There was a 5-fold greater risk of SA in patients who did not receive grafts presoaked in vancomycin (OR, 5.13 [95% CI, 1.16-48.30]; P = .04). Overall, 11 studies were included in the systematic review (29,659 ACLR procedures). The meta-analysis demonstrated a significantly greater risk of SA in those patients who did not receive grafts presoaked in vancomycin (OR, 14.39 [95% CI, 5.90-35.10]; fragility index = 23). This finding held true for the subpopulation receiving hamstring tendon grafts (fragility index = 16), but only a trend was demonstrated for bone–patellar tendon–bone grafts. Conclusion: The meta-analysis demonstrated that presoaking ACL grafts in vancomycin was associated with significant reductions in the rates of SA when all graft types were analyzed together. This finding held true specifically for hamstring tendon autografts. The fragility index of these findings allows for a strong recommendation for the universal use of vancomycin presoaking. However, it should be noted that only a trend toward reduced SA rates was demonstrated with presoaking bone–patellar tendon–bone autografts in vancomycin.
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Affiliation(s)
| | | | | | | | | | - Edoardo Monaco
- Orthopaedic and Trauma Surgery Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
- Catalan Institute of Traumatology and Sports Medicine, Dexeus University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Yoann Bohu
- Clinique du Sport, Paris, France
- Institut de l’Appareil Locomoteur Nollet, Paris, France
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15
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Patients return to sports and to work after successful treatment of septic arthritis following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:1871-1879. [PMID: 34870732 PMCID: PMC9159288 DOI: 10.1007/s00167-021-06819-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine specific return to sports (RTS) and return to work (RTW) rates of patients with septic arthritis following anterior cruciate ligament reconstruction (ACLR), and to assess for factors associated with a diminished postoperative return to physical activity after successful eradication of the infection. METHODS In this study, patients who were treated for postoperative septic arthritis of the knee following anterior cruciate ligament reconstruction between 2006 and 2018 were evaluated at a minimum follow-up (FU) of 2 years. Patients' outcomes were retrospectively analyzed using standardized patient-reported outcome scores including the Lysholm score and the subjective IKDC score, as well as return to sports and return to work questionnaires to assess for the types, number, and frequency of sports performed pre- and postoperatively and to evaluate for potential occupational changes due to septic arthritis following ACLR. To assess for the signifiance of the graft at follow-up, outcomes were compared between patients with a functioning graft at FU and those without, as well as between patients with initial graft retention and those with graft removal and consecutive revision ACLR. RESULTS Out of 44 patients eligible for inclusion, 38 (86%) patients at a mean age of 36.2 ± 10.3 years were enrolled in this study. At a mean follow-up of 60.3 ± 39.9 months, the Lysholm score and the subjective IKDC score reached 80.0 ± 15.1 and 78.2 ± 16.6 points, respectively. The presence of a graft at FU yielded statistically superior results only on the IKDC score (p = 0.014). There were no statistically significant differences on the Lysholm score (n.s.) or on the IKDC score (n.s.) between patients with initial graft retention and those with initial removal who had undergone revision ACLR. All of the included 38 patients were able to return to sports at a median time of 8 (6-16) months after their last surgical intervention. Among patients who performed pivoting sports prior to their injury, 23 (62.2%) returned to at least one pivoting sport postoperatively. Overall, ten patients (26.3%) returned to all their previous sports at their previous frequency. The presence of a graft at FU resulted in a significantly higher RTS rate (p = 0.010). Comparing patients with initial graft retention and those with graft removal and consecutive revision ACLR, there was no statistically significant difference concerning the RTS rate (n.s.). Thirty-one patients (83.8%) were able to return to their previous work. CONCLUSION Successful eradication of septic arthritis following anterior cruciate ligament reconstruction allows for a postoperative return to sports and a return to work particularly among patients with ACL-sufficient knees. However, the patients' expectations should be managed carefully, as overall return rates at the pre-injury frequency are relatively low. LEVEL OF EVIDENCE IV.
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16
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Georgoulis J, Mavrogenis A, Gkiatas I, Chatzipapas C, Koulalis D, Mastrokalos D, Hantes M, Georgoulis A. Higher infection rate after ACL reconstruction with hamstrings tendon autografts compared to bone patellar bone tendon autografts: a review. J Long Term Eff Med Implants 2022; 32:9-13. [DOI: 10.1615/jlongtermeffmedimplants.2022041978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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17
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Taniguchi Y, Kanamori A, Yamazaki M. Difficult Diagnosis of Fungal Arthritis After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00069. [PMID: 35102035 DOI: 10.2106/jbjs.cc.21.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE An 18-year-old woman underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) but developed recurrent knee effusion. At age 25 years, her right knee pain worsened, and radiographs revealed extensive bone loss. She was diagnosed with fungal (Candida parapsilosis) osteomyelitis by synovial fluid cultures. She underwent 2-stage surgery involving an amphotericin B-loaded cement spacer implantation and bone defect grafting. No recurrence of infection has been noted for 3 years postoperatively. CONCLUSIONS Fungal osteomyelitis may have few signs of local infection and often remains undiagnosed until bone loss occurs. Differential diagnosis should include this disease when there is recurrent knee effusion after ACLR.
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Affiliation(s)
- Yu Taniguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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18
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Meglic U, Salapura V, Zupanc O. MRI Findings of Early Osteoarthritis in Patients Who Sustained Septic Arthritis of the Knee After ACL Reconstruction. Orthop J Sports Med 2021; 9:23259671211052519. [PMID: 34778482 PMCID: PMC8573493 DOI: 10.1177/23259671211052519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/26/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Although a rare complication, septic arthritis (SA) after anterior cruciate ligament (ACL) reconstruction has potentially devastating consequences for the knee joint. Purpose: To prospectively analyze, at a mean 4-year follow-up, subjective, clinical, radiographic, and magnetic resonance imaging (MRI) findings between patients with SA and those with no septic complication after ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Of 2006 ACL reconstructions performed between 2004 and 2014, a total of 20 patients experienced SA. All patients were treated with arthroscopic irrigation and graft-retaining debridement immediately after diagnosis and at least 6 weeks of antibiotic treatment. After the exclusion process, 18 patients were included in the SA group and 20 in the control group. At final follow-up at a mean 48 months, a physical examination, KT-1000 arthrometer laxity test, Lysholm knee score, Tegner activity score, and International Knee Documentation Committee radiographic score were completed and then compared with preoperative data. The Boston-Leeds Osteoarthritis Knee Score was used for MRI evaluation at final follow-up to note chondral changes. Results: No significant differences between the SA and control groups were observed in pre- and perioperative variables that could indicate a higher incidence of early osteoarthritis (OA). Although range of motion and knee stability were not significantly different between the groups at final follow-up, the Lysholm score (mean ± SD, 79.8 ± 13.1 vs 90.9 ± 8.6; P < .01) and Tegner score (6.0 ± 1.1 vs 7.0 ± 1.4; P = .03) were significantly lower in the SA group as compared with the control group. MRI evaluation at final follow-up demonstrated a significantly higher degree of early knee OA in the SA group versus the control group. However, no differences in the degree of OA were seen on plain radiographs at final follow-up between the groups. Conclusion: MRI evaluation provided signs of worsened chondral state in the SA group, which could be associated with reduced functional outcome and return to sports. In contrast to radiograph analyses, MRI was excellent at distinguishing damage to the cartilage and can be useful in early follow-up evaluation of patients with SA after ACL reconstruction.
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Affiliation(s)
- Uros Meglic
- Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vladka Salapura
- Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Oskar Zupanc
- Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
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19
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bourbour S, Emaneini M, Mortazavi SJ, Tahmasebi MN, yahyazadeh H, Jabalameli M, Jabalameli F. A More Positive Culture by Resin-containing Media Usage after Suspicious Arthroscopic Infections in Patients Receiving Antimicrobial Therapy. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:496-502. [PMID: 34692931 PMCID: PMC8503766 DOI: 10.22038/abjs.2020.51361.2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although infections following arthroscopic surgery of cruciate ligament and meniscus are uncommon, they have potentially serious consequences for the graft and articular cartilage. This study aimed to investigate the efficacy of correct sampling and appropriate media, especially resin-containing media, for the detection of infections in patients receiving antibiotics under suspicion of joint infection after arthroscopic anterior cruciate ligament (ACL) and meniscal surgery. In such cases, proper sampling and the use of suitable culture media that cause the neutralization of antibiotics are very effective in isolating microorganisms from the patient samples and positive cultures. METHODS In total, 10 patients who had received antibiotics with suspected knee infection after arthroscopic ACL and meniscal surgery were identified after referral to surgeons during a period of 10 months and investigated in this study. The sample collection, culture on various media (i.e., resin-containing culture media), microbiological tests, and antibiotic susceptibility tests were performed in this study. The amplification of the mecA gene using PCR assay was accomplished for methicillin-resistant staphylococcus strains. RESULTS This study was conducted on 10 patients who underwent arthroscopic procedures and had received antibiotics. Overall, joint fluid and tissue culture were positive in 60% of the patients. The resin-containing media revealed a trend toward increased detection of bacteria. Coagulase-negative staphylococcus strains were the most frequently isolated bacteria in arthroscopic ACL surgery infections. Out of five methicillin-resistant staphylococcus strains, four strains were found that were resistant to cefoxitin and positive-mecA designated as methicillin-resistant strains. Except for one case, the rest of the staphylococcal strains were resistant to methicillin but susceptible to vancomycin. CONCLUSION Despite uncommon and low percentage of infections after arthroscopic ACL and meniscal surgery, the results of our study showed that correct sampling, appropriate cultures, especially aerobic and anaerobic resin-containing media, and microbiological testing remained useful and valuable for diagnosing bacterial infections.
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Affiliation(s)
- Samaneh bourbour
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Emaneini
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - S.M. Javad Mortazavi
- Tehran University of Medical Sciences, knee and hip surgeon, Department of Orthopedic Surgery, Imam Khomaini Hospital, Tehran, Iran
| | - Mohamad Naghi Tahmasebi
- Tehran University of Medical Sciences, knee surgeon, Department of Orthopedic Surgery, Shariati Hospital, Tehran, Iran
| | - Hooman yahyazadeh
- Orthopaedic surgeon, bone and joint reconstruction research center, University of Medical Sciences, Department of Orthopedic Surgery, Shafa Yahyaiyan Hospital, Tehran, Iran
| | - Mahmoud Jabalameli
- Orthopaedic surgeon, bone and joint reconstruction research center, University of Medical Sciences, Department of Orthopedic Surgery, Shafa Yahyaiyan Hospital, Tehran, Iran
| | - Fereshteh Jabalameli
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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20
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Yamasaki S, Hashimoto Y, Han C, Nishino K, Hidaka N, Nakamura H. Patients with a quadriceps tendon shorter than 60 mm require a patellar bone plug autograft in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1927-1935. [PMID: 32909058 DOI: 10.1007/s00167-020-06261-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the length and thickness of the quadriceps tendon (QT) and anterior cruciate ligament (ACL) to predict the required QT length for individual ACL reconstruction. METHODS Thirty patients (9 females, 21 males; mean age 24.5 years; mean height 169.3 cm) who underwent ACL reconstruction using the QT with a bone plug autograft were enrolled. The length and thickness of the QT on preoperative magnetic resonance imaging (MRI) were compared with those measured under direct visualization. The ACL length was measured on preoperative MRI and three-dimensional computed tomography after ACL reconstruction. The QT length on MRI was compared with the required graft length, and the factors related to an adequate QT length were assessed. RESULTS The mean QT length on MRI was 60.8 ± 1.3 mm and was significantly positively correlated with the QT length under direct visualization (P < 0.01). On MRI, the mean ACL length was 30.8 ± 1.2 mm and the mean QT thickness was 6.3 ± 0.2 mm. Although the mean QT was 0.1 mm longer than the mean required graft length, the QT on MRI was shorter than the required graft length in 37% of patients (11/30). Adequate QT length was related to a QT length of more than 60 mm, but not to age, sex, height, or ACL length. CONCLUSION Although preoperative MRI predicted the required QT length for ACL reconstruction, 37% of patients lacked an adequate QT length, and a QT shorter than 60 mm required the addition of patellar bone. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shinya Yamasaki
- Department of Orthopaedics Surgery, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan. .,Department of Orthopaedics Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Yusuke Hashimoto
- Department of Orthopaedics Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Changhun Han
- Department of Orthopaedics Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazuya Nishino
- Department of Orthopaedics Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Noriaki Hidaka
- Department of Orthopaedics Surgery, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedics Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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21
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Costa GG, Grassi A, Lo Presti M, Cialdella S, Zamparini E, Viale P, Filardo G, Zaffagnini S. White Blood Cell Count Is the Most Reliable Test for the Diagnosis of Septic Arthritis After Anterior Cruciate Ligament Reconstruction: An Observational Study of 38 Patients. Arthroscopy 2021; 37:1522-1530.e2. [PMID: 33278527 DOI: 10.1016/j.arthro.2020.11.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE (1) To evaluate the diagnostic testing performance of the synovial white blood cell (WBC) count, polymorphonuclear cell percentage, and synovial glucose, synovial protein, synovial lactate dehydrogenase, and synovial C-reactive protein levels as diagnostic markers for the diagnosis of septic arthritis after anterior cruciate ligament (ACL) reconstruction; (2) to define the ideal thresholds of the aforementioned tests, leading to the optimal sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy; and (3) to define the sensitivity of synovial fluid culture and synovial tissue sample culture, as well as determine whether previous antibiotic treatment may affect the accuracy of these tests. METHODS We performed a retrospective analysis of all patients readmitted from January 2009 to September 2019 with signs suggestive of septic arthritis and undergoing a knee aspiration for synovial fluid analysis and culture. The receiver operating characteristic curve and the associated area under the curve were constructed for the aforementioned synovial markers. Sensitivity, specificity, PPV, NPV, and accuracy were calculated for the obtained optimal values. Sensitivity was also calculated for synovial fluid culture and synovial tissue sample culture, and the influence of previous antibiotic treatments on culture sensitivity was evaluated. RESULTS Among 3,408 cases of ACL reconstruction, after the exclusion of 13 patients not meeting the inclusion criteria, 24 infected and 14 uninfected patients were reviewed and included in the analysis. The diagnosis was confirmed by the presence of 2 positive culture findings with the same isolated microorganism or at least 3 of the 4 following criteria: elevated serum C-reactive protein level and erythrocyte sedimentation rate, positive results of histologic analysis of synovial tissue, macroscopic evidence of purulence, and 1 positive culture finding. The receiver operating characteristic curve analysis showed that the most reliable marker for the diagnosis of septic arthritis after ACL reconstruction was the synovial WBC count (area under the curve, 0.89). A cutoff value of 28,100 cells/mL presented the highest accuracy (0.85), highest PPV (0.94), and highest NPV (0.76); moreover, with the threshold set at 40,000 cells/mL, postoperative infection could be diagnosed with 100% specificity. The sensitivity of synovial fluid culture was significantly lower than the sensitivity of synovial tissue sample culture (0.63 vs 0.96, P = .0045); moreover, the sensitivity further decreased if patients took antibiotics before aspiration (0.44 vs 0.73), although this decrease was not statistically significant. CONCLUSIONS The synovial WBC count is the most reliable test for the diagnosis of septic arthritis after ACL reconstruction. Although the sensitivity of synovial fluid culture is affected by previous antibiotic treatment, the synovial WBC count is not influenced and proves to be useful in the diagnosis of this uncommon complication. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
| | - Alberto Grassi
- II Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Mirco Lo Presti
- II Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Sergio Cialdella
- II Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eleonora Zamparini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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22
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Paci JM. Editorial Commentary: Synovial Fluid White Blood Cell Is the Gold Standard to Detect Infection After Anterior Cruciate Ligament Reconstruction: Don't Hesitate to Aspirate. Arthroscopy 2021; 37:1531-1533. [PMID: 33896505 DOI: 10.1016/j.arthro.2020.12.221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
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.
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Lower incidence of post-operative septic arthritis following revision anterior cruciate ligament reconstruction with quadriceps tendon compared to hamstring tendons. Knee Surg Sports Traumatol Arthrosc 2020; 28:2572-2577. [PMID: 32020252 DOI: 10.1007/s00167-020-05878-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/22/2020] [Indexed: 01/23/2023]
Abstract
PURPOSE To determine and compare the incidence of post-operative septic arthritis following revision anterior cruciate ligament reconstruction (R-ACLR) with autologous quadriceps tendon (with patellar bone block) compared to autologous hamstring tendons (semitendinosus and gracilis). METHODS A total of 1638 isolated R-ACLR with either autologous hamstring tendons (n = 1004, 61.3%) or quadriceps tendon (n = 634; 38.7%) were performed between 2004 and 2017 and were retrospectively analysed with regard to the occurrence of post-operative septic arthritis. The technique of R-ACLR did not significantly change during the years of the study. All patients received pre-op i.v.antibiotics, but no presoaking of the grafts in vancomycin was performed in the years of the study. The individual decision of graft choice was based on graft availability, tunnel position and the presence of tunnel widening. Generally, hamstring tendons were preferred. There were no clinically relevant differences between the groups regarding gender or age. Routine follow-up examination was performed 6 weeks after the index operation (follow-up rate 96.5%), and patients unsuspicious for septic arthritis at that time were classified as non-infected. RESULTS Fourteen patients with septic arthritis were identified, resulting in an overall incidence of 0.85%. There was one patient with septic arthritis in the quadriceps tendon group (incidence: 0.16%) and 13 patients in the hamstring tendons group (incidence: 1.29%), respectively. The difference was significant (p = 0.013). CONCLUSION In this series, the incidence of post-operative septic arthritis after R-ACLR was lower when quadriceps tendon graft was used compared to hamstring tendon grafts. LEVEL OF EVIDENCE III.
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Soaking of the graft in vancomycin dramatically reduces the incidence of postoperative septic arthritis after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2587-2591. [PMID: 32030505 DOI: 10.1007/s00167-020-05882-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine and compare the incidence of postoperative septic arthritis following anterior cruciate ligament reconstruction (ACLR) with and without soaking of the graft in vancomycin solution prior to implantation in a large single-centre case series. METHODS From 2004 to 2019, a total of 10,516 primary ACLR were performed and reviewed with regard to the occurrence of postoperative septic arthritis. From February 2017 onwards, all grafts were wrapped in a vancomycin-soaked (5 mg/ml) gauze swab between harvest and implantation (2294 patients, treatment group (2), prospectively followed). These were compared to 8222 patients before that date (control group (1), retrospectively evaluated). The technique of ACLR did not significantly change during the years of the study. There was no difference between the groups with regard to graft choice: Hamstring tendons were used in 99% and quadriceps tendons were used in 1% in both groups, respectively (n.s.). Routine follow-up examination was performed at 6 weeks (follow-up rate 97.1%) postoperatively. Patients with no treatment for septic arthritis at that time were classified as non-infected. RESULTS There were 35 cases of postoperative septic arthritis in group 1 (incidence: 0.4%), and none in group 2 (incidence 0.0%), respectively. The difference was significant (p < 0.001). CONCLUSIONS Soaking of the graft in vancomycin solution prior to implantation dramatically reduces the incidence of postoperative septic arthritis in primary ACLR and should, therefore, be used in prevention of this major complication. LEVEL OF EVIDENCE III.
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Lo Presti M, Costa GG, Grassi A, Cialdella S, Agrò G, Busacca M, Pia Neri M, Filardo G, Zaffagnini S. 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. Am J Sports Med 2020; 48:1907-1915. [PMID: 32520578 DOI: 10.1177/0363546520924823] [Citation(s) in RCA: 12] [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 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.
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Affiliation(s)
- Mirco Lo Presti
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Alberto Grassi
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Sergio Cialdella
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Agrò
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maurizio Busacca
- Department of Radiology and Diagnostic Imaging, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maria Pia Neri
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Naendrup JH, Marche B, de Sa D, Koenen P, Otchwemah R, Wafaisade A, Pfeiffer TR. Vancomycin-soaking of the graft reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2020; 28:1005-1013. [PMID: 30656372 DOI: 10.1007/s00167-019-05353-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 01/11/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE (1) To compare the incidence of post-operative septic arthritis following anterior cruciate ligament reconstruction (ACLR) between patients receiving routine pre-operative intravenous (IV) prophylaxis only intravenous (IV) infection prophylaxis and patients receiving additional graft-soaking in a vancomycin solution (5 mg/ml) perioperatively. (2) To review the literature regarding effects of graft-soaking in vancomycin solutions on outcomes, complication rates and tendon properties in ACLR. METHODS To identify studies pertaining to routine pre-operative IV prophylaxis and additional usage of intra-operative vancomycin-soaked grafts in primary ACLR, the Cochrane Library, SCOPUS and MEDLINE were searched till June 2018 for English and German language studies of all levels of evidence following the PRISMA guidelines. Additionally, all accepted abstracts at the ESSKA 2018, ISAKOS 2017, AGA 2017 and AOSSM 2017 meetings were screened. Data regarding the incidence of septic arthritis were abstracted and combined in a meta-analysis. Data including outcome scores, complication rates and in vitro analyses of tendon properties were collected and summarized descriptively. RESULTS Upon screening 785 titles, 8 studies were included. These studies examined 5,075 patients following ACLR and followed from 6 to 52 weeks post-operatively. Of those 2099 patients in the routine pre-operative IV prophylaxis group, 44 (2.1%) cases of early septic arthritis were reported. In contrast, there were no reports of septic arthritis following ACLR in 2976 cases of vancomycin-soaked grafts. The meta-analysis yielded an odds ratio of 0.04 (0.01-0.16) favouring the addition of intra-operative vancomycin-soaking of grafts. Across all available studies, no differences in clinical outcome (i.e. incidence of ACL revision, IKDC score, Tegner score), biomechanical tendon properties, or cartilage integrity between patients with and without vancomycin-soaked grafts were identified. CONCLUSION The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively prior to graft passage and fixation. Within the limitation confines of this study, intra-operative graft-soaking in vancomycin appears to be a safe and effective method to reduce the incidence of septic arthritis following ACLR. Still, it remains debatable if the available data facilitate the recommendation for a universal application of vancomycin-soaking for all ACLR patients or if it should be reserved for patients at risk, including the use hamstring tendons, revision cases and in the presence of medical preconditions. LEVEL OF EVIDENCE Level IV, systematic review of Level III and Level IV studies.
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Affiliation(s)
- Jan-Hendrik Naendrup
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany.,Department of Orthopaedic Surgery, University of Pittsburgh-UPMC Rooney Sports Complex, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Benedikt Marche
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Darren de Sa
- Department of Orthopaedic Surgery, University of Pittsburgh-UPMC Rooney Sports Complex, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Paola Koenen
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Robin Otchwemah
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Thomas R Pfeiffer
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany. .,Department of Orthopaedic Surgery, University of Pittsburgh-UPMC Rooney Sports Complex, 3200 S Water St, Pittsburgh, PA, 15203, USA.
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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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Gramlich Y, Klug A, Walter G, Kremer M, Hoffmann R, Kemmerer M. Septic Arthritis of Native Shoulder and Knee Joint: What Are the Differences in Bacterial Spectrum, Treatment, and Outcome? Surg Infect (Larchmt) 2019; 21:391-397. [PMID: 31841653 DOI: 10.1089/sur.2019.245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Acute native septic arthritis is a joint-threatening emergency. To date, however, no gold-standard treatment nor joint-specific treatment algorithms exist. We aimed to evaluate the etiologies, bacterial spectrum, treatments, and surgical outcomes of septic arthritis of the shoulder and knee. Methods: Seventy-one patients with septic arthritis of either the knee (n = 42) or the shoulder (n = 29) were followed over a mean period of 40 months (26-65). Data were collected according to the performed surgical procedure and pathway as well as the cause of infection, bacterial spectrum, and the Gächter classification. The prospective clinical examination included the Knee Society Score (KSS) or Constant Score (CS; shoulder group), pre- and post-operative pain, and return to previous activity. Results: Septic arthritis was caused primarily by post-interventional or post-traumatic conditions in the knee group and by hematogenous infection in the shoulder group. Staphylococcus aureus and S. epidermidis were most common, whereas Propionibacerium. were seen only in shoulder infections. Remission rates were 95% in the knee versus 90% in the shoulder group, whereas the mortality rate in the shoulder group was 10% (no one died in the knee group). While most knee infections could be managed with an arthroscopic approach, all shoulder infections necessitated an open approach. The mean KSS was 87.3 (49-100); the mean CS was 66.6 (37-95). Fifty percent of patients in the shoulder group versus 71% in the knee group reached their previous level of activity. Conclusion: The knee group exhibited post-interventional etiology, in line with high-virulence microbes and a high success rate with arthroscopic restoration. Septic shoulder arthritis showed hematogenous scattering, low-virulent microbes, and multiple interventions with a final open approach was always required. In contrast to the knee, in septic arthritis of the shoulder, a significant reduction in function has to be expected.
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Affiliation(s)
- Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Gerhard Walter
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Michael Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Matthias Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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Brophy RH, Huston LJ, Wright RW, Liu X, Amendola A, Andrish JT, Flanigan DC, Jones MH, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Wolcott ML, Wolf BR, Spindler KP. Patients treated with surgical irrigation and debridement for infection after ACL reconstruction have a high rate of subsequent knee surgery. J ISAKOS 2019. [DOI: 10.1136/jisakos-2018-000264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Schüttler KF, Scharm A, Stein T, Heyse TJ, Lohoff M, Sommer F, Spiess-Naumann A, Efe T. Biomechanical and microbiological effects of local vancomycin in anterior cruciate ligament (ACL) reconstruction: a porcine tendon model. Arch Orthop Trauma Surg 2019; 139:73-78. [PMID: 30039308 DOI: 10.1007/s00402-018-3006-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Karl-Friedrich Schüttler
- Centre for Orthopedics and Trauma Surgery, University Hospital Marburg, 35043, Marburg, Germany.
| | - Alexander Scharm
- Centre for Orthopedics and Trauma Surgery, University Hospital Marburg, 35043, Marburg, Germany
| | - Thomas Stein
- Department of Sporttraumatology, Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
- Department of Sports Science, University of Bielefeld, Bielefeld, Germany
| | - Thomas J Heyse
- Centre for Orthopedics and Trauma Surgery, University Hospital Marburg, 35043, Marburg, Germany
| | - Michael Lohoff
- Institute of Medical Microbiology and Hygiene, University of Marburg, Marburg, Germany
| | - Frank Sommer
- Institute of Medical Microbiology and Hygiene, University of Marburg, Marburg, Germany
| | - Anja Spiess-Naumann
- Centre for Orthopedics and Trauma Surgery, University Hospital Marburg, 35043, Marburg, Germany
| | - Turgay Efe
- Centre for Orthopedics and Trauma Surgery, University Hospital Marburg, 35043, Marburg, Germany
- Orthopeadicum Lich, Gottlieb-Daimler-Str. 7a, 35423, Lich, Germany
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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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Lauper N, Davat M, Gjika E, Müller C, Belaieff W, Pittet D, Lipsky BA, Hannouche D, Uçkay I. Native septic arthritis is not an immediate surgical emergency. J Infect 2018; 77:47-53. [PMID: 29742468 DOI: 10.1016/j.jinf.2018.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/21/2018] [Accepted: 02/07/2018] [Indexed: 12/23/2022]
Abstract
Acute native joint septic arthritis is generally considered a surgical emergency, requiring drainage within hours, including during night, weekend or holiday shifts. However, there are few data supporting the need for the disruption caused by this degree of urgency. METHODS We performed a retrospective review of all adult patients seen in our medical center from 1997-2015 with culture-proven septic arthritis and noted the epidemiology of sequelae, and their possible association with a delay in surgical drainage. RESULTS Of 204 septic arthritis episodes, 46 (23%) involved interdigital hand and foot joints. Large joints involved included the knee (n = 67), shoulder (48), hip (22), ankle (8), acromio-clavicular (5), elbow (4), wrist (3), and sterno-clavicular (1) regions. All patients underwent surgical drainage of the joint and received targeted systemic antibiotic therapy. Sequelae of varying severity occurred in 83 patients (41%): recurrences (n = 15); secondary arthrosis (30); persistent pain (9); Girdlestone procedure (9); arthrodesis (9); amputation (8); stiffness (8); and Chronic Regional Pain Syndrome (2). By multivariate Cox regression analysis factors did not predict sequelae included: age; treatment with systemic corticosteroids; pre-existing clinical or radiological arthropathy; total duration of antibiotic therapy; type of joint; and, number of surgical interventions. Similarly, there was no association of sequelae with the number of days of pre-hospitalization joint symptoms (hazard ratio 1.0, 95% confidence interval 0.99-1.01) or hours spent in the emergency department (HR 1.0, 0.9-1.2). Notably, patients who had joint lavage within 6 h of presentation had similar functional outcomes as those with lavage done at 6-12 h, 12-24 h, or > 24 h after presentation. CONCLUSIONS Our data suggest that for native septic arthritis, in the absence of clinical sepsis immediate joint drainage does not appear to reduce the risk of sequelae compared with delayed drainage.
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Affiliation(s)
- Nicolas Lauper
- Orthopaedic Surgery Service, Geneva University Hospitals
| | - Marie Davat
- Orthopaedic Surgery Service, Geneva University Hospitals
| | - Ergys Gjika
- Orthopaedic Surgery Service, Geneva University Hospitals; Hand Surgery Unit, Geneva University Hospitals
| | - Camillo Müller
- Orthopaedic Surgery Service, Geneva University Hospitals; Hand Surgery Unit, Geneva University Hospitals
| | | | - Didier Pittet
- Service of Infectious Diseases, Geneva University Hospitals; Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals; Division of Medical Sciences, University of Oxford, UK
| | | | - Ilker Uçkay
- Orthopaedic Surgery Service, Geneva University Hospitals; Service of Infectious Diseases, Geneva University Hospitals; Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Mena Rosón A, Valencia García H, Moreno Coronas F. Septic arthritis caused by Granulicatella adiacens after anterior cruciate ligament reconstruction. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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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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Mena Rosón A, Valencia García H, Moreno Coronas FJ. Septic arthritis caused by Granulicatella adiacens after anterior cruciate ligament reconstruction. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018; 62:204-206. [PMID: 29422445 DOI: 10.1016/j.recot.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/01/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022] Open
Abstract
Septic arthritis after knee arthroscopy is an extremely rare condition. A rate of 0.15-0.84% cases of postoperative infection is estimated in several series. The arthroscopy procedure most frequently related with an infectious complication is anterior cruciate ligament (ACL) reconstruction, with a prevalence of 0.3-1.7% cases. Staphylococcus sp. is the pathogen most commonly cultured. We describe a case of septic arthritis after ACL reconstruction. We found no published case of septic arthritis caused by this microorganism after knee arthroscopy. It is probably the first case published in the literature.
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Affiliation(s)
- A Mena Rosón
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | - H Valencia García
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - F J Moreno Coronas
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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Erice A, Neira MI, Vargas-Prada S, Chiaraviglio A, Gutiérrez-Guisado J, Rodríguez de Oya R. Septic arthritis following arthroscopic reconstruction of cruciate ligaments of the knee: retrospective case review. Enferm Infecc Microbiol Clin 2017; 36:336-341. [PMID: 28651785 DOI: 10.1016/j.eimc.2017.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Rupture of cruciate ligaments of the knee is a common injury that is repaired by arthroscopic reconstruction, which can give rise to septic arthritis. The objective of this article is to describe the clinical and microbiological aspects of this entity. METHODS Retrospective review of cases of septic arthritis following arthroscopic reconstruction of cruciate ligaments of the knee that occurred at a single institution from 2000-2015. According to time elapsed from surgery, infections were classified as acute (< 14 days), subacute (> 14 days and<30 days), and late (> 30 days). A descriptive and comparative analysis stratified by type of infection and causative microorganism was performed. RESULTS 3,219 patients underwent arthroscopic reconstruction of cruciate ligaments of the knee and 30 (0.9%) developed septic arthritis. Seventeen (57%) were acute infections and 12 (40%) subacute; there was one late infection. The causative microorganisms were coagulase-negative Staphylococci (n=13; 43%), Staphylococcus aureus (n=12; 40%), other grampositive cocci (n=3; 10%), and gramnegative bacilli (n=2; 7%). All patients underwent arthroscopic debridement; no grafts were removed. All patients received antibiotic therapy for a median of 23.5 days (range: 14 - 78 days); all infections were cured. No significant differences were found in any of the variables analysed among the infection type or the causative microorganism. CONCLUSIONS Septic arthritis after arthroscopic reconstruction of cruciate ligaments of the knee is uncommon. It generally presents within 4 weeks of surgery and is caused by Staphylococci. Its treatment consists of arthroscopic debridement (without necessarily removing the graft) and antibiotic therapy.
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Affiliation(s)
- Alejo Erice
- Departamento de Medicina Interna, Hospital Asepeyo, Coslada, Madrid, España.
| | - M Inmaculada Neira
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Santa Cristina,, Madrid, España
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Mester B, Ullerich F, Ohmann T, Glombitza M, Schoepp C. Ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction in a 13-year-old male. Orthop Traumatol Surg Res 2017; 103:619-622. [PMID: 28342819 DOI: 10.1016/j.otsr.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 02/02/2023]
Abstract
We present the case of an adolescent male developing an ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction (ACLR). The patient was shifted to our institution with postoperative septic arthritis associated with a systemic septic condition. Before, repeated arthroscopic surgery had been conducted without any improvement. MRI showed a concomitant osteomyelitis. The infection (Gächter IV, Staphylococcus aureus) was controlled by an open surgical approach and graft removal. An increasing joint stiffness was documented. X-rays showed an ankylosis at 30° of flexion and early closure of growth plates. Functional knee scores showed significantly worse results. Early diagnosis and a stage-adapted treatment in septic arthritis following ACLR are mandatory. In advanced stages or concomitant osteomyelitis an open approach and graft removal may be appropriate. The antibiotic treatment should be adapted consistently.
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Affiliation(s)
- B Mester
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Germany.
| | - F Ullerich
- Klinik für Arthroskopische Chirurgie, Sporttraumatologie und Sportmedizin, BG Klinikum Duisburg, Germany
| | - T Ohmann
- Forschungsabteilung, BG Klinikum Duisburg, Germany
| | - M Glombitza
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Germany
| | - C Schoepp
- Klinik für Arthroskopische Chirurgie, Sporttraumatologie und Sportmedizin, BG Klinikum Duisburg, Germany
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Figueroa D, Calvo R, Figueroa F, Paccot D, Izquierdo G, Morales N. Clinical and arthrometric outcomes of an anatomic outside-in single-bundle anterior cruciate ligament reconstruction using a retrodrill. Knee 2016; 23:1098-1105. [PMID: 27816290 DOI: 10.1016/j.knee.2016.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 05/28/2016] [Accepted: 07/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The main option to perform an anatomic anterior cruciate ligament (ACL) reconstruction is the anteromedial portal (AMP) technique. It has several reported complications (iatrogenic chondral injury, posterior-wall blowout, short sockets, increased risk of injury to common peroneal nerve). In an attempt to avoid these complications the outside-in (OI) technique was revived with the addition of a retrodrill. The aim of this study is to evaluate the clinical and arthrometric outcomes of a series of anatomical OI single bundle ACL reconstruction using a retrodrill. METHODS Prospective case series. KT-1000 and Pivot Shift Test were done at 24 months follow-up. International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores preoperatively and at final follow-up. Complications were reported. Statistical analysis was done with t-test. RESULTS 275 knees of 200 (73%) males and 75 (27%) females were enrolled in the study. Mean age 29.1 years (15-54). Mean follow-up 34.5 months (24-49). Mean preoperatively Lysholm Score 62 (25-95) versus 95 (76-100) at final follow-up (p<0.001) Mean preoperatively IKDC score 60 (26.4-90.8) versus 92 (59.8-100) at final follow-up (p<0.001) Mean Tegner activity Score pre injury 5 versus 5 at final follow-up. (p=0.59) Mean KT-1000 side-to-side difference 2mm (1-6). Pivot Shift test negative in 243 patients (90%); positive in 32 (10%) patients. 13 (5%) ACL re-ruptures. 2 (0.7%) infections. No other complications were reported. CONCLUSION OI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique.
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Affiliation(s)
- David Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile.
| | - Rafael Calvo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Francisco Figueroa
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Daniel Paccot
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Guillermo Izquierdo
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Nelson Morales
- The Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
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Editorial Commentary: Quadriceps Tendon Autograft Use for Anterior Cruciate Ligament Reconstruction Predicted to Increase. Arthroscopy 2016; 32:76-7. [PMID: 26743412 DOI: 10.1016/j.arthro.2015.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/03/2015] [Indexed: 02/02/2023]
Abstract
Quadriceps tendon autograft is the least utilized choice for anterior cruciate ligament reconstruction, but use is expected to increase. Harvest of the full thickness of the distal quadriceps tendon is of concern, but morbidity seems low.
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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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Lubowitz JH. Editorial Commentary: Hamstring Autografts Are More Frequently Associated With ACL Infection. Arthroscopy 2015; 31:1402. [PMID: 26143553 DOI: 10.1016/j.arthro.2015.04.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 02/02/2023]
Abstract
Hamstring autograft is associated with higher rates of ACL infection than other grafts. Hamstring grafts presoaked with vancomycin are recommended.
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Lubowitz JH. Editorial Commentary: Arthroscopy Is a Generally Effective Treatment for Septic Arthritis. Arthroscopy 2015; 31:1371. [PMID: 26143550 DOI: 10.1016/j.arthro.2015.04.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 02/02/2023]
Abstract
Hip bacterial septic arthritis is an indication for arthroscopy in combination with medical management. After arthroscopy, patients must be vigilantly observed; some patients require more than one irrigation and debridement.
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Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. Our Journals Arthroscopy and Arthroscopy Techniques Are Complementary. Arthroscopy 2015; 31:1219-20. [PMID: 26143548 DOI: 10.1016/j.arthro.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 02/02/2023]
Abstract
Your Editors are devoted to both of our journals, Arthroscopy and Arthroscopy Techniques. This month's content includes clinically relevant hip, knee, and shoulder research, and surgical techniques.
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