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Bartek B, Völkner A, Oehme S, Fahy S, Winkler T, Jung T. No significant difference in skin contamination during anterior cruciate ligament reconstruction with and without preoperative skin cleaning. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39359237 DOI: 10.1002/ksa.12476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 10/04/2024]
Abstract
PURPOSE This prospective study aimed to assess whether preoperative antiseptic skin cleansing reduces bacterial contamination and surgical site infections (SSI) following anterior cruciate ligament reconstruction (ACLR). We hypothesized that antiseptic cleaning would lower bacterial load, reducing contamination and early infections. METHODS One hundred and nineteen patients scheduled for ACLR were included in this prospective, nonrandomized study. Individuals were divided into two groups. Patients in the intervention group applied octenisan® wash lotion daily for three days before surgery and used the wash solution instead of their usual shower gel. Additionally, they swiped their leg with octenisan® soaked gloves on the morning of the operation. The control group followed their usual wash routine with no specific instructions. Fluid samples were taken before surgery from the irrigation bag and at 15-min intervals from the reservoir of the sterile surgical drape during the procedure. Suture material used for the ACL graft and meniscus repair were also collected for testing. The samples were subjected to a 14-day incubation period. Follow-up included outpatient visits at 6 weeks, 12 weeks and 6 months with a final evaluation at 12 months. RESULTS Contamination rates showed no significant difference between the control and intervention groups. The mean contamination rate in the control group was 6.4% (n = 22) and 6.6% (n = 24) in the intervention group (p = 0.28). At 12-month follow-up, 110 out of 119 participants were included (52 control, 58 intervention). T tests for age (p = 0.19), BMI (p = 0.66), and surgery duration (p = 0.38) showed no significant differences. No early SSI were observed in either group postoperatively. CONCLUSION Our results indicate that the use of antiseptic wash lotion and gloves does not influence the risk of bacterial contamination during surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Benjamin Bartek
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Alexandra Völkner
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Stephan Oehme
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Stephen Fahy
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Tobias Winkler
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Jung
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
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Cassano GD, Moretti L, Vicenti G, Buono C, Albano F, Ladogana T, Rausa I, Notarnicola A, Solarino G. Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature. Healthcare (Basel) 2024; 12:894. [PMID: 38727451 PMCID: PMC11083079 DOI: 10.3390/healthcare12090894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Infection is an uncommon side effect of arthroscopic surgery, and this percentage is higher in anterior cruciate ligament reconstruction (ACLR) surgery, where graft and fixation devices are used. Infections can not only lead to high re-admission rates and poor functional recovery of the knee but can also have a significant negative impact on the patient's psychological and economic health, especially in athletes, as it can affect their sports career. It is important to be aware of the many risk factors, especially the manifestation of symptoms. These may sometimes be non-specific to the infectious pathology and common to other situations, such as the presence of a significant intra-articular hematoma. Septic arthritis after ACLR can occur at any time after surgery but typically presents acutely, while late manifestation is relatively rare. Diagnosis of infection is based on patient history, physical examination, laboratory parameters, and analysis of synovial fluid after joint aspiration, which is the gold standard for diagnosing post-operative infection. Once symptoms appear and the diagnosis seems certain, it is necessary to intervene quickly with arthroscopic debridement and long-term antibiotic treatment to try to save the graft and resolve the infectious situation to avoid graft failure and arthrofibrotic sequelae. The aim of this paper is to provide an overview of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic evaluation, and current treatment guidelines of septic arthritis after ACLR surgery by analyzing recent literature, in particular meta-analyses and systematic reviews.
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Affiliation(s)
| | | | | | - Claudio Buono
- Orthopaedic & Trauma Unit, Department of Traslational Biomedicine and Neuroscience (DiBraiN), School of Medicine, University of Bari Aldo Moro, AOU Consorziale “Policlinico”, 70124 Bari, Italy; (G.D.C.); (L.M.); (G.V.); (F.A.); (T.L.); (I.R.); (A.N.); (G.S.)
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Häner M, Stoffels T, Guenther D, Pfeiffer T, Imhoff A, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Mehl J, Niederer D, Jung T, Kittl C, Eberle C, Vernacchia C, Ellermann A, Braun PJ, Krause M, Mengis N, Müller PE, Best R, Achtnich A, Petersen W. Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment. Knee Surg Sports Traumatol Arthrosc 2024; 32:223-234. [PMID: 38293720 DOI: 10.1002/ksa.12064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Martin Häner
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
| | | | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Andreas Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | | | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt am Main, Frankfurt, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | | | | | | | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel Niederer
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, Institute of Sport Science, University of Wuppertal, Wuppertal, Germany
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt, German
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Cara Vernacchia
- Department of Physical Medicine & Rehabilitation, Shirley Ryan Ability Lab, Chicago, Illinois, USA
- McGaw, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Pforzheim, Germany
- KSA Aarau/Spital Zofingen, Zofingen, Switzerland
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Tuebingen, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Wolf Petersen
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
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Burnett Z, Stoodley P, Flanigan DC. Editorial Commentary: Low-Grade Infections May Contribute to Anterior Cruciate Ligament Reconstruction Graft Failure. Arthroscopy 2024; 40:409-411. [PMID: 38296444 DOI: 10.1016/j.arthro.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 02/15/2024]
Abstract
The etiology of anterior cruciate ligament (ACL) reconstruction failure is often multifactorial, and the role of subclinical bacterial colonization in ACL reconstruction failure has not been fully elucidated. Although the presence of bacterial metabolism in and of itself does not indicate true clinical infection, low-grade infections may contribute to ACL reconstruction graft failure. Bacterial biofilms on soft tissue grafts are shown to change the crimp patterns of collagen and lower graft load to failure. In addition, bacterial DNA has been reported in 80-87% of failed ACL grafts during revision surgery compared to only 20% of primary ACL grafts. Also, higher bacterial DNA concentration is associated with tibial tunnel widening. Further study is needed to establish if any causal relationship between bacterial colonization and ACL graft failure exists. But it does seem that the circumstantial evidence is pointing to such a relationship.
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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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Figueroa F, Figueroa D, Calvo R, Nuñez M, Serrano G, Barrera J, Putnis S. Vancomycin Presoaking of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction Is Associated With Higher Magnetic Resonance Imaging Graft Signal Without Influencing Clinical Outcome. Arthroscopy 2022; 38:1528-1534. [PMID: 34600069 DOI: 10.1016/j.arthro.2021.09.023] [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: 04/30/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To present the clinical and imaging results of a series of patients undergoing anterior cruciate ligament reconstruction with vancomycin presoaking of the hamstring autograft compared with patients in the immediate period prior, when no vancomycin was used. METHODS This was a retrospective sequential series of patients with anterior cruciate ligament reconstruction using either a graft protocol with no vancomycin presoaking (group 1, January 2013 to October 2015) or a graft protocol with vancomycin presoaking (group 2, November 2015 to December 2018). Lysholm and International Knee Documentation Committee scores were obtained at a minimum 24-month follow-up. Graft ruptures were recorded. Between 6 and 12 months' follow-up, magnetic resonance imaging (MRI) was obtained to evaluate graft healing and integration. RESULTS There were 102 patients (72% male patients), with 40 in group 1 (mean age, 32.2 years) and 62 in group 2 (mean age, 32.3 years). A graft rupture occurred in 5 patients (13%) in group 1 and 6 patients (10%) in group 2 (P = .65). The median Lysholm score was 95 points (interquartile range [IQR], 86-100 points) in group 1 and 95 points (IQR, 90-100 points) in group 2 (P = .37). The median International Knee Documentation Committee score was 93 points (IQR, 82-99 points) in group 1 and 94 points (IQR, 86-99 points) in group 2 (P = .22). MRI evaluation of integration showed that 87 patients (90%) had no synovial fluid at the tunnel-graft interface, without a difference between groups (P = .24). On the basis of graft signal appearance, hyperintense grafts were found in 45 patients (46%); isointense, 45 (46%); and hypointense, 7 (7%). Group 1 had a higher prevalence of hypointense grafts, whereas group 2 had a higher prevalence of hyperintense and isointense grafts (P = .003). CONCLUSIONS Vancomycin presoaking of hamstring grafts increased the number of hyperintense and isointense grafts on MRI. Additionally, more hypointense grafts were noted when vancomycin was not used, suggesting the presence of more mature grafts in the non-vancomycin group. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Francisco Figueroa
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile; Hospital Sotero del Rio, Santiago, Chile.
| | - David Figueroa
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Rafael Calvo
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | | | | | - Javier Barrera
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
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