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Schneider JG, Ormseth B, DiBartola AC, Magnussen RA, Duerr RA, Stoodley P, Flanigan DC. Incidence, Common Pathogens, and Risk Factors for Infection after Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review. J Knee Surg 2024; 37:470-481. [PMID: 37734405 DOI: 10.1055/a-2179-3678] [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] [Indexed: 09/23/2023]
Abstract
We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis, and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction.
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Affiliation(s)
| | | | - Alex C DiBartola
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Magnussen
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Duerr
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Paul Stoodley
- Department of Microbial Infection and Immunity and the Department of Orthopaedics, The Ohio State University School of Medicine, The Ohio State University, Columbus, Ohio
| | - David C Flanigan
- Sports Medicine and the Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Adams BG, Taylor KM, Cameron KL, Ritland BM, Westrick RB. Predicting Postoperative Injury and Military Discharge Status After Knee Surgery in the US Army. Am J Sports Med 2023; 51:2945-2953. [PMID: 37489610 DOI: 10.1177/03635465231187045] [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] [Indexed: 07/26/2023]
Abstract
BACKGROUND Researchers have assessed postoperative injury or disability predictors in the military setting but typically focused on 1 type of surgical procedure at a time, used relatively small sample sizes, or investigated mixed cohorts with civilian populations. PURPOSE To identify the relationship between baseline variables and injury incidence or military discharge status in US Army soldiers after knee surgery. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were obtained from a repository containing personnel, performance, and medical records for all active-duty US Army soldiers. Multivariate logistic regressions were used to estimate the effects of numerous variables on postoperative injury or on medical discharge. Variable selection and model validation were conducted using the k-fold method. RESULTS A total of 7567 soldiers underwent knee surgery between 2017 and 2019. Meniscal procedures were the most common type of surgery (39%), and approximately 71% of the cohort had a postoperative injury. Significant predictors for sustaining a postoperative injury included having a previous nonknee injury (odds ratio [OR], 1.5), female sex (OR, 1.3), and Black race (OR, 1.2). Within 4 years after surgery, 17% of soldiers were discharged from the military because of knee-related disability. Significant predictors for discharge from duty included enlisted rank (OR, 2.3), recent fitness test failure (OR, 1.9), number of previous knee surgeries (OR, 1.7), and having a previous nonknee injury (OR, 1.6). CONCLUSION After knee surgery, nearly three-fourths of the soldiers in this cohort sustained a postoperative injury and almost one-fifth of soldiers were medically discharged from the military within 4 years. This study identified variables that indicate statistically increased risk for these postoperative outcomes and highlighted potentially modifiable factors.
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Affiliation(s)
- Benjamin G Adams
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- School of Health & Rehabilitation Sciences, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Kathryn M Taylor
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Kenneth L Cameron
- John A. Feagin Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, West Point, New York, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Bradley M Ritland
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Richard B Westrick
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
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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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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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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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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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OMAR O, RIZVANOVIC D, WALDÉN M, ERIKSSON K, BARENIUS B, STÅLMAN A. Compensation claims following anterior cruciate ligament injuries reported to the patient insurance company in Sweden in 2005-2014. Acta Orthop 2022; 93:97-102. [PMID: 34726577 PMCID: PMC8815401 DOI: 10.1080/17453674.2021.1996102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patients in the Swedish healthcare system are insured against avoidable adverse events via Landstingens Ömsesidiga Försäkringsbolag (LÖF). We assessed the reasons for compensation claims reported to LÖF following an ACL injury. Patients and methods - We searched the LÖF database for compensation claims related to ACL injuries reported in 2005-2014, and cross-matched claims with the Swedish National Knee Ligament Register. We then performed a review of the medical records. Results - We identified 530 eligible claims in 2005-2014. 352 (66%) claims were accepted by LÖF and 178 claims were rejected. Accepted claims corresponded to fewer than 1% of ACL surgeries performed in the same period. The most common reasons for an accepted claim were postoperative septic arthritis followed by suboptimal surgery and delay in diagnosis and treatment. Interpretation - There are different reasons for accepting a compensation claim following an ACL injury, which represents different treatment errors that can be avoided.
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Affiliation(s)
- Osama OMAR
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Dzan RIZVANOVIC
- Department of Orthopaedics, Växjö Central Hospital, Region Kronoberg, and Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm
| | - Markus WALDÉN
- Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden, and Department of Orthopaedics, Hässleholm-Kristianstad Hospitals, Hässleholm
| | - Karl ERIKSSON
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Björn BARENIUS
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Anders STÅLMAN
- Capio Artro Clinic, and Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
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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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9
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Fungal Septic Knee Arthritis Caused by Aspergillus fumigatus following Anterior Cruciate Ligament Reconstruction. Diagnostics (Basel) 2021; 11:diagnostics11111975. [PMID: 34829322 PMCID: PMC8618586 DOI: 10.3390/diagnostics11111975] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022] Open
Abstract
Postoperative infections after arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) represent a rare but severe complication. An extremely rare case of Aspergillus septic arthritis in a 27-year-old patient following arthroscopic ACLR is reported. The patient presented with signs of knee infection 14 days after ACLR. Two consecutive arthroscopic debridements were performed, while eventually histopathology, cultures and multiplex PCR test revealed Aspergillus identified as A. fumigatus by mass spectrometry. The patient commenced long-term treatment with voriconazole. Fungal arthritis or osteomyelitis following ACLR has a mild local and general inflammatory reaction when compared to the bacterial ones. Nevertheless, such infections may lead to aggressive osseous destruction and necrosis. A high index of suspicion is of utmost importance for early detection, while microscopic, histological examination and multiplex PCR may be more helpful for the diagnosis than cultures since cultures are more time-consuming and may vary depending on different factors.
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10
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Xiao M, Sherman SL, Safran MR, Abrams GD. Surgeon practice patterns for pre-soaking ACL tendon grafts in vancomycin: a survey of the ACL study group. Knee Surg Sports Traumatol Arthrosc 2021; 29:1920-1926. [PMID: 32902684 DOI: 10.1007/s00167-020-06265-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/28/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE To survey members of The ACL study group to determine the current practice patterns surrounding the technique of pre-soaking ACL grafts in vancomycin. METHODS A web-based questionnaire was distributed to members of the ACL Study Group. Questions included the use of vancomycin solution for graft soaking during ACL reconstruction, their protocol for soaking the graft, vancomycin concentration utilized, graft choices, and concerns with the technique. RESULTS Sixty-six (57%) ACL surgeons completed the survey. Approximately one-third (37.9%) of respondents currently pre-soak their ACL grafts in vancomycin prior to implantation, with 60% of these surgeons being from Europe. Seventy-six percent have adopted this practice within the past 5 years. The majority of surgeons wrap the graft in a vancomycin-soaked gauze prior to implantation (56%), soak for a variable amount of time before implantation (56%), use a concentration of 5 mg/mL (68%), and soak hamstring grafts (92%). Concerns included the mechanical properties of the graft (35%), cost of vancomycin (23%), availability (12%), and antibiotic resistance (9%). CONCLUSION This survey demonstrates that 37.9% of ACL study group members currently utilize vancomycin to pre-soak ACL tendon grafts as a means to decrease post-operative infection risk, with the majority of surgeons having implemented this practice within the past 5 years. The biggest concern towards using vancomycin was the mechanical properties of the graft after soaking. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michelle Xiao
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA.
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Significantly Lower Infection Risk for Anterior Cruciate Ligament Grafts Presoaked in Vancomycin Compared With Unsoaked Grafts: A Systematic Review and Meta-analysis. Arthroscopy 2021; 37:1683-1690. [PMID: 33359822 DOI: 10.1016/j.arthro.2020.12.212] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare postoperative infection rates following ACL reconstruction performed with grafts presoaked in vancomycin versus those without vancomycin. METHODS A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I to III studies that compared outcomes of presoaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and included studies documented infection with a minimum follow-up of 30 days. Postoperative infection rates and knee-specific patient-reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and retear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an α level of 0.05 set as significant. RESULTS The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects [7,507 vancomycin and 13,861 no vancomycin], 67% males, mean ± standard deviation age 29.5 ± 1.5 years) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% versus 0.77%; odds ratio 0.07; 95% confidence interval 0.03, 0.18; P < .001). Only 2 studies included patient-reported outcomes, and both demonstrated no difference in International Knee Documentation Committee scores 1 year after surgery for patients with grafts presoaked in vancomycin versus without vancomycin. CONCLUSIONS Soaking ACL tendon grafts with vancomycin before implantation is associated with a nearly 15 times decrease in odds of infection compared with grafts not soaked in vancomycin. Few studies investigated patient-reported outcomes and retear rates after soaking ACL grafts in vancomycin. LEVEL OF EVIDENCE III, systematic review of level III studies.
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12
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Kong Q, Griffis M, Shallop BJ, Khalsa AS, Brougham K, Marchetto PA. Acute Opioid Withdrawal Mimicking Postoperative Joint Infection Following anterior cruciate ligament (ACL) Reconstruction: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923458. [PMID: 32569260 PMCID: PMC7327734 DOI: 10.12659/ajcr.923458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A short course of opioid narcotics is often prescribed for postoperative anterior cruciate ligament (ACL) reconstruction pain management. Unfortunately, there is a well-documented incidence of opioid withdrawal syndrome (OWS) following short-term use of these medications. OWS can present with symptoms such as influenza-like illness. It is important to differentiate OWS from infectious illnesses, especially after surgery. CASE REPORT We present a case of OWS in a patient who underwent ACL reconstruction 7 days prior. The patient's OWS symptoms were similar to symptoms of a postoperative infection. The knee was aspirated, and the analysis of the aspirate was not concerning for an infection. The patient's symptoms spontaneously resolved on postoperative day 10. This is the first documented case of OWS mimicking ACL reconstruction joint infection. CONCLUSIONS OWS after surgery may present with symptoms similar to joint infection. It is important to consider OWS as a potential complication after surgery and differentiate it from infection to avoid any further unnecessary invasive treatments for the patient.
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Affiliation(s)
- Qingwu Kong
- Department of Orthopedic Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA.,Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Martin Griffis
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Brandon J Shallop
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Amrit S Khalsa
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kyle Brougham
- Department of Orthopedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Paul A Marchetto
- Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Rothman Institute, Philadelphia, PA, USA
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13
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Tucker CJ, Cotter EJ, Waterman BR, Kilcoyne KG, Cameron KL, Owens BD. Functional Outcomes After Isolated and Combined Posterior Cruciate Ligament Reconstruction in a Military Population. Orthop J Sports Med 2019; 7:2325967119875139. [PMID: 31656823 PMCID: PMC6791041 DOI: 10.1177/2325967119875139] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: The rates of return to full activity, persistent disability, complications, and surgical revisions after operative management of posterior cruciate ligament (PCL) tears in a physically active population have not been reported. Purpose: To evaluate the clinical outcomes of active military patients with symptomatic PCL tears who underwent surgical reconstruction and compare outcomes between isolated PCL and multiligament injuries. Study Design: Cohort study; Level of evidence, 3. Methods: Individuals undergoing surgical reconstruction of the PCL (Current Procedural Terminology code 29889) were isolated from the Military Health System Management Analysis and Reporting Tool between fiscal years 2005 and 2010. Demographic variables and rates of postoperative complications, activity limitations, rates of revision surgery, physical disability ratings, and ultimate medical discharge were recorded from the electronic medical record and US Army Physical Disability Agency database. Results: A total of 182 patients underwent 193 surgeries, including 118 isolated PCL reconstructions and 75 multiligament knee reconstructions, with an average follow-up of 19.5 months. There were 174 primary procedures and 19 revision reconstructions. The mean ± SD patient age was 28.4 ± 7.2 years, with males comprising 96.2% of patients. The overall surgical complication rate was 12.4%, with a significantly higher rate in multiligament knee reconstructions compared with isolated PCL reconstructions (18.7% vs 8.5%; P = .045). Overall, 35.1% of patients were discharged from military service due to disability. Rates of discharge were significantly higher in those undergoing surgery at lower volume institutions (those that performed <2 PCL reconstructions per year during the study period) than those at higher volume institutions (41.1% vs 26%; P = .040). The overall revision rate was 10.9%, with no significant difference between the isolated PCL and multiligament knee reconstructions. Of the 103 patients with primary isolated PCL reconstructions, 35% underwent medical discharge for persistent knee complaints, and 12.6% required revision PCL reconstruction. The overall failure rate for primary isolated PCL reconstructions, which includes both revision surgery and knee-related medical discharge from military service, was 42.7%. Conclusion: In a physically active, military population, nearly one-third of patients were unable to return to previous level of military function, and 12.6% required revision at short-term follow-up due to persistent instability. Perioperative complication rates were significantly higher among patients with multiligament knee reconstructions.
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Affiliation(s)
- Christopher J Tucker
- Department of Orthopedic Surgery and Rehabilitation, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA
| | - Eric J Cotter
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Kelly G Kilcoyne
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Kenneth L Cameron
- Department of Orthopaedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University Alpert School of Medicine, Providence, Rhode Island, USA
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14
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Munch DRK, Hansen TI, Mikkelsen KL, Krogsgaard MR. Complications and technical failures are rare in knee ligament reconstruction: analyses based on 31,326 reconstructions during 10 years in Denmark. Knee Surg Sports Traumatol Arthrosc 2019; 27:2672-2679. [PMID: 30467581 DOI: 10.1007/s00167-018-5297-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/13/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE Knowledge about treatment injuries (technical failures and complications) in relation to knee ligament reconstructions is sparse. Our purpose was to describe treatment injuries to knee ligament reconstruction in Denmark during a 10-year period and to suggest initiatives to reduce the risk for treatment injuries. METHODS Treatment injuries after knee ligament reconstructions reported to the Danish Patient Compensation Association (DPCA) 2005-2014 were analyzed and compared to information from the Danish Kneeligament Reconstruction Register and Danish National Patient Register. RESULTS The number of knee ligament reconstructions in Denmark 2005-2014, including revisions, was 31,326. Of the 704 cases claimed to DPCA, 371 were approved as treatment injuries (1.42% of all operations). Tunnel malpositioning (135 = 0.43% of all operations), deep infection (0.27%), nerve injury (0.17%), pain (0.12%) and unrecognized combined instability (0.11%) were the most common. Patients operated with anteromedial technique for femoral tunnel placement had a lower incidence (p < 0.0001) of tunnel malpositioning compared to other techniques. Public and private hospitals had the same risk of treatment injures. Hospitals that performed the largest number of reconstructions/year had the smallest risk of a treatment injury (p < 0.001). The total compensation was 7.6 m EURO, which equals 243 EURO/performed knee ligament reconstruction. CONCLUSION Treatment injuries as defined in this study were rare, with tunnel malpositioning being the most common. Analyses of the results indicate that it may be clinically relevant to reduce the number of treatment injures that knee ligament reconstructions are concentrated in clinics with high volume. Also, malpositioning might be reduced by routine documentation of K-wire position before tunnels are drilled. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daniel Rayan Kalakech Munch
- Section for Sports Traumatology M51, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Thomas Irgens Hansen
- Section for Sports Traumatology M51, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Kim Lyngby Mikkelsen
- Danish Patient Compensation Association, Kalvebod Brygge 45, 1560, Copenhagen K, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sports Traumatology M51, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark. .,Danish Patient Compensation Association, Kalvebod Brygge 45, 1560, Copenhagen K, Denmark.
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15
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Mistry H, Metcalfe A, Colquitt J, Loveman E, Smith NA, Royle P, Waugh N. Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective. Knee Surg Sports Traumatol Arthrosc 2019; 27:1782-1790. [PMID: 30874836 PMCID: PMC6541574 DOI: 10.1007/s00167-019-05436-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/20/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To assess the clinical and cost-effectiveness of allografts versus autografts in the reconstruction of anterior cruciate ligaments. METHODS Systematic review of comparative clinical effectiveness and cost-effectiveness analysis. RESULTS Both autograft and allograft reconstruction are highly effective. Recent studies show little difference in failure rates between autografts and allografts (about 6% and 7%, respectively). In cost-effectiveness analysis, the price differential is the main factor, making autografts the first choice. However, there will be situations, particularly in revision ACL reconstruction, where an allograft may be preferred, or may be the only reasonable option available. CONCLUSION In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Hema Mistry
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK.
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick Medical School, Coventry, CV4 7AL, UK
| | - Jill Colquitt
- Effective Evidence, Waterlooville, Hampshire, PO8 9SE, UK
| | - Emma Loveman
- Effective Evidence, Waterlooville, Hampshire, PO8 9SE, UK
| | - Nick A Smith
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Pamela Royle
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK
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16
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Waugh N, Mistry H, Metcalfe A, Colquitt J, Loveman E, Royle P, Smith NA. Allografts in reconstruction of the posterior cruciate ligament: a health economics perspective. Knee Surg Sports Traumatol Arthrosc 2019; 27:1810-1816. [PMID: 30903218 PMCID: PMC6541577 DOI: 10.1007/s00167-019-05477-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/06/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE To review the relative cost-effectiveness of allografts and autografts in reconstruction of the posterior cruciate ligament. METHODS Systematic review and cost-effectiveness analysis. RESULTS The available evidence does not show any significant difference in clinical effectiveness between autografts and allografts. Given that, only a cost analysis is provided, which shows that allografts are more costly. CONCLUSION Given the lack of any benefit of allografts over autografts, autografts should be preferred on cost grounds, if available. However, there may be situations where an allograft is indicated, for example, in multiple ligament reconstructions. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Hema Mistry
- Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Emma Loveman
- Effective Evidence, Waterlooville, Hampshire, UK
| | - Pamela Royle
- Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Nick A Smith
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, UK
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