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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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Clever D, Thompson D, Gosselin M, Brouillet K, Guilak F, Luhmann SJ. Pilot Study Analysis of Serum Cytokines to Differentiate Pediatric Septic Arthritis and Transient Synovitis. J Pediatr Orthop 2021; 41:610-616. [PMID: 34483309 DOI: 10.1097/bpo.0000000000001909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In pediatric patients, the presentation of the nontraumatic acutely painful joint/limb poses a diagnostic dilemma due to the similarity of presentations of the most likely diagnoses [septic arthritis (SA), transient synovitis (TS), osteomyelitis]. Current tools employed to differentiate these diagnoses rely on nonspecific inflammatory markers, radiologic imaging, and arthrocentesis. Diagnostic algorithms utilizing these clinical, radiographic, and biochemical parameters have produced conflicting results. The purpose of this study was to identify a serum-based inflammatory signature which can differentiate SA from TS in pediatric patients. METHODS Serum samples were collected from 22 pediatric patients presenting with joint/extremity pain whose working diagnosis included SA or TS. Each sample was analyzed for serum abundance of 72 distinct biomarkers and cytokines using enzyme linked immunosorbent assay based arrays. Linear discriminant analysis was performed to identify a combinatorial biomarker panel to predict a diagnosis of SA or TS. Efficacy of the biomarker panel was compared with definitive diagnoses as based on laboratory tests, arthrocentesis results, and clinical scenario. RESULTS At the time of presentation: (1) mean erythrocyte sedimentation rate in the SA group was 56.6 mm/h and 12.4 mm/h in the TS group (P<0.001), (2) mean C-reactive protein was 55.9 mg/dL in the SA group and 13.7 mg/dL in the TS group (P=0.12), and (3) mean white blood cell was 10.9 k/mm3 in the SA group and 11.0 k/mm3 in the TS group (P=0.95). A combined panel of 72 biomarkers was examined using discriminant analysis to identify a limited set of predictors which could accurately predict whether a patient was diagnosed with SA or TS. A diagnostic algorithm consisting of transforming growth factor alpha, interleukin (IL)-7, IL-33, and IL-28A serum concentration correctly classified 20 of the 22 cases with a sensitivity and specificity of 90.9% (95% confidence interval: 73.9%-100.0%). CONCLUSION This study identifies a novel serum-based 4-cytokine panel that accurately differentiates SA from TS in pediatric patients with joint/limb pain. LEVEL OF EVIDENCE Level II-diagnostic study.
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Affiliation(s)
| | | | | | - Kirsten Brouillet
- Pediatric Orthopaedic Surgery, Washington University School of Medicine
| | - Farshid Guilak
- Departments of Orthopedic Surgery
- Shriners Hospitals for Children-St. Louis, St. Louis, MO
| | - Scott J Luhmann
- Departments of Orthopedic Surgery
- Pediatric Orthopaedic Surgery, Washington University School of Medicine
- Shriners Hospitals for Children-St. Louis, St. Louis, MO
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Malipeddi R, Nema SK, Gopisankar B, Prabu M, Pasupathy P, Suresh Gandhi B. Clinical Outcomes and Global Health After Joint Debridement in Adult-Onset Septic Arthritis: A Prospective Observational Study. Indian J Orthop 2021; 55:912-917. [PMID: 34194647 PMCID: PMC8192621 DOI: 10.1007/s43465-021-00389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/23/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Despite several reports on risk factors for septic arthritis (SA) in adults, the outcomes on quality of life and joint function are sparsely reported. This study aimed to investigate the quality of life and joint function in adult patients treated for SA. METHODS This prospective observational study enrolled clinically diagnosed adult SA patients and estimated Euroqol 5-dimension 5 levels (EQ-5D-5L) questionnaire, Euroqol Visual Analog Scale (EQ-VAS) and a validated tool for joint function at 1, 3, 6 and 12 months after debridement. RESULTS Twenty seven patients (20 males/7 females) with 21 knees, four shoulders, and two elbows were evaluated. The mean age of the cases was 51(± 13.00) years. Three cases sustained mortality. EQ-5D-5L (P < 0.01) and EQ-VAS (P < 0.01) scores improved significantly between all time frames. Mean Knee society (P < 0.01), Shoulder QuickDASH, and Mayo elbow scores improved at all time frames. There was no difference in primary outcomes between early (< 14 days) and late (14 days or more) presentation. There was no difference in primary outcome measures between confirmed and suspected SA. Fifteen patients could ambulate without support, while 6 needed some support for walking at 1 year. CONCLUSION Improved outcomes can be expected in quality of life and joint function in adults' septic arthritis at the end of 1 year after surgical treatment; however, the effects of delay in presentation need to be investigated further. Isolation of the microorganism from an infected joint has no bearing on the outcome measures.
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Affiliation(s)
- Ranjith Malipeddi
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Sandeep Kumar Nema
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - B. Gopisankar
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - M. Prabu
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - P. Pasupathy
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - B. Suresh Gandhi
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
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Severe septic arthritis of the temporomandibular joint with pyogenic orofacial infections: A case report and review of the literature. Exp Ther Med 2017; 14:141-146. [PMID: 28672905 PMCID: PMC5488428 DOI: 10.3892/etm.2017.4510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 03/03/2017] [Indexed: 11/10/2022] Open
Abstract
Septic arthritis of the temporomandibular joint (SATMJ) is a rare entity that has only been reported a few dozen times worldwide. However, SATMJ is an acute infectious disease and associated with a high risk for misdiagnosis, which results in severe complications for patients. The present study reported a case of an 83-year-old female patient with severe pyogenic orofacial infections caused by right-side SATMJ, which was not cured by abscess incision drainage and anti-microbial treatment. Finally, the clinical signs were resolved by condylectomy and debridement of the erosive septic TMJ, after which the function of the TMJ was completely restored. In conclusion, a timely and correct diagnosis with early treatment is critical to preventing acute complications and late sequelae of SATMJ. In addition, literature associated with this topic was reviewed and discussed.
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Johns BP, Loewenthal MR, Dewar DC. Open Compared with Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee. J Bone Joint Surg Am 2017; 99:499-505. [PMID: 28291183 DOI: 10.2106/jbjs.16.00110] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute native knee septic arthritis is a joint-threatening emergency. Operative treatments by open or arthroscopic methods are available to surgeons. To our knowledge, the literature to date has primarily consisted of case series and no large study has yet compared these methods. The aim of this study was to compare open and arthroscopic treatment for acute native knee septic arthritis. METHODS All adult patients with acute native knee septic arthritis treated at our institution with either open or arthroscopic irrigation from 2000 to 2015 were retrospectively evaluated. The clinical findings, laboratory evidence, arthrocentesis and microbiology results, knee radiographs, and outcomes were compared. RESULTS There were 161 patients (166 knees) with acute native knee septic arthritis treated between 2000 and 2015. Initially, 123 knees were treated by arthroscopic irrigation and 43 knees were treated by open irrigation; however, 71% in the open treatment group required repeat irrigation compared with 50% in the arthroscopic treatment group. The superiority of an arthroscopic procedure persisted after adjustment for potential confounders by multivariable analysis, with an odds ratio of 2.56 (95% confidence interval, 1.1 to 5.9; p = 0.027). After 3 irrigation procedures, the cumulative success rate was 97% in the arthroscopic treatment group and 83% in the open treatment group (p = 0.011). The total number of irrigation procedures required was fewer in the arthroscopic treatment group (p = 0.010). In the arthroscopic treatment group, the mean postoperative range of motion was greater (p = 0.016) and there was a trend toward a shorter median length of stay (p = 0.088). CONCLUSIONS Arthroscopic treatment for acute native knee septic arthritis was a more successful index procedure and required fewer total irrigation procedures compared with open treatment. Long-term postoperative range of motion was significantly greater following arthroscopic treatment. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brenton P Johns
- 1The Bone and Joint Institute, Royal Newcastle Centre and John Hunter Hospital, Newcastle, Australia 2Department of Immunology and Infectious Diseases, John Hunter Hospital, Newcastle, Australia 3School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
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Wallander K, Jorup-Rönström C, Ullberg M, Törnblom I, Ottosson C, Giske CG. Etiology of bone and joint infections: a case series of 363 consecutive patients from an orthopaedic infection unit. Infect Dis (Lond) 2016; 48:618-25. [PMID: 27187631 DOI: 10.1080/23744235.2016.1183814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Bone and joint infections remain a clinical challenge with potentially serious consequences. Nevertheless there is a lack of studies with strict criteria for diagnosis and etiology. The primary aim of this study was to determine the causative agents in orthopaedic infections using strict diagnostic criteria for infection and etiology. The secondary aim was to assess the timing of post-operative infections in relation to pathogens and to compare causative bacteria in different parts of the body. METHODS A retrospective registry study of 363 consecutive cases of bone and joint infections was performed. Microbiological data on sampling and culture results were registered. RESULTS Staphylococcus aureus dominated in both operated (45%) and non-operated (44%) patients, followed in frequency by coagulase-negative staphylococci (CoNS) in operated patients (11%) and beta-haemolytic streptococci in non-operated patients (16%) (p < 0.001). There were no polymicrobial infections in non-surgical cases (p < 0.001). For operated patients, Gram-negative bacilli were observed in 6%, almost exclusively isolated from the lower extremity. Propionibacterium spp. was the most common finding after spinal surgery. In 90/363 (25%), the agent responsible for the infection could not be defined according to the strict criteria used. CONCLUSION S. aureus dominated as etiological agent in all bone and joint infections, including operated patient given peri-operative prophylaxis. Improved timing of antibiotic prophylaxis seen after the introduction of the Swedish national project PRISS may have changed this. The number of infections with uncertain etiology was high, stressing the importance of more studies on diagnostics, as well as strict diagnostic algorithms.
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Affiliation(s)
- Katja Wallander
- a Department of Infectious Diseases , Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Christina Jorup-Rönström
- b Department of Clinical Science and Education , Stockholm South General Hospital, Karolinska Institutet , Stockholm , Sweden
| | - Måns Ullberg
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden
| | - Inger Törnblom
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden
| | - Carin Ottosson
- b Department of Clinical Science and Education , Stockholm South General Hospital, Karolinska Institutet , Stockholm , Sweden
| | - Christian G Giske
- c Department of Clinical Microbiology , Karolinska University Hospital , Stockholm , Sweden ;,d Division of Clinical Microbiology, Department of Laboratory Medicine , Karolinska Institutet Stockholm , Sweden
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Torres-Claramunt R, Gelber P, Pelfort X, Hinarejos P, Leal-Blanquet J, Pérez-Prieto D, Monllau JC. Managing septic arthritis after knee ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2015; 40:607-14. [PMID: 26239533 DOI: 10.1007/s00264-015-2884-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/08/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE Joint infection after anterior cruciate ligament (ACL) reconstruction is uncommon but has potentially serious consequences for the graft and articular cartilage. Most recently published series are in agreement that an urgent arthroscopic washout and antibiotic treatment are mandatory to preserve both graft and cartilage. However, several questions have not as yet been touched upon. METHODS We performed a literature review to assess the most interesting series published about this issue. RESULTS In this review, a management protocol is first presented that discusses the different diagnostic parameters to consider and surgical and antibiotic treatment suggested according to the literature. Outcomes published in different series are also discussed.
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Affiliation(s)
- Raúl Torres-Claramunt
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain. .,IMIM Hospital del Mar Medical Research Institute, Barcelona, Spain.
| | - Pablo Gelber
- Orthopaedic Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Xavier Pelfort
- Orthopaedic Department, Consorci Sanitari de l'Anoia, Avinguda Catalunya 11, 08700, Igualada, Barcelona, Spain
| | - Pedro Hinarejos
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain.,IMIM Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Joan Leal-Blanquet
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Daniel Pérez-Prieto
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Joan C Monllau
- Orthopaedic Department, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, 08003, Barcelona, Spain.,IMIM Hospital del Mar Medical Research Institute, Barcelona, Spain
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Boström Windhamre H, Mikkelsen C, Forssblad M, Willberg L. Postoperative septic arthritis after anterior cruciate ligament reconstruction: does it affect the outcome? A retrospective controlled study. Arthroscopy 2014; 30:1100-9. [PMID: 24836173 DOI: 10.1016/j.arthro.2014.03.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 03/20/2014] [Accepted: 03/21/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the outcome after septic arthritis after anterior cruciate ligament reconstruction (ACLR) is inferior compared with uncomplicated ACLR when treated promptly by use of a standard protocol. METHODS At Capio Artro Clinic, 4,384 primary ACLRs were performed during 2001-2009. All patients with postoperative septic arthritis were retrospectively reviewed, and 43 met the inclusion criteria. Twenty-seven patients agreed to re-examination (infection group) and were compared with 27 matched patients with uncomplicated ACLR (control group). The mean follow-up period was 60 months and 66 months in the infection group and control group, respectively. Re-examination included objective (radiographs, physical examination, functional testing, range of motion, strength, stability, International Knee Documentation Committee questionnaire) and subjective (Knee Injury and Osteoarthritis Outcome Score, Tegner score, Lysholm score, European Quality of Life-5 Dimensions, subjective satisfaction questions, Single Assessment Numeric Evaluation of knee function, visual analog scale pain rating) evaluation. RESULTS There were no significant differences in objective knee function between the groups at follow-up. For subjective knee function, no significant differences between the groups were detected with the Single Assessment Numeric Evaluation score, pain during activity, or Lysholm score. The infection group scored lower on 4 of 5 Knee Injury and Osteoarthritis Outcome Score subscales: pain (P = .014), function in daily living (P = .008), sports/recreation (P = .015), and quality of life (P = .007). The infection group scored lower versus control patients on the Tegner score (P = .001) and European Quality of Life-5 Dimensions scores (P = .004). Both groups improved over time, but the control group scored better only on the Tegner score (P = .004). CONCLUSIONS Septic arthritis after ACLR did not result in inferior objective knee function compared with uncomplicated ACLR. Subjectively, infection patients were as satisfied as non-infection patients, but rehabilitation took longer and fewer patients returned to sports. The findings of this study suggest that anterior cruciate ligament grafts may be retained with prompt, thorough arthroscopic lavage and debridement; correct antibiotics according to cultures; and repeated arthroscopy if necessary. LEVEL OF EVIDENCE Level III, retrospective case-control therapeutic study.
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Affiliation(s)
- Helena Boström Windhamre
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Orthopedic Surgery, Capio St Gorans Hospital, Stockholm, Sweden.
| | - Christina Mikkelsen
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Forssblad
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lotta Willberg
- Capio Artro Clinic, Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes. Knee Surg Sports Traumatol Arthrosc 2013; 21:2844-9. [PMID: 23104168 DOI: 10.1007/s00167-012-2264-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Accepted: 10/16/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes. METHODS A retrospective assessment of knee joint infections occurring after arthroscopically assisted ACL reconstructions done from 2006 to 2009 in two hospitals by the same surgical team is presented. Patients with signs and symptoms of joint infection along with blood and synovial effusion laboratory parameters suggestive of infection were considered as septic arthritis. All the patients were treated with antibiotic therapy according to antibiotic sensitivity and had at least one arthroscopic lavage. Final outcomes were assessed and compared with a control group using the KT-1000 arthrometer, functional testing and radiological examination. RESULTS Fifteen (1.8 %) out of 810 patients included in the study were considered as a joint infection. Microbiology showed that coagulase-negative Staphylococcus was present in 10 patients, Staphylococcus Aureus in three patients (2 MSSA and 1 MRSA) and Propinebacterium sp. in one patient. In one patient, the micro-organism was unknown. At a mean follow-up of 39.3 ± 13 months, the Lysholm score was 77.7 ± 15.3, the IKDC score was 70.4 ± 19.5, and the KT-1000 compared to the non-injured contralateral knee showed a mean difference of 1.3 ± 2 mm. Functional outcomes in the control group were slightly better than those obtained in the infected group (Lysholm score; 90.7 ± 9.4, p = 0.007. IKDC score; 86.6 ± 6.8, p = 0.004). All but one patient retained their reconstructed ACL. CONCLUSIONS The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8 %. Arthroscopic lavages along with antibiotic treatment led us to preserve all but one graft. Functional outcomes in the infected patients were not as good as those obtained in patients without infection.
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Schub DL, Schmitz LM, Sakamoto FA, Winalski CS, Parker RD. Long-term outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med 2012; 40:2764-70. [PMID: 23087081 DOI: 10.1177/0363546512461903] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Septic arthritis is a rare but potentially devastating complication of anterior cruciate ligament (ACL) reconstruction surgery. Several studies, including one by this group, have reported short- and medium-term outcomes, but to our knowledge there are no long-term follow-up studies. HYPOTHESIS Postoperative septic arthritis after ACL reconstruction surgery will lead to diminished long-term outcomes compared with surgery without infectious complications, likely related to the development of arthritis. STUDY DESIGN Case series; Level of evidence, 4. METHODS Four of 831 consecutive patients undergoing arthroscopically guided ACL reconstruction surgeries performed by 1 surgeon were previously reported on by this group at an average follow-up of 36 months. These same patients were contacted and reevaluated. Each patient underwent a physical examination, functional testing, and subjective evaluations with the SF-36, Lysholm, International Knee Documentation Committee (IKDC), and Tegner activity scale scores. Plain film radiographs and magnetic resonance imaging (MRI) scans were analyzed by 2 musculoskeletal radiologists. RESULTS Average follow-up time for this study was 17.9 years, and average age was 44.3 years. No other injuries or surgeries had occurred from the time of the previous study. Each patient had a decline in SF-36, Lysholm, and IKDC score, and the average Tegner score was unchanged. Average vertical hop test performance and Biodex dynamometry were both improved. The average side-to-side displacement measured via the KT-1000 arthrometer was increased. Radiographic and MRI studies revealed progression of arthritis in all patients and ACL graft rupture in 1 patient. CONCLUSION Patients who develop septic arthritis as a complication of ACL reconstruction surgery have diminished long-term subjective, functional, and radiographic outcomes compared with historical reports of uncomplicated cases, likely related to pain from advanced arthritis. As compared with their own earlier follow-up, these patients had declines in pain-related subjective measures but remained stable or improved in both functional testing and activity-related subjective scales.
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Affiliation(s)
- David L Schub
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Sreenivas T, Nataraj AR, Menon J. Acute hematogenous septic arthritis of the knee in adults. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:803-7. [PMID: 23412203 DOI: 10.1007/s00590-012-1071-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 08/15/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY To evaluate the factors associated with acute hematogenous septic arthritis of the knee in adults and to assess the outcome after open knee arthrotomy. METHODS We performed a prospective evaluation of 26 adult patients with acute nongonococcal septic arthritis of the knee presenting within 7 days. All patients underwent open knee arthrotomy, and final evaluation by means of Knee society score of the affected knee was compared with the contra lateral normal knee. RESULTS The average duration of symptoms at the time of presentation was 3.9 days. Staphylococcus aureus was the commonest bacteria isolated in 17 (65.4 %) patients. The average duration of follow-up in our study was 18.5 months. In our study, Knee society score decreases as the age of the patient advances (P < 0.05) and also it was found to be low (P < 0.05) in the affected knee as compared to contra lateral normal knee. CONCLUSION Our study shows that age of the patient at presentation is critical as it shows significant reduction in knee score. This explains that the septic arthritis may contribute to the progression of age-related degeneration of the knee joint. There appears to be no definite contributing factors or conditions associated with acute hematogenous septic arthritis of the knee in adults, although further study may be warranted regarding this matter.
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Affiliation(s)
- T Sreenivas
- Department of Orthopaedics, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Dhanvantrinagar, Puducherry, 605006, India,
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Cai XY, Yang C, Zhang ZY, Qiu WL, Chen MJ, Zhang SY. Septic arthritis of the temporomandibular joint: a retrospective review of 40 cases. J Oral Maxillofac Surg 2009; 68:731-8. [PMID: 19954877 DOI: 10.1016/j.joms.2009.07.060] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Revised: 05/31/2009] [Accepted: 07/31/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE Septic arthritis of the temporomandibular joint is an uncommonly reported entity. The aim of the present study was to review the cases treated at our clinic, analyze the characteristics of this disease and the responses to management, and recommend a protocol for managing suspected cases. PATIENTS AND METHODS A total of 40 consecutive patients were included from 1995 to 2007. Their demographics, predisposing factors, clinical manifestations, radiologic findings, joint fluid analysis results, treatment, and outcomes were reviewed. RESULTS The 40 patients included 26 men and 14 women, with an average age of 36 years. Original infections were found in 15 patients (local spread in 4 and hematogenous dissemination from a distant site in 11). All patients complained of trismus and tenderness in the temporomandibular joint. Sudden malocclusion was found in 33 patients. Joint space widening and limitation of condyle movement were demonstrated by plain film in 33 patients. Increased joint effusion was confirmed by magnetic resonance imaging in 7 patients. Joint fluid was obtained from 35 patients. A high level of neutrophils and fibrin were found under microscopy with hematoxylin-eosin staining. Staphylococcus saprophyticus and S. aureus were cultured from 5 patients. Arthrocentesis under low pressure was applied to 35 patients, and arthroscopy was used in 9 patients. Major sequelae occurred in 11 patients, including fibrosis in 2 and postinfectious osteoarthritis in 9. CONCLUSIONS Septic arthritis of the temporomandibular joint mainly arises from hematogenous spread, but the original infection is often occult. Antibiotic therapy, arthrocentesis under low pressure, and joint immobilization are recommended for patients in the acute stage. The common sequela is osteoarthritis.
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Affiliation(s)
- Xie-Yi Cai
- Department of Oral and Maxillofacial Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, People's Republic of China
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Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2009; 17:1033-42. [PMID: 19381611 DOI: 10.1007/s00167-009-0793-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 03/20/2009] [Indexed: 12/13/2022]
Abstract
Although postoperative septic arthritis is rare after ACL reconstruction, it carries a high morbidity that results in poor clinical outcome. Despite low incidence, it is important to recognize that infection and treat it without delay because of devastating consequences, such as loss of hyaline cartilage and arthrofibrosis, in order to avoid osteoarthritis development and near full range of motion achieved. Herein we discuss the pathogenesis, risk factors, clinical presentation, diagnostic evaluation, treatment protocols and complications of septic knee arthritis after ACL reconstruction.
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Jain S, Tittal P, Rohilla N, Sud A, Yadav CS, Kanojia RK, Kapoor SK, Rastogi S. Acute septic arthritis revisited: a prospective study in 93 patients correlating C-reactive protein levels with duration of intravenous antibiotic therapy, clinical and radiological outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2009. [DOI: 10.1007/s00590-009-0457-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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[Septic arthritis due to Bacteroides fragilis in a patient with non-Hodgkin lymphoma and mixed connective tissue disease]. ACTA ACUST UNITED AC 2008; 3:237-40. [PMID: 21794438 DOI: 10.1016/s1699-258x(07)73694-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 04/07/2006] [Indexed: 11/24/2022]
Abstract
We present a 53 year old woman with pre-existing mixed collagen tissue disease who developped highly-malignant non-Hodgkin lymphoma and 2 years later had left groin abscess, then septic tenosynovitis of the left ankle, septic artrhritis of the right shoulder and purulent tenosynovitis of the right hand. Bacteroides fragilis was identified in synovial fluid drawn from the right shoulder, in blood cultures and in culture of a central venous catheter tip. The primary infection site is presumed to have been the abdominal cavity, and the presence of an indwelling central venous catheter the reason for recurrence of infection. We treated her empyrically with intravenous ampicillin/sulbactam and clindamycine then oral metronidazol until definite resolution of the infection. Septic artrhritis due to Bacteroides fragilis is a rare entity mainly occurring in immunocompromised patients, as shown in this case.
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Lavy CBD. Septic arthritis in Western and sub-Saharan African children - a review. INTERNATIONAL ORTHOPAEDICS 2007; 31:137-44. [PMID: 16741731 PMCID: PMC2267558 DOI: 10.1007/s00264-006-0169-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 04/18/2006] [Accepted: 04/18/2006] [Indexed: 12/17/2022]
Abstract
This article reviews what is known about the incidence, aetiology, presentation, bacteriology and management of septic arthritis in children. It compares where possible the different presentations and characteristics of this condition in the Western and sub-Saharan African regions.
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Affiliation(s)
- Christopher B D Lavy
- Department of Orthopaedic Surgery, College of Medicine, Private Bag 360, Blantyre, Malawi.
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Tsumura H, Ikeda S, Torisu T. Debridement and continuous irrigation for the treatment of pyogenic arthritis caused by the use of intra-articular injection in the osteoarthritic knee: indications and outcomes. J Orthop Surg (Hong Kong) 2005; 13:52-7. [PMID: 15872401 DOI: 10.1177/230949900501300109] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To discuss the indications and therapeutic outcomes of synovectomy, debridement, and continuous irrigation for the treatment of pyogenic arthritis caused by intra-articular injection used in the treatment of osteoarthritis of the knee. METHODS Records of 41 patients with infectious arthritis of the knee who presented to our hospital from 1981 were reviewed. 11 of them had a history of intra-articular injection. They underwent synovectomy, debridement, and continuous irrigation using a Salem double-lumen tube after confirmation that one side of the femorotibial joint cartilage was basically healthy. RESULTS The infection was successfully treated in 9 of the 11 patients. Of these 9 patients, one died after 3 years and 2 underwent total knee arthroplasty after 3 and 8 years. The remaining 6 patients were followed up for 5 to 15 years. Five of them had deteriorating arthropathy, and the condition was unchanged in the others. Two of these 6 patients had pain while walking, and their Japanese Orthopaedic Association scores were 70. The remaining 4 had good knee function and reduction of pain, with a mean Japanese Orthopaedic Association score of 91 and a mean range of motion of 131 degrees. CONCLUSION Arthrodesis is frequently considered the treatment for osteoarthritis if the joint destruction has affected the weight-bearing surface. However, in our experience, even when inflammatory granulation develops in the cartilage surface of one side of the femorotibial joint, good results can still be obtained by synovectomy, debridement, and continuous irrigation. After the pyogenic arthritis has subsided, if osteoarthritis has advanced and bowleg has exacerbated, further treatment options are available, such as tibial resection and even joint replacement. Continuous irrigation should be considered a feasible treatment option for pyogenic arthritis.
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Affiliation(s)
- H Tsumura
- Department of Orthopedic Surgery, Faculty of Medicine, Oita University, Oita, Japan.
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Bar-Natan M, Salai M, Sidi Y, Gur H. Sternoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum 2002; 32:189-95. [PMID: 12528083 DOI: 10.1053/sarh.2002.37284] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To define characteristics of sternoclavicular infection (SCI) in previously healthy patients. METHODS SCI in a previously healthy man is reported along with 4 similar cases found by surveying the hospital's database; 22 previously reported cases were culled from the literature and summarized. RESULTS The frequency of SCI in healthy adults was 0.5% of all bone and joint infections admitted to the hospital. The clinical and bacteriologic features were similar to previous reports in nonselected SCI patients. Computerized tomography (CT) scan, arthrocenthesis, and biopsy were required for diagnosis. Complications included abscess formation, mediastinitis, and sepsis. The majority of patients were treated by surgical drainage and antibiotics. The final outcome was good, without mortality or long-term morbidity. CONCLUSIONS Although SCI is a rare infection in healthy adults, it should be considered in the differential diagnosis of a painful sternoclavicular joint. Prompt diagnosis and appropriate treatment of SCI results in excellent outcome in most cases.
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Affiliation(s)
- Michal Bar-Natan
- Department of Medicine C and Orthopedics and the Rheumatology Unit, The Chaim Sheba Medical Center, Tel Hashomer; and the Sackler Faculty of Medicine, Tel Aviv University, Israel
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Sakiniene E, Collins LV. Combined antibiotic and free radical trap treatment is effective at combating Staphylococcus-aureus-induced septic arthritis. ARTHRITIS RESEARCH 2002; 4:196-200. [PMID: 12010570 PMCID: PMC111022 DOI: 10.1186/ar406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2001] [Revised: 11/21/2001] [Accepted: 11/29/2001] [Indexed: 11/25/2022]
Abstract
Although early antibiotic treatment of patients with septic arthritis eradicates bacteria, joint destruction commonly results from the unregulated host inflammatory responses to infection. The spin trap compound phenyl-N-tert-butyl nitrone (PBN) has been shown to have both anti-inflammatory and antioxidant effects. The aim of this study was to assess the effect of combined systemic administration of PBN and cloxacillin on the development of Staphylococcus aureus arthritis.Three days after Naval Medical Research Institute (NMRI) mice were infected intravenously with S. aureus LS-1, daily treatment was started with cloxacillin alone, PBN alone, or cloxacillin and PBN. Arthritis, weight loss and general condition were evaluated for each mouse, and joints were analyzed histopathologically. Systemic administration of PBN in conjunction with cloxacillin ameliorated the course of experimental S. aureus arthritis, as evidenced by an increased cure rate. Thus, combinatorial antioxidant plus antibiotic anti-inflammatory therapies represent a potentially efficacious approach to the management of septic arthritis.
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Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001; 40:24-30. [PMID: 11157138 DOI: 10.1093/rheumatology/40.1.24] [Citation(s) in RCA: 206] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS AND METHODS To assess the clinical features of septic arthritis and characterize therapeutic strategies and outcome in a prospective study of 75 patients selected by positive synovial fluid culture. RESULTS Underlying joint disease was present in 46 patients, 25 of whom had rheumatoid arthritis and 15 osteoarthritis. Eleven patients were i.v. drug abusers. Fifty-six per cent of cases involved the knee, 15% involved two or more joints, and staphylococci and streptococci were cultured in >90%. Seventy-eight per cent of patients lived in areas of high social deprivation. Fever was present in 64% and the white cell count (WCC) was normal in 38%. The C-reactive protein was elevated in 98%. Leg ulcers were present in 11% of all patients but in 38% of patients who died (P<0.006). Median duration of antibiotic therapy was 15 days i.v. with subsequent oral treatment for 21 days. Thirty-seven per cent of cases required surgical intervention. Mortality was 11%. A raised WCC at presentation (P<0.02) and the development of abnormal renal function (P<0.015) were predictors of poor prognosis.
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Affiliation(s)
- M N Gupta
- Centre for Rheumatic Diseases, University Department of Medicine, Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, UK
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Abstract
The key to successful treatment of acute bacterial arthritis is early diagnosis and initiation of empirical antibacterial therapy. Treatment includes antimicrobial therapy, debridement of the infected joint and treatment of pain. Empirical antibacterial treatment should be re-evaluated as soon as the causative pathogen is identified from joint fluid and other cultures. Mobilisation with partial weight bearing is encouraged early during treatment. The outcome of properly treated bacterial arthritis in the elderly is generally favourable and at least 50% of patients may recover without developing secondary osteoarthritis.
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Affiliation(s)
- P Kortekangas
- Department of Surgery, University of Turku, Finland.
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Smith RL, Kajiyama G, Schurman DJ. Staphylococcal septic arthritis: antibiotic and nonsteroidal anti-inflammatory drug treatment in a rabbit model. J Orthop Res 1997; 15:919-26. [PMID: 9497819 DOI: 10.1002/jor.1100150619] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study evaluated the effects of combining antibiotic therapy with the application of a nonsteroidal anti-inflammatory drug on the degradation of articular cartilage for an animal model of Staphylococcal septic arthritis. Rabbits were infected intra-articularly with Staphylococcus aureus. Antibiotic treatment started 18 hours after infection and continued for 7 days. Treatment with the nonsteroidal anti-inflammatory drug naproxen sodium started 24 hours before infection and continued for either 3 or 7 weeks. The cartilage matrix of uninfected and infected knees was quantified by analysis of glycosaminoglycan and collagen content. Three weeks after infection, the combined treatment of the nonsteroidal anti-inflammatory drug and antibiotics reduced the loss of glycosaminoglycan and collagen from the cartilage of the infected knee by 15 and 30%, respectively, compared with antibiotic treatment alone. Continuing treatment with naproxen sodium for 7 weeks reduced the loss of collagen by 50% when compared with antibiotic treatment alone. The longer period of treatment with naproxen sodium showed little further effect on the loss of glycosaminoglycan than that observed for the 3-week treatment. Treatment with this drug and antibiotics reduced swelling of the knee and levels of prostaglandin E2 in the synovial fluid. The data support the hypothesis that decreasing post-infectious inflammation by adding the drug to a standard antibiotic regimen reduces cartilage damage from Staphylococcal septic arthritis.
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Affiliation(s)
- R L Smith
- Orthopaedic Research Laboratory, Stanford University Medical Center, CA 94305-5341, USA
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