Lessons learnt from an atypical mycobacterium infection post-anterior cruciate ligament reconstruction

Atypical mycobacterium infection following anterior cruciate ligament reconstruction

A man in his 20s presented with instability of the right knee following an incident of fall from a height. He was clinicoradiologically diagnosed to have an anterior cruciate ligament (ACL) tear for which he underwent ACL reconstruction. Postoperatively, he was started on an accelerated ACL rehabilitation protocol. Six weeks postoperatively, he developed features of subclinical septic arthritis for which he underwent arthroscopic debridement. Intraoperative samples cultured Mycobacterium abscessus complex on MGIT 960 system. The patient subsequently had to undergo another debridement after 1 month as there were clinical signs of persisting infection. The graft was intact even on the second debridement and after removing the implants. This case reports a rare complication of ACL reconstruction with infection by atypical mycobacterium and the clinical outcome. It also emphasises that prompt surgical intervention can save the graft.

Recommendations on diagnosis and antimicrobial treatment of infections after anterior cruciate ligament reconstruction (ACL-R) endorsed by ESSKA and EBJIS

Infection after anterior-cruciate ligament reconstruction (ACL-R) is a rare but devastating complication affecting predominantly young and sportive individuals. A timely and correct diagnosis as well as an optimized management are paramount to circumvent serious sequelae and compromise in life quality. These recommendations are primarily intended for use by infectious disease specialists and microbiologists, but also orthopedic surgeons and other healthcare professionals who care for patients with infections after ACL-R. They are based on evidence mainly originating from observational studies and opinions of experts in the field and cover the management of infections after ACL-R with a special focus on etiology, diagnosis, antimicrobial treatment and prevention. Comprehensive recommendations on prevention, surgical treatment and rehabilitation are presented separately in a document primarily addressing orthopedics professionals.

A Systematic Review of Nontuberculous Mycobacterium Infection Following Anterior Cruciate Ligament Reconstruction

Although infection following anterior cruciate ligament (ACL) reconstruction is rare, these cases have potentially catastrophic ramifications. Nontuberculous mycobacteria (NTM) are ubiquitous, located in the water supply and soil. Our objective was to review the literature to characterize NTM infection following ACL reconstruction.

Methods

A database search was performed for arthroscopic ACL reconstructions that resulted in a postoperative diagnosis of NTM infection.

Results

The literature search returned 6 case reports that met the inclusion criteria. The initial postoperative presentation occurred after 3 to 52 weeks, which is consistent with reports of postoperative NTM infection.

Conclusions

The common indolent course of NTM infection hinders prompt diagnosis and treatment. Organism susceptibility testing is crucial for effective treatment and limiting unnecessary antibiotic exposure.

Clinical Relevance

The duration of medical treatment for NTM infection is 4 to 6 months, depending on the severity of disease and species. Based on the aggregate literature, we recommend removal of local implants if the infection is localized and without articular involvement. However, in cases of articular involvement, all fixation and graft material should be removed.

A chronic sinus tract infection developing after suture anchoring of the ankle: A case report

RATIONALE

Suture anchors are increasingly used to fix soft tissue to bone. Favorable outcomes of the modified Brostrom operation (MBO) using suture anchors have been reported. However, to the best of our knowledge, few complications of suture anchors used in ankle surgery have been described. Here, we present a rare case of successful treatment of a chronic sinus tract infection developing after the MBO using a suture anchor.

PATIENT CONCERNS

A healthy 18-year-old high school student presented with a chronic ulcerative wound in his right ankle 1 year after anterior talofibular and calcaneofibular ligament repair using a suture anchor at a local clinic. Clinical examination revealed a 1.5 × 2-cm-sized ulcerative wound, accompanied by a red-black discharge, on the anterior border of the right lateral malleolus. The wound could be approximated to the joint capsule level using a forceps.

DIAGNOSIS

A simple standing anteroposterior radiograph of the right ankle revealed mild, lateral soft-tissue swelling. Magnetic resonance imaging showed that a sinus tract running from the wound to the talar body crossed the anterior joint capsule, and bone marrow edema surrounding the talus.

INTERVENTIONS

We removed the sinus tract and the infected suture anchor. We rendered the wound zigzag-shaped and then performed simple suturing and applied a short leg cast.

OUTCOMES

The wound healed completely by 4 weeks after surgery. The patient reported no complication or recurrence of infection at the 1-year follow-up.

LESSONS

To obtain wound healing, the chronic sinus tract must be removed. If the suture anchor is the cause of infection, it should be removed.

Prosthetic knee joint infection due to Mycobacterium abscessus

Infected total knee arthroplasty (TKA) due to Mycobacterium abscessus is very rare with only three such cases described in literature. Only one case was managed successfully, however, with a prolonged course of anti tubercular therapy. In this case report, we present an elderly lady with infected TKA after 2 years of the primary procedure. Although initially it grew different bacteriae, M. abscessus was isolated during the second debridement. She was successfully treated with total of 5 months of second line anti tubercular drugs with revision prosthesis performed during chemotherapy. Two years followup revealed satisfactory outcome with no relapse.