Infection After ACL Reconstruction

H. Makhmalbaf MDConsultant Orth.& Knee Surgeon

Mashhad University of Medical Sciences

Prevention:

• Patient selection: phenotype, BMI• Environment, surgical technique, experience• Timing of surgery, duration of operation• Antibiotic prophylaxis• Type of graft, sterilization method, instrument• Fixation materials, Bio absorbable or metallic

Risk factors

• Previous surgery• Revision ACL surgery• Presence of metal-works• Simultaneous procedures: PCL rec. osteotomy• Type of graft, sterilization method, instrument• Implants used• Synthetic ligaments

Foreign body in the Joint

Chondrolysis & OA

Infection after ACL

• Superficial or deep infection• Clinical findings• Synovial fluid analysis• Laboratory findings• Imaging: X-ray, MRI

Synthetic Ligament

Treatment options

• IV Antibiotics• Arthroscopic washout & debridement• Open arthrotomy with preservation of graft• Arthrotomy and removal of graft & fixation

material

Outcome of infection

• Reoperations, hospitalization, costs, job loss • Pain, limitation of ROM, scars• Wasted quads, longer rehab period• Graft jeopardy or failure • Loss of playing season or athletic career

Conclusion

• Stick to the principles• Patient selection• Clean operative environment• Operative technique, instruments• Graft selection & sterility• Iv antibiotics• Close observation & prompt intervention

Operative environment

Infection Following Arthroscopic Anterior Cruciate Reconstruction

MAJ Daniel Judd et al.Arthroscopy J. April 2006

Purpose of study:• Review their cases & other reports to identify• Risk factors• Evaluate physical & lab. Findings• Compare different treatments &• Assess clinical outcomes

Results :

• Retrospective study 1994- 2002• 11 infections in 1615 pts.• Hamstring autograft, previous knee surgery• & Acl reconstructions• Tibial Acl graft fixation with a post & washer• Associated with increased infection

The goals of treatment are

• To protect the articular cartilage• To protect the graft• Timely initiation of treatment including• Joint lavage, debridement & antibiotics• Are essential to treatment• Graft & hardware retention is possible• Expedient graft & hardware removal

Septic Arthritis After Arthroscopic ACL Reconstruction, Wang C 2009

Arthroscopy J

• Diagnosis & treatment of septic arthritis• 1997-2007, 21pts. Out of 4068• The most common symptoms were:• Fever, swelling, severe pain, tenderness &• Restricted motion• ESR, CRP &Fibrinogen levels markedly elevated

Septic arthritis after

• Coagulase-neg. Staph was the most common• Both conservative & 0perative treatment were

effective• Longer recovery time and IV antibiotic therapy

in the conservative group

Conclusion:

• Septic arthritis is rare but potentially devastating complication

• Correct diagnosis relies on: • Clinical evaluation, Lab tests• Synovial fluid analysis & bacterial culture• Early diagnosis & prompt treatment• Arthroscopic debridement & irrigation &• Retention of ACL graft when still functional

Autograft contamination during preparation for ACL reconstruction

Michael E Hantes, MD et al JBJS Am 2008

Comments :

• BPB & Hamstring Autografts most commonly• Graft contamination during preparation• By surgical masks, gloves & instruments• Contamination of graft could be a risk factor• In septic arthritis ESR & CRP are elevated

Aim of study:

• Chance of graft contamination• Association between contamination & infec.• Chance of contamination of BPB & Hamstring• Contamination & inflammatory blood markers• 30 pts. In each group• 3 specimens for culture• ESR & CRP checked preop. & 3, 7,20 days post

Results:

• A high rate of contamination (12%)• Contamination rate was equal in two grafts• No association between contamination &

elevation of ESR, CRP• More positive cultures in 2nd & 3rd specimens• Slight elevation of ESR & CRP in all pts.• No association between graft cont. & infection

Previous UTO:

Previous UTO:

MRI of the Knee

After ACL reconstruction:

We have to be careful

Thank you