Journal of Orthopaedic Surgery 2014;22(1):111-7
Graft infection following arthroscopic anterior
cruciate ligament reconstruction: a report of
four cases
James Wee, Keng Thiam Lee
Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
INTRODUCTION
ABSTRACT
Septic arthritis following arthroscopic anterior
cruciate ligament reconstruction (ACL) is a rare
complication and associated with severe morbidity.
Its risk factors include (1) concomitant procedures
during the reconstruction, (2) previous knee surgery,
(3) allograft usage, (4) peri-operative wound
contamination, and (5) presence of intra-articular
foreign bodies. We present a series of 3 men and
one woman aged 22 to 35 years who developed
septic arthritis following ACL reconstruction. The
risk factors identified were local infection (n=2),
previous ipsilateral knee surgery (n=2), and the
use of an allograft (n=1). All patients underwent
emergency knee washout and debridement with
graft retention within 24 hours, together with a course
of intravenous antibiotic therapy. All the patients
achieved eradication of their infections (with intact
ACL grafts) and satisfactory functional outcome at a
mean follow-up of 32 (range, 25–45) months.
Key words: anterior cruciate ligament reconstruction;
arthritis, infectious; infection
Septic arthritis after arthroscopic anterior cruciate
ligament (ACL) reconstruction is rare and may result
in severe morbidity, prolonged hospitalisation, and
poor clinical outcome.1 Its incidence is 0.3 to 1.7%,2–6
whereas the postoperative intra-articular infection
rate is 1.5%.7 Early diagnosis and aggressive treatment
minimises the risks of graft failure, damage to intraarticular hyaline cartilage, and arthrofibrosis,8–10 and
thus is vital in eradicating the infection, preserving
the graft, and achieving good functional outcomes.
Delay in treatment can lead to osteomyelitis, diffuse
chondral thinning, full-thickness osteochondral
defects, and rapid degenerative osteoarthritis.7,11,12 We
report on 4 patients who developed septic arthritis
following arthroscopic ACL reconstruction.
CASE REPORTS
Records of 3 men and one woman aged 22 to 35 years
who developed acute (<2 weeks, n=3) or subacute
(2 weeks to 2 months, n=1) septic arthritis following
arthroscopic ACL reconstruction by a single surgeon
between July 2007 and June 2012 were retrospectively
reviewed (Table). All patients underwent emergency
Address correspondence and reprint requests to: Dr James Wee, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11
Jalan Tan Tock Seng, Singapore, 308433. Email: [email protected]
Journal of Orthopaedic Surgery
112 J Wee and KT Lee
knee washout and debridement with graft retention
within 24 hours, together with a course of intravenous
antibiotic therapy. All the patients achieved
eradication of their infections (with intact ACL grafts)
and satisfactory functional outcome at a mean followup of 32 (range, 25–45) months.
Patient 1
In November 2008, a 28-year-old man presented
with pain and instability of the right knee following
a soccer injury 12 months earlier. He was diagnosed
to have tears of the ACL and medial meniscus, and
underwent arthroscopic ACL reconstruction and
partial medial meniscectomy 3 months later.
On the day of surgery, a 2-cm superficial wound
with an overlying dry scab was noted at the proximal
tibia, around 3 cm distal to the lowest pes anserinus
insertion site. Although there was no evidence of
wound infection, the increased risk of postoperative
infection was a concern. Nonetheless, the patient
declined postponement of the surgery owing to work
commitments.
The right lower limb was cleaned with iodine
and draped. The scab was covered with Ioban
adhesive drape wrapped circumferentially around
the leg. A transtibial technique with a 4-stranded
semitendinosus and gracilis autograft was used. The
graft was fixed with an Endobutton CL loop for the
femur and a GTS interference screw for the tibia.
Partial medial meniscectomy was also performed.
The patient was scheduled for follow-up in 2 weeks
and instructed to return earlier if he became feverish,
unwell, or noted increasing knee pain, swelling, or
discharge from his wounds.
On day 10, he became feverish, but did not
return for earlier review. On day 13, he presented
to the emergency department with discharging
haemoserous fluid from the proximal tibial wound.
A large, warm effusion was noted, with erythema
Table
Patient demographics and outcomes
Parameter
Patient 1
Patient 2
Patient 3
Patient 4
Sex/age (years)
Comorbidities
M/28
Asthma (not on
medication)
Superficial skin
abrasion near
graft harvest site,
concomitant
meniscectomy,
hamstring autograft
Acute
10.0
314.5
92
M/35
-
F/22
-
M/26
-
Risk factors of septic arthritis
Onset of infection
White blood cell count (x109/l)
C-reactive protein (mg/l)
Erythrocyte sedimentation rate
(mm/h)
Treatment
Intravenous antibiotics,
arthroscopic
debridement and
washout
Graft retention
Yes
Follow-up period (months)
45
Knee active range of movement 0º–130º
Anterior drawer test
1+ with firm end-point
Lachmann test
1+ with firm end-point
Pivot shift test
1+
Knee Society knee score
90
Knee Society function score
100
SF-36 physical component
51.5
summary score
SF-36 mental component
58.8
summary score
Subclinical left femoral Previous knee surgery,
intramedullary nail
allograft, concomitant
infection, previous
meniscectomy
knee surgery, hamstring
autograft
Concomitant
meniscectomy,
hamstring autograft
Acute
12.2
239.1
65
Subacute
9.5
77
36
Acute
5.4
114.7
75
Intravenous antibiotics,
arthrotomy, debridement
and washout, removal of
femoral implants
Yes
33
0º–110º
Negative
Negative
Negative
92
100
44.2
Intravenous antibiotics,
arthroscopic
debridement and
washout
Yes
26
0º–130º
Negative
Negative
Negative
95
100
46.3
Intravenous antibiotics,
arthroscopic
debridement and
washout
Yes
25
0º–140º
1+ with firm end-point
1+ with firm end-point
Negative
90
100
49.6
60.8
58.4
51.8
Vol. 22 No. 1, April 2014
around the wound. The previous scab had pealed off.
His white blood cell (WBC) count was 10.0 x109/l,
the C-reactive protein level was 314.5 mg/l, and
the erythrocyte sedimentation rate (ESR) was 92
mm/hr. The seropurulent fluid was positive for
Gram-positive cocci, and cultures grew methicillinsensitive Staphylococcus aureus (MSSA). Intravenous
amoxicillin/clavulanic acid was started, and later
switched to intravenous cloxacillin (based on culture
and sensitivity results).
He immediately underwent arthroscopic
debridement and washout of the tibial wound.
Seropurulent fluid and pus was expressed from
the proximal tibial wound after removal of stitches.
There was severe synovitis of the joint. The ACL graft
was structurally intact though it had some slough on
its surface. Two days later, pus was still expressed
from the wound and thus a second arthroscopic
debridement and washout was performed. Another
2 days later, a third debridement and washout
was performed because the CRP level remained
high at 323.3 mg/l, and the ESR rose to 115 mm/
hr. Nonetheless, specimens from the 2nd and 3rd
washouts were all culture negative. Four days later,
the CRP level had decreased to 24.1 mg/l, and the
ESR to 73 mm/hr. Six days after the first washout, the
proximal tibial wound was sutured, and the drains
were removed when the wound discharge became
minimal. The patient was discharged at day 16. He
received oral cloxacillin for 6 weeks. The CRP level
became normal (3.4 mg/l) 5 weeks after the first
washout. Clinical examination revealed grade-1
Graft infection following arthroscopic ACL reconstruction 113
ACL laxity with a firm end-point. At the 45-month
follow-up, the patient reported no major knee pain
or instability, and was able to jog and engage in
recreational sports.
Patient 2
In October 2008, a 35-year-old man presented with
increasing pain and instability of the left knee
caused by a chronic tear of the ACL. In 2004, he
had undergone retrograde intramedullary nailing
for a closed, comminuted, segmental fracture of
the left femoral shaft after a road traffic accident.
Since July 2005, the 3 interlocking screws near the
femoral condyle was found to be loose and slightly
backed-out (Fig.), but there was no swelling or
tenderness at the site of the interlocking screws. An
option of a 2-stage procedure was provided (first to
remove the retrograde nail and interlocking screws
and to eradicate infection [if any], followed by ACL
reconstruction later), but the patient insisted on a
single-stage procedure.
The hamstring tendon was first harvested and
prepared. The 3 distal interlocking screws were
removed via a lateral incision to avoid interfering
with femoral tunnel reaming. The retrograde nail
was left in situ to reduce contamination of the joint.
The most proximal interlocking screw was found to
be loose with some surrounding granulation tissue,
but no pus or slough. As the hamstring tendon was
already harvested, a decision was made to proceed
with ACL reconstruction. A transtibial technique was
Figure
Patient 2: preoperative radiograph and magnetic resonance images showing a retrograde intramedullary nail with a
loosened interlocking screw and a complete tear of the anterior cruciate ligament in the left knee.
Journal of Orthopaedic Surgery
114 J Wee and KT Lee
used for femoral tunnel reaming. The graft was fixed
with a retrobutton loop in the femur and with a Delta
screw in the tibia.
Gram stains of all intra-operative specimens were
negative, as were bacterial cultures from the tissues
around the loosened screws. However, a culture from
the screws yielded a scanty growth of Pseudomonas
aeruginosa, which was susceptible to ceftazidime but
not to amoxicillin/clavulanic acid, which had been
prescribed to this patient.
On day 8, the patient was readmitted with fever,
increasing knee pain, and swelling for 2 days. The
WBC count was 12.2 x109/l, the CRP level was 239.1
mg/l, and the ESR was 65 mm/hr. 80 ml of turbid
haemopurulent fluid was aspirated from the knee. He
was given intravenous ceftazidime and underwent an
arthrotomy, washout, and removal of the retrograde
nail and proximal interlocking screws, via a medial
parapatellar approach within 24 hours. The ACL
graft was structurally intact. The medullary canal
was hand-reamed and irrigated, and the washout
was completed with 9 litres of pulsed lavage. A drain
was inserted prior to skin closure.
Four days after surgery, the WBC count decreased
to 6.9 x109/l, the CRP level to 32.6 mg/l, and the ESR
rose to 82 mm/hr before declining 3 days later. Gram
stains and cultures of all intra-operative tissues and
fluids were negative, although the WBC count was
normal; this was likely due to the administration of
intravenous ceftazidime before surgery.
Postoperative recovery was uneventful, and
the drain was removed on day 6. Serial tests of
inflammatory markers showed a steady decline,
and the patient was discharged on day 18. He had
received 8 weeks of intravenous ceftazidime in order
to eradicate any concomitant osteomyelitis of the
medullary canal, even though the CRP level returned
to normal (2.0 mg/l) at week 3. At the 33-month
follow-up, there was no recurrence of infection.
He had mild knee pain but reported no instability.
Clinical examination revealed a stable ACL with
good range of knee movement.
Patient 3
In July 2007, a 22-year-old woman underwent
ACL reconstruction of the right knee. In late 2009,
she presented with a 9-month history of pain and
instability in the knee following a twisting injury
during sports. Magnetic resonance imaging revealed
a ruptured ACL graft and a tear in the posterior horn
of the lateral meniscus. In June 2010, she underwent
an arthroscopic revision ACL reconstruction using a
fresh-frozen allograft tendon.
Early osteoarthritic changes were noted in the
patellofemoral and medial compartments. The
tibial and femoral tunnels were freshly drilled via a
transportal technique. The graft was fixed with an
Endobutton CL loop in the femur and a Biosure screw
in the tibia. A partial lateral meniscectomy was also
performed.
At the 15-day follow-up, she had no fever, but
there was a small effusion on the right knee. The
surgical wounds had healed and stitches were
removed. At day 28, she presented with fever for 2 to
3 days and increasing pain and swelling. A large knee
effusion with increased warmth was noted. Knee
aspiration yielded turbid fluid with debris.
She was immediately treated with intravenous
ceftriaxone and cloxacillin, followed by arthroscopic
debridement and washout. Severe synovitis of the
joint and a large amount of turbid fluid and debris
were noted, but the ACL graft was intact. Culture
of the joint fluid yielded methicillin-sensitive
Staphylococcus aureus (MSSA), for which intravenous
cloxacillin was continued. The antibiotic was
switched to intravenous clindamycin owing to an
allergic reaction to cloxacillin.
Four days later, arthroscopic debridement and
washout was repeated, as the drained fluid remained
turbid, and the CRP level and the ESR had increased
to 221.2 mg/l and 98 mm/hr, respectively. Culture of
synovial tissue yielded a scanty growth of MSSA. Two
days later, the CRP level decreased to 132.1 mg/l and
3 days later to 53.4 mg/l. The ESR increased to 118
mm/hr before declining gradually. Serial monitoring
of inflammatory markers showed a steady downward
trend. The patient was discharged on day 16. She had
received 6 weeks of oral clindamycin. Her CRP level
returned to normal (2.9 mg/l) 4 weeks after the first
washout, whereas the ESR took 16 weeks to normalise.
At the 26-month follow-up, she had a stable knee,
with minimal pain, and was able to return to running
and pivoting sports.
Patient 4
In July 2010, a 26-year-old man presented with a
2-year history of pain and instability of the right
knee following a soccer injury. He had a complete
tear of the ACL, a tear of the medial meniscus, and
partial cartilage loss in the medial compartment.
He underwent arthroscopic ACL reconstruction and
a partial medial meniscectomy using a 4-stranded
semitendinosus and gracilis autograft via a transportal
technique. The graft was fixed with an Endobutton
CL loop in the femur and a Biosure screw in the tibia.
At the 15-day follow-up, he was afebrile but had
Vol. 22 No. 1, April 2014
had moderate knee pain for 2 days. A large knee
effusion was noted. Knee aspiration yielded 80 ml of
haemoserous fluid. He declined the offer of surgery
and was therefore prescribed oral amoxicillin/
clavulanic acid for one week. Although the Gram
staining of the joint aspirate was negative, cultures
grew Staphylococcus hominis, which was sensitive
to cloxacillin. The patient refused a knee washout
despite repeated advice. On day 21, he eventually
underwent extensive debridement, synovectomy,
and washout. The ACL graft was intact. A drain was
inserted before closure. Cultures were negative for
bacterial growth, probably owing to his oral antibiotic
therapy. The WBC count was 5.4 x109/l, the CRP level
was 114.7 mg/l, and the ESR was 75 mm/hr. Four day
later, the CRP level was 7.6 mg/l, and the ESR was
20 mm/hr. The patient was discharged on day 8. He
had received 6 weeks of intravenous cloxacillin. He
regained full range of knee motion, despite having
grade-1 laxity with a firm end point. At the 25-month
follow-up, he had no knee pain or instability and was
able to jog and play recreational sports.
DISCUSSION
Risk factors of septic arthritis following arthroscopic
ACL reconstruction include (1) concomitant
procedures during the reconstruction, (2) previous
knee surgery, (3) allograft usage, (4) use of a hamstring
grafts versus bone-patellar tendon-bone grafts, (5)
peri-operative wound contamination, (6) presence of
intra-articular foreign bodies, and (7) contamination
of surgical equipment.2–6
Concomitant procedures
Previous knee surgeries and concomitant procedures
during the ACL reconstruction (e.g. meniscus repair)
are risk factors for postoperative infection.6 This was
probably attributed to increased operation time,
additional or larger incisions, longer tourniquet time,
and suture materials acting as a foreign-body nidus
for infection.
Septic arthritis of the knee is related to concomitant
meniscus repair.4 The extra posteromedial incision for
an inside-out repair technique and the suture materials
are all risk factors. In one series, 50% of patients with
septic arthritis had undergone concomitant surgeries,
compared to only 20% in those without infection.13
However, one study reported that none of the
patients with an infected ACL reconstruction had a
concomitant open procedure (apart from harvesting
of the graft).3 The relative risk of postoperative
Graft infection following arthroscopic ACL reconstruction 115
infection was not significantly higher in patients
with concomitant procedures (relative risk=0.59;
95% confidence interval, 0.25–1.4).14 In our series,
concomitant partial meniscectomy might have been
a contributing factor in patients 1, 3, and 4, whereas
removal of interlocking screws also increased the
operation time in patient 2.
Previous knee surgery
53 to 75% of patients who developed septic arthritis
after ACL reconstruction have previous surgery
to the ipsilateral knee.2,7,11,12,15 The relative risk of
postoperative infections in such patients is 1.9,
and increased to 5.1 if the previous surgery is ACL
reconstruction.11
In our series, patient 2 had undergone retrograde
intramedullary nailing for an ipsilateral femoral
shaft fracture 4 years earlier. A culture from one of
the distal interlocking screws was positive, indicating
pre-existing subclinical infection. In addition, the
intramedullary nail was left in situ during the ACL
reconstruction and could have served as a foreignbody nidus for infection. Patient 3 had undergone
primary ACL reconstruction using a hamstring
autograft. The autograft later failed and was revised
with an allograft. This patient therefore had 2
risk factors: a history of previous ipsilateral ACL
reconstruction and the use of an allograft.
Allograft usage
In a study by the Centers for Disease Control from
a single surgical center, the infection rate for both
autografts and irradiated allografts is 0%, but is 4%
for non-irradiated allografts.16 Most allografts are
not irradiated, as radiation may cause structural
weakening of the graft. In another study, allografts
have a higher rate of infection than autografts (4.4%
vs. 0%).17 Other studies reported no differences in the
postoperative infection rates between allograft and
autologous grafts for ACL reconstruction.3,18
Type of autograft
ACL reconstruction with a hamstring graft is
associated with a higher rate of septic arthritis.3,11
It is postulated that the relatively short hamstring
graft results in increased amounts of suture material
inside the knee joint, which acts as a foreign body.11
Furthermore, harvesting the hamstring tendons
predisposes this area to wound complications.11
Nonetheless, the postoperative infection rate is
not significantly different between 3 different ACL
Journal of Orthopaedic Surgery
116 J Wee and KT Lee
reconstruction techniques (using a patellar tendon
graft with single- or double-incision technique, or
using a hamstring graft).8
Peri-operative wound contamination
Peri-operative wound contamination (including
incision for graft harvesting) may be the most
common source of infection.12 It is postulated that
infection originates from the tibial tunnel and spreads
to the knee joint.7,8,11 Haematoma collection in the
pre-tibial subcutaneous tissue may serve as a nidus
for infection. In our series, peri-operative wound
contamination was a likely risk factor for patients 1
and 2. It is recommended that surgery be postponed
when there is a dry scab near the surgical site. For
patients with peri-articular implants, especially
those that are loose, a 2-stage ACL reconstruction
is recommended to reduce the risk of postoperative
infection. Should a single-stage surgery be performed,
it is advisable to remove all implants before
harvesting the graft. This enables ACL reconstruction
to be postponed, if there is intra-operative suspicion
of infection or an unexpected fracture.
Intra-articular foreign bodies
Increased intra-articular foreign body load
predisposes to infections.7,8,11,19 This includes suture
material from hamstring grafts, implanted material
from meniscal repairs, and pre-existing implants,
such as intramedullary nails.
Contamination of surgical equipment
Increased environmental contamination (such as
excessive traffic of personnel) may be a risk factor
of postoperative septic arthritis.5,11–13,19 Incomplete
sterilisation of inflow cannulae,5 meniscus repair
cannulae,20 or graft boards15 may lead to postoperative
infection. The gap between the metal part and rubber
membranes on the suture clamps cannot be sterilised
satisfactorily despite sterilisation attempts in certified
autoclaves.13
suggested,2,3,25 but others advocate graft removal
only in cases of persistent infection.6,26 In a survey of
74 surgeons, most propose initial debridement with
graft retention, whereas 36% adopt graft removal as
part of the treatment regimen for resistant infection.21
Based on the Gaechter grading system for septic
arthritis of the knee, a stage-adapted treatment
protocol is proposed.15 For Gaechter grades 1 and
2, arthroscopic treatment is suggested. For grades
3 and 4, medial or lateral arthrotomy is suggested.
Graft retention is based on clinical findings. This
treatment protocol has achieved reliable results, with
no recurrence of septic arthritis or development of
osteomyelitis. However, overall results are only fair
compared with patients with no complication. Early
infection can be managed with arthroscopic surgery,
whereas in advanced or chronic infection, a more
radical approach is preferred. Clinical results are
better if the ACL graft remains functional.
In our patients, aggressive, emergency
arthroscopic debridement and washout, with
retention of the ACL graft, successfully eradicated
intra-articular infection, with no recurrence. The CRP
level is the best inflammatory marker for detecting
septic arthritis and monitoring infection status
following knee washout. Its response at the onset
of infection is rapid. All 4 patients had markedly
elevated CRP levels (>100 mg/l) at presentation.
Patients with persistently elevated CRP levels
(patients 1 and 3) had repeat washouts, whereas those
with rapidly declining CRP levels following the first
washout (patients 2 and 4) did not undergo further
washout. The ESR response often lagged clinical
improvement and the decline of CRP levels by days
to weeks; sometimes the ESR even rose temporarily.
Three of the 4 patients had normal WBC count on
admission and throughout the treatment period.
Only patient 2 had a mildly elevated WBC count of
12.2 x109/l on admission. Thus, the WBC count is not
sensitive enough for early diagnosis of postoperative
septic arthritis and for monitoring the clinical course.
The CRP level, together with inspection of the knee
aspirate, is the most sensitive marker for detecting
postoperative infection and for monitoring the
response to treatment.
Treatment
Treatment options include long-term intravenous
antibiotics, arthroscopic or open washout and
debridement, constant joint irrigation, and graft
retention or removal with or without reimplantation.13
The most frequently used treatment is joint irrigation
and debridement with graft retention.5,15,21–24
Immediate removal of the infected ACL graft is
CONCLUSION
Aggressive early knee washout and debridement
with graft retention, and a prolonged course of
intravenous antibiotic therapy are recommended for
treatment of graft infection following arthroscopic
ACL reconstruction. The CRP level is the most
Vol. 22 No. 1, April 2014
sensitive inflammatory marker for detecting
postoperative infection. All our patients recovered
well with reasonably good functional outcomes.
Graft infection following arthroscopic ACL reconstruction 117
DISCLOSURE
No conflicts of interest were declared by the authors.
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