Correspondence Management of Septic Arthritis Following Anterior Cruciate Ligament Reconstruction: A Review of Current Practices and Recommendations
Dr. Cadet or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew and serves as a paid consultant to Smith & Nephew. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company related directly or indirectly to the subject of this article: Dr. Sonnery-Cottet, Dr. Mathieu Thaunat, Dr. Archbold, and Dr. Issartel. http://dx.doi.org/10.5435/ JAAOS-22-05-271 May 2014, Vol 22, No 5
To the Editor: We would like to respond to the article by Cadet et al.1 This well-written article describes the epidemiology, potential risk factors, diagnosis, management, and outcome of septic arthritis, a rare but potentially devastating complication of anterior cruciate ligament (ACL) reconstruction. We conducted a similar study in 20112 and were surprised that the authors did not mention our article in their review. Based on 1,957 ACL reconstructions, we found that the prevalence of septic arthritis was 0.37% in the nonprofessional group and 5.7% in the population of professional athletes. We concluded that both participating in professional sports and having a combined lateral tenodesis were risk factors for the development of infection after ACL reconstruction. We also hypothesized that professional athletes may be part of a specific group of patients who are at higher risk of infection after ACL reconstruction, particularly athletes who participate in outdoor sports. We feel that this information is very important and note that it was not mentioned by Cadet et al.1 It is this highly demanding population of patients, who want a rapid recovery and return to sport, who should be made aware of this increased risk. In addition, with the recent interest in the anterolateral ligament of the knee, lateral tenodesis, or extraarticular surgery, will come back into fashion in the coming years and increase the risk of septic arthritis. In our series, three patients who had a persistent infection despite
antibiotic treatment underwent a second arthroscopic lavage. The tibial screw was changed in these patients because we thought it could explain the reason for the failure of the first arthroscopic lavage as a result of a bacterial biofilm.3 Changing the screw is easily performed when double fixation is used at the initial ACL reconstruction. This information is not specified by Cadet et al1 but seems fundamental to us and explains why we have never had to remove a graft or perform an open arthrotomy in our 10 years of practice. Cadet et al1 also do not specify the mode of administration of antibiotics. All patients in our series were initially begun on a combination of intravenous penicillin and gentamicin. This was changed depending on the cultured organism and its antibiotic sensitivity. After 3 days of intravenous antibiotics, patients were given oral antibiotics for 6 weeks. We enjoyed reading the article by Cadet et al1 and hope that we have added some useful pearls from our own experience that will help improve the management of septic arthritis following anterior cruciate ligament reconstruction. Bertrand Sonnery-Cottet, MD Mathieu Thaunat, MD Lyon, France Pooler Archbold, MD Belfast, Ireland Bertrand Issartel, MD Villeurbanne, France The Author Replies: We thank Dr. Sonnery-Cottet and colleagues for their positive comments about our article.
271
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 1
Arthroscopic images of the knee demonstrating significant synovitis and adhesions in the patellofemoral space before (A) and after (B) arthroscopic débridement.
Figure 2
A, Arthroscopic image demonstrating the anterior cruciate ligament (ACL) graft 6 days after initial irrigation and débridement was performed in a patient with septic arthritis following ACL reconstruction. The graft was attenuated and nonviable and was subsequently removed, along with all hardware. The tunnels and old incision sites were opened and débrided thoroughly. B, No evidence of infection existed 7 months after initial irrigation and débridement. The patient underwent revision reconstruction with a bone–patellar tendon–bone allograft, achieved full, pain-free range of motion, and returned to sports following the staged reimplantation.
We do agree that the finding of Sonnery-Cottet et al2 regarding the higher prevalence of septic arthritis following ACL reconstruction in the professional athlete, compared with a nonprofessional cohort, is very important, and we recognize that the omission of this report was an oversight. In the report of Sonnery-Cottet
272
et al,2 a striking 5 of the 12 patients (42%) who were diagnosed with septic arthritis following ACL reconstruction were professional athletes. This number is alarming given the fact that only 4.5% of the total study population (88 of 1,957 patients) was professional athletes. Furthermore, additional extra-articular procedures
(eg, lateral tenodesis) increased the risk for septic arthritis following ACL reconstruction. I do agree that this is also a very important point and that the discussion of the potential for extra-articular procedures to increase the risk for septic arthritis should not be limited to lateral tenodesis but should extend to other procedures, including meniscal repair and extraarticular ligament reconstruction. We thank the authors for highlighting this very important point. With regard to the authors’ remarks regarding route of administration of antibiotics, we discussed in our report1 that intravenous antibiotics should be initiated. The duration and choice of antibiotic depends on several factors, including the isolated organism, sensitivity of the organism to the antibiotic regimen, clinical response to the chosen antibiotic, and clinical practices of infectious disease specialists guiding the antibiotic regimen. Broad-spectrum antibiotics should be administered only after an arthrocentesis has been performed in an attempt to isolate an organism to deliver organism-specific antibiotic regimens. An oral regimen may be prescribed subsequent to intravenous antibiotic depending on the several factors just outlined. Individual institutions and infectious disease specialists may differ with regard to the antibiotic regimen; thus, there is no standard antibiotic regimen that should be employed for every case. We appreciate the authors’ sharing their treatment of choice with the readership. The point of tibial screw or hardware exchange is important; this should be performed at the index débridement if backup fixation was performed during initial ligament reconstruction. We thank the authors for highlighting this very important point. However, the extent of bacterial biofilm development and adherence is not only isolated at this site but also involves (1) the graft itself,
Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
(2) suture material used for supplementary fixation, and/or (3) femoral fixation devices/hardware. Exchanging the tibial screw implant alone following a single débridement may not be sufficient in many cases. There must be a critical evaluation of the graft and this should happen not only at a single time point (eg, one débridement), but should occur at subsequent time points with serial débridement procedures. The authors state that, in their report, in the three patients in whom a secondary lavage was performed and the tibial screw was exchanged, the graft was able to be preserved and that the patients had a “satisfactory” outcome. The authors did not define in this report what “satisfactory” means. Does this mean that the patient returned to the same or improved level of activity as that before the injury or that the knee remained “aseptic”? The
May 2014, Vol 22, No 5
authors may not have determined that a retained graft needed revision in 10 years; however, it does not necessarily mean that the retained graft was functionally adequate to provide optimal knee function and high patient satisfaction. (Please refer to Figures 2 and 3 of our article1 [reprinted here as Figures 1 and 2, respectively], demonstrating rapid deterioration of the graft despite an improved clinical picture only 6 days following initial lavage and débridement). To imply that a graft rarely needs to be removed after developing septic arthritis following ACL reconstruction may be misleading to the readership of the Journal and may underrepresent the need to critically evaluate graft integrity with subsequent débridements. We appreciate the authors’ comments and their highlighting very
important aspects of the care in the management of the patient with septic arthritis following ACL reconstruction that may have been deficient in our article. Edwin R. Cadet, MD Raleigh, North Carolina
References 1. Cadet ER, Makhni EC, Mehran N, Schulz BM: Management of septic arthritis following anterior cruciate ligament reconstruction: A review of current practices and recommendations. J Am Acad Orthop Surg 2013;21(11):647-656. 2. Sonnery-Cottet B, Archbold P, Zayni R, et al: Prevalence of septic arthritis after anterior cruciate ligament reconstruction among professional athletes. Am J Sports Med 2011; 39(11):2371-2376. 3. Trampuz A, Osmon DR, Hanssen AD, Steckelberg JM, Patel R: Molecular and antibiofilm approaches to prosthetic joint infection. Clin Orthop Relat Res 2003;414: 69-88.
273
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Dr. Cadet or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew and serves as a paid consultant to Smith & Nephew. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company related directly or indirectly to the subject of this article: Dr. Sonnery-Cottet, Dr. Mathieu Thaunat, Dr. Archbold, and Dr. Issartel. http://dx.doi.org/10.5435/ JAAOS-22-05-271 May 2014, Vol 22, No 5
To the Editor: We would like to respond to the article by Cadet et al.1 This well-written article describes the epidemiology, potential risk factors, diagnosis, management, and outcome of septic arthritis, a rare but potentially devastating complication of anterior cruciate ligament (ACL) reconstruction. We conducted a similar study in 20112 and were surprised that the authors did not mention our article in their review. Based on 1,957 ACL reconstructions, we found that the prevalence of septic arthritis was 0.37% in the nonprofessional group and 5.7% in the population of professional athletes. We concluded that both participating in professional sports and having a combined lateral tenodesis were risk factors for the development of infection after ACL reconstruction. We also hypothesized that professional athletes may be part of a specific group of patients who are at higher risk of infection after ACL reconstruction, particularly athletes who participate in outdoor sports. We feel that this information is very important and note that it was not mentioned by Cadet et al.1 It is this highly demanding population of patients, who want a rapid recovery and return to sport, who should be made aware of this increased risk. In addition, with the recent interest in the anterolateral ligament of the knee, lateral tenodesis, or extraarticular surgery, will come back into fashion in the coming years and increase the risk of septic arthritis. In our series, three patients who had a persistent infection despite
antibiotic treatment underwent a second arthroscopic lavage. The tibial screw was changed in these patients because we thought it could explain the reason for the failure of the first arthroscopic lavage as a result of a bacterial biofilm.3 Changing the screw is easily performed when double fixation is used at the initial ACL reconstruction. This information is not specified by Cadet et al1 but seems fundamental to us and explains why we have never had to remove a graft or perform an open arthrotomy in our 10 years of practice. Cadet et al1 also do not specify the mode of administration of antibiotics. All patients in our series were initially begun on a combination of intravenous penicillin and gentamicin. This was changed depending on the cultured organism and its antibiotic sensitivity. After 3 days of intravenous antibiotics, patients were given oral antibiotics for 6 weeks. We enjoyed reading the article by Cadet et al1 and hope that we have added some useful pearls from our own experience that will help improve the management of septic arthritis following anterior cruciate ligament reconstruction. Bertrand Sonnery-Cottet, MD Mathieu Thaunat, MD Lyon, France Pooler Archbold, MD Belfast, Ireland Bertrand Issartel, MD Villeurbanne, France The Author Replies: We thank Dr. Sonnery-Cottet and colleagues for their positive comments about our article.
271
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 1
Arthroscopic images of the knee demonstrating significant synovitis and adhesions in the patellofemoral space before (A) and after (B) arthroscopic débridement.
Figure 2
A, Arthroscopic image demonstrating the anterior cruciate ligament (ACL) graft 6 days after initial irrigation and débridement was performed in a patient with septic arthritis following ACL reconstruction. The graft was attenuated and nonviable and was subsequently removed, along with all hardware. The tunnels and old incision sites were opened and débrided thoroughly. B, No evidence of infection existed 7 months after initial irrigation and débridement. The patient underwent revision reconstruction with a bone–patellar tendon–bone allograft, achieved full, pain-free range of motion, and returned to sports following the staged reimplantation.
We do agree that the finding of Sonnery-Cottet et al2 regarding the higher prevalence of septic arthritis following ACL reconstruction in the professional athlete, compared with a nonprofessional cohort, is very important, and we recognize that the omission of this report was an oversight. In the report of Sonnery-Cottet
272
et al,2 a striking 5 of the 12 patients (42%) who were diagnosed with septic arthritis following ACL reconstruction were professional athletes. This number is alarming given the fact that only 4.5% of the total study population (88 of 1,957 patients) was professional athletes. Furthermore, additional extra-articular procedures
(eg, lateral tenodesis) increased the risk for septic arthritis following ACL reconstruction. I do agree that this is also a very important point and that the discussion of the potential for extra-articular procedures to increase the risk for septic arthritis should not be limited to lateral tenodesis but should extend to other procedures, including meniscal repair and extraarticular ligament reconstruction. We thank the authors for highlighting this very important point. With regard to the authors’ remarks regarding route of administration of antibiotics, we discussed in our report1 that intravenous antibiotics should be initiated. The duration and choice of antibiotic depends on several factors, including the isolated organism, sensitivity of the organism to the antibiotic regimen, clinical response to the chosen antibiotic, and clinical practices of infectious disease specialists guiding the antibiotic regimen. Broad-spectrum antibiotics should be administered only after an arthrocentesis has been performed in an attempt to isolate an organism to deliver organism-specific antibiotic regimens. An oral regimen may be prescribed subsequent to intravenous antibiotic depending on the several factors just outlined. Individual institutions and infectious disease specialists may differ with regard to the antibiotic regimen; thus, there is no standard antibiotic regimen that should be employed for every case. We appreciate the authors’ sharing their treatment of choice with the readership. The point of tibial screw or hardware exchange is important; this should be performed at the index débridement if backup fixation was performed during initial ligament reconstruction. We thank the authors for highlighting this very important point. However, the extent of bacterial biofilm development and adherence is not only isolated at this site but also involves (1) the graft itself,
Journal of the American Academy of Orthopaedic Surgeons
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
(2) suture material used for supplementary fixation, and/or (3) femoral fixation devices/hardware. Exchanging the tibial screw implant alone following a single débridement may not be sufficient in many cases. There must be a critical evaluation of the graft and this should happen not only at a single time point (eg, one débridement), but should occur at subsequent time points with serial débridement procedures. The authors state that, in their report, in the three patients in whom a secondary lavage was performed and the tibial screw was exchanged, the graft was able to be preserved and that the patients had a “satisfactory” outcome. The authors did not define in this report what “satisfactory” means. Does this mean that the patient returned to the same or improved level of activity as that before the injury or that the knee remained “aseptic”? The
May 2014, Vol 22, No 5
authors may not have determined that a retained graft needed revision in 10 years; however, it does not necessarily mean that the retained graft was functionally adequate to provide optimal knee function and high patient satisfaction. (Please refer to Figures 2 and 3 of our article1 [reprinted here as Figures 1 and 2, respectively], demonstrating rapid deterioration of the graft despite an improved clinical picture only 6 days following initial lavage and débridement). To imply that a graft rarely needs to be removed after developing septic arthritis following ACL reconstruction may be misleading to the readership of the Journal and may underrepresent the need to critically evaluate graft integrity with subsequent débridements. We appreciate the authors’ comments and their highlighting very
important aspects of the care in the management of the patient with septic arthritis following ACL reconstruction that may have been deficient in our article. Edwin R. Cadet, MD Raleigh, North Carolina
References 1. Cadet ER, Makhni EC, Mehran N, Schulz BM: Management of septic arthritis following anterior cruciate ligament reconstruction: A review of current practices and recommendations. J Am Acad Orthop Surg 2013;21(11):647-656. 2. Sonnery-Cottet B, Archbold P, Zayni R, et al: Prevalence of septic arthritis after anterior cruciate ligament reconstruction among professional athletes. Am J Sports Med 2011; 39(11):2371-2376. 3. Trampuz A, Osmon DR, Hanssen AD, Steckelberg JM, Patel R: Molecular and antibiofilm approaches to prosthetic joint infection. Clin Orthop Relat Res 2003;414: 69-88.
273
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
