Recurrent surgical site infection after anterior cruciate ligament reconstruction: A case report
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摘要
BACKGROUND Surgical site infections following anterior cruciate ligament(ACL) reconstruction are an uncommon but potentially devastating complication.In this study, we present an unusual case of recurrent infection of the knee after an ACL reconstruction, and discuss the importance of accurate diagnosis and appropriate management, including the issue of graft preservation versus removal.CASE SUMMARY A 33-year-old gentleman underwent ACL reconstruction using a hamstring tendon autograft with suspensory Endobutton fixation to the distal femur and an interference screw fixation to the proximal tibia.Four years after ACL reconstruction, he developed an abscess over the proximal tibia and underwent incision and drainage.Remnant suture material was found at the base of the abscess and was removed.Five years later, he re-presented with a lateral distal thigh abscess that encroached the femoral tunnel.He underwent incision and drainage of the abscess which was later complicated by a chronic discharging sinus.Repeated magnetic resonance imaging revealed a fistulous communication between the lateral thigh wound extending toward the femoral tunnel with suggestion of osteomyelitis.Decision was made for a second surgery and the patient was counselled about the need for graft removal should there be intraarticular involvement.Knee arthroscopy revealed the graft to be intact with no evidence of intra-articular involvement.As such, the decision was made to retain the ACL graft.Re-debridement, excision of the sinus tract and removal of Endobutton was also performed in the same setting.Joint fluid cultures did not grow bacteria.However, tissue cultures from the femoral tunnel abscess grew Enterobacter cloacae complex, similar to what grew in tissue cultures from the tibial abscess five years earlier.In view of the recurrent and indolent nature of the infection, antibiotic therapy was escalated from Clindamycin to Ertapenem.He completed a six-week course of intravenous antibiotics and has been well for six months since surgery, with excellent knee function and no evidence of any further infection.CONCLUSION Prompt and accurate diagnosis of surgical site infection following ACL reconstruction, including the exclusion of intra-articular involvement, is important for timely and appropriate treatment.Arthroscopic debridement and removal of implant with graft preservation, together with a course of antibiotics,is a suitable treatment option for extra-articular knee infections following ACL reconstruction.
BACKGROUND Surgical site infections following anterior cruciate ligament(ACL) reconstruction are an uncommon but potentially devastating complication.In this study, we present an unusual case of recurrent infection of the knee after an ACL reconstruction, and discuss the importance of accurate diagnosis and appropriate management, including the issue of graft preservation versus removal.CASE SUMMARY A 33-year-old gentleman underwent ACL reconstruction using a hamstring tendon autograft with suspensory Endobutton fixation to the distal femur and an interference screw fixation to the proximal tibia.Four years after ACL reconstruction, he developed an abscess over the proximal tibia and underwent incision and drainage.Remnant suture material was found at the base of the abscess and was removed.Five years later, he re-presented with a lateral distal thigh abscess that encroached the femoral tunnel.He underwent incision and drainage of the abscess which was later complicated by a chronic discharging sinus.Repeated magnetic resonance imaging revealed a fistulous communication between the lateral thigh wound extending toward the femoral tunnel with suggestion of osteomyelitis.Decision was made for a second surgery and the patient was counselled about the need for graft removal should there be intraarticular involvement.Knee arthroscopy revealed the graft to be intact with no evidence of intra-articular involvement.As such, the decision was made to retain the ACL graft.Re-debridement, excision of the sinus tract and removal of Endobutton was also performed in the same setting.Joint fluid cultures did not grow bacteria.However, tissue cultures from the femoral tunnel abscess grew Enterobacter cloacae complex, similar to what grew in tissue cultures from the tibial abscess five years earlier.In view of the recurrent and indolent nature of the infection, antibiotic therapy was escalated from Clindamycin to Ertapenem.He completed a six-week course of intravenous antibiotics and has been well for six months since surgery, with excellent knee function and no evidence of any further infection.CONCLUSION Prompt and accurate diagnosis of surgical site infection following ACL reconstruction, including the exclusion of intra-articular involvement, is important for timely and appropriate treatment.Arthroscopic debridement and removal of implant with graft preservation, together with a course of antibiotics,is a suitable treatment option for extra-articular knee infections following ACL reconstruction.
BACKGROUND Surgical site infections following anterior cruciate ligament(ACL) reconstruction are an uncommon but potentially devastating complication.In this study, we present an unusual case of recurrent infection of the knee after an ACL reconstruction, and discuss the importance of accurate diagnosis and appropriate management, including the issue of graft preservation versus removal.CASE SUMMARY A 33-year-old gentleman underwent ACL reconstruction using a hamstring tendon autograft with suspensory Endobutton fixation to the distal femur and an interference screw fixation to the proximal tibia.Four years after ACL reconstruction, he developed an abscess over the proximal tibia and underwent incision and drainage.Remnant suture material was found at the base of the abscess and was removed.Five years later, he re-presented with a lateral distal thigh abscess that encroached the femoral tunnel.He underwent incision and drainage of the abscess which was later complicated by a chronic discharging sinus.Repeated magnetic resonance imaging revealed a fistulous communication between the lateral thigh wound extending toward the femoral tunnel with suggestion of osteomyelitis.Decision was made for a second surgery and the patient was counselled about the need for graft removal should there be intraarticular involvement.Knee arthroscopy revealed the graft to be intact with no evidence of intra-articular involvement.As such, the decision was made to retain the ACL graft.Re-debridement, excision of the sinus tract and removal of Endobutton was also performed in the same setting.Joint fluid cultures did not grow bacteria.However, tissue cultures from the femoral tunnel abscess grew Enterobacter cloacae complex, similar to what grew in tissue cultures from the tibial abscess five years earlier.In view of the recurrent and indolent nature of the infection, antibiotic therapy was escalated from Clindamycin to Ertapenem.He completed a six-week course of intravenous antibiotics and has been well for six months since surgery, with excellent knee function and no evidence of any further infection.CONCLUSION Prompt and accurate diagnosis of surgical site infection following ACL reconstruction, including the exclusion of intra-articular involvement, is important for timely and appropriate treatment.Arthroscopic debridement and removal of implant with graft preservation, together with a course of antibiotics,is a suitable treatment option for extra-articular knee infections following ACL reconstruction.
引文
1 Hantes ME,Raoulis VA,Doxariotis N,Drakos A,Karachalios T,Malizos KN.Management of septic arthritis after arthroscopic anterior cruciate ligament reconstruction using a standard surgical protocol.Knee 2017;24:588-593[PMID:28292568 DOI:10.1016/j.knee.2017.02.007]
2 Kim SJ,Postigo R,Koo S,Kim JH.Infection after arthroscopic anterior cruciate ligament reconstruction.Orthopedics 2014;37:477-484[PMID:24992054 DOI:10.3928/01477447-20140626-06]
3 Van Tongel A,Stuyck J,Bellemans J,Vandenneucker H.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction:a retrospective analysis of incidence,management and outcome.Am JSports Med 2007;35:1059-1063[PMID:17369557 DOI:10.1177/0363546507299443]
4 Mouzopoulos G,Fotopoulos VC,Tzurbakis M.Septic knee arthritis following ACL reconstruction:a systematic review.Knee Surg Sports Traumatol Arthrosc 2009;17:1033-1042[PMID:19381611 DOI:10.1007/s00167-009-0793-1]
5 Binnet MS,Ba?arir K.Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques.Arthroscopy 2007;23:862-868[PMID:17681208 DOI:10.1016/j.arthro.2007.02.008]
6 Babcock HM,Matava MJ,Fraser V.Postarthroscopy surgical site infections:review of the literature.Clin Infect Dis 2002;34:65-71[PMID:11731947 DOI:10.1086/324627]
7 Hogan CJ,Fang GD,Scheld WM,Linden J,Diduch DR.Inhibiting the inflammatory response in joint sepsis.Arthroscopy 2001;17:311-315[PMID:11239354 DOI:10.1053/jars.2001.21492]
8 Matava MJ,Evans TA,Wright RW,Shively RA.Septic arthritis of the knee following anterior cruciate ligament reconstruction:results of a survey of sports medicine fellowship directors.Arthroscopy 1998;14:717-725[PMID:9788367 DOI:10.1016/S0749-8063(98)70098-2]
9 Morand PC,Billoet A,Rottman M,Sivadon-Tardy V,Eyrolle L,Jeanne L,Tazi A,Anract P,Courpied JP,Poyart C,Dumaine V.Specific distribution within the Enterobacter cloacae complex of strains isolated from infected orthopedic implants.J Clin Microbiol 2009;47:2489-2495[PMID:19515837 DOI:10.1128/JCM.00290-09]
10 Mezzatesta ML,Gona F,Stefani S.Enterobacter cloacae complex:clinical impact and emerging antibiotic resistance.Future Microbiol 2012;7:887-902[PMID:22827309 DOI:10.2217/fmb.12.61]
11 Fong SY,Tan JL.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction.Ann Acad Med Singapore 2004;33:228-234[PMID:15098639]
12 Williams RJ,Laurencin CT,Warren RF,Speciale AC,Brause BD,O'Brien S.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction.Diagnosis and management.Am J Sports Med 1997;25:261-267[PMID:9079185 DOI:10.1177/036354659702500222]
13 Judd D,Bottoni C,Kim D,Burke M,Hooker S.Infections following arthroscopic anterior cruciate ligament reconstruction.Arthroscopy 2006;22:375-384[PMID:16581449 DOI:10.1016/j.arthro.2005.12.002]
14 McAllister DR,Parker RD,Cooper AE,Recht MP,Abate J.Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction.Am J Sports Med 1999;27:562-570[PMID:10496570DOI:10.1177/03635465990270050301]
15 Kim TK,Jeong TW,Lee DH.Foreign body reaction after PLC reconstruction caused by a broken PLLAscrew.Orthopedics 2014;37:e1129-e1132[PMID:25437089 DOI:10.3928/01477447-20141124-91]
16 Ambrose CG,Clanton TO.Bioabsorbable implants:review of clinical experience in orthopedic surgery.Ann Biomed Eng 2004;32:171-177[PMID:14964733 DOI:10.1023/B:ABME.0000007802.59936.fc]
17 Saper M,Stephenson K,Heisey M.Arthroscopic irrigation and debridement in the treatment of septic arthritis after anterior cruciate ligament reconstruction.Arthroscopy 2014;30:747-754[PMID:24680320DOI:10.1016/j.arthro.2014.02.015]
18 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 Surg2013;21:647-656[PMID:24187034 DOI:10.5435/JAAOS-21-11-647]
19 Hoffmann H,Roggenkamp A.Population genetics of the nomenspecies Enterobacter cloacae.Appl Environ Microbiol 2003;69:5306-5318[PMID:12957918 DOI:10.1128/AEM.69.9.5306-5318.2003]
20 Davin-Regli A,Pagès JM.Enterobacter aerogenes and Enterobacter cloacae;versatile bacterial pathogens confronting antibiotic treatment.Front Microbiol 2015;6:392[PMID:26042091 DOI:10.3389/fmicb.2015.00392]
2 Kim SJ,Postigo R,Koo S,Kim JH.Infection after arthroscopic anterior cruciate ligament reconstruction.Orthopedics 2014;37:477-484[PMID:24992054 DOI:10.3928/01477447-20140626-06]
3 Van Tongel A,Stuyck J,Bellemans J,Vandenneucker H.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction:a retrospective analysis of incidence,management and outcome.Am JSports Med 2007;35:1059-1063[PMID:17369557 DOI:10.1177/0363546507299443]
4 Mouzopoulos G,Fotopoulos VC,Tzurbakis M.Septic knee arthritis following ACL reconstruction:a systematic review.Knee Surg Sports Traumatol Arthrosc 2009;17:1033-1042[PMID:19381611 DOI:10.1007/s00167-009-0793-1]
5 Binnet MS,Ba?arir K.Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques.Arthroscopy 2007;23:862-868[PMID:17681208 DOI:10.1016/j.arthro.2007.02.008]
6 Babcock HM,Matava MJ,Fraser V.Postarthroscopy surgical site infections:review of the literature.Clin Infect Dis 2002;34:65-71[PMID:11731947 DOI:10.1086/324627]
7 Hogan CJ,Fang GD,Scheld WM,Linden J,Diduch DR.Inhibiting the inflammatory response in joint sepsis.Arthroscopy 2001;17:311-315[PMID:11239354 DOI:10.1053/jars.2001.21492]
8 Matava MJ,Evans TA,Wright RW,Shively RA.Septic arthritis of the knee following anterior cruciate ligament reconstruction:results of a survey of sports medicine fellowship directors.Arthroscopy 1998;14:717-725[PMID:9788367 DOI:10.1016/S0749-8063(98)70098-2]
9 Morand PC,Billoet A,Rottman M,Sivadon-Tardy V,Eyrolle L,Jeanne L,Tazi A,Anract P,Courpied JP,Poyart C,Dumaine V.Specific distribution within the Enterobacter cloacae complex of strains isolated from infected orthopedic implants.J Clin Microbiol 2009;47:2489-2495[PMID:19515837 DOI:10.1128/JCM.00290-09]
10 Mezzatesta ML,Gona F,Stefani S.Enterobacter cloacae complex:clinical impact and emerging antibiotic resistance.Future Microbiol 2012;7:887-902[PMID:22827309 DOI:10.2217/fmb.12.61]
11 Fong SY,Tan JL.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction.Ann Acad Med Singapore 2004;33:228-234[PMID:15098639]
12 Williams RJ,Laurencin CT,Warren RF,Speciale AC,Brause BD,O'Brien S.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction.Diagnosis and management.Am J Sports Med 1997;25:261-267[PMID:9079185 DOI:10.1177/036354659702500222]
13 Judd D,Bottoni C,Kim D,Burke M,Hooker S.Infections following arthroscopic anterior cruciate ligament reconstruction.Arthroscopy 2006;22:375-384[PMID:16581449 DOI:10.1016/j.arthro.2005.12.002]
14 McAllister DR,Parker RD,Cooper AE,Recht MP,Abate J.Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction.Am J Sports Med 1999;27:562-570[PMID:10496570DOI:10.1177/03635465990270050301]
15 Kim TK,Jeong TW,Lee DH.Foreign body reaction after PLC reconstruction caused by a broken PLLAscrew.Orthopedics 2014;37:e1129-e1132[PMID:25437089 DOI:10.3928/01477447-20141124-91]
16 Ambrose CG,Clanton TO.Bioabsorbable implants:review of clinical experience in orthopedic surgery.Ann Biomed Eng 2004;32:171-177[PMID:14964733 DOI:10.1023/B:ABME.0000007802.59936.fc]
17 Saper M,Stephenson K,Heisey M.Arthroscopic irrigation and debridement in the treatment of septic arthritis after anterior cruciate ligament reconstruction.Arthroscopy 2014;30:747-754[PMID:24680320DOI:10.1016/j.arthro.2014.02.015]
18 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 Surg2013;21:647-656[PMID:24187034 DOI:10.5435/JAAOS-21-11-647]
19 Hoffmann H,Roggenkamp A.Population genetics of the nomenspecies Enterobacter cloacae.Appl Environ Microbiol 2003;69:5306-5318[PMID:12957918 DOI:10.1128/AEM.69.9.5306-5318.2003]
20 Davin-Regli A,Pagès JM.Enterobacter aerogenes and Enterobacter cloacae;versatile bacterial pathogens confronting antibiotic treatment.Front Microbiol 2015;6:392[PMID:26042091 DOI:10.3389/fmicb.2015.00392]