Infection After ACL Reconstruction H. Makhmalbaf MD Consultant 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 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 , 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 2 nd & 3 rd specimens Slight elevation of ESR & CRP in all pts. No association between graft cont. & infection

Previous UTO:

MRI of the Knee

After ACL reconstruction:

We have to be careful

Thank you