1. Infection After ACL Reconstruction H. Makhmalbaf MD Consultant Orth.& Knee Surgeon Mashhad University of Medical Sciences

2. 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

3. 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

4. Foreign body in the Joint

5. Chondrolysis & OA

6. Infection after ACL Superficial or deep infection Clinical findings Synovial fluid analysis Laboratory findings Imaging: X-ray, MRI

7. Synthetic Ligament

8. Treatment options IV Antibiotics Arthroscopic washout & debridement Open arthrotomy with preservation of graft Arthrotomy and removal of graft & fixation material

9. 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

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

11. Operative environment

12. Infection Following Arthroscopic Anterior Cruciate Reconstruction MAJ Daniel Judd et al. Arthroscopy J. April 2006

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

14. 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

15. 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

16. Septic Arthritis After Arthroscopic ACL Reconstruction, Wang C 2009 Arthroscopy J

17. 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

18. 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

19. 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

20. Autograft contamination during preparation for ACL reconstruction Michael E Hantes, MD et al JBJS Am 2008

21. 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

22. 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

23. 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

24. Previous UTO:

26. MRI of the Knee

27. After ACL reconstruction:

28. We have to be careful

29. Thank you