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Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (5): 850-856. doi: 10.19723/j.issn.1671-167X.2021.05.007

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Management algorithm for septic arthritis after anterior cruciate ligament reconstruction

WANG Cheng1,MENG Ling-yu2,CHEN Na-yun1,LI Dai1,WANG Jian-quan1,AO Ying-fang1,△()   

  1. 1. Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
    2. Peking University School of Basic Medical Sciences, Beijing 100191, China
  • Received:2021-06-02 Online:2021-10-18 Published:2021-10-11
  • Contact: Ying-fang AO E-mail:aoyingfang@163.com

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Abstract:

Objective: To summarize the experience in the diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction. Methods: A retrospective review was conducted of all the arthroscopic anterior cruciate ligament reconstructions performed at Department of Sports Medicine, Peking University Third Hospital between January 2001 and December 2020. In the study, 65 of 27 867 patients experienced postoperative septic arthritis. The incidence, presentation, laboratory results, treatment, and outcome of all the infected patients were analyzed. The experiences of diagnosis and management of septic arthritis after anterior cruciate ligament reconstruction were summarized. Results: A total of 27 867 anterior cruciate ligament reconstructions were performed at our department between January 2001 and December 2020. In the study, 65 (0.23%) patients were identified with postoperative septic arthritis. The most common symptoms of the infected patients were fever (38.7±0.5) ℃, knee swelling, pain, and restricted motion. The mean peripheral white blood cell count (WBC) was (9.2±2.6)×109/L (range 4.2×109/L-19.4×109/L), with (72.5±6.3) % (range 54.9%-85.1%) polymorphonuclear neutrophils (N). The mean erythrocyte sedimentation rate (ESR) was (59.9±24.1) mm/h (range 9-108 mm/h), C-reactive protein (CRP) was (10.9±5.7) mg/dL (range 1.2-30.8 mg/dL), and fibrinogen (FIB) level was (7.0±1.6) g/L (range 3.7-10.8 g/L). All of the laboratory results were statistically higher in the infection group compared with the normal postoperative group (P<0.001). The synovial white blood cell count (SWBC) of aspirated knee joint fluid was (45.0±29.8)×109/L (range 7.1×109-76.5×109/L). Polymorphonuclear cell percentage (PMNC) was (90.27±7.86) % (range 60%-97%). In the study, 45 patients (69.2%) had positive aspirate cultures. Microbiology showed coagulase-negative Staphylococcus (CNS) and Staphylococcus aureus (SA) were the most common bacterium (34 cases and 7 cases, individually). There were 26 methicillin-resistant Staphylococcus. Both conservative (16 patients) and operative (49 patients) treatments were effective, but conservative group had a longer recovery time (5.6 d vs. 1.6 d, P=0.042). Conclusion: Septic arthritis after arthroscopic anterior cruciate ligament reconstruction is a rare but potentially devastating complication. The correct diagnosis relies on synovial fluid analysis and bacterial culture. Our proposed treatment protocol is arthroscopic debridement and antibiotic therapy as quickly as possible.

Key words: Anterior cruciate ligament, Reconstruction, Complication, Septic arthritis, Management algorithm

CLC Number: 

  • R687

Table 1

Laboratory results in 24 normal postoperative patients and 65 infectious patients"

Items Normal Normal postoperative patients Infectious patients P
WBC/(×109/L) 4-10 6.9±1.8
(4.5-10.5) 9.2±2.6
(4.2-19.4) <0.001
N/% 50-70 60.9±5.1
(53.2-69.2) 72.5±6.3
(54.9-85.1) <0.001
ESR/(mm/h) 0-15 27.5±12.8
(7-44) 59.9±24.1
(9-108) <0.001
CRP/(mg/dL) 0-0.8 2.2±1.8
(0.3-5.6) 10.9±5.7
(1.2-30.8) <0.001
FIB/(g/L) 2-4 5.8±1.1
(4.3-8.0) 7.0±1.6
(3.7-10.8) <0.001

Figure 1

Serial average white blood cell (WBC), polymorphonuclear neutrophils (N), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values in patients with septic arthritis after treatment for the infection"

Table 2

Incidence of septic arthritis after ACL reconstruction"

Literature Publication year Period /years Total number of ACLR patients Total number of infected cases Infected rate/%
Williams, et al[2] 1997 5 2 500 7 0.28
McAllister, et al[3] 1999 11 831 4 0.48
Viola, et al[4] 2000 6 1 794 14 0.78
Indelli, et al[5] 2002 6 3 500 5 0.14
Schollin-Borg, et al[6] 2003 3 575 10 1.74
Burks, et al[7] 2003 11 1 918 8 0.42
Fong, et al[8] 2004 3 472 7 1.48
Musso, et al[9] 2005 5 1 094 11 1.01
Judd, et al[11] 2006 8 1 615 11 0.68
Van Tongel, et al[13] 2007 9 1 736 15 0.86
Schulz, et al[14] 2007 10 513 4 0.78
Binnet, et al[12] 2007 18 1 231 6 0.49
Katz, et al[15] 2008 5 801 6 0.75
Iorio, et al[16] 2008 6 1 052 8 0.76
Wang, et al[17] 2009 11 4 068 21 0.52
Sajovic, et al[18] 2009 11 1 283 3 0.23
Nag, et al[19] 2009 9 1 152 26 2.26
Barker, et al[21] 2010 5 3 126 18 0.58
Monaco, et al[20] 2010 8 1 232 12 0.97
Benner, et al[22] 2011 27 5 364 13 0.24
Sonnery-Cottet, et al[23] 2011 5 1 957 12 0.61
Vertullo, et al[24] 2012 7 1 135 4 0.35
Schub, et al[25] 2012 11 831 4 0.48
Torres-Claramunt, et al[26] 2013 3 810 15 1.85
Risti c ', et al[27] 2014 1 425 17 1.19
Abdel-Aziz, et al[28] 2014 7 2 560 24 0.94
Boström, et al[29] 2014 8 4 384 43 0.98
Calvo, et al[30] 2014 11 1 564 7 0.45
Schuster, et al[31] 2015 10 7 096 36 0.51
Hantes, et al[33] 2017 12 1 242 7 0.56
Pérez-Prieto, et al[32] 2017 4 810 15 1.85
Our study 2021 20 27 867 65 0.23
Total - - 87 538 458 0.52

Figure 2

Management algorithm for septic arthritis after anterior cruciate ligament reconstruction ACLR, anterior cruciate ligament reconstruction; WBC, peripheral white blood cell; N, polymorphonuclear neutrophils; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; SWBC, synovial white blood cell; PMNC, polymorphonuclear neutrophils of synovial fluid; GLU, blood glucose. * Satisfactory is defined as an improvement in clinical signs and decrease in CRP values after treatment."

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