Postoperative Infection after Anterior Cruciate Ligament Reconstruction: Prevention and Management

Abstract

Infection following anterior cruciate ligament (ACL) reconstruction can be one of the most debilitating complications following ACL reconstruction. Its reported incidence is around 1%. Utilization of vancomycin for presoaking the graft is considered an established method for infection prevention. The role of other agents, such as gentamycin needs further investigation. Staphylococci are the predominant causative pathogens, while particular attention should be paid to fungal infections due to their long-standing, occult process. Recent data demonstrate that hamstrings autograft may be at an elevated risk of being contaminated leading to subsequent septic arthritis. Diagnosis is set by clinical and laboratory findings and is usually confirmed by intraoperative cultures. Treatment varies, mainly depending on the intraoperative assessment. Satisfactory outcomes have been reported with both graft retaining and removal, and the decision is made upon the arthroscopic appearance of the graft and the characteristics of the infection. Of note, early management seems to lead to superior results, while persistent infection should be managed with graft removal in an attempt to protect the articular cartilage and the knee function.

Semitendinosus tendons are commonly contaminated with skin flora during graft harvest for anterior cruciate ligament reconstruction

“…Staphylococcus epidermidis (39.4%) was the most common species, followed by Staphylococcus capitis (24.2%). This is coherent with the findings of previous studies and the fact that deep knee infections after ACLR are mainly associated with CNS [ 1 , 9 , 11 , 15 , 21 , 22 ]. Interestingly, this high prevalence of CNS is not seen in other acute orthopaedic-related infections [ 35 ].…”

“…The focus in infection-prevention was specifically directed to the use of hamstring autografts as they were found to be more susceptible to postoperative deep knee infection compared to other auto-and allografts [15][16][17]24]. The parameters that explain the vulnerability of hamstring grafts to infection have not been well studied.…”

ESSKA and EBJIS recommendations for the management of infections after anterior cruciate ligament reconstruction (ACL‐R): prevention, surgical treatment and rehabilitation

“…The technique of soaking the ACL graft in a vancomycin solution was first described by Vertullo et al in 2012. A 5 mg/ml vancomycin solution is used to soak the graft for 10–15 min in order to eradicate contamination and also provide an antibiotic reservoir [23, 29, 45, 68]. A close to 0% infection rate has been found in all relevant studies, in both hamstring or BPTB autograft [5, 18, 42, 46, 47].…”