Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature

Abstract

Osteomyelitis following arthroscopically assisted anterior cruciate ligament (ACL) reconstruction has rarely been reported in the literature. We report a case of a 20-year-old female who had delayed tibial osteomyelitis and a pretibial cyst with culture-positive, oxacillin sensitive Staphylococcus epidermidis 15 months after an ACL reconstruction with hamstring autograft. Soft tissue fixation within the tibial tunnel was with a poly-L-D-lactic acid (PLDLA) bioabsorbable interference screw. The patient underwent surgical treatment with curettage, debridement, hardware removal, and bone grafting of the tibial tunnel followed by a course of intravenous antibiotics. Arthroscopic evaluation demonstrated an intact ACL graft without any evidence of intra-articular infection. The patient returned to collegiate athletics without any complications. While the most common biologic complications include pretibial cysts, granuloma formation, tunnel widening, and inflammatory reactions, infection is exceedingly rare. Late infection and osteomyelitis are also rare but can occur and should be considered in the differential diagnosis.

Treatment of recurrent infection at the tibial bone tunnel after anterior cruciate ligament reconstruction using a medial gastrocnemius muscle flap – A case report

“…Development of infection after ACL reconstruction is extremely rare, however, it sometimes induces severe knee dysfunction [4] , [7] . Treatment of infection can be accomplished by early debridement, constant joint irrigation, long-term intravenous antibiotics, graft retention, or removal [1] , [2] , [5] , [8] . The most frequently used treatment is joint irrigation and debridement with graft retention [9] , [10] .…”

“…Some authors suggested immediate removal of the infected ACL graft [3] , [11] , [12] , but others advocated ACL graft removal only in cases of persistent infection [2] , [13] . Aggressive surgical debridement combined with proper antibiotics according to the isolated pathogen is thought to be the key to effective treatment in cases of persistent infection [3] , [5] , [8] , [12] . This case is an extremely miserable case of prolonged infection after ACL reconstruction with a fistula for two years despite complete removal of the metal implant and debridement of necrotic tissue.…”

Use of biomaterials in scaphoid fracture fixation, a systematic review

“…Late phase foreign body reactions have been reported following biomaterial use both in the early and late postoperative phase 39,40 . Both Waris et al 4 and Givissis et al 25 evaluated the use of third generation synthetic biodegradable screws in metacarpal fractures, finding postoperative tissue reactions presented in a delayed manner.…”

Delayed onset bioabsorbable screw reaction, intact screw extrusion andPseudomonas aeruginosatibial tunnel osteomyelitis years after arthroscopic anterior cruciate ligament reconstruction using hamstring graft

“…The most common infection in ACL reconstruction is septic arthritis, and as such the approach is thorough debridement, and removal of infected graft. Though favourable outcomes have been described with graft retention after removal of implants for those who developed septic arthritis, a protocol for tibial tunnel osteomyelitis has yet to be elaborated 5 16 17. The common causative organisms for infection as a sequelae of ACL reconstruction include Staphylococcus , Peptostreptococcus , Enterococcus and fungal species 16…”