Graft-Preserving Arthroscopic Debridement With Hardware Removal Is Effective for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Clinical, Arthrometric, and Magnetic Resonance Imaging Evaluation

Abstract

Background: Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability. Purpose/Hypothesis: The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function. Study Design: Case series; Level of evidence, 4. Methods: From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis. Results: Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases. Conclusion: Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis.

MRI Findings of Early Osteoarthritis in Patients Who Sustained Septic Arthritis of the Knee After ACL Reconstruction

“…This information strongly suggests the importance of the chondrolytic effect of SA after ACL reconstruction. Pogorzelski et al 17 and Lo Presti et al 10 reported MRI signs of chondral defect appearing in 69% and 63%, respectively, at final follow-up (103 and 101 months). However, as compared with our study design, their follow-up time was >2 times longer, and no control group was presented.…”

“…Arthroscopic debridement with graft preservation and antibiotic therapy has been advocated as the treatment of choice. 10 There is no consensus about the best treatment modality, especially regarding hardware removal and graft-retaining protocol. 10 …”

“… 10 There is no consensus about the best treatment modality, especially regarding hardware removal and graft-retaining protocol. 10 …”

Targeted treatment for osteoarthritis: drugs and delivery system

“…Arthroscopic debridement shows obvious clinical results in elbow OA, and joint foreign body and impingement are considered potential indications (MacLean et al., 2013 ; Carlier et al., 2019 ; French Arthroscopic Society, 2019). Some studies showed that arthroscopic debridement and lavage are also effective in the improvement of symptoms in shoulder, knee and thumb OA (Furia, 2010 ; Bexkens et al., 2018 ; Lo Presti et al., 2020 ). However, some clinical trials and the systematic review showed unsatisfactory results for debridement and lavage procedures that the outcomes after surgery are temporary or no different from placebo procedures (Moseley et al., 2002 ; Kirkley et al., 2008 ; Skelley et al., 2015 ).…”

Editorial Commentary: Synovial Fluid White Blood Cell Is the Gold Standard to Detect Infection After Anterior Cruciate Ligament Reconstruction: Don’t Hesitate to Aspirate

“…Delayed or missed treatment can lead to poor patient outcomes secondary to graft loss, chondral damage, secondary osteoarthritis, arthrofibrosis, and sepsis. [3][4][5] However, with early recognition, diagnosis, and aggressive management, infections can be treated successfully and the ACL graft retained. 1,2,[4][5][6] One must have a high level of suspicion and low threshold for evaluation for possible septic arthritis after ACL reconstruction.…”