Recurrent surgical site infection after anterior cruciate ligament reconstruction: A case report

Abstract

BACKGROUND Surgical site infections following anterior cruciate ligament (ACL) reconstruction are an uncommon but potentially devastating complication. In this study, we present an unusual case of recurrent infection of the knee after an ACL reconstruction, and discuss the importance of accurate diagnosis and appropriate management, including the issue of graft preservation versus removal. CASE SUMMARY A 33-year-old gentleman underwent ACL reconstruction using a hamstring tendon autograft with suspensory Endobutton fixation to the distal femur and an interference screw fixation to the proximal tibia. Four years after ACL reconstruction, he developed an abscess over the proximal tibia and underwent incision and drainage. Remnant suture material was found at the base of the abscess and was removed. Five years later, he re-presented with a lateral distal thigh abscess that encroached the femoral tunnel. He underwent incision and drainage of the abscess which was later complicated by a chronic discharging sinus. Repeated magnetic resonance imaging revealed a fistulous communication between the lateral thigh wound extending toward the femoral tunnel with suggestion of osteomyelitis. Decision was made for a second surgery and the patient was counselled about the need for graft removal should there be intra-articular involvement. Knee arthroscopy revealed the graft to be intact with no evidence of intra-articular involvement. As such, the decision was made to retain the ACL graft. Re-debridement, excision of the sinus tract and removal of Endobutton was also performed in the same setting. Joint fluid cultures did not grow bacteria. However, tissue cultures from the femoral tunnel abscess grew Enterobacter cloacae complex, similar to what grew in tissue cultures from the tibial abscess five years earlier. In view of the recurrent and indolent nature of the infection, antibiotic therapy was escalated from Clindamycin to Ertapenem. He completed a six-week course of intravenous antibiotics and has been well for six months since surgery, with excellent knee function and no evidence of any further infection. CONCLUSION Prompt and accurate diagnosis of surgical site infection following ACL reconstruction, including the exclusion of intra-articular involvement, is important for timely and appropriate treatment. Arthroscopic debridement and removal of implant with graft preservation, together with a course of antibiotics, is a suitable treatment option for extra-articular knee infections following ACL reconstruction.

Silver/Graphene Oxide Nanostructured Coatings for Modulating the Microbial Susceptibility of Fixation Devices Used in Knee Surgery

“…Like most implantable medical devices, interference fixation devices are prone to microbial contamination and colonization [ 19 , 20 ], leading to the occurrence of biofilm-associated infections which cause moderate-to-severe complications that, ultimately, may lead to ligament reconstruction failure [ 21 ]. Biofilms are multicellular, surface-associated microbe communities surrounded by self-produced extracellular polymeric substances (EPSs) that provide protection for bacterial cells—thus rendering them resistant to conventional biocide/biostatic treatments—and the host’s immune response [ 22 , 23 , 24 , 25 , 26 ].…”

Recommendations on diagnosis and antimicrobial treatment of infections after anterior cruciate ligament reconstruction (ACL-R) endorsed by ESSKA and EBJIS

“…Recurrence or persistence of infection after ACL-R have been described and can be related to improper debridement, an infected Baker cyst or incorrect surgical treatment in accordance to the staging by Gächter 17 . Those very few case-reports about chronic infections were due to either the same bacteria (mostly coagulase-negative staphylococci) 18 or fastidious and rare microorganisms (mycobacteria, fungi, etc.)…”