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Patients treated with surgical irrigation and debridement for infection after ACL reconstruction have a high rate of subsequent knee surgery
  1. Robert H Brophy1,
  2. Laura J Huston2,
  3. Rick W Wright1,
  4. Xulei Liu3,
  5. Annunziato Amendola4,
  6. Jack T Andrish5,
  7. David C Flanigan6,
  8. Morgan H Jones5,
  9. Christopher C Kaeding6,
  10. Robert G Marx7,
  11. Matthew J Matava1,
  12. Eric C McCarty8,
  13. Richard D Parker5,
  14. Michelle L Wolcott8,
  15. Brian R Wolf9,
  16. Kurt P Spindler5
  17. MOON Knee Group
    1. 1 Department of Orthopaedics, Washington University, St. Louis, Missouri, USA
    2. 2 Department of Orthopaedics, Vanderbilt Orthopaedic Medical Center, Nashville, Tennessee, USA
    3. 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
    4. 4 Department of Orthopedics, Duke University, Durham, North Carolina, USA
    5. 5 Department of Orthopaedics, Cleveland Clinic, Garfield Heights, Ohio, USA
    6. 6 Department of Orthopaedics, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
    7. 7 Department of Orthopaedics, Hospital for Special Surgery, New York, USA
    8. 8 Department of Orthopaedics, University of Colorado Hospital, Boulder, Colorado, USA
    9. 9 Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
    1. Correspondence to Dr Robert H Brophy, Orthopaedics, Washington University, St. Louis, MO 63130, USA; brophyr{at}wudosis.wustl.edu

    Abstract

    Objectives The purpose of this cross-sectional study was to describe the rates of additional surgery and patient-reported outcomes in patients who underwent surgical irrigation and debridement (I&D) for infection following anterior cruciate ligament reconstruction (ACLR) and test the hypothesis that additional surgery is associated with worse patient-reported outcomes.

    Methods Patients diagnosed with a postoperative infection following ACLR (defined as one requiring surgical treatment with either a deep or superficial I&D) were identified from a prospective cohort. Both primary and revision ACLRs were included, as well as any graft type (autografts and allografts). Patient-reported outcomes (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] and Marx activity level) and subsequent surgeries were collected at 2-year and 6 year follow-up from the initial ACLR surgery. Baseline demographics and 2-year and 6-year outcomes (from initial ACLR) were compared between patients who did or did not undergo additional surgery subsequent to I&D using Wilcoxon rank-sum tests for continuous variables and Fisher’s exact tests for categorical variables.

    Results Twenty-one of 3210 ACLR patients (0.7%) had a postoperative infection requiring surgical I&D. This group consisted of 12 men and 9 women, mean (SD) age of 25.8 (11.3) years, 18 primary and 3 revision ACLRs and 16 autografts and 5 allografts. The mean time from ACLR to the surgical I&D was 39 days. In these patients, IKDC scores improved from 44±17 prior to initial ACLR to 83±16 at 6-year follow-up (p<0.001). While all KOOS scores improved from baseline to final follow-up, activity level decreased from 11±6 to 7±5 points (p<0.001). Follow-up related to subsequent surgery was obtained on 20 of 21 patients (95%). Forty per cent of the infection group (n=8 of 20) underwent additional surgery following their I&D, with three patients (15%) undergoing revision ACLR and one patient (5%) undergoing total knee arthroplasty. Patients who underwent additional surgery had lower Marx activity at 2 years compared with patients who had no subsequent surgeries (4±3vs 9±5 points, p=0.018).

    Conclusion Patients who undergo I&D for an infection following ACLR have a high rate of additional surgery but still attain reasonable clinical outcomes 6 years after ACLR.

    Level of evidence IV

    • outcome studies
    • Acl / Pcl
    • repair / reconstruction
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    Footnotes

    • Contributors RHB contributed to the study design and conception. AA, JTA, RHB, DCF, LJH, MHJ, CCK, RGM, MJM, ECM, RDP, KPS, MLW, BRW and RWW contributed to the collection and assembly of data. LJH contributed to the acquisition and reduction of data. RHB, LJH and XL contributed to the analysis and interpretation of data. RHB and LJH contributed to the drafting of the manuscript, while RHB, LJH, RWW, XL, KPS, AA, JTA, DCF, MHJ, CCK, RGM, MJM, ECM, RDP, MLW and BRW contributed towards the critical revision and final approval of the manuscript.

    • Funding Research reported in this publication was partially supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number R01 AR053684 (KPS). The project was also supported by the Vanderbilt Sports Medicine Research Fund, which received unrestricted educational gifts from Smith & Nephew Endoscopy and DonJoy Orthopaedics.

    • Disclaimer The content is solely the responsibility of the authors and do not necessarily represent official views of the National Institutes of Health.

    • Competing interests AA is a board member (AOSSM and ABOS), consultant (Arthrex), receives royalties (Arthrex, Arthrosurface and Smith & Nephew) and stock/stock options (Arthrosurface, First Ray, Mortise Medical and Rubber City Bracing). RHB receives funds for speaking fees (Arthrex). MHJ is a consultant (JBJS – development of educational materials), an editorial board member (OJSM) and a scientific advisory board member (Samumed). RGM is a board member (JBJS) and receives book royalties (Demos Health and Springer). MM is a board member (Southern Orthopaedic Association). KPS is a consultant (Cytori). BW is a consultant (ConMed). RWW is a board member (ABOS and AOA) and receives book royalties (Wolters Kluwer Lippincott Williams & Wilkins). Although the above listed authors have declared relationships with listed entities, none of the authors feel that these relationships are deemed a conflict of interest with this current manuscript.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement It is the intention to make available final research datasets gathered during the study, performed in a timely manner after publishing said data. Once completed, all deidentified data will be shared with others through presentations at national meetings and by publications in peer-reviewed journals.

    • Collaborators MOON Knee Group consists of (contributing authors listed alphabetically): Annunziato Amendola (Department of Orthopaedic Surgery, Duke University), Jack T Andrish (Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation), David C Flanigan (Department of Orthopaedics, The Ohio State University Wexner Medical Center), Morgan H Jones (Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation), Christopher C Kaeding (Department of Orthopaedics, The Ohio State University Wexner Medical Center), Robert G Marx (Department of Orthopaedics, Hospital for Special Surgery), Matthew J Matava (Department of Orthopaedics, Washington University School of Medicine), Eric C McCarty (Department of Orthopaedics, University of Colorado Denver), Richard D Parker (Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation), Michelle L Wolcott (Department of Orthopaedics, University of Colorado Denver) and Brian R Wolf (Department of Orthopaedics and Rehabilitation, University of Iowa).

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