Published online Jun 18, 2019. doi: 10.5312/wjo.v10.i6.255
Peer-review started: February 11, 2019
First decision: April 15, 2019
Revised: May 7, 2019
Accepted: May 21, 2019
Article in press: May 22, 2019
Published online: June 18, 2019
Processing time: 137 Days and 19.9 Hours
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.
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.
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.
Core tip: Chronic surgical site infections following anterior cruciate ligament (ACL) reconstructions are rare. Most infections occur in the acute or subacute post-operative periods. Astute clinic judgement and patient involvement are key when managing recurrent infections post-ACL reconstruction. Early intervention involving joint washout and debridement as well as commencing culture-directed antibiotic therapy are key. The decision for graft-sparing versus graft-sacrificing surgery remains controversial.