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Instrumentation-specific infection after anterior cruciate ligament reconstruction
Stephen A Parada1, Jason A Grassbaugh, John G Devine
1Madigan Army Medical Center, Tacoma, Washington.
Background:
Anterior cruciate ligament (ACL) reconstruction is uncommonly complicated by postoperative infections, the causes of which are rarely identified.
Hypothesis/Purpose:
The goal of this study was to characterize the relationship between methodological sterilization failure and ACL reconstruction infection at an army medical center.
Study Design:
Case series.
Methods:
Demographic, clinical, and laboratory data were collected on 5 postoperative infections during a 14-week period in 2003. All ACL reconstructions completed within the past 6 years at the institution were reviewed to establish a baseline infection rate.
Results:
There was a 14-week period in which 5 cases of infection occurred postoperatively, an infection rate of 12.2%. Previous and subsequent to the identified period, the established rate of infection after ACL reconstruction was 0.3%. There were no violations of sterile technique noted in any of the identified cases. All cases utilized hamstring autograft. All cases also used the DePuy Mitek Intrafix system for tibial fixation of the graft. Two of these cases had positive cultures.
Conclusions:
An isolated series of increased infection rate led to an investigation into the sterile technique. This revealed gross biomaterial remaining inside instrumentation common to all the cases, the DePuy Mitek Intrafix system. The modular cannulated hex driver, made to fit over a small caliber wire, had no wire brushes of a small-enough diameter for the cleaning and sterilization procedure. After recognition of infection, all patients were treated with surgical irrigation and debridement of the affected knee, as well as individualized antibiotic therapy. Patients were followed postoperatively and no patients required revision ACL reconstruction or radical debridement of the graft.
Insights
Sterilization failures in surgical instrumentation, specifically the DePuy Mitek Intrafix system, were linked to a surge in anterior cruciate ligament (ACL) reconstruction infections. This highlights the critical need for effective cleaning protocols to prevent surgical site infections.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Biomedical Engineering
Background:
- Postoperative infections following anterior cruciate ligament (ACL) reconstruction are uncommon but serious complications.
- The specific causes of these infections are frequently unidentified, posing a challenge for prevention.
Purpose of the Study:
- To investigate the potential link between sterilization failures and ACL reconstruction infections.
- To characterize the relationship between methodological sterilization issues and infection rates at a military medical center.
Main Methods:
- A case series design was employed to analyze 5 postoperative infections over a 14-week period.
- Data collected included demographic, clinical, and laboratory information.
- A historical review of ACL reconstructions over 6 years established a baseline infection rate.
Main Results:
- An unusual cluster of 5 infections resulted in a 12.2% infection rate during the study period, significantly higher than the baseline 0.3% rate.
- No breaches in sterile technique were observed during the procedures.
- All affected cases used hamstring autografts and the DePuy Mitek Intrafix system for tibial fixation; two cases yielded positive cultures.
Conclusions:
- An investigation into a heightened infection rate revealed gross biomaterial within the DePuy Mitek Intrafix system's instrumentation.
- Inadequate cleaning brush sizes for the modular cannulated hex driver hindered effective sterilization.
- Patients treated with irrigation, debridement, and antibiotics recovered without requiring graft revision or extensive debridement.