Recommendations for the management of septic arthritis after ACL reconstruction

To evaluate the current evidence for the management of septic arthritis after anterior cruciate ligament (ACL) reconstruction, the factors that affect the outcome after treatment and the retention of graft and implants.

A systematic literature search of the PubMed database was performed on septic arthritis after ACL reconstruction. A total of 301 publications were initially identified, and 17 papers were found to fulfil the criteria to be included in the review.

There were 196 cases of septic arthritis after ACL reconstruction in over 30,000 ACL reconstructions, making the proportion of infection 0.6%. Most patients (114/123, 92.6%) had an acute or subacute infection at an average of 16.8 ± 10.5 days after ACL reconstruction. Coagulase-negative Staphylococci (CNS) was the most common organism (67/147, 45.6%) followed by Staphylococcus aureus (SA) (35/147, 23.8%); 86.9% underwent surgical treatment of which 92.8% had an average of 1.54 (up to 4) arthroscopic debridements. The group with SA infection had a higher graft removal rate (33.3%, p = 0.019), a longer antibiotic duration (35.4 days, p = 0.047) and a worse range of flexion (111.5°, p = 0.036) than the CNS group.

CNS was the most common organism in septic arthritis after ACL reconstruction followed by SA. For most authors, arthroscopic debridement combined with intravenous antibiotic therapy was the initial treatment of choice. Antibiotic therapy with or without multiple irrigations of the joint is not recommended based on the high failure rates. Delayed diagnosis of more than 7 days or SA infection required a longer duration of antibiotic therapy and increased the likelihood for graft removal and restricted range of motion. Fungal infection and tubercular infection had a high prevalence of late diagnosis and open debridement.

Systematic review, Level IV.