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Septic arthritis after ACL reconstruction - Nhiễm trùng khớp sau tái tạo dây chằng chéo trước
- 1. Septic Arthritis ACL Reconstruction Current Practices and Recommendations Nguyen Q T Q, MD Department of Orthopedic Surgery Hue National Hospital
- 2. Introduction • Incidence 0.1-1.7% • 6x cost of treatment
- 3. Epidemiology • Bacteria • Staphylococcus aureus • Gram-positive organisms • Gram-negative bacilli • Fungal species • Mycobacterial species Immunosuppression
- 4. Diagnosis Clinical Manifestations • <2 weeks, 2 weeks – 2months, >2 months • Pain, swelling, warmth, ROM • Fever • Immediate • Early • Late • Delayed Day 3
- 5. Diagnosis Serum analysis White blood cell (WBC) count C-reactive protein level Erythrocyte sedimentation rate Blood cultures 2 weeks Not reliable Procalcitonin Cut-off: 0.5 ng/ml Follow- up Cut-off: 0.4 ng/ml CRP >41 mg/dL ESR >32 mm/hour
- 6. Diagnosis Synovial fluid Prior to antibiotics Positive synovial fluid Gram stain and/or culture Negative synovial fluid cultures - WBC counts (>100,000/ 25,000, neutrophils)
- 8. Treatment Goals • Protect articular cartilage • Eradicate infection • Retain the graft Management • Antibiotic therapy • Arthroscopic irrigation, debridement +/- graft Joint destruction Immediatel y
- 9. Antibiotic therapyTreatment Initiate • Immediately after arthrocentesis Type • Empiric antimicrobial therapy • Tailored to culture Duration: uncertain • 4-6weeks • IV 2 weeks =>OR 4 weeks, CRP => normal values Gram-positive cocci Vancomycin: 15 to 20 mg/kg/dose IV every 8 to 12 hours • Methicillin-susceptible S.A: beta-lactam • Methicillin-resistant S.A: vancomycin linezolid clindamycin Gram-negative bacilli Cephalosporin (+ ciprofloxacin Pseudomonas aeruginosa) Aztreonam Gram stain is negative Vancomycin (+ cephalosporin) Intra-articular antibiotics? • Drug levels in joint fluid • Induce an inflammatory response • Risk of iatrogenic complications
- 11. SurgeryTreatment Immediate arthroscopic irrigation and debridement • Immediate? • Lavage? • Synovectomy? Graft removal? • Significant intrasubstance degeneration • Gross evidence of infection compromising the graft • Nonfunctional graft
- 12. Second arthroscopyTreatment Sign of active infection • fever • unresolved inflammatory markers • persistent wound drain, warm, erythematous knee Condition of the graft and joint Recommend additional surgical debridement => lower the infection burden chronic infection synovitis progressive chondral deterioration postoperative stiffness
- 13. PostopTreatment • Immobilize • gentle ROM exercises • Closed-suction drainage system • Continual irrigation system
- 14. BiofilmTreatment
- 15. RifamycinTreatment Linezolid + rifampin/ vancomycin + rifampin is effective • Animal model of MRSA osteomyelitis • Retention of the infected foreign body Cure rate • 12/12 (100%) ciprofloxacin-rifampin • 7/12 (58%) ciprofloxacin-placebo 300 to 450 mgx2/day Several days after • surgical debridement • anti-staphylococcal therapy
- 16. ACL revisionTreatment 6-month period ACL reconstruction one stage two stage
- 17. Graft retentionOutcome Restoring the patient to preinjury functional and activity levels Complications include pain, stiffness, articular cartilage degeneration, and graft weakening or failure Overall results are much less satisfactory
- 18. Conclusion Rare but devastating Early diagnosis Appropriate treatment Second irrigation + debridement Adjunctive rifampin Pain, stiffness Infection after ACL reconstruction
- 19. Thank You!!