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AUGUST 2010| Volume 33 Number 8

Case Report

abstract

Full article available online at OrthoSuperSite.com/view.aspx?rID=66664

Arthroscopic Treatment of Acute SepticArthritis After Meniscal AllograftTransplantationJI-HOON BAE, MD; HONG-CHUL LIM, MD; HAK JUN KIM, MD; TAIK-SUN KIM, MD; JAE-HYUK YANG, MD;

JUNG-RO YOON, MD

Dr Bae is from the Department of Orthopedic Surgery, Korea University College of Medicine, Ansan

Hospital, Ansan, Drs Lim and Kim (Hak Jun) are from the Department of Orthopedic Surgery, Korea

University College of Medicine, Guro Hospital, and Drs Kim (Taik-Sun), Yang, and Yoon are from the

Department of Orthopedic Surgery, Seoul Veterans Hospital, Seoul, Korea.

Drs Bae, Lim, Kim (Hak Jun), Kim (Taik-Sun), Yang, and Yoon have no relevant financial relation-

ships to disclose.

Correspondence should be addressed to: Jung-Ro Yoon, MD, Department of Orthopedic Surgery,

Seoul Veterans Hospital, 6-2, Dunchon-dong, Kangdong-gu, Seoul 134-060, Korea (Republic of Korea)(zenyjr@yahoo.co.kr).

doi: 10.3928/01477447-20100625-24

We present the 30-month follow-up results of an acute septic arthritis of the knee af-

ter meniscal allograft transplantation, which was successfully treated with graft reten-

tion. A 21-year-old man presented with a 4-month history of right knee pain follow-

ing arthroscopic subtotal lateral meniscectomy. Plain radiographs showed there was

no arthritic change with neutral limb alignment. Fourteen days after meniscal allograft

transplantation, septic arthritis was confirmed with positive cultures for Staphylococcus

epidermidis, and arthroscopic debridement and irrigation were performed. The suggest-

ed procedures of our treatment regimen include arthroscopic debridement and irrigation

with 10 L of normal saline as soon as possible after diagnosis or a clinical suspicion is

reached, repeated irrigation under the local anesthesia and intravenous antibiotics until

clinical symptoms and laboratory results improve. The decision to repeat the debride-

ment was based on clinical and laboratory results. We reevaluated the patients the third

or fourth day after every arthroscopic treatment. At last follow-up, 2 years after the final

operation, the patient had no clinical sign of infection. Erythrocyte sedimentation rateand C-reactive protein level were normal and plain radiographs indicated no arthritic

change. Further the patient had full pain-free range of knee motion. At this time the

Lysholm knee score was 89 and the Tegner score was 5. Magnetic resonance imaging

30 months postoperatively revealed slight (3 mm) extrusion without tear. This case is

notable because it shows that early aggressive arthroscopic debridement and repeated

irrigation with graft retention can be an effective treatment regimen in selected cases.

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ORTHOPEDICS | ORTHOSuperSite.com

Case Report

Septic arthritis after meniscus al-

lograft transplantation is rare but

a serious complication that may

require graft removal.1 Although several

reports regarding the treatment and prog-

nosis of septic arthritis following anterior

cruciate ligament (ACL) reconstruction

have been issued,2,3 there are no pub-

lished reports about the treatment regi-

men of septic arthritis following menis-

cus allograft transplantation. This article

presents a case of a 21-year-old man with

acute septic arthritis of the knee after me-

niscus allograft transplantation.

CASE REPORTA 21-year-old man presented with a 4-

month history of right knee pain following

arthroscopic subtotal lateral meniscectomy.

Physical examination revealed joint line ten-

derness on the lateral aspect of the knee joint,

a positive McMurray test, and full range of

motion. Plain radiograph showed no arthritic

change and neutral limb alignment (Figure 1).

Arthroscopic examination revealed no chon-

dral lesion and no ligament instability.

Lateral meniscus allograft transplantation

was performed using a fresh frozen lateral

meniscus allograft. Postoperatively, 1.7 g of

cefuroxime, a first generation cephem antibi-

otic, was intravenously administered for 3 days

from the day of surgery to prevent infection in

accord with our standard practice.On postoperative day 7, the patient devel-

oped a low-grade fever (37.5C-38C) with

pain and swelling in the right knee. Physi-

cal examination showed erythema, a heating

sensation, and tenderness over the right knee.

Septic arthritis was clinically suspected. Initial

laboratory tests showed a leukocyte count of

11860/mm3, a C-reactive protein (CRP) level

of 42.75 mg/L (normal range, 0-3.5 mg/L), and

an erythrocyte sedimentation rate (ESR) of 53

mm/hour (normal range, 0-20 mm/hour).

Joint fluid analysis showed turbid color,

a leukocyte count of 38,800/mm3 (97% poly,

3% lymphocyte), decreased glucose, and in-

creased protein. Blood cultures and joint aspi-

ration culture were negative. Additionally, 160

mg/day of tobramycin was administered for

gram-negative organism coverage. However,

clinical symptom and laboratory findings did

not improve. On postoperative days 10 and 13,

synovial fluid analysis showed cloudy color,

increased white blood count (30,000/mm3),

decreased glucose, and cultures were positive

for Staphylococcus epidermidis. The antibiot-

ics were changed and 400 mg/day of Cipro-

floxacin and 600 mg/day of clindamycin were

administered.

On postoperative day 15, arthroscopic de-

bridement and irrigation were performed. Ma-

jor synovectomy of the suprapatellar pouch,

medial and lateral gutters, femoral notch, and

anterior portion of the knee was performed and

was found to be grossly infected, and necrotic

tissue was debrided. Cartilage seemed to be vi-

able and the graft was retained. A fibrous layer

that formed on the graft was gently removedtaking care not to damage the graft. The joint

was irrigated with 10 L of normal saline.

Two lines (3.2-mm thickness) were placed into

the joint through superolateral and inferome-

dial portals for drainage. However, continuous

irrigation was not performed.

Intraoperative joint culture was positive

for S epidermidis and intravenous antibiotics

(400 mg/day of ciprofloxacin and 600 mg/day

of clindamycin) were continued. When clini-

cal and laboratory findings did not improve,

repeated irrigation was performed under local

anesthesia with 3- to 4-day intervals.

After intra-articular (40 cc) and periportal

injections (10 cc) of a mixture of 1% lidocaine

25 cc and 0.25% bupivacaine 25 cc, the joint

was irrigated with 10 L of normal saline using

an arthroscopic inflow system through the an-

terolateral and inferomedial portals. Each time

no evidence of graft contamination was found.

Additional irrigation was performed 5 times

until clinical symptoms and ESR and CRP

level were improved.

On postoperative day 31, the patient was

symptom free and the CRP level had declined

to 1.30 mg/L. Drainage lines were removed and

passive and active assisted knee range of motion

exercises were started within pain limits, and fol-

lowed by a knee strengthening exercise. Seven

weeks after meniscal allograft transplantation,

intravenous antibiotics were discontinued and

oral antibiotics were prescribed for 4 weeks.

At last follow-up, 2 years after his initial

presentation, the patient had no clinical sign

of infection. Erythrocyte sedimentation rate

and CRP level were normal and plain radio-

graphs indicated no arthritic change (Figure

2A). Further the patient had a full pain-free

range of knee motion (Figure 2B). At this time

the Lysholm knee score was 89 and the Tegner

score was 5. Magnetic resonance imaging 30

months postoperatively revealed slight (3 mm)

extrusion without tear (Figure 2C).

DISCUSSIONSeptic arthritis after meniscal allograft

transplantation is a rare but potentially

devastating complication. Unfortunately,

few reports describe the treatment of sep-

tic arthritis occurring as a complication ofmeniscal allograft transplantation,4 and

we are unaware of any guidelines con-

cerning the management and prognosis

of septic arthritis after meniscus allograft

transplantation. The treatment protocol

we adopted in this patient was based on

the treatment of septic arthritis after ar-

throscopic ACL reconstruction.3,5,6

It has been reported that arthroscopic

debridement and irrigation is likely to be

successful for the treatment of acute in-

fection after arthroscopic surgery.3,7 Graft

retention depends on several factors. Some

authors prefer to remove the graft imme-

diately,7-9 while others retain the graft3,10,11

or remove it only if infection persists.12,13

Matava et al14 surveyed 74 surgeons on thisFigure 1: Preoperative plain radiograph of both knees

showing no evidence of degenerative change.

1

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ARTHROSCOPIC TREATMENTOF ACUTE SEPTIC ARTHRITIS | BAEETAL

topic and found that 5 different treatments

were used to treat deep infections. The ma-

jority proposed initial debridement with

graft retention, and in cases of resistant in-

fection, 50% recommended graft removaland 36% viewed graft removal as a part of

the treatment regimen. Our aim was to re-

tain a functional graft during treatment.

Many surgeons recommend repeated

debridement and irrigation. The decision

to repeat debridement and irrigation is

based on clinical and laboratory results.

Van Tongel et al3 reported performing

repeat arthroscopic debridement in 7 pa-

tients with septic arthritis after ACL re-

construction. They reevaluated patients

4 days after each arthroscopic treatment

and when clinical and laboratory results

showed no or only slight amelioration,they performed a new debridement. In our

practice, the decision to repeat irrigation

is based on Van Tongels suggestion, but

it is more strictly applied. If a clinical or

laboratory result has not improved, we re-

peat irrigation, and when pain, swelling,

erythema, and a heating sensation persist

over the knee, or when ESR and CRP

level have not improved, we repeated ar-

throscopic irrigation with 10 L of normal

saline every 3 or 4 days until both clinical

and laboratory results improve.

The procedures presented in this case

differ in several ways from generally ac-

cepted procedures. First, repeat irrigation

was performed under local anesthesia,

which can reduce complications related to

multiple general anesthesia and can lessen

the mental, physical, and economic burdens

imposed on the patient. Second, we did not

perform debridement or synovectomy dur-ing repeat irrigation under local anesthe-

sia, although it is critical that any fibrous

inflammatory layer on a graft be removed.

One reason for this was patient inconve-

nience due to local anesthesia. However,

little inflammatory tissue was observed on

the graft when we evaluated it. Fibrin clots

were easily removed by irrigation only.

Third, in accord with our standard practice

3.2-mm lines were used for drainage in the

knee joint postoperatively. We used these

large-diameter drainage lines to prevent

fibrin clot and fibrous tissue blockages.

During treatment, no problems related todrainage lines were encountered.

Our proposed treatment regimen in-

cludes early diagnosis and arthroscopic de-

bridement with retention of a functional

graft followed by repeated irrigation every

3 to 4 days under local anesthesia until

clinical and laboratory results improve.

This regimen provides a means of eradicat-

ing infection and maintaining a well func-

tioning graft in patients with septic arthritis

after meniscus allograft transplantation.

REFERENCES1. Rijk PC. Meniscal allograft transplantation,

I: background, results, graft selection andpreservation, and surgical considerations.Ar-throscopy. 2004; 20(7):728-743.

2. Dixon P, Parish EN, Cross MJ. Arthroscopicdebridement in the treatment of the infectedtotal knee replacement.J Bone Joint Surgery

Br. 2004; 86(1):39-42.

3. Van Tongel A, Stuyck J, Bellemans J, Vanden-neucker H. Septic arthritis after arthroscopicanterior cruciate ligament reconstruction: aretrospective analysis of incidence, manage-ment and outcome.Am J Sports Med. 2007;35(7):1059-1063.

4. Kuhn JE, Wojtys EM. Allograft meniscustransplantation. Clin Sports Med. 1996;15(3):537-536.

5. Wang C, Ao Y, Wang J, Hu Y, Cui G, Yu J.Septic arthritis after arthroscopic anteriorcruciate ligament reconstruction: a retro-spective analysis of incidence, presentation,treatment, and cause. Arthroscopy. 2009;25(3):243-249.

6. Kurokouchi K, Takahashi S, Yamada T,Yamamoto H. Methicillin-resistant Staphy-lococcus aureus-induced septic arthritis afteranterior cruciate ligament reconstruction.Ar-

throscopy. 2008; 24(5):615-617.7. Indelli PF, Dillingham M, Fanton G, Schur-

man DJ. Septic arthritis in postoperative an-terior cruciate ligament reconstruction. ClinOrthop Relat Res. 2002; (398):182-188.

8. Burks RT, Friederichs MG, Fink B, LukerMG, West HS, Greis PE. Treatment of post-operative anterior cruciate ligament infectionswith graft removal and early reimplantation.

Am J Sports Med. 2003; 31(3):414-418.

9. Zalavras CG, Patzakis MJ, Tibone J, WeismanN, Holtom P. Treatment of persistent infectionafter anterior cruciate ligament surgery. ClinOrthop Relat Res. 2005; (439):52-55.

10. McAllister DR, Parker RD, Cooper AE, Re-cht MP, Abate J. Outcomes of postoperativeseptic arthritis after anterior cruciate liga-ment reconstruction.Am J Sports Med. 1999;

27(5):562-570.11. Viola R, Marzano N, Vianello R. An unusual

epidemic of Staphylococcus-negative infec-tions involving anterior cruciate ligamentreconstruction with salvage of the graft andfunction.Arthroscopy. 2000; 16(2):173-177.

12. Burke WV, Zych GA. Fungal infection fol-lowing replacement of the anterior cruciateligament: a case report. J Bone Joint Surg

Am. 2002; 84(3):449-453.

13. Williams RJ III, Laurencin CT, Warren RF,Speciale AC, Brause BD, OBrien S. Septic ar-thritis after arthroscopic anterior cruciate liga-ment reconstruction. Diagnosis and manage-ment.Am J Sports Med. 1997; 25(2):261-267.

14. Matava MJ, Evans TA, Wright RW, ShivelyRA. Septic arthritis of the knee following an-terior cruciate ligament reconstruction: resultsof a survey of sports medicine fellowship di-rectors.Arthroscopy. 1998; 14(7):717-725.

Figure 2: Plain radiograph taken at 30 months postoperatively showing no evidence of degenerative

change (A). The patient had full range of motion (B). MRI taken at 30 months postoperatively showing no

evidence of arthritic change and a well contained graft (C).

2A 2B 2C

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