Case Report

Arthroscopic Treatment of Acute Septic Arthritis After Meniscal Allograft Transplantation

abstract
Full article available online at OrthoSuperSite.com/view.aspx?rID=66664
We present the 30-month follow-up results of an acute septic arthritis of the knee after meniscal allograft transplantation, which was successfully treated with graft retention. A 21-year-old man presented with a 4-month history of right knee pain following 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 conrmed with positive cultures for Staphylococcus epidermidis, and arthroscopic debridement and irrigation were performed. The suggested 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 debridement 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 nal operation, the patient had no clinical sign of infection. Erythrocyte sedimentation rate and 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.

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 nancial relationships 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) ([email protected]). doi: 10.3928/01477447-20100625-24

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 Case Report

eptic arthritis after meniscus allograft transplantation is rare but a serious complication that may require graft removal.1 Although several reports regarding the treatment and prognosis of septic arthritis following anterior cruciate ligament (ACL) reconstruction have been issued,2,3 there are no published reports about the treatment regimen of septic arthritis following meniscus allograft transplantation. This article presents a case of a 21-year-old man with acute septic arthritis of the knee after meniscus allograft transplantation.

CASE REPORT
A 21-year-old man presented with a 4month history of right knee pain following arthroscopic subtotal lateral meniscectomy. Physical examination revealed joint line tenderness 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 chondral 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 rst generation cephem antibiotic, 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 developed a low-grade fever (37.5C-38C) with pain and swelling in the right knee. Physi-

1
Figure 1: Preoperative plain radiograph of both knees showing no evidence of degenerative change.

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 uid analysis showed turbid color, a leukocyte count of 38,800/mm3 (97% poly, 3% lymphocyte), decreased glucose, and increased protein. Blood cultures and joint aspiration culture were negative. Additionally, 160 mg/day of tobramycin was administered for gram-negative organism coverage. However, clinical symptom and laboratory ndings did not improve. On postoperative days 10 and 13, synovial uid analysis showed cloudy color, increased white blood count (30,000/mm3), decreased glucose, and cultures were positive for Staphylococcus epidermidis. The antibiotics were changed and 400 mg/day of Ciprooxacin and 600 mg/day of clindamycin were administered. On postoperative day 15, arthroscopic debridement and irrigation were performed. Major 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 viable and the graft was retained. A brous layer that formed on the graft was gently removed taking 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 inferomedial portals for drainage. However, continuous irrigation was not performed. Intraoperative joint culture was positive for S epidermidis and intravenous antibiotics (400 mg/day of ciprooxacin and 600 mg/day of clindamycin) were continued. When clinical and laboratory ndings 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 inow system through the anterolateral 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 followed 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 radiographs 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).

DISCUSSION
Septic arthritis after meniscal allograft transplantation is a rare but potentially devastating complication. Unfortunately, few reports describe the treatment of septic arthritis occurring as a complication of meniscal allograft transplantation,4 and we are unaware of any guidelines concerning 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 arthroscopic ACL reconstruction.3,5,6 It has been reported that arthroscopic debridement and irrigation is likely to be successful for the treatment of acute infection after arthroscopic surgery.3,7 Graft retention depends on several factors. Some authors prefer to remove the graft immediately,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 this

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ARTHROSCOPIC TREATMENT OF ACUTE SEPTIC ARTHRITIS | BAE ET AL

2. Dixon P, Parish EN, Cross MJ. Arthroscopic debridement in the treatment of the infected total knee replacement. J Bone Joint Surgery Br. 2004; 86(1):39-42. 3. Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med. 2007; 35(7):1059-1063. 4. Kuhn JE, Wojtys EM. Allograft meniscus transplantation. 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 anterior cruciate ligament reconstruction: a retrospective analysis of incidence, presentation, treatment, and cause. Arthroscopy. 2009; 25(3):243-249. 6. Kurokouchi K, Takahashi S, Yamada T, Yamamoto H. Methicillin-resistant Staphylococcus aureus-induced septic arthritis after anterior cruciate ligament reconstruction. Arthroscopy. 2008; 24(5):615-617. 7. Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2002; (398):182-188. 8. Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med. 2003; 31(3):414-418. 9. Zalavras CG, Patzakis MJ, Tibone J, Weisman N, Holtom P. Treatment of persistent infection after anterior cruciate ligament surgery. Clin Orthop Relat Res. 2005; (439):52-55. 10. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 1999; 27(5):562-570. 11. Viola R, Marzano N, Vianello R. An unusual epidemic of Staphylococcus-negative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function. Arthroscopy. 2000; 16(2):173-177. 12. Burke WV, Zych GA. Fungal infection following replacement of the anterior cruciate ligament: 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 arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med. 1997; 25(2):261-267. 14. Matava MJ, Evans TA, Wright RW, Shively RA. Septic arthritis of the knee following anterior cruciate ligament reconstruction: results of a survey of sports medicine fellowship directors. Arthroscopy. 1998; 14(7):717-725.

2A

2B

2C

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).

topic and found that 5 different treatments were used to treat deep infections. The majority proposed initial debridement with graft retention, and in cases of resistant infection, 50% recommended graft removal and 36% viewed graft removal as a part of the treatment regimen. Our aim was to retain 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 patients with septic arthritis after ACL reconstruction. 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 repeat 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 arthroscopic 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 accepted 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 during repeat irrigation under local anesthesia, although it is critical that any brous inammatory layer on a graft be removed. One reason for this was patient inconvenience due to local anesthesia. However, little inammatory 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 brin clot and brous tissue blockages. During treatment, no problems related to drainage lines were encountered. Our proposed treatment regimen includes early diagnosis and arthroscopic debridement 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 eradicating infection and maintaining a well functioning graft in patients with septic arthritis after meniscus allograft transplantation.

REFERENCES
1. Rijk PC. Meniscal allograft transplantation, I: background, results, graft selection and preservation, and surgical considerations. Arthroscopy. 2004; 20(7):728-743.

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