Burak DEMİRAĞ, ÖMER KAYS ÜNAL, CÜNEYT ÖZAKIN

Ön çapraz bağ rekonstrüksiyonu sonrası septik artritte greft koruyucu debridman

Amaç: Ön çapraz bağ (ÖÇB) onarımı sonrası gelişen septik artrit nadir olmakla birlikte, klinik sonuçları olumsuz etkileyen, morbiditesi yüksek bir komplikasyondur. Günümüzdeki tedavi seçenekleri, uzun süreli antibiyotik tedavisi, artroskopik veya açık cerrahi lavaj, aspirasyon, sürekli irigasyon, grefti yerinde bırakma ve reimplantasyon yaparak veya yapmadan greft ve tespit materyallerini çıkarmak gibi yöntemlerdir. Çalışmamızın amacı greft ve tespit materyalleri çıkarılmadan, artroskopik debridman ile birlikte uygulanacak uzun dönem antibiyotik tedavisinin ÖÇB rekonstrüksiyonu sonrası gelişen septik artrit üzerindeki sonuçlarını değerlendirmekti. Çalışma planı: Uludağ Üniversitesi Ortopedi ve Travmatoloji kliniğinde geçirdikleri ÖÇB rekonstrüksiyonu sonrası septik artrit gelişen 7 hasta (6 erkek, 1 kadın; ortalama yaş: 29; dağılım: 21-40) çalışmaya alındı. Hastalardan üçü profesyonel sporcu, biri ağır işçi, üçü hafif-orta düzey işçi, biri de amatör sporcu idi. Hastalara 6 hafta boyunca uzun süreli antibiyotik tedavisi uygulandı. Rehabilitasyon hastaların efüzyon, ağrı ve genel durumuna göre düzenlendi. Değerlendirmeler klinik sonuçlar, manuel Lachman ve pivot shift testleri ile Tegner aktivite, Lysholm ve IKDC skorlarına göre yapıldı. Bulgular: Hastalarda ortalama 6˚ (dağılım: 0˚-15˚) fleksiyon kaybı ve 3 ˚(dağılım: 0˚-5˚) ekstansiyon kaybı görüldü. Manuel Lachman testi tüm hastalarda normale yakın değerler verdi. Pivot shift testleri 3 hastada pozitif, 4 hastada negatif idi. Yapılan son kontrollerde, ameliyat öncesi ve sonrası ortalama Tegner akvite skorları, sırasıyla, 6 (dağılım: 4-7) ve 5 (dağılım: 4-7) idi. Ameliyat öncesi ve sonrası ortalama Lysholm skorları, sırasıyla, 73.2 (dağılım: 67-79) ve 74.1 (dağılım: 79-89); ortalama IKDC skorları da 78.0 (dağılım: 70-100) ve 80.0 (dağılım: 70-100) idi. Kuadriseps çevresi sağlam bacaktakinin %91’i (dağılım: 88-93) olarak ölçüldü. Tek bacak sıçrama mesafesi longitüdinal olarak sağlam tarafın %78’i (dağılım: 63-100), horizontal olarak sağlam tarafın %72’si (dağılım: 88-93) oranındaydı. Çıkarımlar: Aktivite düzeyleri orta olan hastalarda uzun süreli antibiyotik tedavisi ile birlikte greft ve implantlar korunarak yapılan artroskopik cerrahi drenajın etkili bir yöntem olduğunu, sporcu ve ağır işçilerde ise bu yöntemin bir miktar performans kaybına yol açabileceğini saptadık. Farklı aktivite seviyesindeki hastalarda uygun tedavi yönteminin belirlenmesi için başka çalışmaların yapılması gerekmektedir.

Graft retaining debridement in patients with septic arthritis after anterior cruciate ligament reconstruction

Objective: Although septic arthritis following anterior cruciate ligament (ACL) reconstruction is a rare complication, it has a high morbidity deteriorating the clinical outcome. Current treatment options include long-term antibiotic therapy, open or arthroscopic surgical lavage, aspiration, continuous irrigation, graft preservation, and removal of graft and fixation materials with or without reimplantation. The aim of our study was to evaluate the results of long-term antibiotic treatment with arthroscopic debridement without graft and fixation materials removal in the treatment of septic arthritis following ACL reconstructions. Methods: Seven patients (6 male, 1 female; mean age: 29 years; range: 21 to 40 years) who had septic arthritis following ACL reconstruction at Uludağ University, Department of Orthopaedics and Traumatology were included in this study. Three of the patients were athletes, 1 was a heavy-duty worker, 3 were light-medium-duty workers and 1 was an amateur sportsman. Long-term antibiotic therapy was used for 6 weeks. Rehabilitation was arranged according to the patients’ effusion, pain and general condition. Evaluations were made using clinical results, manual Lachman and pivot shift tests, and Tegner activity, Lysholm, and IKDC scores. Results: Patients had a mean of 6 (range: 0 to 15) degrees of flexion loss and 3 (range: 0 to 5) degrees of extension loss. Manual Lachman test was near normal for all patients. Pivot shift was positive for 3 and negative for 4 patients. Preoperative and postoperative mean Tegner activity scores were 6 (range: 4 to 7) and 5 (range: 4 to 7), respectively. Preoperative and postoperative mean Lysholm scores were 73.2 (range: 67 to 79) and 74.1 (range: 79 to 89), respectively. Preoperative and postoperative mean IKDC scores were 78.0 (range: 70 to 100) and 80.0 (range: 70 to 100), respectively. Mean leg circumference across the quadriceps muscle was 91% (range: 88 to 93) of the contralateral leg. Single-leg longitudinal jumping length was 78% (range: 63 to 100) of the uninvolved leg. Single-leg horizontal jumping was 72% (range: 88 to 93) of the contralateral leg. Conclusion: Long-term antibiotic therapy and arthroscopic drainage without graft or fixation material removal is effective in patients of regular activity level. Although this procedure is equally successful for treating the infection in competitive athletes and heavy workers, it also results in slight performance loss. Further review is necessary to determine which treatment is suitable for which activity level.

___

1. Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following anterior cruciate ligament reconstruction. Arthroscopy 2006;22:375-84.
2. Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early re-implantation. Am J Sports Med 2003;31:414-8.
3. 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 Mar;25(3):243-9.
4. Williams RJ, Laurencin CT, Warren RF, Speciale AC, Brause BD, O’Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: diagnosis and management. Am J Sports Med 1997;25:261-7.
5. Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H. Septic arthritis afterarthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med 2007;35:1059-63.
6. Armstrong RW, Bolding F, Joseph R. Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors. Arthroscopy 1992;8:213-23.
7. Indelli P, Dillingham M, Fanton G, Schuman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2002;(398):182-8.
8. 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;27:562-70.
9. Binnet MS, Baflar›r K. Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques. Arthroscopy 2007;23:862-8.
10. Matawa 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;14:717-25.
11. Fong SY, Tan JL. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Ann Acad Med 2004;33:228-34.
12. Margheritini F, Camillieri G, Mancini L, Mariani PP. Creactive protein and erythrocyte sedimentation rate changes following arthroscopically assisted anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2001;9:343-5.
13. Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2009;17: 1033-42.
14. Reginato AJ, Feldman E, Rabinowitz JL. Traumatic chylous knee effusion. Ann Rheum Dis 1985;44:793-7.
15. Smith RL, Schurman DJ, Kajiyama G, Mell M, Gilkerson E. The effect of antibiotics on the destruction of cartilage in experimental infectious arthritis. J Bone Joint Surg Am 1987;69:1063-8.
16. Cohen SB, Gill SS, Baer GS, Leo BM, Scheld WM, Diduch DR. Reducing joint destruction due to septic arthrosis using an adenosine2A receptor agonist. J Orthop Res 2004;22:427-35.
17. Bunnell S. Ischaemic contracture, local, in the hand. J Bone Joint Surg Am 1953;35:88-101.
18. Sapega AA, Heppenstall RB, Chance B, Park YS, Sokolow D. Optimizing tourniquet application and release times in extremity surgery. A biochemical and ultrastructural study. J Bone Joint Surg Am 1985;67:303-14.
19. Maletis GB, Samuelson TS, Drez D Jr. Synovial response to intra-articular metal debris: implications for anterior cruciate ligament reconstruction. Arthroscopy 2002;18: 61-3.