Postarthroscopy Surgical Site Infections: Review of the Literature

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1 REVIEW ARTICLE Postarthroscopy Surgical Site Infections: Review of the Literature Hilary M. Babcock, 1 Matthew J. Matava, 2 and Victoria Fraser 1 1 Infectious Disease Division, Department of Internal Medicine, and 2 Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri The use of arthroscopy for both diagnosis and operative intervention has been increasing steadily since its introduction in the 1970s. It is generally associated with fewer complications and shorter times to mobilization than are open procedures. Overall reported rates of complications are low (0.1% 0.6% of procedures). This review focuses on infectious complications of arthroscopy, which are rare (0.01% 0.48% of procedures) but result in significant morbidity for the patient when they occur. The most commonly reported causative organisms are staphylococci. Several outbreaks have been reported related to breaks in infection control or to contaminated instruments. Suggested risk factors include use of intra-articular corticosteroids, prolonged tourniquet time, patient s age 150 years, failure to prepare the surgical site again before conversion to arthrotomy, procedure complexity, and a history of previous procedures. However, most reports use variable and unclear definitions of infection, which makes it difficult to draw firm conclusions. The first arthroscopic examinations of the knee were performed in 1918 on cadavers by Professor Kenji Takagi in Japan. In the 1950s, with improved lens and lighting systems, Dr. Masaki Watanabe developed the first functional arthroscope, the Watanabe number 21. Its use was noted in the United States and by the early 1970s the American Academy of Orthopedic Surgeons was sponsoring courses to teach the new procedure to interested doctors. The International Arthroscopy Association was founded in 1974, and in the early 1980s, a journal dedicated to arthroscopy began publication: Arthroscopy: The Journal of Arthroscopic and Related Surgery [1]. The use of arthroscopy has been increasing steadily since its introduction, and it is now being used for both diagnostic and operative purposes [2]. In general, arthroscopy is associated with fewer complications and Received 14 May 2001; revised 6 August 2001; electronically published 21 November Reprints or correspondence: Dr. Hilary M. Babcock, Campus Box 8051, 660 South Euclid Ave., St. Louis, MO (hbabcock@im.wustl.edu). Clinical Infectious Diseases 2002; 34: by the Infectious Diseases Society of America. All rights reserved /2002/ $03.00 with shorter mobilization and recovery times, compared with the more invasive open arthrotomy procedures [3 5]. For open procedures, studies have reported rates of associated complications of up to 14.6% [6]. Risks include effusions (12% of procedures), deep vein thrombosis (1.8% 46%), nerve injuries, and arterial injury or aneurysm formation [6]. Arthroscopy is generally perceived to be lower risk and to provide significant savings in time and money for the patient and the health care system. Over the last decade, there have been efforts to define the expected complication rate for arthroscopic procedures, risk factors for complications, and the clinical presentation of the most common complications. Some complications, such as hemarthrosis and effusion, persist at rates similar to those for open procedures. Other complications are unique to arthroscopy, such as instrument breakage and pneumoscrotum [7]. However, overall reported rates of complications are usually low, ranging from 0.1% to 0.6% [8]. Infectious complications of arthroscopy appear to be fairly rare. However, they carry significant morbidity and can interfere with a patient s recovery from what is supposed to be a low-risk procedure. Because treatment usually involves surgery and intravenous admin- Postarthroscopy Surgical Site Infections CID 2002:34 (1 January) 65

2 istration of antibiotics, these complications also come at a significant cost. Infectious complications may also be largely preventable; strict adherence to aseptic technique and infection control measures often result in immediate decreases in infection rates. This article will review infectious complications of arthroscopy, including published incidence rates, microbiology, risk factors, clinical presentation, treatment practices, and outcomes. INFECTION RATES Reported rates of infection after arthroscopic knee surgery range from 0.01% [9] to 0.48% [10] (table 1). Unfortunately, many of these studies determined surgical site infection rates on the basis of self-reports or historical surveys, and most did not use a standardized definition of infection. Many did not even indicate the definition of infection that was used to gather the data. In 1992, the Centers for Disease Control and Prevention (CDC) published a standardized set of definitions for surgical site infections for use in infection control, which categorized postoperative surgical wound infections as superficial, incisional, deep incisional, and organ or space surgical site infections [21]. Many of the studies of postarthroscopy surgical site infections were performed before publication of the CDC guidelines and used various criteria for defining an infection. In many studies, positive joint fluid culture results were required for inclusion of a case as an infection [13, 15, 16], whereas the CDC guidelines list that criterion as only one of several and, therefore, allow inclusion of many more cases. In 1983 and 1985, 2 national surveys were performed by the Complications Committee of the Arthroscopy Association of North America. These surveys were based on the responding physicians recall of all complications, including infections, associated with arthroscopic procedures. There were no guidelines given to the responding physicians about how to define an infection, and no details were required besides an estimated number. In 1985, DeLee [8] reported that 0.08% of recalled cases that had occurred during a 10-year period ending in 1983 had been complicated by infection. In 1986, on the basis of survey data from , Small [11] reported a similar postsurgical infection rate of 0.07% (298 infections for 395,566 procedures); 67.4% of those infections were described as deep infections (as specified by the reporting surgeon). In both reports, the authors acknowledge that retrospective reporting by survey and reliance on the memory of the reporting physician would doubtless result in overestimation of the number of procedures performed and underestimation of the associated complications. A later survey by Small [2] involved 21 surgeons experienced in arthroscopy who reported the numbers and types of procedures they performed and the associated complication rates monthly for a period of 19 months in This study reports a somewhat higher rate of infectious complications: 0.2%. Infection was the second most common complication, Table 1. Summary of rates of postarthroscopy surgical site infection reported in the literature (case reports not included). Study, reference No. of cases of infection/ total no. of procedures Overall infection rate, % Comments Johnson et al. [9] 5/12, Infection rate: 0.01% for diagnostic procedures, 0.03% for operative procedures DeLee [8] 95/118, AANA survey 1 Small [11] 298/395, AANA survey 2 Sherman et al. [6] NA/ Infection defined as purulent joint fluid and positive result of joint fluid culture Ajemian et al. [12] 3/151 (0/222) a 2.0 (0) a Outbreak investigation D Angelo and Ogilvie-Harris [13] 9/ Infection defined as purulent joint fluid and positive result of joint fluid culture Small [2] 21/10, Survey Collins [14] 2/ Portal infections only; none deep Armstrong et al. [15] 18/4256 (2/2206) a 0.42 (0.09) a Outbreak investigation Armstrong and Bolding [16] 4/101 (1/579) a 3.9 (0.2) a Outbreak investigation Williams et al. [17] 7/ Intra-articular infections after ACL Wieck et al. [18] 1/ wound infection; none deep Matava et al. [19] NA 0.2 Survey McAllister et al. [10] 4/ Intra-articular infections after ACL Viola et al. [20] 10/70 (1/400) a 14.3 (0.25) a Outbreak investigation NOTE. AANA, Arthroscopy Association of North America; ACL, anterior cruciate ligament; NA, not available. a Outbreak rate (postoutbreak rate). 66 CID 2002:34 (1 January) Babcock et al.

3 after hemarthrosis. Again, no definition of infection was given and the severity of infection was not indicated, so it is unclear whether this reported rate includes superficial surgical site infections, in addition to septic arthritis. More recently, Matava et al. [19] reported a survey of 74 sports medicine fellowship directors, asking them to report the number of arthroscopic anterior cruciate ligament (ACL) reconstructions they had performed in the previous 2 5 years and how many subsequent intra-articular infections they had treated. These reports were limited to septic arthritis and so excluded superficial surgical site infections. Extrapolating from the number of procedures and number of infections per surgeon, Matava et al. [19] estimated that postoperative septic arthritis occurred after 0.2% of procedures. All the reporting surgeons were considered to be experts in their field. Again, this estimate is based on self-reported data, but it does specify the type of infection reported: septic arthritis. Investigators who give a working definition of infection in their reports often rely on culture data. Sherman et al. [6] reported on the rate of arthroscopy complications in their practices by retrospectively reviewing 2640 knee procedures that they had performed. They defined infection as purulent fluid aspirated from the knee from which 1 organism was isolated, and reported an infection rate of 0.1%. They provided some data about wound infections, but combined them with other minor complications in the category wound healing, which included drainage, wound dehiscence, and suture abscesses. For this class of complication, they reported a higher infection rate of 3.3%. Armstrong and Bolding [16] reported an elevated rate of septic arthritis following arthroscopy at 1 institution, where there were 4 infections for 101 arthroscopic procedures performed during a 3-month period (infection rate, 4%). During the next 6 months of surveillance, the rate decreased to 1.2% (3 infections for 251 procedures). After targeted interventions to correct identified problems in aseptic technique, the surgical site infection rate during the next 12 months dropped even lower, to 0.2% (1 infection for 579 procedures). For an infection to be included in this report, the patient had to have clinical signs and symptoms of infection, purulent joint fluid, and a positive fluid culture result. Viola et al. [20] described an outbreak of infection after ACL reconstruction and report that the infection rate increased from 0.15% (2 infections for 1300 procedures) to 14.3% (10 infections for 70 procedures). These infections were defined clinically by the symptom complex of pain, swelling, and fever and a response to antibiotics. Of 12 total infections, only 2 had positive fluid culture results. Williams et al. [17] reported 7 deep infections of the knee, described as intra-articular, for 2500 ACL reconstructions performed during (infection rate, 0.3%). No information on superficial site infections was given. McAllister et al. [10] reported 4 episodes of septic arthritis for 831 arthroscopic ACL reconstructions (infection rate, 0.48%); all cases had positive fluid cultures. Armstrong et al. [15] reported that surveillance during a 4- year period at a surgicenter revealed 18 cases of surgical site infection for 4264 arthroscopic procedures (infection rate, 0.42%). All cases were defined by a positive joint fluid culture result. After the study and education of the clinic staff about its findings, the infection rate dropped to 0.09% during the next 2 years. Again, no information was given on superficial surgical site infections or on suspected infections for which culture results were negative. Ajemian et al. [12] reported that an investigation at 1 hospital found that 3 of 151 patients had developed septic arthritis after arthroscopy during a 3-month period in 1984 (infection rate, 2%). All 3 patients had positive joint fluid culture results. After instituting targeted changes in protocol, there were no infections for the next 222 procedures performed. D Angelo and Ogilvie-Harris [13], in an article evaluating prophylactic antibiotic use, reported 9 infections in 4000 procedures (infection rate, 0.23%). All 9 patients with infection had purulent joint fluid cultures with positive results. No information was given about the incidence of suspected or clinically diagnosed infection or superficial site infection. Several articles provide more detailed information. Johnson et al. [9], reporting on the use of 2% glutaraldehyde for disinfecting arthroscopes between procedures, noted an overall infection rate of 0.04% (5 infections for 12,505 procedures performed during 8 years): 0.01% for diagnostic arthroscopy and 0.03% for operative arthroscopy. One of these infected patients developed septic arthritis of a prosthetic knee, and 4 of the patients had localized wound infections. One surgeon reported on his own experience with the first 1500 arthroscopic procedures he performed during a 10-year period [14]. He reported 2 portal infections (infection rate, 0.13%) but no deep infections or septic arthritis. Only a single randomized, placebocontrolled, blinded study has evaluated the efficacy of antibiotic prophylaxis with arthroscopy, and it did not identify any deep infections in 437 patients; however, there was 1 superficial wound infection (infection rate, 0.23%) [18]. MICROBIOLOGY In the majority of reports, the pathogens most commonly identified from surgical site infections that occur after arthroscopy are Staphylococcus species (table 2). Although Staphylococcus aureus is still more commonly reported, coagulase-negative Staphylococcus (CNS) is increasingly recognized as a significant pathogen. In some studies, 2 fluid cultures positive for CNS were required for a case of infection to be included, which demonstrates the difficulty doctors have in distinguishing con- Postarthroscopy Surgical Site Infections CID 2002:34 (1 January) 67

4 Table 2. Microbiologic findings from articles reviewed that reported 11 case of postarthroscopy surgical site infection and included microbiologic data. Organism isolated No. (%) of cases Staphylococcus aureus 99 (28.5) Coagulase-negative Staphylococcus 62 (17.9) Staphylococcus species (not specified) 144 (41.5) Streptococcus species 20 (5.8) Pseudomonas aeruginosa 10 (2.9) Enterobacter cloacae 1 (0.3) Clostridium perfringens 1 (0.3) None 10 (2.9) Total no. of cases with microbiologic data 347 (100) tamination from disease [15]. In 1 report, diagnosis was significantly delayed because a positive culture result was wrongly thought to be due to a contaminant [16]. Streptococcal species have the third-highest incidence, and Pseudomonas species are reported with some frequency. Studies have noted single cases of infection with Enterobacter cloacae [16], anaerobic Streptococcus [species 9], Peptostreptococcus species [17], Staphylococcus caprae [22], and Acinetobacter calcoaceticus [18]. Some patients had infections due to 11 organism. There are case reports of infections due to less common organisms as well, including Neisseria meningitidis [7], and an infection with Clostridium perfringens that resulted in clostridial myonecrosis [23]. RISK FACTORS FOR INFECTION Risk factors for infection have been addressed in multiple studies, although they usually have been identified through surveillance analysis, with or without comparison with controls. Several risk factors have been suggested by this uncontrolled data (table 3). One article noted that several infectious complications occurred after conversion to open arthrotomy without new skin preparation and draping. This practice was changed, but no follow-up data were provided [9]. One case report suggested that any foreign body, even staples, could increase the risk of infection [27]. Other studies have implied that ACL grafts could fall into this category [25]. One article found that risk factors for any complication, not specifically infection, were patient age 150 years and tourniquet time 160 min [6]. The practice of tying sutures over the skin in meniscal repairs has largely been eliminated because it was associated with increased rates of infection. Infection control investigations of outbreaks at specific institutions have been able to identify some very specific problems (table 4). Interventions to correct these problems have led to decreases in infection rates. The use of intraoperative intra-articular steroids has been discussed frequently as a risk factor for infection [15, 24]. Many possible explanations have been offered, including that this use of steroids decreases the organism burden required for infection, that it decreases pain and so masks early signs of infection and permits premature mobilization, and that it delays healing and therefore allows a longer time for ingress of organisms through the portals [24, 28]. Other authors have not confirmed the association [13]. The CDC recommends avoiding the use of intraoperative intra-articular steroids [21]. The study by D Angelo and Ogilvie-Harris [13] attempted to identify patients at high risk for infection and was unable to confirm that any of the above risk factors predicted infection. They found that, in 8 cases in 4000 procedures, only operative (vs. diagnostic) arthroscopy predicted infection. The authors used this data and a cost-effectiveness analysis to suggest that prophylactic antibiotics should be used if the infection rate is 10.08% because they could not identify before surgery who was likely to get an infection. Antibiotic prophylaxis appears to be widely used; the survey by Matava et al. [19] found that 98% of respondents reported that they administered preoperative antibiotic prophylaxis, most frequently with cefazolin. Most of the studies reviewed here, however, did not discuss the use of antibiotic prophylaxis [6, 8, 9, 11, 12, 14, 16, 22, 24, 26 28] or reported that either all [10, 17, 25] or none [13] of the infected patients received it. Wieck et al. [18] attempted to address the issue of the use of antibiotic prophylaxis by performing a randomized, placebocontrolled, double-blinded trial of 437 patients, and they found no deep infections, although the sample size was small. The single patient who developed a superficial infection had not received antibiotics. Wieck et al. [18] recommended against the use of routine prophylactic antibiotics because the rates of infection were already low. CLINICAL PRESENTATION OF SURGICAL SITE INFECTIONS AFTER ARTHROSCOPY The clinical presentations of surgical site infections after arthroscopy that have been noted in the literature are fairly uniform. The most common symptoms are pain and swelling, which are almost always present. The time from the procedure until diagnosis is most frequently reported as 5 10 days but can be longer. In 1 patient, an infection developed 4 months after surgery [15]. Fever is not always present, and often there is no peripheral leukocytosis. Reported erythrocyte sedimentation rates range from 23 [25] to 191 mm/h [20], although not all reports assessed this parameter. At least 1 article suggested that the diagnosis of infection with CNS might be delayed because of a more indolent clinical course [15, 22, 27]. 68 CID 2002:34 (1 January) Babcock et al.

5 Table 3. Risk factors suggested to increase the risk of postarthroscopy surgical site infection. Study, reference No. of cases of infection/ total no. of procedures Suggested risk factor(s) Ajemian et al. [12] 3/373 High levels of personnel traffic in the operating room Armstrong et al. [15] 20/6462 Administration of intra-articular corticosteroids Montgomery and Campbell [24] 3/1500 Administration of intra-articular corticosteroids Armstrong et al. [15] 20/6462 Procedure complexity McAllister et al. [10] 4/831 Procedure complexity Williams et al. [17] 7/2500 Procedure complexity Armstrong et al. [15] 20/6462 History of instrumentation in the same joint McAllister et al. [10] 4/831 History of instrumentation in the same joint Blevins et al. [25] 3/NR a ACL grafts Carr and Frymoyer [26] Case report Active infection at another site D Angelo and Ogilvie-Harris [13] 9/4000 Operative (vs. diagnostic) arthroscopy Johnson et al. [9] 5/12,505 Conversion to arthrotomy without repeating skin preparation Matava et al. [19] NA Use of surgical drains Sherman et al. [6] NA/2640 Patient age 150 years; tourniquet time 160 min Toye et al. [27] Case report Presence of any foreign body, including staples NOTE. NA, not available; NR, not reported. a These 3 cases occurred in a 4-day period. TREATMENT Most patients are treated with a combination of medical and surgical intervention. Only patients with minor portal infections required orally administered antibiotics alone, without debridement [18]. All patients with more significant infections received intravenous antibiotics for prolonged courses, ranging from 14 days [13] to 4 weeks [17, 25 27] or 6 weeks [25]. All these patients required hospitalization. In reports that specified the duration of hospitalization, it ranged from 13 days [15] to 4 weeks [26]. For some patients, intravenous antibiotic therapy was followed by another 2 4 weeks of oral antibiotic therapy. Most patients required irrigation and lavage of the joint, either arthroscopically or by means of open arthrotomy [9, 13, 15, 17, 20, 26], although some were managed with multiple aspirations [15, 20, 27]. Some patients required 11 debridement procedure. In 1 case of prosthetic joint infection after arthroscopy, explantation and prolonged antibiotic therapy were required, with delayed reimplantation at 12 months [9]. It was noted in several cases that, although arthroscopic lavage was often adequate for debridement, extra-articular or loculated foci of infection could be missed [17]. For several patients, removal of the ACL graft was required before clinical improvement was noted, and 1 patient had persistently positive joint fluid culture results until the graft was removed [25]. OUTCOMES Not all of the articles reviewed included outcome information. However, many patients experience decreased function of the involved joint. The initial national survey [8] reported that, of those patients who developed a postoperative infection, 18.9% had a poorer outcome, with decreased knee flexion. Armstrong et al. [15] reported that 23 (96%) of 24 patients were cured, and 1 developed osteomyelitis. However, they also reported that 73% of these patients were without disability, so even some patients cured of their infections apparently had decreased function. D Angelo and Ogilvie-Harris [13] noted that 4 of 9 patients had residual symptoms. Williams et al. [17] reported that, of 7 patients, 2 reported no pain at the time of followup; 4 reported minimal pain; and 1 patient, in whom osteomyelitis had developed, reported moderate pain and a decreased range of motion. Of the 3 patients described by Blevins et al. [25], 2 reported no residual symptoms. Viola et al. [20] reported that, for their patients, recovery time was prolonged, but eventual functional outcomes were normal. Because these studies were not controlled trials designed to assess validated outcome measures, it is difficult to draw conclusions, but, clearly, infectious complications can be associated with some disability after these usually well-tolerated procedures. DISCUSSION Infectious complications after arthroscopic intervention are uncommon. Expected or optimal infection rates are difficult to ascertain from the existing literature. Infection rates are often reported without clear definitions of cases. There may be reporting bias as well. The CDC s published guidelines for defining surgical site infections [21] are very clear and could be Postarthroscopy Surgical Site Infections CID 2002:34 (1 January) 69

6 Table 4. Summary of results of reported investigations of outbreaks of postarthroscopy surgical site infection. Study, reference No. of cases of infection/ total no. of procedures Source(s) of infection Ajemian et al. [12] 3/151 Dusty air vent directly over table of instruments in the operating room Armstrong and Bolding [16] 7/352 Electrocardiogram leads that crossed shoulder surgical sites were contaminated with Pseudomonas from touching water on the floor of the operating room; inadequate glutaraldehyde disinfection time in the operating room Blevins et al. [25] 3/NR a One set of meniscal cannulas that were used for all 3 cases were contaminated with coagulase-negative staphylococci due to inadequate cleaning before disinfection Viola et al. [20] 10/70 Inflow cannulas received in sterile packages were contaminated with coagulase-negative staphylococci NOTE. NR, not reported. a These 3 cases occurred in a 4-day period. applied more widely for the standardized reporting by practitioners and institutions around the country. The inclusion of clinically suspected infections, which are often treated even in the absence of a positive joint fluid culture result, might raise reported rates. Specifying surgical site infections as deep, superficial, or organ-space infections (in this case, septic arthritis) would also provide more specific information that practicing centers could then use for comparison. Staphylococci remain the organisms most commonly isolated from postarthroscopy surgical site infections. These organisms are primarily skin flora, and their predominance supports the need for careful skin preparation and sterile technique when performing arthroscopy. CNS are increasingly recognized as true pathogens in these infections and should not be disregarded when found in culture of samples from an affected joint. Several articles [15, 22, 27] suggest that a more indolent clinical course might be seen with these organisms; therefore, the index of suspicion must be high for patients who have slower recovery times and persistent discomfort. Risk factors for infection remain difficult to define because few are consistent between reports. Several authors noted that more-complicated procedures and longer duration of surgery were risk factors. The use of intraoperative intra-articular corticosteroids appears to be falling out of favor, a change that is in accordance with current CDC guidelines. In addition, outbreak investigations have often discovered very specific causes of increased rates of infection. Although uncommon, postarthroscopy surgical site infections do cause significant morbidity for patients, usually requiring readmission to the hospital, at least 1 additional operation, and prolonged antibiotic therapy, both intravenous and oral. Recovery is also prolonged and often results in suboptimal joint function. These outcomes have a significant costs for the patient and the health care system, which have not been quantified in most studies of postarthroscopy surgical site infections. More data on this aspect of these complications would also be useful. Institutions performing arthroscopy should perform surveillance, coordinating the efforts of infection control personnel, operating room personnel, and orthopedic surgeons to determine rates of postoperative infections. If rates are high or increase above the usual rate for the institution, an outbreak investigation may be warranted to ensure that sterile technique and adequate disinfection methods are being used. Contamination of equipment should also be excluded. Ongoing surveillance and feedback, even without other specific interventions, is often enough to lower infection rates. References 1. Jackson RW. Arthroscopic surgery. J Bone Joint Surg Am 1983; 65: Small N. 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