Differential Diagnosis of Reactive and Infectious Arthritis after Anterior Cruciate Ligament Reconstruction
ARTICLE PDF (Українська)

Keywords

anterior cruciate ligament, synovitis, septic arthritis, reactive arthritis, differential diagnosis.

How to Cite

Kostrub, O., Kotiuk , V., Liutko , O., Kolov , H., Blonskyi , R., & Zasadniuk , I. (2020). Differential Diagnosis of Reactive and Infectious Arthritis after Anterior Cruciate Ligament Reconstruction. Herald of Orthopaedics, Traumatology and Prosthetics, (1(104), 39-48. https://doi.org/10.37647/0132-2486-2020-104-1-39-48

Abstract

Summary. Relevance. Negative results of the anterior cruciate ligament (ACL) reconstruction occur in 10-20% of cases. The incidence of infectious arthritis can reach up to 1.7% and even up to 7.1%, according to the literature. However, ACL reconstruction can be complicated not only by infectious but also by reactive arthritis. Differential diagnosis between infectious and reactive arthritis is often hard to be done, but it is necessary for effective treatment.

Objective: to determine the possible causes of the development of reactive and infectious arthritis after ACL reconstruction, peculiarities of their diagnostics and differential diagnostics.

Materials and Methods. The literature data regarding the frequency of reactive and infectious arthritis after various methods of surgical treatment of ACL injury and the use of different types of implants, as well as laboratory indicators of the activity of the inflammatory process in the postoperative period and such indicators in reactive and infectious arthritis, were analyzed. We also analyzed literature data on the sensitivity and specificity of various methods of microbiological studies in patients with infectious synovitis or arthritis.

Results. Numerous probable causes of a higher incidence of infectious arthritis in ACL reconstruction are suspected. Synthetic implants may be the cause of the development of reactive arthritis, according to a number of studies. Our experience in using different biodegradable fixators from various manufacturers suggest that the percentage of complications depends not only on the fact of the biodegradability of the implant, but on its composition, and even on the percentage of tricalcium phosphate or the manufacturer. Therefore, it is impossible to unambiguously state that biodegradable fixators are worse or better then metallic or non-biodegradable polymeric ones. However, on average, if we consider all existing fixators from various manufacturers, the number of complications when using biodegradable implants is higher. Diagnosis of reactive arthritis is often based on negative bacteriological findings. Given the not always high sensitivity of bacteriological inoculation of synovial fluid and the duration of the investigation, we cannot rely only on its results.

Conclusions. The most difficult for differential diagnosis between infectious and reactive arthritis (synovitis) is acute synovitis after ACL reconstruction with normal results of bacteriological studies, but high biochemical parameters of inflammation. We suggest to suspect infectious arthritis after ACL reconstruction in the following hemogram values: 1) CRP >40-50 mg/l, 2) ESR >30-50 mm/h, 3) fibrinogen >800 mg/ml, 4) procalcitonin in blood plasma >0.5 ng/ml, 5) leukocytosis and left shift of the leukocyte formula, with the following synovial fluid test parameters: a) CRP >40-50 mg/l, b) leukocytosis with an increase in the percentage of polymorphonuclear leukocytes >75%.

https://doi.org/10.37647/0132-2486-2020-104-1-39-48
ARTICLE PDF (Українська)

References

Hart JM, Turman KA, Diduch DR, Hart JA, Miller MD. Quadriceps muscle activation and radiographic osteoarthritis following ACL revision. KneeSurgSportsTraumatolArthrosc. 2011;19(4):634–40.

Weiler A, Schmeling A, Stohr I, Kaab MJ, Wagner M. Primary versus single-stage revision anterior cruciate ligament reconstruction using autologous hamstring tendon grafts: a prospective matched-group analysis. Am J SportsMed. 2007;35(10):1643–52.

Allen CR, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. OrthopClinNorthAm. 2003;34(1):79–98.

Schollin-Borg M, Michaëlsson K, Rahme H. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy. 2003 Nov;19(9):941-7.

Collette M, Cassard X. The Tape Locking Screw technique (TLS): A new ACL reconstruction method using a short hamstring graft. Orthop Traumatol Surg Res. 2011;97(5):555-9. doi: 10.1016/j.otsr.2011.03.016.

Kim HJ, Lee HJ, Lee JC, Min SG, Kyung HS. Evaluation of Infection after Anterior Cruciate Ligament Reconstruction during a Short Period. Knee Surg Relat Res. 2017 Mar 1;29(1):45-51. doi: 10.5792/ksrr.16.019.

Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District, 1982–1991. Ann Rheum Dis 1999;58:214–19.

Cooper C, Cawley MID. Bacterial arthritis in an English Health district; a 10-year review. Ann Rheum Dis 1986;45:458–63.

Crawford C, Kainer M, Jernigan D, Banerjee S, Friedman C, Ahmed F, Archibald LK, Investigation of Postoperative Allograft-Associated Infections in Patients Who Underwent Musculoskeletal Allograft Implantation, Clinical Infectious Diseases 2005;41(2):195–200. https://doi.org/10.1086/430911.

Colin F, Lintz F, Bargoin K. Guillard C, Venet G, Tesson A, Gouin F. Aseptic arthritis after ACL reconstruction by Tape Locking Screw (TLS®): Report of two cases. Orthop Traumatol Surg Res. 2012;98(3):363-365, https://doi.org/10.1016/j.otsr.2011.08.020.

Woods GA, Indelicato PA, Prevot TJ. The Gore-Tex anterior cruciate ligament prosthesis. Two versus three year results. AmJSportsMed 1991;19:48—55.

Paulos LE, Rosenberg TD, Grewe SR, Tearse DS, Beck CL. The GORE-TEX anterior cruciate ligament prosthesis. A long-term follow-up. AmJSportsMed 1992;20:246—52.

Muren O, Dahlstedt L, Brosjö E, Dahlborn M, Dalén N. Gross osteolytic tibia tunnel widening with the use of Gore-Tex anterior cruciate ligament prosthesis. Acta Orthop 2005;76:270-274.

Dahlstedt L, Dalén N, Jonsson U, Adolphson P. Cruciate ligament prosthesis vs. augmentation. A randomized, prospective 5-year follow-up of 41 cases. Acta OrthopScand 1993;64:431-433.

Bowyer GW, Matthews S. Anterior cruciate ligament reconstruction using the Gore-Tex ligament. J R Army Med Corps 1991;137:69-75.

Indelicato PA, Pascale MS, Huegel MO. Early experience with the GORE-TEX polytetrafluoroethylene anterior cruciate ligament prosthesis. Am J Sports Med 1989;17: 55-62.

Ferkel RD, Fox JM, Wood D, Del Pizzo W, Friedman MJ, Snyder SJ. Arthroscopic “second look” at the GORE-TEX ligament. Am J Sports Med 1989;17:147-152.

Glousman R, Shields C, Kerlan R, et al. Gore-Tex prosthetic ligament in anterior cruciate deficient knees. Am J Sports Med 1988;16:321-326.

Barrett GR, Line LL, Shelton WR, Manning JO, Phelps R. The Dacron ligament prosthesis in anterior cruciate ligament reconstruction. A four-year review. Am J SportsMed 1993;21:367-373.

Wilk RM, Richmond JC. Dacron ligament reconstruction for chronic anterior cruciate ligament insufficiency. Am JSports Med 1993;21:374-380.

Andersen HN, Bruun C, Sønergåro-Petersen PE. Reconstruction of chronic insufficient anterior cruciate ligament in the knee using a synthetic Dacron prosthesis A prospective study of 57 cases. Am J Sports Med 1992;20:20-23.

Klein W, Jensen K-U. Synovitis and artificial ligaments. Arthroscopy 1992;8:116-124.

Bartolozzi P, Salvi M, Velluti C. Long-term follow-up of53 cases of chronic lesion of the anterior cruciate ligament treated with an artificial Dacron Stryker ligament. Ital J Orthop Traumatol 1990;16:467-480.

Batty LM, Norsworthy CJ, Lash NJ, Wasiak J, Richmond AK, Feller JA. Synthetic devices for reconstructive surgery of the cruciate ligaments: a systematic review. Arthroscopy. 2015;31(5):957-68. doi:10.1016/j.arthro.2014.11.032.

Gao K, Chen S, Wang L, et al. Anterior cruciate ligament reconstruction with LARS artificial ligament: A multicenter study with 3- to 5-year follow-up. Arthroscopy 2010;26:515-523.

Norsworthy CJ, Tulloch SJ, Devitt BM, Porter TJ, Hartwig TR, Klemm HJ. My experience with the LARS ACL device at minimum 5 year follow up. Conference Proceedings. ISAKOS Congress 2017, 15:50, Wednesday June 7.

Cassard X, Bowen M, Collette M, Lanternier H, de Polignac T, Robert H. Comments on: “aseptic arthritis after ACL reconstruction by Tape Locking Screw (TLS): report of two cases” by F. Colin, F. Lintz, K. Bargoin, C. Guillard, G. Venet, A. Tesson, F. Gouin published in Orthop Traumatol Surg Res 2012;98(3):363-5. Orthop Traumatol Surg Res. 2012 Nov;98(7):854; author reply 855. doi: 10.1016/j.otsr.2012.09.002.

Böstman O, Päivärinta U, Partio E, Vasenius J, Manninen M, Rokkanen P. Degradation and tissue replacement of an absorbable polyglycolide screw in the fixation of rabbit femoral osteotomies. Journal of Bone and Joint

Weiler A, Helling HJ, Kirch U, Zirbes TK, Rehm implants for racture fixation: experimental study in sheep. Journal of Bone and Joint Surgery. British Volume 1996;78(3):369‐76.

Konan SM, Haddad FS. The unpredictable material properties of bioabsorbable PLC interference screws and their adverse effects in ACL reconstruction surgery. Knee Surgery, Sports Traumatology, Arthroscopy 2008;17:293-297.

Alonso B, Sobrón FB, Vidal C, Vaquero J. Pretibial pseudocyst after anterior cruciate ligament reconstruction with a biocomposite screw Acta Ortop Mex 2016;30(3):150-153.

Konan S, Haddad FS. A clinical review of bioabsorbable interference screws and their adverse effects in anterior cruciate ligament reconstruction surgery. Knee 2009;16(1):6‐13.

Shen C, Jiang S-D, Jiang L-S, Dai L-Y. Meta-Analysis Bioabsorbable Versus Metallic Interference Screw Fixation in Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of Randomized Controlled Trials. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2010;26(5):705-713.

Debieux P, Franciozi CE, Lenza M, Tamaoki MJ, Magnussen RA, Faloppa F, Belloti JC. Bioabsorbable versus metallic interference screws for graft fixation in anterior cruciate ligament reconstruction. Cochrane Database Syst Rev. 2016 Jul. 24;7:CD009772. doi: 10.1002/14651858.CD009772.pub2. Review. PubMed PMID:27450741; PubMed Central PMCID: PMC6458013.

Fink C, Benedetto KP, Hackl W, Hoser C, Freund MC, Rieger M. Bioabsorbable polyglyconate interference screw fixation in anterior cruciate ligament reconstruction: a prospective computed tomography-controlled study. Arthroscopy. 2000;16(5):491-8. PubMed PMID: 10882444.

Weiss KS, Weatherall JM, Eick J, Ross JR. Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature. Case Rep Orthop. 2017;2017:6383526. doi: 10.1155/2017/6383526.

Baums MH, Zelle BA, Schultz W, Ernstberger T, Klinger HM. Intraarticular migration of a broken biodegradable interference screw after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Sep;14(9):865-8. PubMed PMID: 16479410.

Pinczewski LA, Salmon LJ. Editorial Commentary: The Acrid Bioscrew in Anterior Cruciate Ligament Reconstruction of the Knee. Arthroscopy. 2017;33(12):2195-2197. doi: 10.1016/j.arthro.2017.08.229.

Lindström M, Wredmark T, Wretling ML, Henriksson M, Felländer-Tsai L. Post-operative bracing after ACL reconstruction has no effect on knee joint effusion. A prospective, randomized study. Knee. 2015;22(6):559-64. doi: 10.1016/j.knee.2015.04.015.

Darabos N, Hundric-Haspl Z, Haspl M, Markotic A, Darabos A, Moser C. Correlation between synovial fluid and serum IL-1beta levels after ACL surgery-preliminary report. Int Orthop. 2009;33(2):413–418. doi:10.1007/s00264-008-0649-1.

Maletis GB, Samuelson TS, Drez D Jr. Synovial response to intra-articular metal debris: Implications for anterior cruciate ligament reconstruction. Arthroscopy. 2002 Jan;18(1):61-3. PubMed PMID: 11774143.

Stucken C, Garras DN, Shaner JL, Cohen SB. Infections in anterior cruciate ligament reconstruction. Sports Health. 2013;5(6):553–557. doi:10.1177/1941738113489099.

Natsheh A, Cohen D, Ben Chetrit E, Nesher G, Breuer GS. Synovial Fluid Culture: Comparison of Two Culture Methods [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). 2018 ACR/ARHP Annual Meeting Abstracts. Session Title: Infection-related Rheumatic Disease Poster. Abstract Number: 1218. https://acrabstracts.org/abstract/synovial-fluid-culture-comparison-of-two-culture-methods/.

Shmerling RH. Synovial fluid analysis: a critical reappraisal. Rheum Dis Clin North Am 1994;20:503.

Shmerling RH, Delbanco TL, Tosteson ANA, Trentham DE. Synovial fluid tests. What should be ordered? JAMA 1990;264:1009–14.

Parvizi J, Ghanem E, Sharkey P, Aggarwal A, Burnett RS, Barrack RL. Diagnosis of infected total knee: findings of a multicenter database. Clin Orthop Relat Res. 2008;466(11):2628–2633. doi:10.1007/s11999-008-0471-5.

Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, Mandrekar JN, Cockerill FR, Steckelberg JM, Greenleaf JF, Patel R. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007 Aug 16;357(7):654-63. PubMed PMID: 17699815.

Jordan RW, Smith NA, Saithna A, Sprowson AP, Foguet P. Sensitivities, specificities, and predictive values of microbiological culture techniques for the diagnosis of prosthetic joint infection. Biomed Res Int. 2014;2014:180416. doi:10.1155/2014/180416

Sorlin P, Mansoor I, Dagyaran C, Struelens MJ. Comparison of resin-containing BACTEC plus Aerobic/F* medium, with conventional methods for culture of normally sterile body fluids. J Med Microbiol 2000;7:787–91.

Von Essen R, Holtta A. Improved method of isolating bacteria from joint fluids by the use of blood culture bottles. Ann Rheum Dis 1986;45:454–7.

Mathews CJ, Coakley G. 2008. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol 20:457–462. doi:10.1097/BOR.0b013e3283036975.

Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR, Infectious Diseases Society of America. 2013. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56:e1–e25. doi:10.1093/cid/cis803.

Jennings JM, Dennis DA, Kim RH, Miner TM, Yang CC, McNabb DC. False-positive Cultures After Native Knee Aspiration: True or False. Clin Orthop Relat Res. 2017;475(7):1840–1843. doi:10.1007/s11999-016-5194-4.

Martinot M, Sordet C, Soubrier M, Puéchal X, Saraux A, Lioté F, Guggenbuhl P, Lègre V, Jaulhac B, Maillefert JF, Zeisel M, Coumaros G, Sibilia J. Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients. Clin Exp Rheumatol. 2005;23(3):303-10. PubMed PMID:15971417.

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):243-9. doi:10.1016/j.arthro.2008.10.002.

Wang C, Ao Y, Fan X, Wang J, Cui G, Hu Y, Yu J. C-reactive protein and erythrocyte sedimentation rate changes after arthroscopic anterior cruciate ligament reconstruction: guideline to diagnose and monitor postoperative infection. Arthroscopy. 2014;30(9):1110-5. doi: 10.1016/j.arthro.2014.03.025.

Margheritini F, Camillieri G, Mancini L, Mariani PP. C-reactive protein and erythrocyte sedimentation rate changes following arthroscopically assisted anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2001;9(6):343-5.

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):1059-63.

Carpenter CR, Schuur JD, Everett WW, Pines JM. 2011. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med 18:781–796. doi:10.1111/j.1553-2712.2011.01121.x.

Tande AJ, Patel R. 2014. Prosthetic joint infection. Clin Microbiol Rev 27:302–345. doi:10.1128/CMR.00111-13.

Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. 2006. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am 88:1251–1257. doi:10.2106/JBJS.E.00216.

Margaretten ME, Kohlwes J, Moore D, Bent S. 2007. Does this adult patient have septic arthritis? JAMA 297:1478–1488. doi:10.1001/jama.297.13.1478.

Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. 2004. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 86-A:1629–1635.

Shen CJ, Wu MS, Lin KH, Lin WL, Chen HC, Wu JY, Lee MC, Lee CC. 2013. The use of procalcitonin in the diagnosis of bone and joint infection: a systemic review and meta-analysis. Eur J Clin Microbiol Infect Dis 32:807–814. doi:10.1007/s10096-012-1812-6.

Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. West J Emerg Med. 2019;20(2):331–341. doi:10.5811/westjem.2018.10.40974.

Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2002;(398):182-8.

Kersey R, Benjamin J, Marson B. White blood cell counts and differential in synovial fluid of aseptically failed total knee arthroplasty. J Arthroplasty 2000;15:301–4.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.