Abstract
Things fall apart; the centre cannot hold. … The ceremony of innocence is drowned.
William Butler Yeats, The Second Coming, 1920
Spring came early to Illinois this year. Wherever you looked, vibrant green shoots were popping out of the ground, a visual reminder of the beauty and vitality of nature. Unless, of course, your glance fell upon the iris bed in my front yard. There, small mounds of stunted leaves huddled fearfully amid the advancing patches of decaying vegetation and bare earth. The warmth and moisture that fosters the return of life in the spring had provided perfect conditions for the growth of Erwinia carotovora, the organism responsible for iris soft rot.
Northern Illinois does not furnish the ideal climate for growing tall bearded irises, so I am always vigilant for the early signs of infection. This year, however, the disease attacked with astonishing virulence. Impressive clumps of irises turned a sickly yellow-brown color overnight. The normally crisp rhizomes at the base of the plants dissolved into a foul-smelling mixture of putrefied plant tissue and bacteria that could only be described as herbaceous pus.
The treatment for iris soft rot is radical debridement; removing all affected leaves and scraping away the diseased rhizome until healthy tissue is exposed. An antiseptic solution of household bleach can sterilize the open wounds. If the clump has not been completely destroyed, new fans of leaves will eventually bud off the remaining rhizome.
A bed of decaying plants is a depressing site, assaulting us with a memento mori just where we anticipate a vision of life and renewal. A postoperative infection is even more distressing to an orthopaedic surgeon, who expects to bring restored function, not destruction and further impairment, to an injured athlete. Two articles in this month's AJSM address the unpleasant subject of infection after anterior cruciate ligament (ACL) reconstruction.
In “Septic Arthritis After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Retrospective Analysis of Incidence, Management, and Outcome,” Van Tongel and colleagues reviewed 15 cases of postoperative infection treated with arthroscopic debridement and synovectomy. Nine of these patients came from the authors’ own practice. Almost all of the infections occurred within the first 2 months following the ACL reconstructions, most of which used autogenous hamstring grafts. Seven of the patients required 2 or more arthroscopic procedures to eradicate the infection. A damaged graft was removed in 1 case, while 2 others ruptured after the patients returned to sports.
For an article that describes the treatment of a surgical complication, the report of Van Tongel et al is fairly upbeat. Among the 11 patients who were followed—a mean of 58 months (range, 9-99) after surgery—2 patients had an IKDC score of normal, 7 nearly normal, and 2 abnormal. The average Lysholm score was 83 (range, 57-100), and the mean Tegner activity level was 5.6 (range, 3-10). Three of these patients, however, showed early radiographic signs of arthrosis.
“Septic Arthritis of the Knee After Anterior Cruciate Ligament Surgery” by Schulz et al strikes a more somber note. These authors treated 24 patients according to an algorithm based upon the stage of the infection. The initial treatment of 8 patients with Gaechter stage 2 infections was arthroscopic synovectomy, while stage 3 and 4 cases were addressed with arthrotomy, “near-total” synovectomy, and delayed closure. Gentamicin-containing beads were implanted in all patients, requiring at least 1 additional “second-look” procedure for removal.
At the time of surgery, the grafts were found to be destroyed in 8 of Schulz's patients. Nine of the remaining 16 grafts were removed, and 7 were salvaged. The results at a mean of 66 months (range, 11-142) postoperatively were sobering. The mean subjective IKDC score was 64 (range, 31-92), and the Lysholm score was 65 (range, 25-91). On the objective IKDC scale, 8 were normal or nearly normal, while 16 were abnormal or severely abnormal. The Tegner activity score declined to 3.8 from a preoperative level of 6.1. Fourteen patients had an IKDC radiographic rating of abnormal or severely abnormal.
At first glance, these articles might seem to send us conflicting messages. However, the patient populations of the 2 studies differ substantially. Schultz's study included more chronic and recalcitrant cases. Two thirds of the patients were referred to these authors after initial attempts at other institutions had failed to clear the infections. The complications were first diagnosed an average of 2 months after surgery, ranging up to 196 days, and Schultz's first surgical interventions took place after a mean of 91 days (range, 5-243).
A synthesis of the 2 articles suggests that early diagnosis and decisive treatment is the key to optimal results in these unfortunate cases. Those of Schulz's patients who ultimately achieved an IKDC clinical rating of normal averaged 11 days between the primary surgery and reoperation for infection, while those left with “severely abnormal” function averaged 123 days. Unlike irises, humans cannot just bud off another limb to replace one blighted by infection.
The welcome rarity of infections following ACL reconstruction makes it difficult to investigate their treatment in an ideal fashion. These 2 studies are noteworthy for their size, length of follow-up, and use of a consistent treatment approach. Taken together, they suggest that acute infections are apt to respond to arthroscopic management, while more deep-seated ones are liable to require more extensive surgery and yield less satisfying outcomes. Like all case series, they are unable to compare directly 2 therapeutic alternatives. They say to the reader, “If you follow this management plan for similar patients, these are the results that you are likely to attain.” Beyond that, we cannot be certain whether every detail of either treatment algorithm was optimal or necessary.
A rotting iris bed may cause a gardener to wonder why he or she chose that hobby in the first place, and a postoperative infection may temporarily have the same effect on an orthopaedic surgeon. Our training, however, teaches us that complications do occur after surgery, even when we try our best to prevent them. When things fall apart, we must gather our forces and seek the most effective methods to put them right again.
