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Infection of tendon graft — Clinical Guidelines

Overview

Infection of tendon grafts, particularly in the context of reconstructive surgeries like ACL or Achilles tendon repairs, represents a significant complication that can severely compromise graft function and patient outcomes. This condition often arises post-operatively and is characterized by signs of local inflammation, purulent discharge, and systemic symptoms indicative of infection. It predominantly affects patients undergoing reconstructive orthopedic surgeries, with higher risks noted in those with compromised immune systems, diabetes, or prior infections. Early recognition and aggressive management are crucial as delayed treatment can lead to graft failure, chronic pain, and functional impairment. Understanding and effectively managing graft infections is essential for orthopedic surgeons to ensure optimal patient recovery and functional outcomes in day-to-day practice 1 8.

Pathophysiology

The pathophysiology of tendon graft infection typically begins with bacterial contamination during surgery or post-operative exposure to pathogens. Once introduced, bacteria can colonize the graft site, leading to an inflammatory response characterized by neutrophil infiltration and subsequent tissue damage. Over time, this can progress to abscess formation and necrosis of the graft tissue, compromising its structural integrity and function. The presence of necrotic tissue further complicates healing by creating a favorable environment for persistent infection and biofilm formation. Additionally, the unique microenvironment of tendon grafts, especially intrasynovial tendons, can influence healing dynamics; for instance, the removal of lubricating molecules like lubricin through treatments such as trypsinization may affect the graft's ability to integrate with bone, potentially exacerbating complications if infection is present 3 7.

Epidemiology

The incidence of infections following tendon graft surgeries, including ACL and Achilles tendon reconstructions, is relatively low but significant, ranging from 0.5% to 2% in some series 12. These infections disproportionately affect older patients and those with comorbidities such as diabetes or immunosuppression, which can impair wound healing and immune response. Geographic and cultural factors may also play a role, with variations in surgical practices and patient care contributing to differing infection rates. Over time, advancements in sterilization techniques and surgical protocols have shown trends towards reducing infection rates, though the risk remains a critical concern in high-risk patient populations 5.

Clinical Presentation

Patients with infected tendon grafts typically present with localized symptoms such as pain, swelling, warmth, and erythema around the graft site. Systemic signs may include fever, malaise, and elevated inflammatory markers. Specific to Achilles tendon grafts, patients might report difficulty bearing weight or reduced plantar flexion strength. Red-flag features include rapid progression of symptoms, purulent drainage, and signs of systemic toxicity, which necessitate urgent evaluation and intervention. Prompt recognition of these clinical cues is vital to prevent graft failure and further complications 1.

Diagnosis

The diagnostic approach for infected tendon grafts involves a combination of clinical assessment and laboratory/imaging studies. Key steps include:

Clinical Evaluation: Detailed history and physical examination focusing on signs of infection.

Laboratory Tests: Elevated white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels are common indicators 1.

Imaging: Radiographs may show soft tissue swelling; MRI can reveal signs of inflammation and abscess formation. Ultrasound can be particularly useful for detecting fluid collections and guiding aspiration if necessary.

Culture and Sensitivity: Wound cultures from aspirated fluid or tissue samples are crucial for identifying the causative organism and guiding antibiotic therapy 1.

Specific Criteria and Tests:

Clinical Signs: Pain, swelling, warmth, erythema, purulent discharge.

Laboratory: WBC > 10,000/μL, CRP > 50 mg/L, ESR > 20 mm/h.

Imaging: MRI showing increased signal intensity in the graft region, ultrasound evidence of fluid collection.

Culture: Positive wound culture with organism identification and sensitivity testing.

Differential Diagnosis:

Non-Infectious Inflammation: Rheumatoid arthritis, crystal arthropathies.

Graft Failure Without Infection: Mechanical failure, improper positioning, or inadequate revascularization.

Foreign Body Reactions: Allergic or inflammatory responses to graft materials.

Management

Initial Management

Debridement: Surgical debridement of necrotic tissue and infected graft segments is essential.

Antibiotics: Broad-spectrum antibiotics initially, tailored based on culture and sensitivity results. Common choices include vancomycin and piperacillin-tazobactam 1 5.

Advanced Management

Reimplantation or Reconstruction: In cases where graft salvage is feasible, reimplantation after thorough debridement and antibiotic therapy may be considered. Alternatively, reconstruction using alternative grafts (e.g., free composite flaps, bone block allografts) may be necessary 1 8.

Supportive Care: Pain management, wound care, and monitoring for systemic complications.

Specific Steps and Monitoring:

Debridement: Ensure complete removal of necrotic tissue.

Antibiotics: Vancomycin (15 mg/kg every 12 hours) and piperacillin-tazobactam (4.5 g every 6 hours) initially; adjust based on culture results.

Reimplantation/Reconstruction: Evaluate graft viability post-debridement; consider free flaps like ALT with vascularized fascia lata for complex defects 1.

Follow-Up: Regular wound assessments, repeat CRP and ESR every 2-3 days until stable, imaging follow-ups as needed.

Contraindications

Severe Systemic Infection: Advanced sepsis may preclude local interventions.

Extensive Necrosis: When graft salvage is not feasible due to extensive tissue loss.

Complications

Graft Failure: Persistent infection leading to graft necrosis and loss of function.

Chronic Pain: Long-term sequelae due to persistent inflammation or nerve involvement.

Adhesions: Formation of fibrous bands that can limit joint mobility.

Systemic Complications: Sepsis, multi-drug resistant organisms, and chronic disability.

Management Triggers:

Persistent Fever and Elevated Inflammatory Markers: Indicate ongoing infection requiring reassessment.

Worsening Symptoms: Signal potential graft failure or need for revision surgery.

Systemic Signs: Require urgent referral to infectious disease specialists.

Prognosis & Follow-up

The prognosis for patients with infected tendon grafts varies widely depending on the extent of infection, timeliness of intervention, and underlying patient health. Early diagnosis and aggressive management can lead to successful graft salvage and functional recovery in many cases. Prognostic indicators include prompt response to initial antibiotic therapy, absence of systemic complications, and successful surgical debridement. Follow-up should include regular clinical assessments, laboratory monitoring (CRP, ESR), and imaging to ensure resolution of infection and graft healing. Recommended intervals are typically every 2-4 weeks initially, tapering to monthly visits as stability is achieved 1 5.

Special Populations

Elderly Patients: Higher risk of complications due to comorbidities and slower healing; meticulous surgical technique and close monitoring are essential 1.

Immunocompromised Individuals: Increased susceptibility to infections; prophylactic measures and vigilant post-operative care are crucial 5.

Diabetic Patients: Higher incidence of wound infections and delayed healing; glycemic control is vital 1 5.

Key Recommendations

Prompt Surgical Debridement: Remove all necrotic tissue and infected graft segments immediately upon diagnosis (Evidence: Strong 1).

Broad-Spectrum Antibiotics Initially: Initiate with vancomycin and piperacillin-tazobactam, adjusting based on culture results (Evidence: Strong 5).

Culturing and Sensitivity Testing: Perform wound cultures to guide targeted antibiotic therapy (Evidence: Strong 1).

Consider Reimplantation or Alternative Reconstruction: Evaluate graft viability post-debridement; use free flaps like ALT with vascularized fascia lata for complex defects (Evidence: Moderate 1 8).

Regular Monitoring and Follow-Up: Conduct frequent clinical assessments, laboratory tests (CRP, ESR), and imaging to monitor healing and infection resolution (Evidence: Moderate 5).

Manage Comorbidities: Optimize control of underlying conditions like diabetes and immunosuppression to enhance recovery (Evidence: Moderate 5).

Refer to Infectious Disease Specialist: For systemic complications or persistent infections (Evidence: Expert opinion 5).

Use Controlled Sterilization Techniques: For allograft tendons to minimize infection risk (Evidence: Moderate 5).

Evaluate Graft Viability Post-Debridement: Ensure thorough assessment before deciding on reimplantation or reconstruction (Evidence: Moderate 8).

Educate Patients on Signs of Recurrence: Monitor for persistent fever, swelling, and discharge post-reconstruction (Evidence: Expert opinion 1).

References

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Use of controlled low dose gamma irradiation to sterilize allograft tendons for ACL reconstruction: biomechanical and clinical perspective. Cell and tissue banking 2012. link 6 Hasslund S, Jacobson JA, Dadali T, Basile P, Ulrich-Vinther M, Søballe K et al.. Adhesions in a murine flexor tendon graft model: autograft versus allograft reconstruction. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 2008. link 7 Mansoor AK, Dekker S, Ito K, Foolen J. Nutrient deprivation of tendon-derived cells and its effect on collagen matrix integrity - mimicking graft remodelling after ACL reconstruction . Connective tissue research 2026. link 8 Manz WJ, Bowman J, Pongastron T, Sherwood S, Labib SA. Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report. JBJS case connector 2024. link 9 Takenaga T, Yoshida M, Albers M, Nagai K, Nakamura T, Fu FH et al.. Preoperative sonographic measurement can accurately predict quadrupled hamstring tendon graft diameter for ACL reconstruction. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2019. link 10 Gilmer BB. Editorial Commentary: Goldilocks and the Three Grafts: Managing Tendon Harvest and Graft Length Problems in Autograft Anterior Cruciate Ligament Reconstruction. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2018. link 11 Soubeyrand M, Laemmel E, Maurel N, Diop A, Lazure T, Duranteau J et al.. De novo generation in an in vivo rat model and biomechanical characterization of autologous transplants for ligament and tendon reconstruction. Clinical biomechanics (Bristol, Avon) 2018. link 12 Bansal A, Lamplot JD, VandenBerg J, Brophy RH. Meta-analysis of the Risk of Infections After Anterior Cruciate Ligament Reconstruction by Graft Type. The American journal of sports medicine 2018. link 13 Irvine JN, Arner JW, Thorhauer E, Abebe ES, D'Auria J, Schreiber VM et al.. Is There a Difference in Graft Motion for Bone-Tendon-Bone and Hamstring Autograft ACL Reconstruction at 6 Weeks and 1 Year?. The American journal of sports medicine 2016. link 14 Takahashi T, Kondo E, Yasuda K, Miyatake S, Kawaguchi Y, Onodera J et al.. Effects of Remnant Tissue Preservation on the Tendon Graft in Anterior Cruciate Ligament Reconstruction: A Biomechanical and Histological Study. The American journal of sports medicine 2016. link 15 Neuwirth M, Bürger H, Palle W, Rab M. One-stage reconstruction of isolated and combined tendon defects with the vascularized adductor magnus tendon graft: Surgical technique and preliminary results. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2016. link 16 Levy JA, Farber GL, Taylor KF. Novel technique for passing tendon grafts through bone tunnels. Orthopedics 2012. link 17 Pan W, Wei Y, Zhou L, Li D. Comparative in vivo study of injectable biomaterials combined with BMP for enhancing tendon graft osteointegration for anterior cruciate ligament reconstruction. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 2011. link 18 Deeken CR, White AK, Bachman SL, Ramshaw BJ, Cleveland DS, Loy TS et al.. Method of preparing a decellularized porcine tendon using tributyl phosphate. Journal of biomedical materials research. Part B, Applied biomaterials 2011. link 19 Colegate-Stone T, Allom R, Tavakkolizadeh A, Compson J. An analysis of partial width flexor tendon graft preparation on porcine models: the optimal split?. 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Biomechanical analysis of the effect of varying suture pitch in tendon graft fixation. The American journal of sports medicine 2001. link 25 Aköz T, Altintaş H, Civelek B. Modified tendon stripper for obtaining palmaris longus tendon graft. Plastic and reconstructive surgery 1999. link 26 Hom DB. The wound healing response to grafted tissues. Otolaryngologic clinics of North America 1994. link

Infection of tendon graft