Α. Zahos, +Efthymia
Giannitsioti, *Panayiotis N. Soucacos.
*Orthopaedical Department of the University
of Athens, General University Hospital “ATTIKON”, Rimini 1, 13822
+Department of Internal Medicine of the
University of Athens, General University Hospital “ATTIKON”,
Rimini 1, 13822 Haidari, Greece.
Address for Correspondence
Dimitrios S. Mastrokalos, M.D.
Orthopaedic Surgeon, Lecturer,
1st Orthopaedical Department of the University of Athens,
General University Hospital “ATTIKON”,
Rimini 1, 13822 Haidari, Greece.
210 8152818, +30 6944577148
A case of septic arthritis caused by Serratia
marcescens, after arthroscopical anterior cruciate ligament
(ACL) reconstruction in a patient with no history of intravenous
drug abuse, is reported. A 37-year-old man underwent
arthroscopical ACL reconstruction with a quadruple hamstring
graft. Eight days postoperatively, he developed fever (> 39o
C), knee pain, erythema and effusion with suppuration. He was
readmitted to the hospital with the diagnosis of septic
arthritis. The patient's erythrocyte sedimentation rate
(73mm/1st hour), C-reactive protein level (143mg/L), and white
blood cell count were high (10.47x103 /μL).
The joint was aspirated and fluid was sent for cultures that
revealed the presence of S. marcescens. S. marcescens, is a gram
negative bacteria which belongs to enterobacteriae and is mainly
involved in nosocomial and intravenous drug users’ infections.
In our case, the infection was first treated with immediate
arthroscopic irrigation and debridement, in order to save the
graft. Due to persistence of symptoms, clinical and laboratory
findings, a second arthroscopic irrigation and debridement with
removal of the graft and hardware was necessary. Intravenous
antibiotic administration for 6 weeks, followed by oral
administration for 18 weeks was also given.
Keywords: Serratia marcescens;
septic arthritis knee; ACL reconstruction
According to a report by the American
Academy of Orthopaedic Surgeons on ACL reconstruction in October
2000, approximately 50.000 ACL reconstructions were performed
each year in USA. Septic arthritis of the knee joint, although
rare, is a potential complication, which may affect the
functional outcome. The authors report on a case of S. marcescens
infection after arthroscopical ACL reconstruction.
A 37 year old man, unemployed, with no
history of intravenous drug addiction, underwent arthroscopic
ACL reconstruction with a quadrupled hamstrings’ autograft on
his left knee. Surgical technique included standard knee portals
for arthroscopic surgery (anteromedial and anterolateral) and
one vertical 2,5 cm harvesting incision above pes anserinus. The
diagnostic arthroscopy showed intact cartilage, menisci and
posterior cruciate ligament. Rigid Fix system (Mitek - Johnson &
Johnson) was used for the proximal graft fixation at the femur
and IntraFix for distal fixation at the tibia (LIT) (Mitek -
Johnson & Johnson).
7 days post-operatively the patient
presented with persistent fever (> 39o C), acute pain, effusion
and redness of his knee. Besides, he had remarkable drainage of
pus through both arthroscopic portals. The harvesting incision
was also inflamed with excessive pus drainage. The WBC
ESR (73mm/1st hour) and CRP (143mg/L) were increased. Culture
obtained by swab from the portals revealed S. marcescens
susceptible to cephalosporins, carbapenems and quinolones.
Arthroscopical extensive synovectomy and irrigation were done in
an attempt to retain the graft. Debridement of the harvesting
incision also took place. Intraoperative cultures demonstrated
the same pathogen. The patient initiated intraoperativelly
antimicrobial treatment with ciprofloxacin 600 mg intravenous
two times a day, after the cultures had been taken. Three days
postoperatively, infection signs still persisted and lab tests
ESR:73mm/1st hour, CRP:143mg/L) were still abnormal. Then a
second arthroscopic debridement was performed, consisting of
synovectomy, irrigation and removal of the graft and hardware.
Through a mini incision, both PLA absorbable pins were removed
from the femour. The whole IntraFix system was also removed from
the tibia through the harvesting incision. Synovial membrane
biopsies and cultures were also taken intraoperatively.
S.marcescens was isolated by PLA and synovial membrane as well
again. The patient continued antimicrobial therapy with
ciprofloxacin intravenously, 600 mg two times a day
intravenously for 6 weeks, followed by 1000 mg twice a day per
os for 18 weeks. Gradually, infection clinical signs and
symptoms as well as laboratory inflammation markers subsided to
normal with complete clinical remission. No relapse of the
infection was noted during an 18-month follow-up period. The
patient has completely restored his moving abilities which allow
him to have access to a nearly normal life, concerning the
remained instability. One year after the completion of the
treatment the patient is symptom free with WBC (4.3x103 /μL),
ESR (3mm/1st hour) and CRP (<3.12mg/L) in normal range and he
is scheduled for a new attempt to reconstruct the ACL.
The incidence of septic arthritis after
arthroscopic ACL reconstruction varies from 0.3% to 0.14%.
The average interval between the ACL reconstruction and the
onset of septic arthritis varies between 7.5 and 11 days.
S.marcescens, is a gram negative bacteria
which belongs to enterobacteriae and is mainly involved in
nosocomial infections, being the cause in 4% of bacteremias and
nosocomial pneumonias and in 2% of urinary tract infections,
surgical site infections and soft tissue infections as well .
It may also be involved in intravenous drug users’ infections.
S. marsences can adhere to material surface and demonstrates a
high affinity for medical device as catheters, ventilators,
surgical instruments, but also for liquid medias  S.
marcescens is spread to the nosocomial environment mainly by the
hands of the health care personnel and it has been described in
epidemics in surgical and neonatal intensive care units.
Treatment of an infected knee joint after
ACL reconstruction should include intravenous antibiotics for a
minimum of 6 weeks, prompt nonsteroidal antiinflammatory drugs (NSAIDs),
and a surgical procedure with debridement and extensive lavage
in a main attempt to save the graft . Successful outcome of
S.marcescens septic arthritis treated by arthroscopic surgery in
combination with intraoperative large-volume irrigation has been
In our case, the portal of entrance of
S.marcesens remained unknown as no nosocomial or
community-associated source of the infection was identified.
Ciprofloxacin was the treatment of choice both in order to avoid
the development of inducible antimicrobial resistance of
cephalosporins during the long-term therapy and to benefit from
the oral route of administration and the good pharmacokinetics
properties of quinolones in bone and joint tissues.
Treatment of septic arthritis caused by S.
marcescens after arthroscopical ACL reconstruction can be
achieved by extensive debridement, with removal of all fixation
material and graft, if needed, followed by long term
antimicrobial therapy of quinolons.
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