ISSN 0972-978X 

  About COAA







Septic Arthritis By Serratia Marcescens After Arthroscopical ACL Reconstruction With Hamstrings:  A Case Report

*Dimitrios S. Mastrokalos, *Konstantinos Α. Zahos, +Efthymia Giannitsioti,  *Panayiotis N. Soucacos.

*Orthopaedical Department of the University of Athens, General University Hospital “ATTIKON”, Rimini 1, 13822 Haidari, Greece.
+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
Phone: +30 210 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

J.Orthopaedics 2006;3(3)e13


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.

Case report 

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 (10.47x103 /μL), 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 (WBC:11.1x103 /μL, 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.

Discussion :

The incidence of septic arthritis after arthroscopic ACL reconstruction varies from 0.3% to 0.14%.[1] 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 [2]. 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 [3]  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 [1]. Successful outcome of S.marcescens septic arthritis treated by arthroscopic surgery in combination with intraoperative large-volume irrigation has been reported [4].

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.[5]

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.

Reference :

  1. Williams RJ III, Laurencin CT, Warren RF, Speciale AC, Brause BD, O’Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction.  Diagnosis and management.  Am J Sports Med 1997;25:261-7

  2. Eisenstein B, Zaleznik D. Enterobacteriaceae. In :Mandell GL,Bennett JE,Dolin R,( eds). Principles and Practice of Infectious Diseases,5th ed, Vol I. Philadelphia Churchill Livingstone USA 2000:3177-3191.

  3. Cooper R, Mills J. Serratia endocarditis. A follow-up report. Arch Intern Med 1980;140:199-202.

  4. Yamamoto Y, Ide T, Hachisuka N et al. Arthroscopic surgery for septic arthritis of the hip joint in 4 adults. Arthroscopy, 2001;17:290-7.

  5. Pitout JD, Sanders CC, Sanders WE Jr. Antimicrobial resistance with focus on beta lactam resistance of gram-negative bacilli. Am J Med 1997;103:51-9.

This is a peer reviewed paper 

Please cite as : Dimitrios S. Mastrokalos: Septic Arthritis By Serratia Marcescens After Arthroscopical ACL Reconstruction With Hamstrings:  A Case Report

J.Orthopaedics 2006;3(3)e13





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.