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J Bone Joint Surg Am. 2013 May 1;95(9):843-9, S1-6. doi: 10.2106/JBJS.L.00408.

Incidence of knee sepsis after ACL reconstruction at one institution: the impact of a clinical pathway.

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  • 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A665, Baltimore, MD 21224-2780, USA.



After experiencing an unusually high incidence of knee sepsis after anterior cruciate ligament (ACL) reconstruction, we sought to (1) describe how we resolved this problem through temporary discontinuation of the procedure, formation of a multidisciplinary ACL Task Force, systematic investigation of clinical data and institutional care practices, and development and implementation of an evidence-based ACL Clinical Pathway (the Pathway); and (2) report our findings and results.


From 1999 through 2008, thirty-seven cases of knee sepsis after ACL reconstruction were recorded at our institution. In 2008 (yearly incidence, 4.4%), ACL reconstructions were temporarily suspended and a Task Force was assembled to (1) identify infection risk factors or epidemiological links among cases, (2) inspect environment and processes for possible infection sources, and (3) update existing perioperative practices according to current evidence-based guidelines to reduce surgical site infection risk. These actions led to the development of the Pathway for patients and providers. The rates of knee sepsis before and after the Pathway was implemented were compared.


There was no consistent risk factor or epidemiologic link among the cases of knee sepsis other than the time and place of the ACL reconstruction. Process review identified shortfalls in decontamination and sterilization of some surgical equipment. Perioperative care practices review revealed wide interprovider variation. Pathway implementation reduced the rate of knee sepsis after ACL reconstruction from 1.96% (twenty-four cases after 1226 ACL reconstructions performed from 2002 to 2008) to 0% (zero cases after 500 ACL reconstructions performed from 2008 to 2011); the difference was significant (p = 0.003).


When a Task Force investigation suggested that knee sepsis after ACL reconstruction was a multifactorial problem, we implemented and standardized evidence-based perioperative care practices via the institution-wide Pathway, which significantly improved the quality and consistency of care for patients undergoing ACL reconstruction, as well evidenced by the elimination of knee sepsis.

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