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Incidence of Knee Sepsis After ACL Reconstruction at One InstitutionThe Impact of a Clinical Pathway
V. Franklin Sechriest, MD1; Joseph R. Carney, MD2; Michael A. Kuskowski, PhD2; James L. Haffner, RN, MSN, MSPH2; Mollie J. Mullen, MBA, RN2; Captain Dana C. Covey, MD2
1 c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A665, Baltimore, MD 21224-2780. E-mail address for E.P. Henze: ehenze1@jhmi.edu
2 Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, Suite 5, San Diego, CA 92134-1005
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Investigation performed at the Department of Orthopaedic Surgery and the Directorate for Surgical Services, Naval Medical Center San Diego, San Diego, California; the Minneapolis Geriatric Research, Education and Clinical Center, Minneapolis Veterans Administration Medical Center, Minneapolis, Minnesota; and the Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, Baltimore, Maryland

Disclaimer: The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 May 01;95(9):843-849. doi: 10.2106/JBJS.L.00408
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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.

Clinical Relevance: 

For the care of surgical patients in many settings, there remains disparity between the best available evidence and actual clinical practices. This study shows how a hospital community implemented and standardized a bundle of evidence-based practices to significantly improve the quality of clinical outcomes for patients undergoing an orthopaedic procedure.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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