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Bacterial DNA is associated with tunnel widening in failed ACL reconstructions

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To determine if tunnel widening, defined as change in maximal tunnel diameter from the time of initial bone tunnel drilling to revision surgery is associated with bacterial deoxyribonucleic acid (DNA) presence and concentration in torn graft tissue from failed anterior cruciate ligament reconstructions (ACLRs).

Methods

Thirty-four consecutive revision ACLRs were included (mean age 27.3 years SD 10.9; median time to failure 4.9 years range 105 days–20 years). Graft selection of the failed reconstruction was 68% autograft, 26% allograft, and 6% autograft/allograft hybrid with a mean drilled tunnel diameter of 8.4 mm SD 0.8. Maximal tunnel diameters prior to revision were measured on pre-operative three-dimensional imaging and compared to drilled tunnel diameters at the time of the previous reconstruction. Tissue biopsies of the failed graft were obtained from tibial, femoral, and intraarticular segments. Sterile water left open to air during revision ACLRs and tissue from primary ACLRs were used as negative controls. Clinical cultures were obtained on all revision ACLRs and PCR with universal bacterial primer on all cases and negative controls. Fluorescence microscopy was used to confirm the presence and location of biofilms in two patients with retrieved torn graft tissue and fixation material. Amount of tunnel widening was compared to bacterial DNA presence as well as bacterial DNA concentration via Welch ANOVA.

Results

Bacterial DNA was present in 29/34 (85%) revision ACLRs, 1/5 (20%) of primary ACLR controls and 0/3 (0%) sterile water controls. Cultures were positive (coagulase negative Staphylococcus sp.) in one case, which also had the greatest degree of tunnel widening. Femoral widening was greater in cases with detectable bacterial DNA (mean widening 2.6 mm SD 3.0) versus without (mean 0.3 mm SD 0.6) (p = 0.003) but was unaffected by bacterial DNA concentration (p = 0.44). Tibial widening was not associated with the presence of bacterial DNA (n.s.); however, higher bacterial DNA concentrations were observed in cases with tibial widening ≥ 3.0 mm (median 2.47 ng bacterial DNA/µg total DNA) versus widening < 3.0 mm (median 0.97 ng bacterial DNA/µg total DNA) (p = 0.046). Tunnel widening was not associated with time to failure, graft selection, or number of prior surgeries (n.s., all comparisons). Fluorescence microscopy confirmed the presence of biofilms on ruptured tendon graft as well as fixation material in 2/2 cases.

Conclusion

Bacterial DNA is commonly encountered on failed ACLR grafts and can form biofilms. Bacterial DNA does not cause clinically apparent infection symptoms but is associated with tunnel widening. Further research is needed to determine whether graft decontamination protocols can reduce graft bacterial colonization rates, ACLR tunnel widening or ACLR failure risk.

Level of evidence

Therapeutic III.

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Funding

This project was funded in part by the National Institutes of Health, NIH RO1 GM124436-01.

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Authors and Affiliations

  1. Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA

    David C. Flanigan, Joshua S. Everhart, Alex C. DiBartola, Moneer M. Abouljoud, Robert A. Magnussen, Christopher C. Kaeding & Paul Stoodley

  2. Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA

    David C. Flanigan, Moneer M. Abouljoud, Robert A. Magnussen & Christopher C. Kaeding

  3. Department of Microbial Infection and Immunity, The Ohio State University, Columbus, USA

    Devendra H. Dusane & Paul Stoodley

  4. National Centre for Advanced Tribology, Department of Mechanical Engineering, Southampton University, Southampton, UK

    Paul Stoodley

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  1. David C. Flanigan
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  2. Joshua S. Everhart
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  3. Alex C. DiBartola
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Correspondence to David C. Flanigan.

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Conflict of interest

Paul Stoodley receives funding from Biocomposites Ltd., 3M Orthopaedics, Smith & Nephew, and Zimmer Biomet. David C. Flanigan receives funding from Depuy Mitek Inc., Smith & Nephew, Vericel, Ceterix Orthopaedics, Conmed, Histogenics Corporation, Moximed, and Zimmer Biomet.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Flanigan, D.C., Everhart, J.S., DiBartola, A.C. et al. Bacterial DNA is associated with tunnel widening in failed ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 27, 3490–3497 (2019). https://doi.org/10.1007/s00167-019-05405-6

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  • DOI: https://doi.org/10.1007/s00167-019-05405-6

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