Risk factors for postoperative surgical site infections after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Abstract

Objectives: The primary aim was to evaluate risk factors for surgical site infections after anterior cruciate ligament reconstruction (ACLR). The secondary aim was to investigate the surgical site infection incidence rate and the mean time to postoperative surgical site infection symptoms.

Design: Systematic review and meta-analysis.

Data sources: PubMed, Embase and Web of Science were searched from database inception to September 2021 and updated in April 2022.

Eligibility criteria: Quantitative, original studies reporting potential risk factors for surgical site infections after ACLR were included.

Results: Twenty-three studies with 3871 infection events from 469 441 ACLRs met the inclusion criteria. Male sex (OR 1.78, p< 0.00001), obesity (OR 1.82, p=0.0005), tobacco use (OR 1.37, p=0.01), diabetes mellitus (OR 3.40, p=0.002), steroid use history (OR 4.80, p<0.00001), previous knee surgery history (OR 3.63, p=0.02), professional athlete (OR 4.56, p=0.02), revision surgery (OR 2.05, p=0.04), hamstring autografts (OR 2.83, p<0.00001), concomitant lateral extra-articular tenodesis (OR 3.92, p=0.0001) and a long operating time (weighted mean difference 8.12, p=0.005) were identified as factors that increased the risk of surgical site infections (superficial and deep) after ACLR. Age, outpatient or inpatient surgery, bone-patellar tendon-bone autografts or allografts and a concomitant meniscus suture did not increase the risk of surgical site infections. The incidence of surgical site infections after ACLR was approximately 1% (95% CI 0.7% to 1.2%). The mean time from surgery to the onset of surgical site infection symptoms was approximately 17.1 days (95% CI 13.2 to 21.0 days).

Conclusion: Male sex, obesity, tobacco use, diabetes mellitus, steroid use history, previous knee surgery history, professional athletes, revision surgery, hamstring autografts, concomitant lateral extra-articular tenodesis and a long operation time may increase the risk of surgical site infections after ACLR. Although the risk of surgical site infections after ACLR is low, raising awareness and implementing effective preventions for risk factors are priorities for clinicians to reduce the incidence of surgical site infections due to its seriousness.

Keywords: infection; knee; ligaments; meta-analysis; risk factor.

Figure 1

Flow diagram of the study selection procedure.

Figure 2

Forest plot detailing the association of patient-related factors as dichotomous variables with surgical site infections after anterior cruciate ligament reconstruction. (A) sex; (B) obesity; (C) tobacco user; (D) diabetes mellitus; (E) steroid use history; (F) previous knee surgery history; (G) professional athletes. IV, inverse variance.

Figure 3

Forest plot detailing the association of age (A) and operating time (B) as continuous variables with surgical site infections after anterior cruciate ligament reconstruction. IV, inverse variance.

Figure 4

Forest plot detailing the association of surgery-related factors as dichotomous variables with surgical site infections after anterior cruciate ligament reconstruction. (A) Outpatient or inpatient surgery; (B) revision or primary surgery; (C) hamstring autografts or BPTB autografts; (D) hamstring autografts or allograft; (E) BPTB autografts or allografts; (F) a concomitant meniscal suture; (G) a concomitant lateral extra-articular tenodesis. BPTB, bone-patellar tendon-bone; IV, inverse variance.