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Background: 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., Methods: 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., Results: 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)., Conclusions: 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.

Blast and fragment injuries of the musculoskeletal system are the most frequently encountered wounds in modern warfare. Most injuries to the musculoskeletal system involve so-called secondary blast injuries in which casing fragments and other debris become flying projectiles. Nonoperative treatment of selected wounds caused by small-fragment debris has been successful but remains controversial. Successful surgical treatment depends on meticulous wound débridement, with excision of nonviable tissue and foreign material likely to cause infection; adequate drainage; and delayed closure. Advanced internal fixation techniques used in modern trauma centers to treat predominantly blunt trauma may not be appropriate for care of orthopaedic war wounds in a field setting.

The complex anatomy of the posterolateral corner of the knee is due largely to the evolutionary changes in the anatomic relationships of the fibular head, the popliteus tendon, and the biceps femoris muscle. Recent research has improved our understanding of the popliteus complex, particularly the role of the popliteofibular ligament. Biomechanical studies provide a scientific basis for clinical examination of the knee with suspected injury of the posterolateral corner. All grade-I and most moderate grade-II injuries of the posterolateral structures can be treated nonoperatively, but residual laxity may remain, especially in knees with grade-II injury. Acute grade-III isolated or combined injury of the posterolateral corner is best treated early, by direct repair, if possible, or else by augmentation or reconstruction of all injured ligaments. Chronic injury of the posterolateral corner, whether isolated or combined, is probably best treated by reconstruction of the posterolateral corner along with reconstruction of any coexisting cruciate ligament injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a known tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament.