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. Author manuscript; available in PMC: 2023 Apr 1.
Published in final edited form as: J Pediatr Orthop. 2022 Apr 1;42(4):e362–e366. doi: 10.1097/BPO.0000000000002080

Rates of Infection after ACL Reconstruction in Pediatric and Adolescent Patients: A MarketScan database study of 44,501 patients

Matthew T Eisenberg 1, Andrew M Block 1, Matthew L Vopat 1, Margaret A Olsen 2,3, Jeffrey J Nepple 1
PMCID: PMC8901548  NIHMSID: NIHMS1771508  PMID: 35132010

Introduction:

Due to the innovation of recent surgical techniques and an increase in sports participation, anterior cruciate ligament (ACL) reconstruction has been increasingly performed in pediatric and adolescent patients [1–3]. Infection after ACL reconstruction remains one of the most serious complications after this procedure. In addition to potential long-term damage to the knee cartilage, infection after ACL reconstruction results in a significant increase in healthcare costs (median cost of infection of $19,356) [4]. While this complication has been well investigated in adults [5–11], it has not been well assessed in the pediatric and adolescent patients. Infection rates and risk factors for infection may be different in the pediatric population (compared to adults) because differences exist both in patient characteristics and ACL graft type. The paucity of research on infection rate in pediatric patients undergoing ACL reconstruction is currently inadequate to provide reliable, generalizable estimates of the risk of serious complication [12–14].

Recently, administrative insurance data has been increasingly used to identify the rate of healthcare related complications such as surgical site infections (SSI) in large groups of patients with acceptable accuracy [15–18]. This approach has advantages compared to traditional use of patient cohorts, including assessing very large groups of patients not feasibly assessed in traditional retrospective or prospective studies. In insurance databases such as MarketScan (IBM Corp., Armonk, NY), utilization of healthcare resources is tracked without regards to location, thus minimizing loss to follow-up that occurs in traditional studies. Warren et al. [19] used administrative data to define the rate of infection after ACL reconstruction procedures and established the acceptable accuracy of this approach (supporting evidence of treatment was found in 94% of cases).

The purpose of the current study was (1) to define the rate of infection requiring surgical treatment after ACL reconstruction in pediatric and adolescent patients, (2) to compare the rate of infection to young adults undergoing ACL reconstruction and (3) to determine if rates of infection vary by age and sex utilizing a previously validated approach in an administrative database.

Methods:

We performed a retrospective comparative cohort study of the rates of infection after ACL reconstruction utilizing the IBM Marketscan® Commercial Database. The Marketscan Database was used to access health care utilization data for individuals aged 5–30 years old who underwent arthroscopic ACL reconstructive surgery from 2006 to 2018. The MarketScan database contains data for over 150 million individuals in the US, consisting of medical and prescription drug claims for privately insured individuals, spouses and dependents who obtain insurance through their employers or from some health plans [20].

Eligible patients in this study had at least 90 days of insurance coverage prior to and 180 days after the ACL reconstruction surgery. Records of arthroscopic ACL reconstruction performed between 2006 and 2018 were identified by Current Procedures Terminology (CPT) code 29888. Given the pre- and post-operative coverage requirements, the 2006 year only includes patients undergoing ACL surgery during nine eligible months while the 2018 data includes only six eligible months. Patients were excluded if they had a co-existing posterior cruciate ligament injury, lateral collateral ligament injury, or posterolateral corner injury, identified by International Classification of Diseases Ninth Revision (ICD-9) and Tenth (ICD-10) codes, given the increased complexity of multi-ligamentous knee injuries (Appendix 1).

Patients 5–17 years of age were classified as the pediatric/adolescent group, while patients 18–30 years of age were classified as the young adult comparison group. Age in the pediatric/adolescent group was subclassified as pediatric (5–14 years old) and adolescent (15–17 years old).

The presence of infection in this study within 180 days after surgery was defined utilizing the following ICD-9 and ICD-10 codes (Appendix 2) in a previously validated approach [19]: “septic arthritis,” “infective myositis,” “postoperative infection,” and “other infection to lower leg.” The observation period for development of infection was through 180 days after surgery. We required CPT-4 codes consistent with knee specific surgical treatment of infection within 180 days of ACL reconstruction procedure to confirm occurrence of infection (Appendix 2). This approach includes infections requiring surgical reoperation and does not include wound infections that were managed with antibiotics alone.

Statistical Analysis

Data were analyzed using the SAS v9.3 (SAS Institute Inc., Cary, NC). A chi-square test was utilized to determine if differences existed across age groups, sex and geographic location. A p-value of <0.05 was considered significant. When analyzing trends in infection rates over time, Spearman rho statistics were used to test for correlations between a target year and infection rate (expressed as a percentage of total number ACL reconstruction cases in a target year).

Results:

During the 12-year study period from 2006 to 2018, 44,501 pediatric/adolescent patients undergoing ACL reconstruction were identified in the MarketScan Database. The number of patients and rate of infection in each age group and further analyzed by sex can be seen in table 1.

Table 1.

Rates of infection following ACL Reconstruction procedures in the pediatric/adolescent (age 5–17), pediatric (age 5–14), adolescent (age 15–17) and young adult (age 18–30) populations.

Population Total, n (%) Males, n (%) Females, n (%)
Pediatric/Adolescent 230/44,501 (0.52) 116/20,107 (0.58) 114/24,394 (0.47)
 Pediatric 32/8,569 (0.37) 12/3,207 (0.37) 20/5,330 (0.38)
 Adolescent 198/35,932 (0.55) 104/16,784 (0.62) 94/18,950 (0.50)
Young Adult 294/63,495 (0.46) 212/41,373 (0.52) 82/22,122 (0.37)
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The overall infection rate in the pediatric/adolescent group was 0.52%, with 230 infections identified out of 44,501 ACL reconstruction procedures. Among the pediatric/adolescent group, pediatric patients had a significantly lower rate of infection at 0.37% compared to adolescents at 0.55% (p=0.039). There were no differences in 180-day infection rates between the pediatric/adolescent group (0.52%, 95% CI 0.45–0.59%) and the young adult group (0.46%, 95% CI 0.41–0.52%, p=0.227). In the pediatric/adolescent group there was no significant difference between the rate of infection in males versus females (0.58% vs 0.47%, p=0.109). No significant difference in infection rates by sex were seen when separating into the pediatric (p=0.994) and adolescent (p=0.118) subgroups. In the young adult group however, males had a significant higher rate of infection compared to females (0.52% vs. 0.37%, p=0.014).

In the pediatric/adolescent population a statistically significant negative correlation (Spearman rho −0.66, p=0.013) was seen between the rate of infection and year in which the ACL procedures were totaled. This suggests the rate of infection decreased in the pediatric/adolescent population over the 12-year study period. In the young adult population no significant correlation (p=0.325) was seen between the rate of infection and year in which the ACL procedures were totaled. This suggests the rate of infection was fairly constant in the young adult population over the 12-year study period (Figure 1).

Figure 1.

Figure 1.

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The rate of infection requiring treatment in the pediatric/adolescent (age 5–17) and young adult (age 18–30) groups after undergoing ACL reconstruction from 2006 to 2018.

Infection rates by geographic location were available in 44,022 of the pediatric/adolescent patients. Infections rates in the West, Northeast, North-Central and South were 0.39% (n=29/7,463), 0.57% (n=36/6,343), 0.53% (n=61/11,420) and 0.56% (n=106/18,796) respectively. No significant difference was found when comparing the West (p=0.086), Northeast (p=0.698), North-Central (p=0.962) and South (p=0.391) to the combined infection rates of the remaining geographic locations.

Discussion:

In the current study, we utilized a previously established approach to identify infections requiring surgical treatment after ACL reconstruction utilizing MarketScan administrative data. The study cohort included 44,501 pediatric/adolescent patients undergoing ACL reconstruction, while the largest traditional pediatric cohort in the literature in this population is 419 patients [12]. In the pediatric/adolescent population our study establishes a rate of infection of 0.52%. These rates did vary by age group, with rates of infection slightly higher in the adolescent patient (0.55%) compared to the pediatric patient (0.37%, p=0.039). When comparing the pediatric/adolescent group to young adults we saw no significant difference in rates of infection (0.52% vs 0.46%, p=0.210).

The risk of infection after ACL reconstruction in the pediatric and adolescent population had not previously been well defined. In one study in a pediatric population of patients (mean age = 16.1) utilizing data from the American Board of Orthopaedic Surgery (ABOS) undergoing ACL reconstruction found an infection rate of 1.61% [14]. However, no standardized definition of infection was utilized in this study, compared to the approach in the current study. In a study of the National Health Service in England using the Hospital Episode Statistic database of 16,125 ACL reconstructions performed on a population under the age of 20 (mean age = 16.9) showed that a rate of reoperation for infection was 0.31% (n=50/16,125) [13]. The majority (91.14%, n=14,697) of patients included in this study were in the 15–19 year old age range while only 1,428 patients (8.86%) were under the age of 15 [13]. Our study included a much larger group of 8,569 younger pediatric patients aged 5–14 years old and established a rate of infection of 0.37% in that age group. Thus, our study provides a better age-specific rates of infection in the pediatric patient undergoing ACL reconstruction.

The risk of infection after ACL reconstruction in adults has been more extensively defined. Although most of the literature consists of single center studies with reported infection rates ranging from 0.14–1.96% [19]. In the Multicenter Orthopaedic Outcomes Network (MOON) cohort of 2198 patients (mean age 26.8), Brophy et al. [6] reported an infection rate of 0.8%. However, it has been shown in adults that graft choice plays a role in controlling rates of infection. With one meta-analysis illustrating that bone-patellar tendon-bone (BPTB) autografts had a 77% lower incidence of deep infection compared with hamstring autografts (0.15% vs 0.77%, p = < 0.001) [21]. Unfortunately, graft type information is not available in the Marketscan data. However, in the current study, we saw no differences in infection rates in pediatric/adolescent patients (where hamstring autografts are predominant), compared to young adult patients (where BPTB are more common).

Previous studies have shown there are sex-specific differences in rates of infection depending on type of procedure [22, 23]. In a study looking at a multitude of arthroscopic procedures in different orthopedic specialties, Aghdassi et al. [22] looked at 13,275 females and 16,753 males (average age of 49) and found that males had increased risk of SSI compared to their female counterparts (OR = 2.07). We found similar differences in young adults, where males had significantly higher infection rates (0.52% vs. 0.37%, p=0.014). This may be due to the increased risk of colonization of Staphylococcus aureus previously reported in males which has been shown to increase the risk of SSI [24–26]. Conversely, in pediatric and adolescent populations, we did not see a significant difference in males versus females (0.58% vs 0.47%, p= 0.124). The current study demonstrated a slightly lower rate of infection in the pediatric group (0.37%) compared to the adolescent group (0.55%). This difference could also be due to differences in bacterial colonization, but this is less well supported in the literature.

There are some inherent limitations to our study. As this study used administrative claims data to determine rate of infection after ACL reconstruction, medical records were not able to be reviewed for more precise patient and treatment information. This limits the ability to determine the role of patient and surgical factors not captured in the database. As claims data relies on secondary analysis of data collected for other purposes, this may lead to inaccuracies which could have impacted our analysis. However, the accuracy of this approach in infection after ACL surgery has been previously established. This approach identifies individuals undergoing reoperation with diagnostic coding consistent with infection. The rate of surgery during the perioperative period related to infection not attributable to the ACL surgery would be expected to be exceedingly uncommon, and have minimal effect of the current estimates. Additionally, the current study estimates for infection rates include only infections requiring surgery and do not include superficial infections successfully treated with oral antibiotics that don’t progress to require surgery. Furthermore, as this study utilized data from privately insured individuals, those who are self-pay or use Medicaid or other government insurance programs were not able to be evaluated in the current study. This may result in our findings not being generalizable to the entire population, but more generalizable data sources are not available. Previously it has been shown that graft choice plays an important role in controlling infection [8]. A meta-analysis consisting of 21,368 patients (mean age 27.1 to 31.8) also showed soaking ACL tendon grafts with vancomycin before implantation has become increasingly utilized and has been associated with nearly 15 times decreased risk of infection compared to grafts not soaked in vancomycin (0.013% vs 0.77%, P < 0.001) [27]. Unfortunately, we are unable to determine the utilization of these practices and other intraoperative risk factors such as use of preoperative antibiotics, surgical duration, or tourniquet use during the study period. However, the approach to identify infection we used has proven accuracy specifically in the setting of ACL reconstruction [19], and has advantages of large size and eliminating loss of patients to follow-up. A future multicenter study evaluating this demographic data could be used to confirm our findings and further analyze risk factors associated with infection in this population.

In conclusion, this study utilizing administrative data of 44,501 pediatric/adolescent patients found the rate of infection to be 0.52%. We found the adolescent population to have a significantly higher risk of infection compared to their pediatric counterpart (0.55% vs. 0.37%). However, there was no significant difference in infection rates between the pediatric/adolescent population and young adults. Additionally, there was no difference between rates of infection in males versus females in the pediatric/adolescent population. Furthermore, this study provides a reference rate of infection after pediatric ACL reconstruction that can be used for comparison to individual surgeons in clinical practice.

Supplementary Material

Supplemental Data File (.doc, .tif, pdf, etc.)

Acknowledgements:

The authors would like to acknowledge John Sahrmann for programming support.

Conflicts of Interest and Source of Funding:

This research was funded by NIH CTSA Grant #UL1 TR002345. The Center for Administrative Data Research is also supported in part by Grant Number R24 HS19455 through the Agency for Healthcare Research and Quality (AHRQ). MAO has grant funding and consulting work from Pfizer. JJN received research grant from Smith and Nephew Inc. and served as a consultant; received research grant from Stryker, Zimmer Biomet, Department of Defense; received royalties from Responsive Arthroscopy and served as a consultant. MTE, AMB, and MLV report no conflicts of interest or funding to disclose.

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Supplementary Materials

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