Tom Brady and his knee infection

New England Patriots quarterback Tom Brady recently underwent repair of his anterior cruciate ligament at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles. His doctor was Neal S. ElAttrache, who’s a renowned orthopedic surgeon and former team physician of an NFL team.

Unfortunately, his post-op course has been complicated by an infection. On his website, TomBrady.com, he acknowledged this and said that the original procedure was “rock solid,” and that the infection was “very treatable.”

Apparently, more procedures had to be performed, according to the Boston Herald:

Doctors are so concerned about containing the infection in Tom Brady’s left knee they have performed three procedures in an attempt to eradicate it, according to a source familiar with the Patriots quarterback’s travails on the West Coast.

This is especially troubling since the infection may cause the ACL repair to fail:

If the infection is not brought under control, the patellar tendon graft used to replace Brady’s anterior cruciate ligament could become compromised, according to the Herald’s report. If that happens, he will have to undergo another surgery on the ACL. That would reset the clock on his rehabilitation.

He’s currently on a 6-week course of IV antibiotics, with close follow-up to monitor the infection’s resolution.

Arun Ramappa, chief of sports medicine at Beth Israel Deaconess Medical Center, speculates on the case, and is optimistic:

In all likelihood, they’ll be able to eradicate the infection, and be able to maintain the original surgery. What it sounds like, is they’re doing everything they can to try to preserve his knee, preserve the graft, so they don’t have to do another surgery. If he’s had three surgeries, they must be quite concerned about there being an infection.

ESPN cites another physician however, Dr. Rob Gotlin, saying that a repeat ACL repair is doomed to fail if the infection isn’t cleared out.

Anesthesiologist bookofjoe goes further, saying that the doctors better have gotten all of the infection, or else Brady will be dealing with this long-term:

It could be a one-time occurrence in which, as Brady stated above, surgeons were able to completely clear the joint space “” or there may have been subclinical traces left behind which won’t surface for a while, but might well go on to take up permanent residence in his knee.

A chronically infected replacement ligament “” in effect, a foreign body in the joint space “” is a potential career-ender, as infection weakens the surgical repair and surrounding tissues, making re-injury more likely.

He goes on to cite the case of Cleveland Browns receiver Joe Jurevicius who also contracted an infection after his knee surgery.

The Patriots are unhappy that Brady went to Los Angeles for treatment, preferring that he stay in Boston:

The Patriots, as an organization, are upset with the situation because they were clear that they wanted Brady’s surgery done under the direction of doctors of their choosing in Boston, sources told ESPN.

Several issues arise from the story. First, the infection. This does seem like bad luck (or was it, as newspapers peg him thinking wedding reception in New York). With the rash of MRSA skin infections in the news, is this a possibility? Is the IV antibiotic he’s taking vancomycin, which is commonly used to treat these drug-resistant staph infections?

The second issue is whether the team has a right to be upset at Brady’s choice of doctor. Is there a contractual obligation for Brady to see a team-approved physician? If not, shouldn’t the patient have total say to be treated by a physician they are comfortable with?

The bottom line is that this is a grim situation for Brady. His knee cannot begin to heal without eradication of the infection, which will not even be known for another six or so weeks. If the infection persists, the ACL repair would need to be redone and may not even take.

This worst-case scenario puts next season, and perhaps his career, in jeopardy.

Update:
The Boston Globe comes out with a story that sheds more light.

i) Brady has a septic joint, with the best case scenario delaying rehab by several months.
ii) During the initial surgery, both the MCL and ACL were repaired.
iii) A septic joint as a complication of ACL repair is rare, and occurs in less than 1 percent of cases.

Update 10/24 –
Boston Herald:
“According to the source, during the process of the reconstruction, while Brady was under anesthesia, ElAttrache realized the knee was still unstable after moving it around because the MCL hadn’t fully healed. It was decided at that point to also repair the MCL, and, according to the source, that’s the incision that ultimately became infected.

To make the MCL more sound, ElAttrache had to make a separate incision from the portal hole used for the ACL repair, the source said.”

Famed sports orthopedist, Dr. James Andrews:
“Neal called me in confidence to run this problem by me to see what I thought . . . We went over that, one, he should be aggressive about going back in, don’t wait on it, don’t let [the infection] continue to declare itself. Get it washed out and scope it. And I said he’d probably have to re-scope it several more times to make sure he got it under control.”

Boston Herald columnist, Ron Borges:
“This is not to say that Dr. Neal ElAttrache of the Kerlan-Jobe Orthopaedic Clinic in Los Angeles has never fixed a knee before. He repaired a ruptured ACL and torn medial meniscus in present WBC heavyweight champion Vitali Klitschko in 2005. At that time Dr. ElAttrache said Klitschko would be unable to participate in professional athletics for six months. Klitschko, for reasons unknown, didn’t fight again for more than three years, choosing to retire instead.”

Update 10/25 –
New York orthopedic surgeon Riley Williams III, via MedPage Today:
“Dr. Williams, who was not involved in the case, said the infection likely involved Staphylococcus epidermidis rather than the more serious S. aureus.

Infectious are unusual in knee surgeries in any case, he said. He led a study in the 1990s that found an infection rate at the Hospital for Special Surgery of 0.3%, he said, which had not changed much since. “I know it’s less than 1%,” he said.

S. aureus is the pathogen in a minority of cases, Dr. Williams said. Most infections in knee surgeries involve S. epidermidis, a relatively benign organism in normal skin flora.

He said the repeated washouts along with IV and oral antibiotics are the standard of care when infections do occur.”

topics: mrsa, infection

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