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The Utility of Claims Data for Infection Surveillance following Anterior Cruciate Ligament Reconstruction1

  • Michael V. Murphy (a1), Dongyi (Tony) Du (a2), Wei Hua (a2), Karoll J. Cortez (a3), Melissa G. Butler (a4), Robert L. Davis (a4), Thomas DeCoster (a5), Laura Johnson (a6), Lingling Li (a1), Cynthia Nakasato (a7), James D. Nordin (a8), Mayur Ramesh (a6), Michael Schum (a9), Ann Von Worley (a9), Craig Zinderman (a2), Richard Platt (a1) and Michael Klompas (a1)...



To explore the feasibility of identifying anterior cruciate ligament (ACL) allograft implantations and infections using claims.


Retrospective cohort study.


We identified ACL reconstructions using procedure codes at 6 health plans from 2000 to 2008. We then identified potential infections using claims-based indicators of infection, including diagnoses, procedures, antibiotic dispensings, specialty consultations, emergency department visits, and hospitalizations. Patients’ medical records were reviewed to determine graft type, validate infection status, and calculate sensitivity and positive predictive value (PPV) for indicators of ACL allografts and infections.


A total of 11,778 patients with codes for ACL reconstruction were identified. After chart review, PPV for ACL reconstruction was 96% (95% confidence interval [CI], 94%–97%). Of the confirmed ACL reconstructions, 39% (95% CI, 35%–42%) used allograft tissues. The deep infection rate after ACL reconstruction was 1.0% (95% CI, 0.7%–1.4%). The odds ratio of infection for allografts versus autografts was 0.41 (95% CI, 0.19–0.78). Sensitivity of individual claims-based indicators for deep infection after ACL reconstruction ranged from 0% to 75% and PPV from 0% to 100%. Claims-based infection indicators could be combined to enhance sensitivity or PPV but not both.


While claims data accurately identify ACL reconstructions, they poorly distinguish between allografts and autografts and identify infections with variable accuracy. Claims data could be useful to monitor infection trends after ACL reconstruction, with different algorithms optimized for different surveillance goals.

Infect Control Hosp Epidemiol 2014;35(6):652–659


Corresponding author

Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215 (


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Presented in part: 17th Annual HMO Research Network Conference; Boston, Massachuestts; March 23–25, 2011; 18th Annual HMO Research Network Conference; Seattle, Washington; April 29–May 2, 2012.



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1. Greenberg, DD, Robertson, M, Vallurupalli, S, White, RA, Allen, WC. Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2010;92(14):24022408.
2. Lyman, S, Koulouvaris, P, Sherman, S, Do, H, Mandl, LA, Marx, RG. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 2009;91(10):23212328.
3. Katz, LM, Battaglia, TC, Patino, P, Reichmann, W, Hunter, DJ, Richmond, JC. A retrospective comparison of the incidence of bacterial infection following anterior cruciate ligament reconstruction with autograft versus allograft. Arthroscopy 2008;24(12):13301335.
4. Crawford, C, Kainer, M, Jernigan, D, et al. Investigation of postoperative allograft-associated infections in patients who underwent musculoskeletal allograft implantation. Clin Infect Dis 2005;41(2):195200.
5. Cohen, SB, Sekiya, JK. Allograft safety in anterior cruciate ligament reconstruction. Clin Sports Med 2007;26(4):597605.
6. Mallick, TK, Mosquera, A, Zinderman, CE, Martin, LS, Wise, RP. Reported infections after human tissue transplantation before and after new food and drug administration (FDA) regulations, United States, 2001 through June, 2010. Cell Tissue Bank 2012;13(2):259267.
7. Cartwright, EJ, Prabhu, RM, Zinderman, CE, et al. Transmission of Elizabethkingia meningoseptica (formerly Chryseobacterium meningosepticum) to tissue-allograft recipients: a report of two cases. J Bone Joint Surg Am 2010;92(6):15011506.
8. Mei-Dan, O, Mann, G, Steinbacher, G, Ballester, SJ, Cugat, RB, Alvarez, PD. Septic arthritis with Staphylococcus lugdunensis following arthroscopic ACL revision with BPTB allograft. Knee Surg Sports Traumatol Arthrosc 2008;16(1):1518.
9. Mroz, TE, Joyce, MJ, Steinmetz, MP, Lieberman, IH, Wang, JC. Musculoskeletal allograft risks and recalls in the United States. J Am Acad Orthop Surg 2008;16(10):559565.
10. Lee, EH, Ferguson, D, Jernigan, D, et al. Invasive group-A streptococcal infection in an allograft recipient. A case report. J Bone Joint Surg Am 2007;89(9):20442047.
11. Wang, S, Zinderman, C, Wise, R, Braun, M. Infections and human tissue transplants: review of FDA MedWatch reports 2001–2004. Cell Tissue Bank 2007;8(3):211219.
12. Brief report: investigation into recalled human tissue for transplantation—United States, 2005–2006. MMWR Morb Mortal Wkly Rep 2006;55(20):564566.
13. Kainer, MA, Linden, JV, Whaley, DN, et al. Clostridium infections associated with musculoskeletal-tissue allografts. N Engl J Med. Jun 17 2004;350(25):25642571.
14. Barbour, SA, King, W. The safe and effective use of allograft tissue—an update. Am J Sports Med 2003;31(5):791797.
15. Centers for Disease Control and Prevention. Hepatitis C virus transmission from an antibody-negative organ and tissue donor—United States, 2000–2002. MMWR Morb Mortal Wkly Rep 2003;52(13):273276.
16. Centers for Disease Control and Prevention. Update: allograft-associated bacterial infections—United States, 2002. MMWR Morb Mortal Wkly Rep 2002;51(10):207210.
17. Centers for Disease Control and Prevention. Septic arthritis following anterior cruciate ligament reconstruction using tendon allografts—Florida and Louisiana, 2000. MMWR Morb Mortal Wkly Rep. 2001;50(48):10811083.
18. Food and Drug Administration (FDA). Guidance for Industry: MedWatch Form FDA 3500A: Mandatory Reporting of Adverse Reactions Related to Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/Ps). Silver Spring, MD: FDA, 2005. Accessed October 19, 2011.
19. Sands, K, Vineyard, G, Livingston, J, Christiansen, C, Platt, R. Efficient identification of postdischarge surgical site infections: use of automated pharmacy dispensing information, administrative data, and medical record information. J Infect Dis 1999;179(2):434441.
20. Miner, AL, Sands, KE, Yokoe, DS, et al. Enhanced identification of postoperative infections among outpatients. Emerg Infect Dis 2004;10(11):19311937.
21. Lawson, EH, Louie, R, Zingmond, DS, et al. A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications. Ann Surg 2012;256(6):973981.
22. Huang, SS, Placzek, H, Livingston, J, et al. Use of Medicare claims to rank hospitals by surgical site infection risk following coronary artery bypass graft surgery. Infect Control Hosp Epidemiol 2011;32(8):775783.
23. Sands, KE, Yokoe, DS, Hooper, DC, et al. Detection of postoperative surgical-site infections: comparison of health plan–based surveillance with hospital-based programs. Infect Control Hosp Epidemiol 2003;24(10):741743.
24. Calderwood, MS, Ma, A, Khan, YM, et al. Use of Medicare diagnosis and procedure codes to improve detection of surgical site infections following hip arthroplasty, knee arthroplasty, and vascular surgery. Infect Control Hosp Epidemiol 2012;33(1):4049.
25. Olsen, MA, Fraser, VJ. Use of diagnosis codes and/or wound culture results for surveillance of surgical site infection after mastectomy and breast reconstruction. Infect Control Hosp Epidemiol 2010;31(5):544547.
26. Platt, R, Kleinman, K, Thompson, K, et al. Using automated health plan data to assess infection risk from coronary artery bypass surgery. Emerg Infect Dis 2002;8(12):14331441.
27. Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36(5):309332.
28. Barker, JU, Drakos, MC, Maak, TG, Warren, RF, Williams, RJ 3rd, Allen, AA. Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction. Am J Sports Med 2010;38(2):281286.
29. Anderson, DJ, Chen, LF, Sexton, DJ, Kaye, KS. Complex surgical site infections and the devilish details of risk adjustment: important implications for public reporting. Infect Control Hosp Epidemiol 2008;29(10):941946.
30. Ming, DY, Chen, LF, Miller, BA, Anderson, DJ. The impact of depth of infection and postdischarge surveillance on rate of surgical-site infections in a network of community hospitals. Infect Control Hosp Epidemiol 2012;33(3):276282.
31. Wang, C, Ao, Y, Wang, J, Hu, Y, Cui, G, Yu, J. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, presentation, treatment, and cause. Arthroscopy 2009;25(3):243249.
32. Van Tongel, A, Stuyck, J, Bellemans, J, Vandenneucker, H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med 2007;35(7):10591063.
33. Binnet, MS, Basarir, K. Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques. Arthroscopy 2007;23(8):862868.
34. Judd, D, Bottoni, C, Kim, D, Burke, M, Hooker, S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 2006;22(4):375384.
35. Burks, RT, Friederichs, MG, Fink, B, Luker, MG, West, HS, Greis, PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med 2003;31(3):414418.
36. Schollins-Borg, M, Michaelsson, K, Rahme, H. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy 2003;19(9):941947.
37. Indelli, PF, Dillingham, M, Fanton, G, Schurman, DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2002(398):182188.
38. Viola, R, Marzano, N, Vianello, R. An unusual epidemic of Staphylococcus-negative infections involving anterior cruciate ligament reconstruction with salvage of the graft and function. Arthroscopy 2000;16(2):173177.
39. McAllister, DR, Parker, RD, Cooper, AE, Recht, MP, Abate, J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med 1999;27(5):562570.
40. Williams, RJ 3rd, Laurencin, CT, Warren, RF, Speciale, AC, Brause, BD, O’Brien, S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med 1997;25(2):261267.


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