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==Overview==
==Overview==
Successful treatment of septic arthritis include both anti microbial therapy and removal of intra-articular pus with surgical management. Surgical or [[Arthroscopy|arthroscopic]] management will increase the risk of infections when compared to diagnostic [[Arthroscopy|arthroscopic]] procedures without further procedures. Infection rate depends on the type of procedure (open procedures 17% and [[Arthroscopy|arthroscopic]] procedures 11%), duration of the procedure and prior joint disease.<ref name="pmid1637435">Armstrong RW, Bolding F, Joseph R (1992) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1637435 Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors.] ''Arthroscopy'' 8 (2):213-23. PMID: [https://pubmed.gov/1637435 1637435]</ref>
Surgical management options include:
* Closed needle aspiration
* Open drainage
* Tidal irrigation
* [[Arthroscopy]]
* Arthrotomy
There is no specific guidelines for the surgical management but the efficacy of the surgical treatment depends on the clinical condition of the patient.
==Surgical Management==
==Surgical Management==
Arthroscopic procedures combined with a anti microbial regimen is an efficient way in treating septic arthritis. If symptoms persist with antibiotic therapy, repeated arthroscopic irrigation can be beneficial. Surgical management is useful mainly in non gonococcal arthritis, but in [[Gonococcal infection|gonococcal]] arthritis they are rarely used such as in patients with persistent effusion and procedures such as tidal irrigation, [[Arthroscopy|arthroscopic]] lavage or arthrotomy or open drainage are less commonly used in gonococcal arthritis.<ref name="pmid11061294">Stutz G, Kuster MS, Kleinstück F, Gächter A (2000) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11061294 Arthroscopic management of septic arthritis: stages of infection and results.] ''Knee Surg Sports Traumatol Arthrosc'' 8 (5):270-4. [http://dx.doi.org/10.1007/s001670000129 DOI:10.1007/s001670000129] PMID: [https://pubmed.gov/11061294 11061294]</ref>
{| Class="wikitable" style="border: 2; background: none;"                                                       
!Surgical management option
! Description
|-
!Needle aspiration
|
* Best initial surgical option if joint is easily accessible such as peripheral joints except in hip( e.g. Knee, ankle, elbow and wrist etc.).<ref name="pmid6773530">Rosenthal J, Bole GG, Robinson WD (1980) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6773530 Acute nongonococcal infectious arthritis. Evaluation of risk factors, therapy, and outcome.] ''Arthritis Rheum'' 23 (8):889-97. PMID: [https://pubmed.gov/6773530 6773530]</ref> Require 5-7 days for adequate response to needle drainage.
* Very accessible to remove large amount of [[purulent]] synovial fluid unless there is presence of negative prognostic factors such as:<ref name="pmid769545">Goldenberg DL, Cohen AS (1976) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=769545 Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis).] ''Am J Med'' 60 (3):369-77. PMID: [https://pubmed.gov/769545 769545]</ref><ref name="pmid3883171">Goldenberg DL, Reed JI (1985) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3883171 Bacterial arthritis.] ''N Engl J Med'' 312 (12):764-71. [http://dx.doi.org/10.1056/NEJM198503213121206 DOI:10.1056/NEJM198503213121206] PMID: [https://pubmed.gov/3883171 3883171]</ref><ref name="pmid1115748">Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES (1975) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1115748 Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage.] ''Arthritis Rheum'' 18 (1):83-90. PMID: [https://pubmed.gov/1115748 1115748]</ref>
** Delayed diagnosis , and chronic failure of less invasive methods to clear the infection
** Complicated joint involvement such as [[sternoclavicular joint]],
** Extremes of age
** Chronic use of [[immunosuppressive drugs]]
** Presence of underlying joint diseases or [[Osteomyelitis|juxtra-glomerular osteomyelitis]]<ref name="pmid6773530">Rosenthal J, Bole GG, Robinson WD (1980) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6773530 Acute nongonococcal infectious arthritis. Evaluation of risk factors, therapy, and outcome.] ''Arthritis Rheum'' 23 (8):889-97. PMID: [https://pubmed.gov/6773530 6773530]</ref>
* Useful in repetitive drainage in the management of recurrent infections (frequency include daily initially and then twice daily until the effusion no longer accumulate)<ref name="pmid6807166">Rinaldi RZ, Harrison WO, Fan PT (1982) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6807166 Penicillin-resistant gonococcal arthritis. A report of four cases.] ''Ann Intern Med'' 97 (1):43-5. PMID: [https://pubmed.gov/6807166 6807166]</ref> 
|-
!Open drainage
|
* Initial open drainage is useful in patients with inaccessible joint involvement such as axial joints (e.g. hip, shoulder and sternoclavicular joint) especially in children.<ref name="pmid13542125">SAMILSON RL, BERSANI FA, WATKINS MB (1958) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=13542125 Acute suppurative arthritis in infants and children; the importance of early diagnosis and surgical drainage.] ''Pediatrics'' 21 (5):798-804. PMID: [https://pubmed.gov/13542125 13542125]</ref>
* Useful in:<ref name="pmid6752200">Jackson MA, Nelson JD (1982) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6752200 Etiology and medical management of acute suppurative bone and joint infections in pediatric patients.] ''J Pediatr Orthop'' 2 (3):313-23. PMID: [https://pubmed.gov/6752200 6752200]</ref>
** Persistent joint infections ( > 7 days)<ref name="pmid3883171">Goldenberg DL, Reed JI (1985) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3883171 Bacterial arthritis.] ''N Engl J Med'' 312 (12):764-71. [http://dx.doi.org/10.1056/NEJM198503213121206 DOI:10.1056/NEJM198503213121206] PMID: [https://pubmed.gov/3883171 3883171]</ref><ref name="pmid7057556">Ho G, Su EY (1982) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7057556 Therapy for septic arthritis.] ''JAMA'' 247 (6):797-800. PMID: [https://pubmed.gov/7057556 7057556]</ref>
** Patient with delayed initiation of treatment with prior history of joint disease
** Presence of loculations that inhibit drainage
** Inadequate clinical response with gradual decrease in [[WBC]] count in synovial fluid and negative gram stain
** Presence of coexistent [[osteomyelitis]]<ref name="pmid462600">Petersen S, Knudsen FU, Andersen EA, Egeblad M (1979) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=462600 [Acute hematogenous osteomyelitis and purulent arthritis in childhood. A 10-year retrospective study with follow-up studies].] ''Ugeskr Laeger'' 141 (23):1563-7. PMID: [https://pubmed.gov/462600 462600]</ref>
** Patients with [[Prosthetic|prosthetic joint]] infection
|-
!Tidal irrigation
|
* Bed side procedure and effective as [[arthroscopy]]
* It is a closed-system irrigation method may be useful in:<ref name="pmid7057556">Ho G, Su EY (1982) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7057556 Therapy for septic arthritis.] ''JAMA'' 247 (6):797-800. PMID: [https://pubmed.gov/7057556 7057556]</ref>
** when there is incomplete evacuation with needle [[aspiration]] 
** When multiple synovial fluid samples demonstrate different characteristics
** When imaging studies demonstrating the presence of loculations inside the synovium
|-
!Arthroscopic lavage
|
* Useful in persistent joint infections ( >7 days)<ref name="pmid7057556">Ho G, Su EY (1982) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7057556 Therapy for septic arthritis.] ''JAMA'' 247 (6):797-800. PMID: [https://pubmed.gov/7057556 7057556]</ref>
* Best effect seen in patients with deep joint involvement such as hip with loculations or [[abscesses]]
* Allows extensive debridement with small incision which  allows rapid recovery<ref name="pmid769545">Goldenberg DL, Cohen AS (1976) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=769545 Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis).] ''Am J Med'' 60 (3):369-77. PMID: [https://pubmed.gov/769545 769545]</ref>
* It is less invasive than open drainage and more efficacious than needle aspiration in both drainage and visualization of the joint
|-
!Arthrotomy
|Arthrotomy best useful in:<ref name="pmid3883171">Goldenberg DL, Reed JI (1985) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3883171 Bacterial arthritis.] ''N Engl J Med'' 312 (12):764-71. [http://dx.doi.org/10.1056/NEJM198503213121206 DOI:10.1056/NEJM198503213121206] PMID: [https://pubmed.gov/3883171 3883171]</ref><ref name="pmid6749955">Knights EM (1982) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6749955 Infectious arthritis.] ''J Foot Surg'' 21 (3):229-33. PMID: [https://pubmed.gov/6749955 6749955]</ref>
* Patients with increased risk of [[neuropathy]] or compromised blood supply when infected joint is not accessible with less invasive methods.  Joint decompression with arthrotomy will reduce these complications
* When the infected pathogen is confirmed as [[Pseudomonas]] to reduce oxygen tension and [[PH]] in infected joint.
* In patients with negative prognostic factors
|}
As the volume of synovial fluid, the cell count, and the % of [[polymorphonuclear leukocytes]] decrease with each aspiration, it is advisable to switch to combination therapy with both antibiotics and needle aspiration whenever needed.
==References==
==References==
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Latest revision as of 00:09, 30 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Overview

Successful treatment of septic arthritis include both anti microbial therapy and removal of intra-articular pus with surgical management. Surgical or arthroscopic management will increase the risk of infections when compared to diagnostic arthroscopic procedures without further procedures. Infection rate depends on the type of procedure (open procedures 17% and arthroscopic procedures 11%), duration of the procedure and prior joint disease.[1]

Surgical management options include:

  • Closed needle aspiration
  • Open drainage
  • Tidal irrigation
  • Arthroscopy
  • Arthrotomy

There is no specific guidelines for the surgical management but the efficacy of the surgical treatment depends on the clinical condition of the patient.

Surgical Management

Arthroscopic procedures combined with a anti microbial regimen is an efficient way in treating septic arthritis. If symptoms persist with antibiotic therapy, repeated arthroscopic irrigation can be beneficial. Surgical management is useful mainly in non gonococcal arthritis, but in gonococcal arthritis they are rarely used such as in patients with persistent effusion and procedures such as tidal irrigation, arthroscopic lavage or arthrotomy or open drainage are less commonly used in gonococcal arthritis.[2]

Surgical management option Description
Needle aspiration
  • Best initial surgical option if joint is easily accessible such as peripheral joints except in hip( e.g. Knee, ankle, elbow and wrist etc.).[3] Require 5-7 days for adequate response to needle drainage.
  • Very accessible to remove large amount of purulent synovial fluid unless there is presence of negative prognostic factors such as:[4][5][6]
  • Useful in repetitive drainage in the management of recurrent infections (frequency include daily initially and then twice daily until the effusion no longer accumulate)[7]
Open drainage
  • Initial open drainage is useful in patients with inaccessible joint involvement such as axial joints (e.g. hip, shoulder and sternoclavicular joint) especially in children.[8]
  • Useful in:[9]
    • Persistent joint infections ( > 7 days)[5][10]
    • Patient with delayed initiation of treatment with prior history of joint disease
    • Presence of loculations that inhibit drainage
    • Inadequate clinical response with gradual decrease in WBC count in synovial fluid and negative gram stain
    • Presence of coexistent osteomyelitis[11]
    • Patients with prosthetic joint infection
Tidal irrigation
  • Bed side procedure and effective as arthroscopy
  • It is a closed-system irrigation method may be useful in:[10]
    • when there is incomplete evacuation with needle aspiration
    • When multiple synovial fluid samples demonstrate different characteristics
    • When imaging studies demonstrating the presence of loculations inside the synovium
Arthroscopic lavage
  • Useful in persistent joint infections ( >7 days)[10]
  • Best effect seen in patients with deep joint involvement such as hip with loculations or abscesses
  • Allows extensive debridement with small incision which allows rapid recovery[4]
  • It is less invasive than open drainage and more efficacious than needle aspiration in both drainage and visualization of the joint
Arthrotomy Arthrotomy best useful in:[5][12]
  • Patients with increased risk of neuropathy or compromised blood supply when infected joint is not accessible with less invasive methods. Joint decompression with arthrotomy will reduce these complications
  • When the infected pathogen is confirmed as Pseudomonas to reduce oxygen tension and PH in infected joint.
  • In patients with negative prognostic factors

As the volume of synovial fluid, the cell count, and the % of polymorphonuclear leukocytes decrease with each aspiration, it is advisable to switch to combination therapy with both antibiotics and needle aspiration whenever needed.

References

  1. ↑ Armstrong RW, Bolding F, Joseph R (1992) Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors. Arthroscopy 8 (2):213-23. PMID: 1637435
  2. ↑ Stutz G, Kuster MS, Kleinstück F, Gächter A (2000) Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthrosc 8 (5):270-4. DOI:10.1007/s001670000129 PMID: 11061294
  3. ↑ 3.0 3.1 Rosenthal J, Bole GG, Robinson WD (1980) Acute nongonococcal infectious arthritis. Evaluation of risk factors, therapy, and outcome. Arthritis Rheum 23 (8):889-97. PMID: 6773530
  4. ↑ 4.0 4.1 Goldenberg DL, Cohen AS (1976) Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 60 (3):369-77. PMID: 769545
  5. ↑ 5.0 5.1 5.2 Goldenberg DL, Reed JI (1985) Bacterial arthritis. N Engl J Med 312 (12):764-71. DOI:10.1056/NEJM198503213121206 PMID: 3883171
  6. ↑ Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES (1975) Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum 18 (1):83-90. PMID: 1115748
  7. ↑ Rinaldi RZ, Harrison WO, Fan PT (1982) Penicillin-resistant gonococcal arthritis. A report of four cases. Ann Intern Med 97 (1):43-5. PMID: 6807166
  8. ↑ SAMILSON RL, BERSANI FA, WATKINS MB (1958) Acute suppurative arthritis in infants and children; the importance of early diagnosis and surgical drainage. Pediatrics 21 (5):798-804. PMID: 13542125
  9. ↑ Jackson MA, Nelson JD (1982) Etiology and medical management of acute suppurative bone and joint infections in pediatric patients. J Pediatr Orthop 2 (3):313-23. PMID: 6752200
  10. ↑ 10.0 10.1 10.2 Ho G, Su EY (1982) Therapy for septic arthritis. JAMA 247 (6):797-800. PMID: 7057556
  11. ↑ Petersen S, Knudsen FU, Andersen EA, Egeblad M (1979) [Acute hematogenous osteomyelitis and purulent arthritis in childhood. A 10-year retrospective study with follow-up studies.] Ugeskr Laeger 141 (23):1563-7. PMID: 462600
  12. ↑ Knights EM (1982) Infectious arthritis. J Foot Surg 21 (3):229-33. PMID: 6749955



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