Septic arthritis surgical management

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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

Surgical management options include:

• Needle aspiration
  • 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 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, arhtroscopic lavage or arthrotomy or open drainage are less commonly used in gonococcal arthritis.

Surgical management option		Description
Needle aspiration	Closed needle aspiration	Best initial surgical option if joint is easily accessible such as peripheral joints. ( e.g. Knee, ankle, elbow and wrist etc.) Very accessible to remove large amount of purulent synovial fluid unless there is presence of negative prognostic factors such as: 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 juxtra-glomerular osteomyelitis Useful in repetitive drainage in the management of recurrent infections
	Open drainage	Open drainage is useful in patients with inaccessible joint involvement such as axial joints (e.g. hip, shoulder and sternoclavicular joint Useful in persistent joint infections ( > 7 days)
Tidal irrigation		Bed side procedure and effective as arthroscopy It is a closed-system irrigation method may be useful in: 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) 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 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: 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

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