Septic arthritis surgical management: Difference between revisions

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!Closed needle aspiration
!Closed needle aspiration
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* Best initial surgical option if joint is easily accessible such as peripheral joints. ( e.g. Knee, ankle, elbow and wrist etc.)
* Best initial surgical option if joint is easily accessible such as peripheral joints. ( 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>
* Very accessible to remove large amount of purulent synovial fluid unless there is presence of negative prognostic factors such as:
* 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>
** Delayed diagnosis , and chronic failure of less invasive methods to clear the infection
** Delayed diagnosis , and chronic failure of less invasive methods to clear the infection
** Complicated joint involvement such as sternoclavicular joint,
** Complicated joint involvement such as sternoclavicular joint,
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* Open drainage is useful in patients with inaccessible joint involvement such as axial joints (e.g. hip, shoulder and sternoclavicular joint
* 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)  
* Useful in 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>
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! colspan="2" |Tidal irrigation
! colspan="2" |Tidal irrigation
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* Bed side procedure and effective as arthroscopy
* Bed side procedure and effective as arthroscopy
* It is a closed-system irrigation method may be useful in:  
* 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 there is incomplete evacuation with needle aspiration   
** When multiple synovial fluid samples demonstrate different characteristics
** When multiple synovial fluid samples demonstrate different characteristics
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! colspan="2" |Arthroscopic lavage
! colspan="2" |Arthroscopic lavage
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* Useful in persistent joint infections ( >7 days)
* 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
* 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  
* 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
* It is less invasive than open drainage and more efficacious than needle aspiration in both drainage and visualization of the joint
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! colspan="2" |Arthrotomy
! colspan="2" |Arthrotomy
|Arthrotomy best useful in:
|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
* 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.
* When the infected pathogen is confirmed as Pseudomonas to reduce oxygen tension and PH in infected joint.

Revision as of 16:57, 24 January 2017

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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.)[1]
  • Very accessible to remove large amount of purulent synovial fluid unless there is presence of negative prognostic factors such as:[2][3]
    • 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)[3][4]
Tidal irrigation
  • Bed side procedure and effective as arthroscopy
  • It is a closed-system irrigation method may be useful in:[4]
    • 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)[4]
  • 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[2]
  • 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:[3][5]
  • 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.

Surgical Management

References


Template:WikiDoc Sources

  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
  2. ↑ 2.0 2.1 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
  3. ↑ 3.0 3.1 3.2 Goldenberg DL, Reed JI (1985) Bacterial arthritis. N Engl J Med 312 (12):764-71. DOI:10.1056/NEJM198503213121206 PMID: 3883171
  4. ↑ 4.0 4.1 4.2 Ho G, Su EY (1982) Therapy for septic arthritis. JAMA 247 (6):797-800. PMID: 7057556
  5. ↑ Knights EM (1982) Infectious arthritis. J Foot Surg 21 (3):229-33. PMID: 6749955
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