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

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.

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.

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.). 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: 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 (frequency include daily initially and then twice daily until the effusion no longer accumulate)
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. Useful in: Persistent joint infections ( > 7 days) 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 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: 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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