Arthroscopic management of septic arthritis of the wrist

Bacterial septic arthritis of the wrist is a joint-threatening emergency that is often treated by open irrigation and debridement (I and D). There is evidence that patients with isolated septic arthritis of the wrist require fewer operations and have a shorter hospital stay when treated arthroscopically. This article describes the surgical technique for arthroscopic I and D of the wrist and discusses the indications and benefits of arthroscopic versus open I and D for septic arthritis of the wrist.     

Long-term results of bacterial septic arthritis of the wrist

Septic arthritis of the wrist is a serious condition, yet little is known about its long-term outcome. A retrospective analysis of 22 patients treated for bacterial septic arthritis of the wrist was conducted with subsequent follow-up of 18 patients with a median period of 44 months to assess functional results via DASH-Score and clinical examination.Arthrotomy was used to treat all patients; in 19 patients, multiple operations were needed to cure the infection. Follow-up revealed a mean DASH-score of 34 (SD 22) and a significant correlation with needed surgical radicality and number of needed operations. The range of motion of the wrist and grip strength of the affected side was 49% (SD 20%) and 70% (SD 28%) of the contralateral side, respectively. In conclusion, septic arthritis of the wrist leads to long-term functional restrictions with a strong correlation with the stage of the disease. Hence, early diagnosis and treatment are paramount.     

Contribution of arthroscopy in case of septic appearance arthritis of the wrist: A nine cases series

Septic arthritis of the wrist is a diagnostic and therapeutic emergency. Synovectomy and lavage by arthrotomy is often followed by stiffness. The purpose of this study was to evaluate the diagnostic and therapeutic contribution of emergency arthroscopic synovectomy with intraarticular lavage. Nine patients were operated on for wrist pathology with septic appearance. All had signs of local inflammation, three showed locoregional inflammation, three were febrile. In one patient several joints were involved. Seven patients presented with inflammatory or degenerative arthritis. All patients underwent emergency surgery using radiocarpal joint puncture, arthroscopic exploration, intraarticular lavage and synovectomy at both the radiocarpal and midcarpal joints. The results were evaluated by pain, Quick DASH, grip strength, and wrist range of motion. In three cases, joint fluid appeared clear, in three it was turbid, and in three purulent. Gram stain and culture revealed bacteria in four cases. Synovitis was radiocarpal four times, radiocarpal and midcarpal once. In one case, there was radiocarpal and midcarpal chondritis. Average pain was 5.3/10 preoperatively and 2/10 at the last clinical follow-up visit. Mean grip strength was 23.3 kg on the involved side vs. 33.5 kg on the opposite one. Mean flexion was 55° for the involved wrist vs. 68°; mean extension was 52° for the affected wrist vs. 59°. No patient was reoperated on. In all cases, there was no sign of local inflammation, regional lymphadenopathy or systemic infection at the last follow-up. One patient died of colon metastatic cancer. Another patient developed a severe Complex Regional Pain Syndrome type I (CRPS1). Our results suggest three principles of management of wrist arthritis with septic appearance: extended surgical indication, emergency operation and arthroscopic procedure.     

Sternoclavicular joint septic arthritis and mediastinitis. A case report and review of the literature

Septic arthritis of the sternoclavicular joint is rare. Its causes have been reported to include immuno-compromizing diseases, intravenous drug abuse, fractures of the clavicle or catheterization of the subclavian vein. We report a case of septic arthritis of the SCJ in a diabetic patient following periarticular injection of steroids in the ipsilateral shoulder, as this route of infection has not been documented, to our knowledge, in the literature to date. We review the literature regarding epidemiology and methods of surgical treatment that have been proposed, and present our own surgical experience. Bacterial infection should always be suspected in cases of SCJ arthritis. If surgery is required, it is important to remember that bony procedures leave vascular structures exposed, making their cover by myoplasty mandatory.     

Acute septic arthritis of the hip in children

Thirty-three cases of acute septic arthritis of the hip in children were treated at our hospital from 1986 to 1997. The average follow-up period was 6 years (range 2–¶11 years). In 17 cases the right hip was affected, and in 16 the left hip. The average duration of symptoms was 5 days (range 1–14 days). Microorganisms were isolated from the blood, joint aspirate, or surgical specimens in 25 cases (76%). Staphylococcus aureus was the most common bacteria found (44%). Those patients with S. aureus infection were older than 1 year of age. There was no significant difference in the final outcome between the younger and the older age groups. Twenty-six out of 33 patients (89%) had a satisfactory outcome. Satisfactory results can also be expected with arthrocentesis and medical treatment if the diagnosis is made early, and antibiotic treatment affords a good clinical response. Four out of 7 cases with an unsatisfactory result were associated with osteomyelitis of the proximal femur. The two most important factors associated with poor results included a delay of definite treatment lasting longer than 5 days and the presence of osteomyelitis of the proximal femur.     

膝关节感染性关节炎的关节镜治疗

背景：膝关节感染性关节炎的治疗由于所需时间长、易复发和术后功能恢复差等特点,一直是关节外科临床上的棘手问题,相关的病例报道很多,但对手术技术细节的全面探讨并不多见。目的：探讨关节镜下清理、冲洗、置管,术后持续大流量灌洗治疗膝关节感染性关节炎的疗效及技术细节。方法：回顾性分析2004年1月至2014年8月,采用关节镜下清理及术后持续灌洗的方法治疗的膝关节感染性关节炎患者14例。男9例,女5例;年龄28-81岁,平均（48.07±14.56）岁。比较患者术前、术后1周及末次随访时膝关节的伸屈活动度、VAS评分及Lysholm评分。结果：14例患者平均随访（24.18±12.60）个月（3-45个月）。膝关节术前、术后1周和末次随访时的平均伸直度分别为5.71°±5.29°、3.57°±3.49°和1.14°±1.50°;平均屈曲度分别为85.77°±33.32°、95.01°±25.12°和116.79°±11.43°;VAS评分分别为（8.64±0.97）分、（5.43±1.80）分和（1.14±1.19）分。术前和末次随访时的Lysholm评分分别为（51.93±10.86）分和（89.07±4.99）分。至末次随访时,无1例复发。t检验结果：术后1周和末次随访时的VAS评分均较术前有明显下降（P〈0.05）,末次随访时的Lysholm评分与术前比较明显增加（P〈0.05）。术后1周的伸屈度与术前比较,无明显统计学差异（P〉0.05）,但末次随访时的伸屈度数与术前比较,均有显著统计学差异（P〈0.05）。结论：关节镜下清理、冲洗、置管,术后持续灌洗治疗膝关节感染性关节炎可以显著改善患膝的症状及功能,是一种创伤小、恢复快的有效方法。     

Pseudoparalysis in the Pavlik Harness: beware of septic arthritis

Purpose Pseudoparalysis of the leg occurring during use of the Pavlik Harness (PH) is a seldom-reported condition. Three cases of pseudoparalysis are reported here to illustrate the need for careful assessment of this condition. Methods A series of patients using the PH and presenting with pseudoparalysis was compiled following a retrospective review of case notes. Results In 3 cases, infants treated for developmental dysplasia of the hip using the PH were found to have developed a pseudoparalysis of the affected limb. All presented with similar signs, with the infant being systemically irritable and reluctant to move the limb. In 2 of the cases, this was related to the harness—its removal resulted in recovery of the affected limb. The third case was proven to be septic arthritis, unrelated to the harness, and treatment by means of arthrotomy, intravenous antibiotics and use of the PH for hip stabilisation was used successfully. In the first two cases, the pseudoparalysis was noticed at routine review clinic, and clinical assessment, ultrasound scan and blood tests were performed. The case of septic arthritis was similarly assessed, following referral by paediatric physicians. Conclusion Pseudoparalysis in the PH is a rare event and requires careful investigation.     

Arthroscopic diagnosis and treatment of septic arthritis of the hip joint

Septic arthritis of the hip joint can be difficult to detect clinically and usually requires a formal arthrotomy for adequate drainage and debridement of the joint. This case report presents a patient for whom the diagnosis and treatment were performed arthroscopically. This technique allows isolation of the organism as well as the opportunity to irrigate, lavage, and debride the joint through a small puncture wound only.     

Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist

Purpose

The wrist is involved early in rheumatoid arthritis and is often severely affected. A stable wrist is crucial to good hand function, which often necessitates a fusion. One of the most commonly used techniques in rheumatoid patients is the Mannerfelt arthrodesis. In this retrospective study the outcome and the patient’s subjective satisfaction are presented and compared to other techniques. Also the influence of the position of the wrist following a fusion procedure is analysed.

Methods

Thirty-four wrists were retrospectively analysed using radiological measurements, functional scores such as the Disabilities of the Arm, Shoulder and Hand (DASH) and a pain assessment. The objective function of the hand with the fused wrist was assessed.

Results

In 92.6 % of wrists the patients rated their satisfaction as good or excellent. The mean DASH score post-operatively was 63.3. Of the wrists, 17 were fixed in a median flexed position of 13° and 17 wrists in a median extended position of 8°. There was no statistically significant correlation between the position of the wrist and the satisfaction or objective function. The rate of fusion was 94.1 %.

Conclusions

The Mannerfelt arthrodesis achieves good results and provides a high rate of satisfaction and pain relief in our study. It has major advantages compared to other wrist fusion techniques in the rheumatoid patient. We could not show clear statistical evidence for better results in either a flexed or an extended position, but the ratings of the patients indicated better subjective results with a slightly extended position of the arthrodesis.     

Joint space height correlates with arthroscopic grading of wrist arthritis

Background

Osteoarthritis of the radiocarpal joints is commonly encountered by hand surgeons. To date, there is no well-defined method of radiographically grading osteoarthritis of the wrist.

Methods

Preoperative radiographs of 48 patients undergoing wrist arthroscopy were evaluated retrospectively. Images were graded subjectively by five surgeons based on overall severity of arthritis, osteophytes, subchondral cysts, and subchondral sclerosis. The joint space height (JSH) ratio was calculated by measuring the space of the mid-radioscaphoid and mid-radiolunate joints and dividing each by the height of the capitate. Arthroscopic grading of arthritis was obtained from operative records and compared to subjective and objective grades. ANOVA testing evaluated for statistical significance with p < 0.05. Inter-rater and intra-rater reliability was determined using Pearson’s correlation analysis and Cohen’s kappa coefficient.

Results

Objective measurement using the JSH ratio demonstrated a significant decrease as arthroscopic arthritis grade increased for both radioscaphoid and radiolunate joints. Subjective grading of radioscaphoid and radiolunate joints was able to detect moderate/severe, but not mild arthritis. Subjective grading underestimated the degree of arthritis, particularly in the radiolunate joint. Inter-rater reliability was better for objective compared to subjective grading.

Conclusions

Subjective grading of wrist arthritis can detect moderate/severe radiocarpal arthritis but poorly evaluates early arthritis and underestimates severity. Objective grading using the JSH ratio accurately grades radioscaphoid arthritis and detects early radiolunate arthritis. The JSH ratio more accurately assesses radiocarpal arthritis compared with subjective grading. As there currently is no accepted method to radiographically grade wrist arthritis, the JSH ratio represents a promising option.     

Failure of arthroscopic meniscal repair following septic arthritis

Three cases are described in which failure of arthroscopic meniscal repair performed with an inside-out technique occurred following postoperative septic arthritis. Confirmation of septic arthritis was made by bacterial culture of joint fluid aspirates. The treatment consisted of arthroscopic lavage and intravenous antibiotics. In all cases, diagnostic arthroscopy at the time of lavage showed an intact repair site. However, further follow-up arthroscopy revealed disruption at the repair site with no signs of healing.     

Arthroscopic treatment for septic arthritis of the shoulder in an infant

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, débridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40°C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and débridement, may be one of the options for treating septic arthritis of an infants shoulder.     

New classification for septic arthritis of the hand

The severity of septic arthritis of the hand and the prospects for restoration of joint function are determined by a complex of factors. Among them, the leading role belongs to local changes in tissue structures. This includes the destruction of articular cartilage and bone tissue with the development of osteomyelitis, the involvement of paraarticular soft tissues in the purulent process, and the destruction of the flexor/extensor tendons of the fingers. The currently missing specialized classification of septic arthritis could help in systematizing the diseases, determining treatment tactics, and predicting the results of treatment. The classification of septic arthritis of the hand proposed for discussion is based on the following principle: Joint−Wound−Tendon (J_xW_xT_x); J_x characterizes damage to the osteochondral structures of the joint, W_x is the presence of paraarticular purulent wounds or fistulas, and T_x is destruction of the flexor/extensor tendons of the finger. The classification of the diagnosis makes it possible to assess the nature and severity of damage to the structures of the joint and may also be useful when comparing the results of treatment of septic arthritis of the hand.     

Self-identified functional limitations improve in patients with degenerative wrist arthritis after surgery

Study DesignThis is a prospective cohort pilot study.BackgroundDegenerative wrist arthritis leads to pain, loss of strength, mobility, function, and impairments in psychological well-being. Accurate assessment of functional limitations that are unique to the individual is essential for successful treatment that best meets those specific needs.Purpose of the StudyTo identify and determine if self-identified functional limitations improve in patients who underwent surgery for degenerative wrist arthritis.MethodsPatients with degenerative wrist arthritis who were scheduled for surgery were prospectively recruited (n = 14, mean age + SD = 42 + 16, 10 males, 4 females) into a pilot study that measured self-identified functional limitations and outcomes. Inclusion criteria included a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, scapholunate interosseous ligament tear, or Kienböck disease. Exclusion criteria included a history of neuromuscular disease or concomitant ipsilateral musculoskeletal injury. Data were collected during two 20-minute sessions, preoperatively and one year postoperatively, utilizing the Patient-Rated Wrist Evaluation and the Canadian Occupational Performance Measure.ResultsAll patients reported significant decreases (P < .001) in total pain (mean change = 17.6, SD = 8.5) and total disability (mean = 17.8, SD = 9.1) on the Patient-Rated Wrist Evaluation from presurgery to postsurgery, with a large effect size of d > 0.8. Patients also reported significant improvements (P < .001) in mean performance (mean = 3.5, SD = 1.5) and mean satisfaction (mean = 4.0, SD = 2.1) with self-identified activities on the Canadian Occupational Performance Measure, with an effect size of d > 0.8.ConclusionPatients with degenerative wrist arthritis reported significant postoperative improvement in both performance and satisfaction in self-identified activities. Consideration of patient-specified goals can inform both patients and clinicians during the surgical decision-making process and allow for more individualized care.     

Acromioclavicular joint septic arthritis in an immunocompetent child: A case report

Septic arthritis of acromioclavicular (AC) joint is a rare entity. It is generally seen in patients who are immunocompromised. Only 15 cases have been reported till now, with only one case series of 6 patients. We report a case of septic arthritis of AC joint in an immunocompetent child. A 9 years old girl presented with history of pain in left shoulder for 4 days associated with fever. No history suggestive of any immunocompromised state was complained. On local examination, a swelling of around 3 cm in diameter was found over left AC joint region with raised local temperature, tenderness on palpation and positive response in fluctuation test. Total leukocyte count was 18.7 × 10⁹/L with 80% of neutrophils. Erythrocyte sedimentation rate (ESR) was 28 mm/1 h. C-reactive protein (CRP) was 12 mg/L. X-ray showed enlarged left AC joint space. Ultrasound revealed hypoechoic collection in the AC joint and the surrounding area. The aspirate was thick and purulent in nature, revealing Gram positive cocci at staining. Arthrotomy and thorough lavage of AC joint was done. Culture of the aspirate showed Methicillin Resistant Staphylococcus Aureus (MRSA) after 48 hours that was sensitive to amikacin, gentamicin, erythromycin and teicoplanin. Patient was symptom-free at 2 months of follow-up with no signs of osteomyelitis on the radiographs. Thus this is the first case of AC joint septic arthritis in healthy individual. Being proximal to the shoulder joint, AC joint septic arthritis can be confused with the shoulder joint septic arthritis. Thus, high index of suspicion is required for accurate diagnosis.     

Primary septic arthritis of the acromio-clavicular joint: case report and review of literature

Primary septic arthritis of the Acromio clavicular joint is an uncommon disorder and is rarely seen even in an immunocompromised individual. We report a case of primary septic arthritis of the acromio-clavicular (A-C) joint caused by Staphylococcus aureus without any predisposing factors. The patient was admitted with left shoulder pain, restricted movements and fever. Laboratory parameters showed high C-reactive protein, raised erythrocyte sedimentation rate and leucocytosis. Blood cultures were positive for Staphylococcus-aureus. Magnetic resonance imaging (MRI) using Gadolinium enhancement revealed marked effusion in the A-C joint. Aspiration from the A-C joint revealed a heavy growth of Staphylococcus-aureus. The patient was successfully treated with 8 weeks of appropriate antibiotics with complete resolution of infection and return to full function.     

Developments in diagnosis and treatment of paediatric septic arthritis

Acute septic arthritis in children is an orthopaedic emergency. A delay in diagnosis and inappropriate treatment can result in devastating damage to the joint with lifelong disability as a consequence. The clinical presentation can be a diagnostic challenge, especially in young children. A recent systematic review showed that joint tenderness and fever are important signals of septic arthritis. Ultrasound is helpful in detecting the presence of a joint effusion. Plain radiographs may show bone changes but magnetic resonance imaging is the most reliable imaging study for detecting concomitant osteomyelitis. The diagnosis of acute septic arthritis is highly suggestive when pus is aspirated from the joint, in case of a positive culture or a positive gram stain of the joint fluid, or if there is a white blood-cell count in the joint fluid of more than 50000/mm³. Staphylococcus aureus is the most commonly cultured organism. Recent systematic reviews have identified the most effective drainage techniques, including needle aspiration, arthroscopy and arthrotomy, depending on the affected joint. After the drainage procedure it is important to monitor the clinical and laboratory outcomes. Additional drainage procedures may be necessary in select cases.     

Greater trochanteric preserving hip arthroplasty in the treatment of infantile septic arthritis: long-term results

Background  

Balanced forces around the hip joint are critical for normal development of the hip joint, so it should be considered in every hip reconstructive procedure.     

Three-decade trends in the distribution of organisms causing septic arthritis in native joints: Single-center study of 374 cases

ObjectiveA rise in the incidence of septic arthritis due to methicillin-resistant Staphylococcus aureus (MRSA) has been reported in several parts of the world. Here, our objective was to look for changes over the last 30 years in the distribution and antibiotic susceptibility profiles of organisms responsible for septic arthritis.MethodsWe conducted a single-center retrospective study of all cases of septic arthritis documented by joint specimens and/or blood cultures between 1979 and 2008. Prosthetic joint infections were excluded.ResultsWe enrolled 374 patients, of whom 127, 136, and 111 were included during each decade, respectively. We detected no significant time trends in the proportions of staphylococci (67%, 65%, and 64%), streptococci (14%, 21%, and 17%), or Gram-negative rods (7%, 10%, and 14%). Tuberculosis was more common during the earliest decade (1979–1988, n = 10, 4, 2%; P < 0.05). No significant changes occurred in the proportions of methicillin-resistant staphylococci or MRSA (13%, 11%, 15%). Age and prevalence of risk factors for infection increased over time.ConclusionThe distribution and susceptibility of organisms causing septic arthritis has changed little over time. Our findings do not support the use of broader-spectrum antibiotics when empirical treatment is deemed necessary at our center.