Arthroscopic treatment for acute septic arthritis of the hip joint in adults

Purpose

The purpose of our study was to evaluate the efficacy and safety of the arthroscopic management of septic arthritis of the hip joint.

Methods

From October 2009 to October 2010, nine patients with septic arthritis of the hip were treated with arthroscopic debridement and drainage and systemic antibiotics according to bacterial sensitivity or with empiric antibiotics if no bacteria was isolated from the cultures. All patients were placed in the supine position on a fracture table, and two or three arthroscopic portals were used. The medical records were retrospectively reviewed to determine the efficacy and safety of hip arthroscopy for septic arthritis.

Results

There were 4 men and 5 women, with a mean age of 49.8 years (SD 12.1). No major complication related to arthroscopy of the hip was encountered. Staphylococcus aureus was identified in 4 patients. Average follow-up was 19.4 months (SD 4.1). Septic arthritis relapsed in one patient, but the other 8 patients experienced no recurrence during the follow-up period.

Conclusions

Arthroscopic lavage and debridement is a safe and effective procedure for septic arthritis of the hip joint.

Level of evidence

IV.     

Recommendations for the management of septic arthritis after ACL reconstruction

Purpose

To evaluate the current evidence for the management of septic arthritis after anterior cruciate ligament (ACL) reconstruction, the factors that affect the outcome after treatment and the retention of graft and implants.

Methods

A systematic literature search of the PubMed database was performed on septic arthritis after ACL reconstruction. A total of 301 publications were initially identified, and 17 papers were found to fulfil the criteria to be included in the review.

Results

There were 196 cases of septic arthritis after ACL reconstruction in over 30,000 ACL reconstructions, making the proportion of infection 0.6 %. Most patients (114/123, 92.6 %) had an acute or subacute infection at an average of 16.8 ± 10.5 days after ACL reconstruction. Coagulase-negative Staphylococci (CNS) was the most common organism (67/147, 45.6 %) followed by Staphylococcus aureus (SA) (35/147, 23.8 %); 86.9 % underwent surgical treatment of which 92.8 % had an average of 1.54 (up to 4) arthroscopic debridements. The group with SA infection had a higher graft removal rate (33.3 %, p = 0.019), a longer antibiotic duration (35.4 days, p = 0.047) and a worse range of flexion (111.5°, p = 0.036) than the CNS group.

Conclusions

CNS was the most common organism in septic arthritis after ACL reconstruction followed by SA. For most authors, arthroscopic debridement combined with intravenous antibiotic therapy was the initial treatment of choice. Antibiotic therapy with or without multiple irrigations of the joint is not recommended based on the high failure rates. Delayed diagnosis of more than 7 days or SA infection required a longer duration of antibiotic therapy and increased the likelihood for graft removal and restricted range of motion. Fungal infection and tubercular infection had a high prevalence of late diagnosis and open debridement.

Level of evidence

Systematic review, Level IV.     

Arthroscopic management of the throwing athlete's shoulder: indications, techniques, and results

This article briefly describes the various pathologic lesions seen in the throwing athlete's shoulder. The pathologic conditions discussed include primary and secondary impingement, tensile lesions of the rotator cuff and biceps-labral complex, glenohumeral laxity, labral tears, and AC joint injuries. Mechanism of injury, indications, and arthroscopic management of these lesions are discussed.     

Magnetic resonance imaging of septic arthritis

Septic arthritis is a disabling and life-threatening disease that requires early diagnosis for optimal outcome. Although traditionally a clinical and laboratory diagnosis, some patients may be misdiagnosed and referred for magnetic resonance (MR) imaging. Therefore, radiologists need to be aware of the MR imaging findings of septic arthritis, its complications, and diagnostic pitfalls.     

化脓性髋关节炎的CT与MRI表现

目的分析化脓性髋关节炎的CT与MRI表现,并评价其临床意义。方法回顾性分析30例经临床和手术病理证实的化脓性髋关节炎患者的CT与MRI表现,其中,行CT检查24例,MRI检查15例,同时行CT与MRI检查者9例。结果在CT与MR像上,软组织肿胀分别见于20例和14例,关节腔积液分别见于24例和15例,滑膜及肉芽组织增生分别见于13例和11例,关节间隙改变分别见于13例和9例,骨质改变分别见于24例和15例。CT显示骨内积气4例,MRI显示软组织脓肿1例。结论 MRI对化脓性髋关节炎的早期病理改变,诸如少量关节腔积液、邻近软组织轻度肿胀以及骨质早期改变的显示,明显优于CT,但是CT对骨内积气和骨质晚期改变的显示优于MRI。CT与MRI在化脓性髋关节炎诊断与指导治疗中起重要作用。     

Arthroscopic management of glenohumeral instability

There has been substantial development of techniques for performing arthroscopic surgery of the shoulder over the past 20 years. A multitude of arthroscopic techniques have been developed in an attempt to manage the unstable glenohumeral joint while decreasing surgical morbidity. The results obtained with arthroscopic stabilization have been widely variable. This review will examine the current status of arthroscopic management of glenohumeral instability. The techniques and results of arthroscopic stabilization for primary anterior glenohumeral instability, recurrent anterior instability, and multidirectional instability will be discussed. A brief discussion on thermal capsulorrhaphy is included.     

Arthroscopic management of subscapularis tears

Tears of the subscapularis were previously believed to be rare, but are now recognized to be very common. As maintenance of the subscapularis footprint is integral to normal biomechanical function of the shoulder it is important for the shoulder surgeon to be adept at recognizing and treating these tears. A combination of physical examination tests can be used to determine both the presence and size of a subscapularis tear. Compared with posterosuperior rotator cuff tears, magnetic resonance imaging detection of subscapularis is less reliable and therefore requires a high index of suspicion. Arthroscopic repair of the subscapularis presents unique challenges but can be safely and successfully performed with careful attention to detail. The results of arthroscopic subscapularis repair are encouraging at intermediate follow-up and comparable with or better than that reported with open repair.     

Arthroscopic treatment of acromioclavicular joint injuries and results

Injuries and conditions that affect the AC joint are common. Low-grade separations, degenerative conditions, and osteolysis of the distal clavicle are frequently dealt with by the treating physician. Proper assessment requires a thorough history, examination, and radiologic work-up. An injection of bupivicaine into the AC joint can be a very useful test to evaluate the source of pain about the symptomatic shoulder. Most conditions affecting the AC joint can be treated conservatively, but patients who do not respond to these treatments or athletes who do not wish to modify their activities may require resection of the distal clavicle and the AC joint. Operative intervention can be performed as an open procedure with good results. Recent advances in operative arthroscopic procedures allow us to replicate and exceed the results of the open resection. Arthroscopic resection can be undertaken via a direct approach that does not violate the subacromial space or via an indirect or bursal approach. The indirect approach allows you to assess both the subacromial space and the AC joint because impingement pathology and subacromial compromise are frequently associated with AC change. The advantage of an arthroscopic resection is its ability to be performed as an outpatient procedure with less compromise of musculotendinous structures, shorter rehabilitation, and quicker return to activity. The amount of bone resection necessary is less than with the open procedure because of the ability to preserve the stabilizing properties of the superior AC ligaments. Resection of 4 mm to 8 mm of bone is all that may be required to give uniformly good results. Arthroscopic resection of the distal clavicle is technically demanding and requires skill and familiarity with other arthroscopic shoulder procedures. Complications related to this procedure are relatively infrequent and include infection, residual pain, lack of adequate bone resection, and instability, particularly in patients with previous grade 1 and 2 separations. Less commonly noted is the symptomatic development of heterotopic bone. To the accomplished arthroscopic shoulder surgeon, arthroscopic resection of the symptomatic AC joint gives excellent clinical results that allow a compromised athlete a relatively quick return to desired sport activities.     

MRI findings of treated bacterial septic arthritis

Introduction

The purpose of this study was to report the MRI findings that can be encountered in successfully treated bacterial septic arthritis.

Materials and methods

The study included 12 patients (8 male and 4 female; mean age 38?years, range 9–85) with 13 proven cases of bacterial septic arthritis. The joints involved were hip (n?=?3), knee (n?=?3), shoulder (n?=?2), sacroiliac (n?=?2), ankle (n?=?1), wrist (n?=?1), and elbow (n?=?1). MRI examinations following surgical debridement and at initiation of antibiotic therapy and after successful treatment were compared for changes in effusion, synovium, bone, and periarticular soft tissues. Imaging findings were correlated with microbiological and clinical findings.

Results

Joint effusions were present in all joints at baseline and regressed significantly at follow-up MRI (p?=?0.001). Abscesses were present in 5 cases (38?%), and their sizes decreased significantly at follow-up (p?=?0.001). Synovial enhancement and thickening were observed in all joints at both baseline and follow-up MRI. Myositis/cellulitis was present in 10 cases (77?%) at baseline and in 8 cases (62?%) at follow-up MRI. Bone marrow edema was present in 10 joints (77?%) at baseline and persisted in 8 joints (62?%). Bone erosions were found in 8 joints (62?%) and persisted at follow-up MRI in all cases.

Conclusion

The sizes of joint effusions and abscesses appear to be the factors with the most potential for monitoring therapy for septic arthritis, since both decreased significantly following successful treatment. Synovial thickening and enhancement, periarticular myositis/cellulitis, and bone marrow edema can persist even after resolution of the infection.     

Arthroscopic Bankart repair: results and risk factors of recurrence of instability

The purpose of this study was to discover the recurrence rate of instability after arthroscopic Bankart repair and to assess risk factors for recurrence, with special interest in bone defects seen on preoperative plain radiographs. Consecutive unselected patients (182; 186 shoulders) with recurrent instability (redislocation or subluxation) after initial traumatic anteroinferior shoulder dislocation were operated on using arthroscopic suture-anchor repair at our institution during 2000–2005. Demographic data and details of the operation were retrospectively reviewed from case records, and glenoid and Hill–Sachs lesions were assessed from preoperative radiographs. The primary outcome measure was recurrence of instability (redislocation or subluxation). Functional results were assessed via Oxford instability scores and subjective shoulder values (SSVs), using postal questionnaires. One hundred and seventy-four shoulders (170 patients) were assessed after a median of 51 (range 24–95) months’ follow-up. The recurrence rate of instability was 19% (redislocation 9% and subluxation 10%). Eighteen patients (10%) needed further surgery. The mean Oxford instability score was 21 and the mean SSV 84%. The recurrence rate among patients aged 20 or less was 44% and among patients over 20, 12%. Multivariate logistic regression analysis showed that age ≤20 (OR 8.8), Hill–Sachs lesion (OR 3.3), glenoid erosion (OR 2.7) and length of follow-up (OR 1.5) were the most important risk factors for recurrence. Young age is the most important risk factor for recurrence of instability after arthroscopic suture-anchor Bankart repair. Bone defects seen in preoperative plain radiographs are less important and more accurate imaging is needed to reveal their true role for recurrence of instability.     

Arthroscopic treatment of lateral epicondylitis: Indication, technique and early results

The purpose of this study is to present the results of the arthroscopic treatment of lateral epicondylitis. Twenty patients with lateral epicondylitis (mean age 42 years) were treated arthroscopically. The average duration of symptoms prior to surgery was 14 months. The arthroscopic joint inspection showed an intact capsule in seven patients (type-I lesion), in eight patients a linear capsule tear (type-II lesion) and in six patients a complete rupture of the capsule (type-III lesion). An associated intraarticular pathology was documented in eight patients. Within an average follow-up period of 1.8 years, local pain and function were documented and analyzed. Subjective pain at rest was reduced from 5.0 to 0.5 points, pain at daily living activities from 6.0 to 1.0 points and pain at athletic activities from 7.3 to 1.2 points in the VAS score. Function increased from 5.2 to an average value of 10.9 (max. 12 points). Patients returned back to work after 3.2 weeks. In conclusion, the arthroscopic release in patients with radial epicondylitis is a reproducible method with a marked postoperative increase in function within a short rehabilitation period.     

Chronic septic arthritis of the adult hip: computed tomographic features

Abnormalities on computed tomography (CT) are described in 12 adults in whom septic arthritis of the hip was diagnosed. Presenting symptoms varied, as did CT findings. Soft tissue abnormalities ranged from intra-articular effusion to large abscess formation, and bone changes ranged from minimal erosion of articular surfaces to gross destruction of the proximal femur and acetabulum. CT can be helpful in the evaluation of septic arthritis of the hip because of its superior demonstration of soft tissue detail. An accurate diagnosis can be established in unsuspected cases and can be confirmed when clinical indicators are vague.     

Arthroscopic management of lateral meniscal cysts

This study presents seven cases of lateral meniscal cysts treated arthroscopically. All were noted to have meniscal lesions at the time of surgery; there were five flap tears and two radial tears. Partial arthroscopic meniscectomy was performed and the contents of the cysts were manipulated into the joint in six of seven cases. One patient underwent open cyst excision in addition to partial arthroscopic meniscectomy. Followup ranged from 18 months to 4 years with an average of 28 months. There were no cyst recurrences. The pathologic basis of the meniscal cyst is controversial, but recent work suggests the etiology is infiltration of joint fluid through micro and macro tears in the meniscus. Partial meniscectomy retains valuable meniscal function while minimizing the likelihood of cyst reformation. We found arthroscopic partial meniscectomy with manipulation of the contents of the cyst into the joint to be a successful alternative to complete open meniscectomy.     

Arthroscopic management of femoroacetabular impingement: osteoplasty technique and literature review

Morphological and spatial abnormalities of the proximal femur and acetabulum have been recently recognized as causes of femoroacetabular impingement. During joint motion in hips with femoroacetabular impingement, abnormal bony contact occurs, and soft tissue structures (chondral and labral) often fail. Femoroacetabular impingement has been reported to be a contributor to early-onset joint degeneration. Ganz et al have described good midterm success with an open surgical dislocation approach to reconstruct normal joint clearance. The purpose of this report is to discuss relevant literature and describe an arthroscopic approach to treat femoroacetabular impingement. This approach has particular relevance in high-demand patients, particularly in athletes seeking to return to high-level sport.     

Arthroscopic management of posterior shoulder instability

The etiology of posterior shoulder instability is multifactorial. Similarly, the surgical treatment of posterior shoulder instability requires more than one management technique. During the past 7 years we have used an anatomic specific approach to posterior shoulder instability, relying on physical examination and diagnostic arthroscopy to determine the correct repair technique. This study reports our results with 61 consecutive patients with refractory posterior shoulder instability requiring surgical correction. In each instance, the specific pathologic entity causing instability was corrected in an anatomic specific approach to the disorder. All patients were re-evaluated 1 to 6 years postoperatively (mean, 34 months). Fifty-five of 61 patients maintained stable shoulders, indicating a 90% success rate with this approach to posterior instability. We would recommend this approach in the management of posterior shoulder instability refractory to rehabilitative treatment.