The Value of Arthroscopic Surgery for Septic Wrist Arthritis
This is the first study to compare the results of open surgery versus arthroscopic surgery for septic arthritis of the wrist. The procedure was an irrigation and dÃ©bridement. That means once the surgeon accessed the area of infection (either through an open incision or arthroscopically), saline fluid was used to flush the area clean (irrigation). In a second step (dÃ©bridement), any fluid and any loose tissue or fragments of cartilage were removed.
Septic arthritis is the invasion of a joint by an infectious agent that produces arthritis. It can affect any of the joints in the body but has a tendency to settle in the large joints. This includes the hip, knee, and shoulder. The infectious agent starts someplace else (often a skin infection called cellulitis or from a urinary tract infection. It travels to the joint directly by local spread or through the blood system.
Risk factors for septic arthritis include joint replacement, cancer, kidney failure, or other chronic diseases. For example, chronic alcoholism, diabetes, rheumatoid arthritis, or other connective tissue disorder have been linked with septic arthritis. Taking medications that can suppress the immune system (e.g., prednisone, other immune modulators such as current or recent chemotherapy) is another potential risk factor for developing septic arthritis.
Septic arthritis of the wrist doesn't happen very often. At the Mayo Clinic (where this report is from), they treated 40 wrists over a 10-year period of time. That accounts for why published studies are few and far between on the management of septic wrist problems. A typical patient profile was age over 60, multiple comorbidities (other health problems), and immunosuppression. In most cases, the infection was cultured and found to be a staph infection.
Surgeons have successfully treated septic arthritis of these larger joints with arthroscopic irrigation and dÃ©bridement. Open incision surgery remains the standard for the wrist. Both surgical techniques (open and arthroscopic) are described in detail to help the reader understand the potential advantages and disadvantages of each approach.
Arthroscopic surgery allows the surgeon to make tiny incisions that don't endanger the ligaments or cartilage. There is less pain and no open, draining wound. On the other hand, an open incision gives the surgeon a full view of the wrist anatomy making it easier to avoid cutting blood vessels or damaging other tissues such as nerves.
The authors cast a wide net in terms of looking for differences in treatment effects between the two procedures. They included lab work such as white blood-cell count and sed rate (both are measures of inflammation) and identification of the bacterial content of the culture.
They also kept track of how many days patients were in the hospital, how long they took antibiotics, any record of deaths, and the total number of procedures required until the all clear bell was sounded indicating successful treatment of the joint infection. Pain levels, wrist range-of-motion, and load tolerated through the wrist were measured for patients in both groups and compared.
In general, the patients who developed septic arthritis were in poor health with multiple problems and taking medications that suppressed the immune system. The most common medications of this type were steroids and chemotherapy. Half the total group had septic arthritis in another joint (sometimes in several other joints). The cause of the infection was usually staphylococcus aureus, otherwise more commonly known as a staph infection.
A significant number in each group required more than one irrigation and dÃ©bridement procedure before the infection was stopped. Most of the time, the procedure only had to be repeated one time for patients in either group. But in some patients (again, in both groups), as many as four or five repeat procedures were required.
Patients with multiple infected joint sites were much more likely to need a second operation. Length of hospital stay increased dramatically when repeat procedures were performed. When comparing patients who only had one septic joint (wrist), the length of hospital stay for arthroscopic surgery was much less (two to 12 days) compared with open surgery (seven to 34 days).
Intravenous antibiotics are an important post-operative treatment for septic arthritis. Comparing the arthroscopic group to the open group, the arthroscopic group had one week less of antibiotics. That is actually quite a cost savings. On the down side of things, there were a fair number of deaths in both groups due to sepsis and multisystem organ failure. Sepsis refers to total body infection.
The authors observed within their own study a general trend toward more arthroscopies for the treatment of septic wrist arthritis as time went by. They found that by the end of the study that patients with isolated (just wrist) septic arthritis treated arthroscopically had fewer operations and fewer days in the hospital. They concluded that this treatment approach is just as successful and more cost effective compared with the same kind of surgery done as an open procedure.
Douglas M. Sammer, MD, and Alexander Y. Shin, MD. Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist. In The Journal of Bone and Joint Surgery. June 2009. Vol. 91A. No. 6. Pp. 1387-1393.
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