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The role of arthroscopy in the treatment of septic arthritis.

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737
BRIEF REPORT
THE ROLE OF ARTHROSCOPY IN THE TREATMENT OF SEPTIC
ARTHRITIS
MARK P. JARRETT, LEONARD GROSSMAN, ARTHUR H. SADLER. and ARTHUR I. GRAYZEL
Despite the introduction of effective antibiotics,
infectious arthritis remains a cause of destructive synovitis (1). Proper treatment of a closed space infection,
such as the joint cavity, requires drainage of the purulent materials. Drainage by needle aspiration is generally recommended except in septic arthritis of the hip in
children, which usually requires an immediate surgical
procedure (2). In contrast, many surgeons recommend
early arthrotomy in all cases of septic arthritis.
Presented here is a patient with bilateral knee infections due to Proteus mirabilis. She did not respond to
appropriate antibiotics and closed aspiration, but due to
her unstable medical condition, an arthrotomy was felt
to be inadvisable. An arthroscope was therefore used to
lyse adhesions, drain loculations, and place irrigation
catheters. In view of the low morbidity associated with
this procedure, it should be examined as an alternative
procedure to open surgical drainage in the management
of persistent arthritis of the knee.
CASE REPORT
A 34-year-old woman presented to the emergency room with a 2-day history of vomiting and right
lower quadrant abdominal pain. Physical examination
revealed a temperature of 39.1"C and signs of peritonitis. Laboratory evaluation demonstrated a leukocytosis
From the Departments of Medicine and Orthopedic Surgery,
Montefiore Hospital and Medical Center, Albert Einstein College of
Medicine, Bronx, New York.
Supported by a clinical research center grant from the Arthritis Foundation and by grant T32 AM07273 from the National Institues of Health.
Address reprint requests to Arthur I. Grayzel, MD, Division
of Rheumatology, Montefiore Hospital and Medical Center, 11 1 East
210th Street, Bronx, NY 10467.
Submitted for publication September 8, 1980 accepted in revised form December 18. 1980.
Arthritis and Rheumatism, Vol. 24, No. 5 (May 1981)
and bacteriuria. Gentamicin 80 mg intramuscularly
every 8 hours and ampicillin 2.0 gm intravenously every
4 hours were begun.
On the night of admission the patient underwent
an exploratory laparotomy. Operative findings were a
normal appendix and evidence of pelvic inflammatory
disease on the right. Postoperatively the patient remained febrile. Blood cultures from the day of admission grew Proteus mirabilis, and intraoperative peritoneal cultures grew Escherchiu coli. Chloramphenicol
500 mg intravenously every 6 hours was then added to
the regimen. On the third hospital day, an intravenous
pyelogram demonstrated right ureteral obstruction with
a staghorn calculus. On that day the platelet count was
noted to have fallen to 35,000 cells/mm3. On the fourth
hospital day a pulmonary embolus was diagnosed by
lung scan, and continuous intravenous heparinizaton
was begun. The patient remained febrile and repeat
blood cultures grew P mirabilis despite the demonstration of adequate gentamicin peak and trough blood levels.
On the sixth hospital day, the rheumatology service was asked to evaluate the patient because of a swollen right knee that had developed 12 hours before. She
denied any history of previous joint problems. Examination by several observers during her preceding hospital course had not revealed any evidence of synovitis. At
this time the patient was febrile to 39.4"C with mild
dyspnea at rest. All joints were normal except the right
knee which was warm, red, extremely tender, and bearing a large effusion. There was severe pain on any attempt to move the joint.
X-ray examination revealed a large effusion with
normal bone and cartilage. Arthrocentesis yielded 60 ml
of viscous yellow fluid. Analysis of the fluid revealed
55,000/mm3 white blood cells with a differential count
of 90% polymorphonuclear cells and 10% lymphocytes,
a glucose of 46 mg/100 ml (simultaneous serum glucose
BRIEF REPORTS
738
of 100 mg/100 ml), and no crystals. Gram stain showed
numerous gram-negative rods. Cultures of the fluid subsequently grew P mirabilis, with the same sensitivities as
in the blood. Treatment now included twice daily
needle drainage of her knee, resting splints, and daily
passive range of motion exercises.
On the eighth hospital day the patient developed
severe respiratory distress secondary to another pulmonary embolus, and required intubation and ventilatory
assistance. Blood and synovial fluid cultures continued
to grow P mirabilis. The thrombocytopenia was, however, resolving. Further workup for an abscess was postponed due to the patient’s poor ventilatory status.
The patient was noted to have developed evidence of inflammation of the left knee on the tenth hospital day. Arthrocentesis yielded 30 ml of purulent fluid
that grew P mirabilis. Gentamicin was stopped and
tobramycin 80 mg intramuscularly every 8 hours was
substituted; trimethoprim-sulfamethoxazole was also
added. By the twenty-sixth hospital day, blood cultures
were persistently sterile, but both knees continued to reaccumulate purulent fluid that was culture positive, despite daily drainage and adequate synovial fluid tobramycin levels.
Due to the patient’s poor medical condition and
anticoagulation, it was thought that bilateral arthrotomies were not advisable, and bilateral arthroscopy
was performed instead. The synovium was inflamed and
edematous. Fibrous adhesions, loculated pockets of pus,
and cartilaginous degeneration were noted in both
knees. No areas of osteomyelitis were seen. Using the
arthroscope, the surgeons were able to lyse the fibrous
adhesions, disrupt the walls of loculations, lavage the
joint well, and place catheters for continuous irrigation.
The patient tolerated the procedure well, and 3 days
later synovial fluid cultures of both knees were sterile.
After 8 days the irrigating catheters were removed, and
she subsequently had no further evidence of joint infection. The patient was started on a program of intensive
rehabilitation. She was discharged with full range of
motion of both knees 2 months later following a partial
nephrectomy and removal of the staghorn calculus. Xrays of the knees at the time of discharge showed only
juxtaarticular osteoporosis.
DISCUSSION
In the pre-antibiotic era, open surgical drainage
was the only treatment of infectious arthritis. Repeated
aspirations of the hip can be both difficult and hazardous; therefore even with the advent of effective antibiot-
ics, joints such as the hip usually require early surgical
drainage for proper treatment. The role of open surgical
drainage in septic arthritis of the knee remains controversial.
In a retrospective review of 59 patients treated
with either initial surgical drainage or closed aspiration
drainage, Goldenberg et a1 found closed drainage to be
as effective as open drainage (3). They noted that the
factor determining the approach taken appeared to be
whether the patient was on a surgical (open drainage
recommended) or medical service (closed drainage). Using wide open arthrotomy and early active range of motion, Ballard et a1 had poor results in only 18% of a
group of 34 patients who were unresponsive to medical
therapy or had infected penetrating wounds of the joint
(4). However, the postoperative recovery period was
long, with incisions remaining open an average of 84
days. In most cases articular cartilage was visible for
several weeks, and in one case 3 months.
In a recent review of gram-negative septic arthritis, Bayer et a1 described complete recovery in 90% of
their surviving patients (5). There was no difference in
outcome between patients treated with closed versus
open surgical drainage. However, open surgical drainage was required in more than half of the patients because of perisynovial abcesses or osteomyelitis.
Thus, the previous literature, which is all retrospective, supports the concept that aggressive closed
drainage may be sufficient, in addition to appropriate
antibiotics, in early infectious arthritis. If adequate
drainage due to loculations is not achieved or osteomyelitis has occurred, open surgical drainage, with its
longer postoperative recovery period, should be instituted. The outcome of a specific treatment regimen for
septic arthritis, however, is dependent on the infecting
organism, the joint involved, and the host’s immune system (6).
Open surgical drainage would usually have been
performed earlier in the course of this patient’s illness
because of continued active infection despite appropriate antibiotics. Due to her multiple medical complications, however, any surgical procedure was considered a
risk. Also, the possibility of a long postoperative course
was undesirable because of recurrent pulmonary emboli. Therefore, the arthroscope was used to clear the loculations, lavage the joints, and place irrigation catheters. The procedure was performed with local
anesthesia, and the patient required only small incisions
for the arthroscope and drains. Additionally, adequate
visualization of the joint demonstrated there was no
BRIEF REPORTS
osteomylitis, and active rehabilitation was possible
within 48 hours of the procedure.
Although the arthroscope is considered a valuable diagnostic instrument, there have been few references to the role of arthroscopy in the management of
infectious arthritis. One author states that infection is a
relative contraindication to arthroscopy (7). Jackson
and Dandy state that the arthroscope can be used in the
management of septic arthritis, but do not cite case histories (8). In his textbook on arthroscopy, O’Connor
does describe 2 patients in whom the arthroscope was
used in the treatment of septic arthritis (9). However,
there has been no mention in the rheumatology literature of this particular form of treatment. From our experience with this patient, we propose that the arthroscope be examined as an alterative to open surgical
drainage in infectious arthritis of the knee when antibiotics and closed aspiration drainage have failed. Arthroscopy is a low risk procedure and does not preclude a
later arthrotomy if necessary.
ACKNOWLEDGMENT
We would like to the thank Dr. Frank R. Schmid for
review of the manuscript.
739
REFERENCES
1. Sharp JT, Lidsky MD, Duffy J, Duncan MW: Infectious
arthritis. Arch Intern Med 139:1125-1130, 1979
2. Schmid FR: Principles of diagnosis and treatment of infectious arthritis, Arthritis and Allied Conditions. Ninth edition. Edited by DJ McCarty. Philadelphia, Lea & Febiger,
1979, pp 1337-1352
3. Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES:
Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum 18:83-90, 1975
4. Ballard A, Burkhalter WE, Mayfield GW, Dehne E, Brown
PW: The functional treatment of pyogenic arthritis of the
adult knee. J Bone Joint Surg 57-A:1119-1123, 1975
5. Bayer AS, Chow AW, Louie JS, Nies KM, Guze LB:
Gram-negative bacillary septic arthritis: clinical, radiographic, therapeutic, and prognostic features. Semin Arthritis Rheum 7:123-132, 1977
6. Goldenberg DL, Brandt KD, Cathcart ES, Cohen AS:
Acute arthritis caused by gram-negative bacilli: a clinical
characterization. Medicine 53: 197-208, 1974
7. McGinty JB: Symposium on Arthroscopy and Arthrography of the Knee. St. Louis, CV Mosby Co., 1978, p 263
8. Jackson RW, Dandy DJ: Arthroscopy of the Knee. New
York, Grune and Stratton, Inc., 1976, p 81
9. OConnor RL: Arthroscopy. Philadelphia, J.B. Lippincott
CO., 1977, pp 93-96
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