65: Arthroscopic Treatment for Septic Arthritis

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Procedure 65 Arthroscopic Treatment for Septic Arthritis

William B. Geissler, Daniel C.M. Williams

Indications

Arthroscopic synovectomy has been shown to be beneficial in patients with symptomatic, refractory reactive arthritis.

• Arthroscopy will allow for diagnosis and treatment of suspected joint infection.

• Arthroscopy assists in distinguishing between infectious and noninfectious inflammatory arthritis.

Arthroscopy allows for not only continuous irrigation of joint space but also débridement of infected material.

• Smaller incisions and quicker return to use of wrist are desired by the patient as well as the surgeon.

Examination/Imaging

Clinical Examination

Examine the entire wrist for swelling, redness, warmth, and pain.

The range-of-motion examination will produce exquisite pain with both active and passive motion.

Hematogenous spread will manifest with systemic signs of infection, which may include fever, chills, tachycardia, and diaphoresis.

Evaluation with laboratory tests should be done and should include white blood cell count (WBC), erythrocyte sedimentation rate, and C-reactive protein levels.

Joint fluid can be obtained at the initiation of the procedure and should be evaluated with Gram staining, culture and sensitivity, WBC count, and crystal analysis.

Imaging

Radiographs should be obtained and are useful for determining foreign bodies, soft tissue gas, and osteomyelitis.

Magnetic resonance imaging can also be obtained and can give a better view of joint effusion, soft tissue fluid collections, and bone involvement.

Surgical Anatomy

Structures to be identified and marked are Lister tubercle, articular margins, and the radius and ulna.

Tendons that should be identified are the extensor digitorum communis (EDC), the extensor digiti minimi (EDM), and the extensor carpi ulnaris (ECU).

Portal sites 3-4, 4-5, radial and ulna midcarpal, and 6U are marked before starting the procedure.

Positioning

A sterile traction tower is used to suspend the elbow flexed at 90 degrees.

The index and long finger are placed in finger traps, and a 10-lb weight is applied through the traction tower (Fig. 65-1).

A gravity inflow system is used instead of the typical infusion pump system to help decrease the chance of disseminating infected fluid into the surrounding soft tissue structures.

An arthroscope, 30-degree angled lens, camera, and full radius joint shaver setup are needed for this procedure.

FIGURE 65-1

Exposures

Extremity exsanguination is generally contraindicated because of the joint infection. In some situations a tourniquet may be used to allow better visualization of the wrist joint. If a tourniquet is used, the arm is elevated to let the blood drain before tourniquet inflation.

The anatomic landmarks are identified before starting the procedure. The portal sites are then marked, which are the radiocarpal, 3-4, 6R, 6U, and radial and ulna midcarpal portals.

The 6R portal is located by palpating the ECU tendon. The portal is made just radial to the tendon.

The 3-4 portal is located by palpating the concavity between the extensor pollicis longus and EDC tendons just distal to Lister tubercle in line with the radial border of the long finger (Fig. 65-2).

The radial midcarpal portal is located about 1 cm distal to the 3-4 portal, and the ulna midcarpal portal is located about 1 cm distal to the 6R portal in line with the midaxis of the ring finger.

FIGURE 65-2

Procedure

Step 1

Inflow is initially placed through the 6U portal. The joint is inflated.

A skin incision is made with a no. 11 blade scalpel at the 3-4 portal site. Only the skin should be incised, and the blade should be carried distally while the skin is retracted proximally with the thumb.

A blunt curved hemostat should be used to dissect down to the wrist joint capsule using a spread and push technique. Care should be taken to avoid damaging the dorsal sensory nerves and the superficial veins that run in a longitudinal fashion (Fig. 65-3).

To stay parallel to the articular surface, the trocar is angled 10 degrees proximally with respect to the volar inclination.

Entry into the joint capsule should be done in a controlled fashion using gentle pressure on a blunt trocar (Fig. 65-4).

The 3-4 portal will be used as the visualization portal.

FIGURE 65-3

FIGURE 65-4

Step 1 Pearls

When introducing the blunt trocar, care must be taken not to plunge into the joint space. A controlled entrance is necessary to avoid injury to the internal structures.

The radioscaphocapitate, long radiolunate, triangular fibrocartilage complex, lunotriquetral interosseous ligament, ulnolunate ligament, and ulnotriquetral ligament can all be viewed from the 3-4 portal.

Inflow is provided through the 6U portal and outflow through the arthroscopic cannula. This allows for greater flow of fluid to irrigate the joint (Fig. 65-5).

FIGURE 65-5

Step 1 Pitfalls

Inflow through the arthroscope cannula does not provide sufficient irrigation of the joint because of the small space between the arthroscope and the cannula.

Visualization to the synovitis can be initially difficult. Be patient.

Visualization is key. Advance the arthroscope ulnarly near the 6R portal. Insert the shaver and start making room in the joint.

Step 2

An 18-gauge needle is inserted into the joint under visualization with the arthroscope in the 3-4 portal.

A skin incision is made with a no. 11 blade scalpel at the 6R portal site. Only the skin should be incised, and the blade should be carried distally while the skin is retracted proximally.

Once again, care should be taken to avoid damaging the superficial sensory nerves and veins when using a curved hemostat to dissect down to the joint capsule.

Entry into the joint with a blunt trocar is made in a neutral position, instead of in an angled fashion.

The 6R portal will be the working portal and will be used for the motorized shaver and suction.

Step 2 Pearls

The ulnar half of the lunate, TFCC, and ulnocarpal ligaments are best viewed from the 6R portal.

Step 2 Pitfalls

It is important to use a needle to identify the exact location of the 6R portal as viewed arthroscopically.

The TFCC and/or the articular cartilage of the lunate and triquetrum may be injured if the portal is too far distal or proximal.

Step 3: Radiocarpal Evaluation

The radiocarpal joint should be examined in a systematic fashion.

Beginning in a radial to ulnar fashion, the articular surfaces of the scaphoid, lunate, and triquetrum should be evaluated. Care should be taken to thoroughly examine the surfaces for cartilage erosion or wear.

Next, the scapholunate, lunotriquetral, and radiocarpal ligaments should be examined. The ligaments should be carefully evaluated for laxity, step-offs, and tears.

After evaluating those ligaments, the articular surface of the radius and the TFCC should be evaluated. Attention should be paid to any tears centrally or in the periphery or the articular disk.

When synovitis, debris, or loculations are encountered, they should be débrided with the shaver as completely as possible (Fig. 65-6).

It is easier to shave the reactive synovitis from the ulnar side of the wrist with the arthroscope in the 3-4 portal and the shaver in the 6R portal.

The instruments are then reversed, and the radial synovitis is débrided with the shaver in the 3-4 portal and the arthroscope in the 6R portal.

FIGURE 65-6

Step 3 Pearls

When evaluating the TFCC, attention should be paid to any tears centrally or in the periphery or the articular disk, and these should be documented. The shaver can be used to help completely delineate the extent of the tear.

Step 3 Pitfalls

It is important to know normal from abnormal.

Do not confuse the normal prestyloid recess with a peripheral tear of the TFCC.

The pisiform may be visualized about 60% of the time with the arthroscope in the 6R portal. This is a normal finding.

Step 4: Midcarpal Evaluation

After the proximal radiocarpal joint space has been thoroughly evaluated, the midcarpal space should be examined.

The radial midcarpal and ulnar midcarpal portals are accessed in a fashion similar to that of the proximal portals.

The radial midcarpal portal is used as the visualization portal, and the ulnar midcarpal portal is used as the working portal.

The distal articular surface of the capitate is easily viewed and should be examined first.

Next, the proximal row bones should be evaluated by inspecting the distal articular surfaces of the scaphoid, lunate, and triquetrum.

The scapholunate and lunotriquetral ligaments and joints are evaluated for laxity, step-offs, tears, or widening.

The Geissler classification system is useful in grading and describing any ligamentous injuries between the proximal row of carpal bones.

The ulnar-sided synovitis is débrided with the arthroscope in the radial midcarpal portal and the shaver in the ulna midcarpal portal.

The instruments are then reversed, and the radial synovitis is débrided with the shaver in the radial midcarpal portal and the arthroscope in the ulna midcarpal portal.

Step 4 Pearls

Both midcarpal and radiocarpal evaluations are needed to correctly use the Geissler classification system.

Step 4 Pitfalls

It is easy to damage the articular cartilage of the midcarpal row when making the midcarpal portal.

Always use a needle to confirm the ideal location of the midcarpal portal before making an incision.

Always use a blunt trocar when placing the arthroscope in the midcarpal spaces.

Stop if resistance is felt.

Postoperative Care and Expected Outcomes

The skin incision can be either left open or loosely approximated with Steri-Strips.

The wrist can be placed in a volar resting splint or can be placed in a soft dressing.

Depending on the clinical scenario, postoperative intravenous antibiotics should be continued and tailored based on the Gram stain and culture and sensitivity results.

Digital range-of-motion exercises are started immediately.

Wrist range of motion and strengthening are initiated as tolerated.

Birman MV, Strauch RJ. Management of the septic wrist. J Hand Surg [Am]. 2011;36:324-326.

This paper reviewed data on septic wrists treated with needle aspiration, open surgical technique, and arthroscopic management. Several retrospective studies were examined. Their review showed that all techniques were useful in some regard; however, there was no solid evidence to determine the relative effectiveness of the procedures. (Level IV evidence)

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. 1975;18:83-90.

This paper compared needle aspiration of a septic joint with open surgical drainage. This is a retrospective study that compared data from 59 patients over an 8-year period. All of the patients had proven bacterial arthritis. Forty-two patients were treated with needle aspiration, and 17 were treated with open surgical drainage. Sixty-seven percent of patients treated with aspiration had complete recovery. Only 42% of patients treated with open surgery had complete recovery. Also, only 21% of patients in the aspiration group had poor results compared with 55% of in the open surgical group. Poor result was defined as flexion deformity of 10 degrees or greater, ankylosis, secondary osteomyelitis, or persistent effusion. This paper concluded that in initial management of a septic joint, needle aspiration is more favorable than open surgery. (Level IV evidence)

Sammer D, Shin A. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg [Am]. 2010;92:107-113.

The authors used a retrospective comparison of patients treated with either arthroscopic or open surgical treatment of a septic wrist. The study looked at 11 years of data and involved a single institution. Their findings showed that arthroscopic treatment not only was effective but also led to fewer subsequent operations and shorter hospital stays. (Level IV evidence)

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