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Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist
Douglas M. Sammer, MD1; Alexander Y. Shin, MD2
1 Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110
2 Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address: shin.alexander@mayo.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Jun 01;91(6):1387-1393. doi: 10.2106/JBJS.H.00630
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Abstract

Background: Open irrigation and débridement is the standard of treatment for septic arthritis of the wrist. Although isolated cases of arthroscopic irrigation and débridement have been reported, a comparison of arthroscopic and open techniques has not been performed, to our knowledge. The purpose of this study was to compare the two methods of management.

Methods: A retrospective comparison of patients with septic arthritis of the wrist initially treated, over an eleven-year period, with open or arthroscopic irrigation and débridement was undertaken at a single institution. The clinical presentation, laboratory and microbiological findings, hospital course, complications, and outcomes were compared between the two groups.

Results: Between 1997 and 2007, thirty-six patients with septic arthritis involving a total of forty wrists were identified. Nineteen wrists (seventeen patients) were initially treated with open irrigation and débridement, and twenty-one wrists (nineteen patients) were initially treated arthroscopically. Eleven wrists in the open-treatment cohort required repeat irrigation and débridement, and eight wrists in the arthroscopy cohort required a repeat procedure. If a repeat irrigation and débridement was required, it was performed in an open fashion in all but two cases. When the comparison included all of the patients in the series, no difference between the two cohorts was found with regard to the number of irrigation and débridement procedures required or the length of the hospital stay. However, when the comparison was limited to the patients with isolated septic arthritis of the wrist, it was found that only one of seven wrists in the open-treatment cohort but all eight wrists in the arthroscopy cohort had been successfully managed with a single irrigation and débridement procedure (p = 0.001). No patient in whom isolated septic arthritis of the wrist had been treated with arthroscopic irrigation and débridement required a second operation. The patients in whom isolated septic arthritis of the wrist was treated with the open method stayed in the hospital for an average of sixteen days compared with a six-day stay for those in whom isolated septic arthritis of the wrist was treated with the arthroscopic method (p = 0.04). The ninety-day perioperative mortality rate in the series was substantial (18% [three patients] in the open-treatment cohort and 21% [four patients] in the arthroscopy cohort).

Conclusions: Arthroscopic irrigation and débridement is an effective treatment for patients with isolated septic arthritis of the wrist; these patients had fewer operations and a shorter hospital stay than did patients who had received open treatment. However, these benefits were not seen in patients with multiple sites of infection.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Alexander Y. Shin, MD
    Posted on December 29, 2009
    Drs. Shin and Sammer respond to Dr. Rashkoff
    Mayo Clinic, Rochester, Minnesota

    We appreciate Dr. Rashkoff’s comments. We agree that there are situations in which MRI can be helpful, such as differentiating transient synovitis of the hip from septic arthritis, or evaluating the extent of osteomyelitis. However, we believe that in spite of advances in MRI technology, septic arthritis of the wrist remains a clinical diagnosis supported by laboratory findings (serology and arthrocentesis results). Furthermore, we believe that, in the vast majority of cases, MRI is unnecessary and should not delay the diagnosis or treatment of septic arthritis of the wrist. Finally, we believe that the advent of new antibiotics has not significantly altered the treatment of the disease, which includes antimicrobial therapy combined with thorough drainage and debridement.

    Evan Rashkoff, MD
    Posted on November 06, 2009
    Re: Drs. Shin and Sammer respond to Dr. Strauch
    NULL

    To the Editor:

    I am writing in response to the interesting dialogue regarding Drs. Shin and Sammer's article comparing the open and arthroscopic management of septic arthritis of the wrist (1). I was the author of the study quoted in their exchange (2). Our original study was conducted between 1978 and 1982 at Jackson Memorial Hospital in Miami, Florida under the supervision of William Burkhalter, MD prior to the availability of MRI scans or wrist arthroscopy and before the advent of our current generation of very effective antibiotics.

    In my opinion, all of the methods of treating septic arthritis of the wrist mentioned can be acceptable, but the efficacy of one particular form of treatment depends upon the bacterial organism recovered and the presence of co-morbidities, such as rheumatoid arthritis. Treatment always should be specific for the individual patient.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am. 2009;91:1387-93.

    2. Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg Am. 1983;65:824-8.

    Alexander Y. Shin, MD
    Posted on July 07, 2009
    Drs. Shin and Sammer respond to Dr. Strauch
    Mayo Clinic, Rochester, Minnesota

    We would like to thank Dr. Strauch for his comments. As the purpose of our study was to compare open irrigation and debridement (I&D) with arthroscopic I&D, we did not evaluate or discuss needle aspiration as a treatment for septic arthritis of the wrist. Additionally, since there are no high-quality randomized controlled trials comparing surgical I&D with needle aspiration, an argument can be made that there is no definitive gold standard for treating septic arthritis of the wrist. However, the predominant opinions in the hand surgery literature are that prompt surgical drainage is the primary treatment for septic arthritis of the wrist. For example, Rashkoff et al. (1) suggested that, “any treatment short of arthrotomy in the face of the diagnosis is ill-advised". Stevanovic and Sharpe called septic arthritis in the hand and wrist a, “surgical emergency” and suggested that serial aspiration is “therapeutically unpredictable” (2). Dr. Strauch’s comments highlight the divide between the surgical and medical literature. While there are some articles that support needle aspiration for the treatment of septic arthritis, these are predominantly found in the rheumatologic literature (3,4). There are likely multiple reasons for this difference, but one possible explanation is that rheumatologists tend to treat a different part of the spectrum of septic arthritis than do hand surgeons. Regardless, a prospective randomized comparison of the three methods (open I&D, arthroscopic I&D, and needle aspiration) would certainly provide more information about the respective roles for each approach. However, because of the low incidence of septic arthritis in the wrist, this would be logistically difficult, and would likely require a multi-center effort.

    References

    1. Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg Am. 1983;65:824-8.

    2. Stevanovic MV, Sharpe F. Acute infections in the hand. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, editors. Green’s operative hand surgery. 5th ed. Philadelphia: Elsevier; 2005. p 77-81.

    3. Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, Walker D, Coakley G. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-5.

    4. 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.

    Robert J. Strauch, MD
    Posted on June 03, 2009
    Standard of treatment?
    Columbia University Medical Center, New York, New York

    To the Editor:

    I read with interest the article by Drs. Sammer and Shin in which they compare arthroscopic and open treatment of septic arthritis of the wrist(1). However, I would raise the point that the authors' statement in the opening paragraph that, "...open irrigation and debridement remains the standard of treatment for the (septic) wrist", is not supported by the current medical literature to date(2).

    While the shoulder and hip are not amenable to easy aspiration, aspiration of the wrist joint is usually a simple matter, often performed by non-surgeons as well as orthopaedic surgeons. To date, there have been no convincing studies supporting open or arthroscopic drainage of the septic wrist compared with needle aspiration. In my own practice, I have been quite satisfied using needle aspiration and intravenous antibiotics for the successful treatment of the majority of patients with septic arthritis of the wrist. Therefore, while arthroscopic drainage of the septic wrist may be superior to open drainage, it may not be superior to needle aspiration alone--a point not discussed anywhere in the article.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References:

    1.Douglas M. Sammer and Alexander Y. Shin Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist J Bone Joint Surg Am 2009; 91: 1387-1393

    2. Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, Walker D, Coakley G. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-5. Epub 2007 Jan 12.

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