Full text of DOI:10.1007/s001670000129

Knee Surg, Sports Traumatol, Arthrosc
2000) 8:270–274
(
KNEE
DOI 10.1007/s001670000129
Gordian Stutz
Arthroscopic management
of septic arthritis:
stages of infection and results
Markus S. Kuster
Frank Kleinstück
André Gächter
Abstract Seventy-six patients with
septic arthritis (78 affected joints)
were treated with a combination of
arthroscopic irrigation, débridement, dorferi (3%), and others in 5%. In
and antibiotic therapy according to the stage I group only one patient
the tested bacterial sensitivity. There needed repeated arthroscopic irriga-
were 62 knee, 10 shoulder, 5 ankle tion, in the stage II group 52%, and
tococci (15%), pneumococci (6%),
Escherichia coli (4%), Staphylococ-
cus epidermidis (3%), Borrelia burg-
Received: 28 January 2000
Accepted: 2 June 2000
Published online: 20 July 2000
©
Springer-Verlag 2000
joints, and 1 hip joint. No antibiotics in the stage III group 75%. Open re-
were added to the irrigating solution. vision for eradication of the infection
The arthroscopic and radiological
stage of infection, treatment, and
outcome in these patients was ana-
lyzed. The patients were classified
was necessary in one joint with stage
II and in two joints with stage III in-
fection (3%). Two joints of the stage
III group needed additional surgery
into three groups according to initial after successful treatment of the in-
stage of joint infection (stage I: 21
patients, 22 joints; stage II: 43 pa-
tients, 44 joints; stage III: 12 pa-
fection. The combination of arthro-
scopic irrigation and systemic antibi-
otic therapy was able to cure 91% of
tients, 12 joints). Causes of infection the affected joints. Open revision
were: hematogenous dissemination
in 54%, postoperative wound infec-
tion in 28% (17% after open, 11%
was necessary in 4% of joints. The
number of arthroscopic procedures
and the efficacy of treatment de-
after arthroscopic procedures). Other pended on the initial stage of the in-
causes were: 10% intra-articular
steroid injections, 3% diagnostic
punctures, and 3% open traumatic
injury of the joint. In 78% of the in-
fected joints the causative organism
could be identified: Staphylococcus
fection. It is concluded that an ar-
throscopic staging of the initial joint
infection has prognostic and thera-
peutic consequences.
G. Stutz (✉) · M. S. Kuster · F. Kleinstück ·
A. Gächter
Department of Orthopedic Surgery,
Kantonsspital St. Gallen,
9
007 St. Gallen, Switzerland
Keywords Arthroscopy · Infection ·
e-mail: gordianstutz@yahoo.com
Tel.: +41-71-4941111
aureus was the most common organ- Risk factors
ism found (42%), followed by strep-
Fax: +41-71-4942871
of continuous irrigation and the use of antibiotic or anti-
septic additives are controversial in the literature. Jackson
18] and Jackson and Parsons [19] have proposed a dis-
Introduction
[
The rate of complications and fatal outcomes in the man- tension-irrigation technique in which one first irrigates
agement of septic arthritis was dramatically reduced with and débrides the joint, then inserts two drains into the
the introduction of arthroscopic débridement and the con- joint and distends it through the drains with saline solu-
comitant development of potent antibiotics [37]. The role tion with antibiotic and mucolytic agents added over 3 h,

271
and finally drains the joint for another 1 h. This therapy is tients (12 joints) a stage III infection. The correlation of results and
complications to the initial stage of infection was analyzed retro-
continued for 6–8 days. In addition to the local disten-
spectively. If the infection did not recur, and the patient had no fur-
sion/irrigation process, intravenous antibiotics are also ad-
ther therapy 1 year postoperatively, the infection was considered to
ministered. Other authors recommend [9, 27] or reject
17, 35] the use of continuous irrigation-suction drains
be cured.
The average age of the patients was 53 years (range 17–94), in
the stage I group 50 years (22–86), in the stage II group 52 years
17–89), and in the stage III group 65 years (range 38–94 years).
[
with antibiotics added to the irrigating solution. However,
the severity of septic arthritis may vary significantly and
could explain some of these controversies. No data have
yet been reported on the treatment of septic arthritis in
correlation with arthroscopic staging of the infection.
This study presents the results of a management regi-
men of septic arthritis based on the initial stage of the in-
fection.
(
Results
A hematogenous cause was found in 54% of the affected
joints and a postoperative infection in 28% (17% after
open, 11% after arthroscopic procedure). Ten percent of
the patients had an intra-articular infiltration of steroids,
and 4% had a diagnostic puncture. In 4% there was a trau-
matic penetration of the joint (Table 2). In 78% of joints
the causative organism was identified by bacteriological
Patients and methods
Seventy-six patients (44 men, 32 women) with septic arthritis
(
78 affected joints) were treated with a combination of arthro- cultures (Table 3). Almost 25% of those in the stage I and
scopic irrigation and systemic antibiotic therapy between January
988 and June 1998 (62 knees, 10 shoulders 5 ankle and 1 hip
II groups had Gram-negative stains; the causative organ-
ism was identified in all but one patient of the stage III
group. The most common risk factors for joint infection
1
joint; Table 1). Patients with total joint replacement were not in-
cluded in this series. Ringer’s solution was used to irrigate the
joints, and no antibiotics or antiseptics were added. An average of were generalized sepsis (12%) and trauma (11%).
5
–6 l (2–12 l) were used for irrigation. All wound drains were re-
In stage I, a single arthroscopic irrigation combined
with systemic antibiotic therapy was sufficient in 21 of
moved within the first 24 h. During arthroscopy aspirates and
biopsy specimens were taken for Gram stain, bacteriological cul-
ture, and antibiotic sensitivity tests. Patients with negative micro-
biology results were included in this series only if the joint fluid
22 infected joints. One joint underwent a second arthro-
scopic irrigation. The septic arthritis was cured by arthro-
examination was negative concerning crystals. Antibiotic therapy scopic therapy combined with systemic antibiotic therapy
was started afterwards. The antibiotic therapy was adapted by the
in 96% of the infected joints. One patient died due to
consultant for infectious diseases depending on the final result of
the microbiology. In patients with negative bacteriology results in-
travenous administration of cephalosporine was continued until the
C-reactive protein level and erythrocyte sedimentation rate re- tion was sufficient to cure the infection in 48% of the
turned to normal. The infection was staged according to the crite-
esophageal bleeding.
In stage II, one arthroscopic decompression and irriga-
44 infected joints, a second course of irrigation was nec-
ria of Gächter [10]:
essary in 23%, a third in 23%, and a fourth in 6%. The
•
•
•
Stage I: opacity of fluid, redness of the synovial membrane, pos- mean interval between first and second irrigations was
sible petechial bleeding, no radiological alterations
Stage II: severe inflammation, fibrinous deposition, pus, no ra-
diological alterations
3
days (range 1–7), and between the second and third irri-
gations 5 days (3–6). One patient needed additional open
Stage III: thickening of the synovial membrane, compartment synovectomy because the infection could not be con-
formation (“sponge-like” arthroscopic view, especially in the trolled arthroscopically. One patient with endocarditis and
suprapatellar pouch), no radiological alterations
septic arthritis caused by bacterial dissemination died
•
Stage IV: aggressive pannus with infiltration of the cartilage,
possibly undermining the cartilage, radiological signs of sub-
chondral osteolysis, possible osseous erosions and cysts.
7
days after arthroscopic irrigation in the course of the
Arthroscopic irrigation has been shown to be insufficient in stage
IV [11, 12], and open revision was performed; hence patients with Table 2 Cause of septic arthritis
stage IV infection were not included in this study.
At the initial arthroscopy 21 patients (22 joints) showed a stage Cause
I infection; 43 patients (44 joints) a stage II infection, and 12 pa-
Stage I
(n=22)
Stage II
(n=44)
Stage III Total
(n=12) (n=78)
n
%
n
%
n
%
n
%
Table 1 Affected joints
Hematogenous
Postoperative
Open procedure
Arthroscopic procedure 3
11 50 22 50
9
1
1
–
2
1
1
0
75 42 54
6
3
28 15 34
8
–
–
22 28
13 17
Joint
Stage I
n=22)
Stage II
(n=44)
Stage III
(n=12)
Total
(n=78)
–
–
9
6
5
1
4
2
–
–
(
9
11
Knee
18
–
3
37
6
1
7
4
1
–
62
10
5
Iatrogenic
4
1
3
1
18
–
–
11
–
–
17 11 14
Shoulder
Ankle
Hip
Diagnostic puncture
Intra-articular steroids
Penetrating trauma
–
–
0
3
8
3
4
10
4
1
–
1
4
5

272
Table 3 Causative organisms
Organisms
Stage I
n=22)
Stage II
(n=44)
Stage III
(n=12)
Total
(n=78)
(
n
%
n
%
n
%
n
%
Negative bacteriological result
Staphylococcus aureus
Streptococci
5
9
2
1
1
1
1
1
1
–
–
22.8
40.9
9.1
4.5
4.5
4.5
4.5
4.5
4.5
–
11
18
8
24.9
40.9
18.2
4.5
4.5
2.3
2.3
–
1
6
2
2
–
–
–
–
–
–
1
8.3
49.9
16.7
16.7
–
17
33
12
5
21.8
42.2
15.4
6.4
Pneumococci
2
Escherichia coli
2
3
3.8
Staphylococcus epidermidis
Borrelia burgdorferi
Pseudomonas aeruginosa
Enterococci
1
–
2
2.6
1
–
2
2.6
–
–
1
1.3
–
–
–
1
1.3
Mycobacterium tuberculosis
Haemophilus influenzae
1
2.3
–
–
1
1.3
–
–
8.3
1
1.3
Table 4 Arthroscopic procedures in correlation to the stage of in-
fection
disease. In the remaining patients arthroscopic therapy
and systemic antibiotic therapy were sufficient to cure the
septic arthritis (95%).
Arthroscopic Stage I
Stage II
joints
(n=44)
Stage III
joints
(n=12)
Total
joints
(n=78)
In stage III, one course of arthroscopic irrigation and procedures
débridement was sufficient to cure the infection in 3 of the
joints
n=22)
(
1
2 infected joints, a second arthroscopic procedure was
One
21
1
–
21
10
10
3
3
5
3
1
45
16
13
4
necessary in 4, a third in 2, and a fourth in 1 joint. The
mean interval between the first and second procedures
was 3 days (range 1–6), and between the second and third
procedures 6 days (2–7). Two patients with endocarditis
and bacterial dissemination died, the one 5 days and the
Two
Three
Four
–
other 8 days after arthroscopic therapy. Two patients essary in more than 50% of stage II or stage III infections
needed additional open synovectomy of the joints for the (Fig.1). As seen in Table 4, the number of necessary
eradication of the infection, and in two patients secondary arthroscopies was correlated to the initial stage of infec-
operations were necessary to treat the effects of the joint tion.
destruction (one total knee arthroplasty, one total ankle
Overall 91% of the 78 infected joints were cured with
arthroplasty). In 67% of the stage III group arthroscopic arthroscopic irrigation/débridement and systemic antibi-
irrigation and débridement combined with systemic an- otic therapy. However, the efficacy decreased with in-
tibiotic therapy were sufficient to cure the septic arthritis. creasing severity of the initial stage of infection: 96% in
While a single arthroscopic irrigation was sufficient to stage I, 95% in stage II, and 67% in stage III (Fig.1). In
cure most stage I infections, repeated irrigations were nec- this study hardware (plates, screws, staples, wire) was
used in ten patients: in four patients in stage I, five in
stage II, and one in stage. Removal of hardware was nec-
essary only in one patient of the stage II group with an in-
ternal fixation of a fracture of the patella. Open revision
was necessary in one stage II joint and in two stage III
joints.
Discussion
The present study is one of the larger surveys analyzing
the arthroscopic treatment of septic arthritis. Diagnostic
arthroscopies without additional procedures seem to have
a very low risk of infection, varying between 0.1 and
0.42% in the literature [2, 6, 32, 39]. Postoperative infec-
tions were found in 28% of our patient population (open
procedures 17% and arthroscopic procedures 11%). Most
of these patients were transferred from other hospitals.
Fig.1 Efficacy of the first arthroscopic irrigation

273
The infection rate was found to increase with increasing 17, 30, 34, 36]. In the present study no antibiotics were
operating time, increased number of procedures during added to the irrigation solution since several clinical and
surgery, prior procedures, and previous intra-articular experimental studies have shown sufficient antibiotic lev-
steroid injections [2].
els in the synovial fluid after intravenous administration
Ten percent of our patients showed an infection after in- of antibiotics [8, 24, 28]. Furthermore Argen et al. [1] de-
tra-articular administration of steroids. Increased rates after scribed a chemical synovitis after intra-articular instilla-
intra-articular administration of steroids have been re- tion of antibiotics. Also, no antiseptic additives to the irri-
ported repeatedly in the literature [13, 15, 23]. Gray and gation fluid were used in the present study because of re-
Gottlieb [16] performed an experimental study on risks and ported toxicity to the articular cartilage with irreversible
benefits of intra-articular steroid injections. In their rabbit damage [12].
model systemic cortisone given daily 1 week before and 1
Jackson [18] has reported good results using a disten-
week after bacterial joint inoculation reduced the infecting sion-irrigation technique in a small number of patients. Ir-
dose of micrococcus 100,000-fold, while a single dose of rigation-suction drains have also been proposed by Pari-
intra-articular prednisolone given at the time of bacterial sien and Shaffer [27] and Gainor [9]. Several studies have
inoculation reduced the infecting dose 10,000-fold.
found increased secondary infections and recurrences
In the treatment of septic arthritis the proportion of with the use of irrigation-suction drains [6, 29, 36]. The
bacteriological identifications varies from 63% to 100% present study also showed that irrigation suction drains
[8, 12, 17, 27, 35]. The causative organism was identified were not necessary.
in 78% of our patients, depending on the initial stage of For stage III infections débridement of necrotic mater-
infection. While 25% of stage I and II Gram stains were ial and adhesiolysis was performed with a shaver. We do
negative, all but one were positive in stage III infections. not recommend a synovectomy initially, in order to pre-
It is possibly that higher rates of identified causative or- serve the synovial membrane as a barrier for the micro-
ganism could have been achieved by taking five tissue organisms [11, 12, 27]. In contrast to the recommenda-
biopsy specimens, as recommended by Kamme and Lind- tions of some authors [17, 18, 39], 41% of our patients
berg [21]. As confirmed in other reports in the literature needed repeated arthroscopic irrigations because of per-
[2, 6, 27, 32, 35, 39], the most common organism identi- sistent infection. The rate of repeated arthroscopic proce-
fied in the present study was Staphylococcus aureus. dures in the present study depended on the initial stage of
Clinical and experimental studies have shown a rela- the infection. Open revision was seldom needed (4%). We
tionship between early and aggressive initiation of treat- found an increased risk of therapy failure in the stage II
ment and the success of therapy in septic arthritis [22, 26, and III groups. Thiery [36] reported in a multicenter study
38]. Nord et al. [25] showed in a goat model that if an in- 10.9% failures and 10.9% recurrences in 46 patients. Ivey
fected knee joint is diagnosed early, and appropriate an- and Clark [17] prospectively studied the results of 13
tibiotic therapy is initiated immediately, arthrotomy and adult patients treated with arthroscopic decompression,
needle aspiration can effectively eradicate the infection, débridement, and shaving. They reported two failures and
with only minimum damage to the cartilage. Despite the no recurrences.
good results reported with repeated needle aspiration [14,
In conclusion, arthroscopic decompression/irrigation
31] sufficient drainage of the joint by this method may be combined with a systemic antibiotic regimen is an effi-
doubted [5, 7]. Some authors perform arthrotomy for the cient way of treating septic arthritis. If symptoms of in-
treatment of septic arthritis, with reportedly good results fection persist under antibiotic therapy, arthroscopic irri-
[3, 5]. The present data suggest that open revision and gation can be repeated with good results. The number of
synovectomy are seldom necessary for most cases of sep- arthroscopic irrigations and the efficacy of treatment are
tic arthritis and should be reserved for severe cases with influenced by the initial stage of infection. The shaver
concomitant osseous infection [12]. Good to excellent re- should be used for débridement of necrotic tissue and ad-
sults of arthroscopic therapy of septic arthritis in infants hesiolysis only, and care should be taken to leave the sy-
and adults have been reported by several authors [9, 12, novial membrane intact. There is no indication for the in-
17, 18, 20, 27, 33, 35, 36]. There is a general agreement tra-articular use of antibiotics because of possible chemi-
about the necessity of a combination of arthroscopy and cal synovitis or antiseptic agents because of their cartilage
systemic antibiotics. Some authors also advocate intra- toxicity. The use of wound drains is not necessary. Irriga-
articular antibiotics [8, 9, 24, 27] while others refrain tion-suction drains are not recommended.
from the use of intra-articular antibiotic administration [4,

274
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