Abstract
Background:
Surgical options for septic arthritis include open arthrotomy or an arthroscopic procedure. The optimal surgical technique remains a matter of debate as acceptable results have been reported for both.
Purpose:
To evaluate the efficacy of arthroscopy versus arthrotomy for the treatment of septic arthritis in large and intermediate-sized joints.
Study Design:
Systematic review; Level of evidence, 3.
Methods:
A literature search was performed of the PubMed and Cochrane online databases through September 2023 identifying articles comparing arthroscopy with arthrotomy for the treatment of septic arthritis. Eligible articles included retrospective or prospective comparative studies investigating reoperation, perioperative complications, or clinical outcomes after arthroscopic or open treatment for septic arthritis of the shoulder, elbow, wrist, hip, knee, or ankle in adults.
Results:
In total, 23 articles with 34,248 patients met the inclusion criteria comparing arthroscopy with arthrotomy. In 14 of the 20 (70%) studies that reported on reoperation rates, there was no significant difference in arthroscopic versus open surgical management for septic arthritis. Four (20%) studies reported lower reoperation rates when arthroscopy was utilized compared with open arthrotomy. One single-institution study found arthrotomy to be more effective for shoulder septic arthritis, and another favored open surgery only in the presence of erosions. In 11 of 23 (47.8%) studies, no difference in complications or clinical outcomes was found. However, 11 of 23 (47.8%) studies comprising the shoulder, wrist, hip, knee, and ankle reported a significant benefit to arthroscopy for improved outcomes.
Conclusion:
Arthroscopic surgery for the treatment of septic arthritis involving the shoulder, wrist, hip, knee, and ankle appears to be safe and effective. Reoperation rates, short-term complications, and functional outcomes tend to be similar or in favor of arthroscopy when compared with arthrotomy.
Bacterial septic arthritis is considered an orthopaedic emergency with an estimated annual incidence of 2 to 10 cases per 100,000 people. 9 Although the knee, hip, and shoulder are most implicated, any synovial joint has the potential to be involved. 1 Delayed diagnosis and treatment can result in complications such as irreversible bone and cartilage destruction, ankylosis, and death. 25 The mainstay of treatment involves irrigation and debridement with concomitant antibiotic therapy. 9 Surgical options include open arthrotomy or an arthroscopic procedure. The optimal surgical technique remains a matter of debate. Acceptable results have been reported for both open and arthroscopic surgery. 14 Proponents of arthroscopy consider it to be less invasive with decreased morbidity, although others question if it allows sufficient debridement. 31
The purpose of this systematic review was to evaluate the efficacy of arthroscopy versus arthrotomy for the treatment of septic arthritis in large and intermediate-sized joints. We hypothesized that arthroscopy would be at least as effective as arthrotomy in the surgical treatment of septic arthritis.
Methods
Search Strategy
A literature search was performed through September 2023 using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles comparing arthroscopy with arthrotomy for the treatment of septic arthritis. 26 The PubMed and Cochrane databases were searched using the following algorithm: ((arthroscopic) OR (arthroscopy)) AND ((open) OR (arthrotomy)) AND (septic arthritis). Titles and abstracts were screened by 2 authors (B.M.N. and A.S.P.), and articles meeting inclusion criteria underwent a full-text review for eligibility. Additionally, references of selected articles were screened for missed articles meeting the inclusion criteria.
Inclusion and Exclusion Criteria
Inclusion criteria included retrospective or prospective comparative studies investigating reoperation, perioperative complications, or clinical outcomes after arthroscopic or open treatment for septic arthritis of the shoulder, elbow, wrist, hip, knee, or ankle. Exclusion criteria included those with <10 patients per cohort, pediatric studies, animal studies, case series, studies on nonnative joints, studies without statistical analysis of the desired outcomes, and those without full-text English versions available.
Data Abstraction
Two reviewers (B.M.N. and A.S.P.) independently collected data utilizing a Microsoft Excel spreadsheet. Data related to study design and setting, diagnostic criteria, methods to control confounding, mean follow-up, study groups, reoperations, and outcome measures were recorded.
Statistical Analysis
The primary outcome of this study was reoperation for failed surgical treatment of septic arthritis. Failure was defined as persistent infection necessitating repeat surgery based on factors such as drainage, uptrending inflammatory markers, or abnormally elevated synovial white blood cell count. Secondary outcomes included various postoperative complications and functional measures. Forest plots for reoperations with 95% confidence intervals were computed, when possible.
Results
Description of Studies
The literature search revealed 241 total studies (Figure 1). After screening, 31 studies were reviewed for eligibility. Ultimately, 23 studies of at least level of evidence 3 met the inclusion criteria and were selected. They included 17,036 and 17,212 patients undergoing arthroscopy and arthrotomy, respectively. There were 12 studies (1 randomized trial) pertaining to the knee, 7 on the shoulder, 2 involving the wrist, and 1 each for the hip and ankle (Appendix Tables A1 and A2, available in the online version of this article). There were no comparative elbow studies. The study setting consisted of 15 database studies, while the remaining 8 were performed at a single institution. The reoperation rate was the most assessed outcome—included in all but 3 studies. Various adverse events such as readmission, blood transfusions, and wound complications, as well as functional outcomes like range of motion (ROM), were frequently secondarily assessed.
PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) flow diagram.
Shoulder
Seven studies analyzed outcomes for shoulder septic arthritis with 10,305 shoulders (4224 in the arthroscopy group and 6081 in the arthrotomy group). Reoperation rates ranged from 5.1% to 55.6% in the arthroscopy group and 7.4% to 18.4% in the arthrotomy group (Figure 2A). Four studies found no difference in reoperation rate or other outcome measures.4,15,21,29 Upfill-Brown et al 36 carried out a database study with >4000 shoulders and found lower rates of repeat irrigation and debridement, decreased hospital costs, shorter length of stay, less blood transfusion, and fewer wound complications in the arthroscopy compared with the arthrotomy cohort. After a subgroup analysis, the revision surgery rates did not differ in patients <65 years of age or those with sepsis. Two studies, each with >2-year follow-up on average, favored arthrotomy. Böhler et al 3 found arthrotomy to be more effective at reducing reoperations; however, ROM outcomes were similar. They speculated that during arthroscopy with high-pressure irrigation, microorganisms may be disseminated into the surrounding soft tissues, thus contributing to infection recurrence. Lee et al 22 reported better reoperation rates, University of California–Los Angeles scores, and ROM in their arthrotomy cohort when erosions were identified on preoperative radiographs or magnetic resonance imaging scans. Otherwise, reinfection was similar between groups.
Forest plots for reoperations after arthroscopy versus open arthrotomy for septic arthritis of the (A) shoulder, (B) wrist, (C) hip, (D) knee, and (E) ankle.
Wrist
Two studies analyzed outcomes for wrist septic arthritis with 1185 wrists (233 in the arthroscopy group and 952 in the arthrotomy group). Reoperation rates ranged from <5.2% to 38.1% in the arthroscopy group and 1.6% to 57.9% in the arthrotomy group (Figure 2B). In the database study by Moran et al, 28 the authors were unable to extract the specific number of reoperations, thus limiting more precise statistical analysis on this metric. They did find that arthroscopy was more commonly utilized in patients <60 years of age, but there was no difference in 90-day complications or readmissions. The main findings by Sammer and Shin 33 included similar efficacy between arthroscopic and open treatment; however, when excluding patients with multiple sites of infection, arthroscopic treatment resulted in significantly fewer operations and a shorter hospital stay for patients with isolated septic arthritis.
Hip
One study analyzed outcomes for hip septic arthritis with 421 hips (34 in the arthroscopy group and 387 in the arthrotomy group). Reoperation rates were 38.2% and 46.0% in the arthroscopy and arthrotomy groups, respectively (Figure 2C). The authors of this database study found similar efficacy for 30-day reoperations, but significantly fewer total adverse events in the arthroscopy group on univariate analysis. 20 However, the incidences of minor and serious adverse events were similar between groups.
Knee
Twelve studies (1 randomized trial) analyzed outcomes for knee septic arthritis with 21,426 knees (12,377 in the arthroscopy group and 8998 in the arthrotomy group). Reoperation rates ranged from 0% to 50.4% in the arthroscopy group and 7.6% to 71.4% in the arthrotomy group (Figure 2D). Three studies found no difference in reoperation rate or other outcome measures.5,19,30 Two studies favored arthroscopy with regard to reoperation rate and postoperative ROM,2,17 leading to the recommendation to reserve open arthrotomy for patients with osseous involvement. 2 One study reported similar rates of readmission and complications, but improved infection eradication after arthroscopy. 29 The remaining 6 studies found at least 1 outcome measure favoring arthroscopy despite similar reoperation rates.7,10,12,18,35,37 This includes the database study of Upfill-Brown et al 37 of >14,000 patients, which suggested that arthroscopic irrigation and debridement was associated with reduced complications and health care resources. Reoperation rates were similar between groups, and the total cohort revision rate was 15.0% at a median of 7 days after the index procedure. Another study identified methicillin-resistant Staphylococcus aureus (MRSA) infections as an independent risk factor for failure of surgical treatment, with a 38% overall failure rate, regardless of technique, when MRSA was present. 12 The failure rate was more pronounced in the arthroscopic group.
Ankle
One study analyzed outcomes for ankle septic arthritis with 962 ankles (168 in the arthroscopy group and 794 in the arthrotomy group). Reoperation rates were 10.7% for both arthroscopy and arthrotomy groups (Figure 2E). This database study found higher odds of surgical site infection and readmission at 90 days in the arthrotomy group, on multivariate analysis. 32
Discussion
In this systematic review of 23 studies comprising >34,000 patients, our findings suggest that arthroscopic management of septic arthritis is both safe and effective, and potentially associated with less morbidity and better functional outcomes than arthrotomy. These findings were consistent for all joints we assessed.
Twenty percent of studies in our review found lower reoperation rates when arthroscopy was performed. There was only 1 study, with a relatively small cohort of shoulders, that found open surgery to be more effective regarding reoperations. 3 Theoretically, arthroscopy is less invasive, yet may allow improved visualization and access to the entire joint, helping to achieve a more thorough debridement. In a meta-analysis comparing arthroscopy with arthrotomy for the treatment of septic arthritis, after subanalysis, the authors found that arthroscopy for the knee and shoulder resulted in a lower risk of reoperation, shorter length of hospitalization, and deceased complications. 1 Additionally, they found a pooled reinfection rate of 14.4%. Walinga et al 39 pooled 8586 joints undergoing arthroscopy or arthrotomy for septic arthritis and found a failure rate of 26%. These values are in line with our pooled reoperation rate of 14.3%.
Advocates of arthroscopy may claim a superior postoperative course. Specific benefits may include decreased morbidity, less pain, and accelerated rehabilitation. 24 About 50% of the studies in our review found arthroscopy to be superior to arthrotomy for at least 1 secondary outcome in the postoperative course. Two recent systematic reviews compared arthroscopy with open arthrotomy for the treatment of knee septic arthritis, one reporting arthroscopy to be associated with superior patient-reported outcomes and the other finding greater knee ROM and lower complication rates in the arthroscopy cohort.23,31 In 2 level of evidence 4 systematic reviews of arthroscopic treatment for septic arthritis involving the hip and ankle, the authors of each study concluded arthroscopy to be a safe and effective treatment option.6,24 However, neither study included an open arthrotomy cohort for comparison. A review of case series and case reports for shoulder septic arthritis suggested that arthroscopic treatment can be effective, although results were more guarded, owing to a high reoperation rate at 30%. However, there were several potential confounding variables, including high rates of patients with immunosuppression, MRSA infection, or delayed time to surgery. 25 Although there have been no comparative trials for elbow septic arthritis, 2 case series have shown good results suggesting arthroscopy as a viable treatment option.27,38 Two low-powered studies have supported the use of arthroscopy in pediatric septic arthritis; however, their inclusion is beyond the scope of this review.8,16
Understanding the cost implications of various treatment options may influence a surgeon's surgical approach. Yet, resource utilization remains underreported. One study found that arthroscopic treatment of septic shoulder arthritis significantly reduced hospital costs by $4154 compared with open treatment. 36 For the knee, one study found similar hospital costs regardless of surgical approach, 19 whereas another found a $5674 cost savings associated with arthroscopy. 37
A nationwide database survey found that 70% of orthopaedic surgeons prefer arthroscopy for surgical treatment of septic knee arthritis. 13 Yet, they found no consensus regarding the gold-standard treatment. Many elements play a role in determining which surgical technique to use when treating septic arthritis. This includes surgeon factors such as arthroscopic proficiency and comfort level. Arthroscopy of the hip, elbow, wrist, and ankle, especially, often necessitates subspecialized training. Consequently, our data show that arthrotomies were performed 5 times more often for the wrist and ankle and 10 times more frequently for the hip. Although this disparity is likely attributed to selection bias, arthroscopy does seem to be an appropriate option for these joints. Furthermore, hospital factors like staff familiarity with arthroscopy equipment and timing of operating room availability may also have an influence. Patient factors (comorbidities, age, and existing arthritis) and infection characteristics (duration of symptoms, bacterial pathogen, and infection severity) may also be considered. Specifically, the presence of radiographic lesions on preoperative magnetic resonance imaging scans or radiographs and extra-articular infection are risk factors for failure of arthroscopic treatment.22,40 Multiple studies have also cited MRSA infection and elevated synovial white cell count as risk factors for failure of either arthroscopic treatment or a single surgical debridement.3,11,12,34
One of the strengths of our review was the large number of patients we were able to include. To our knowledge, only 1 previous systematic review has compared the efficacy of arthroscopy versus arthrotomy for septic arthritis, which looked at the shoulder, wrist, hip, and knee in 10,000 patients. 1 Several large database studies have since been published. In our review, we report on an additional 24,000 patients, thus strengthening the validity of our findings. Another strength of our methodology was selecting only comparative studies, whereas many previous reviews have included level 4 studies. We thought the inclusion of a comparative group would provide more objective support when choosing a surgical treatment. However, the literature can still benefit from more comparative studies investigating the intermediate-sized joints. In addition, more well-designed prospective trials to validate our findings should be carried out.
Limitations
We recognize several limitations of the current study. Most of the studies included in our review were retrospective, and more than half involved data extracted from various databases. This increases the potential for selection bias as patient factors or severity of infection may contribute to the selection of surgical technique or outcomes. Although many studies utilized a multivariate analysis or other methods to control confounding, several unmeasured variables such as the causative pathogen, duration of infection, and extent of articular involvement may contribute to confounding bias. Sometimes, a second-look reoperation is in the surgical plan, and this practice would not be accounted for when analyzing reoperations. While most studies utilized a short-term follow-up period, some patients were followed for several years. Thus, some of the reported reoperations may have been related to sequelae of septic arthritis rather than persistent infection. This could either overestimate the rates of treatment failure for eradicating infection or include subsequent surgeries that are independent of the initial surgical technique. Nonetheless, it should be emphasized that the purpose of this study was to evaluate efficacy of surgical techniques, not indications. Finally, we were only able to include 1 or 2 studies for the wrist, hip, and ankle, which speaks to the limited literature available. As such, these findings should be interpreted with caution.
Conclusion
Arthroscopic surgery for the treatment of septic arthritis involving the shoulder, wrist, hip, knee, and ankle appears to be safe and effective. Reoperation rates, short-term complications, and functional outcomes tend to be similar or in favor of arthroscopy when compared with arthrotomy.
Supplemental Material
sj-pdf-1-ajs-10.1177_03635465241285878 – Supplemental material for Arthroscopy Is at Least as Effective as Arthrotomy for Treatment of Septic Arthritis in Adults: A Systematic Review of Large and Intermediate Joints
Supplemental material, sj-pdf-1-ajs-10.1177_03635465241285878 for Arthroscopy Is at Least as Effective as Arthrotomy for Treatment of Septic Arthritis in Adults: A Systematic Review of Large and Intermediate Joints by Brandon M. Nudelman, Amit S. Piple and Richard D. Ferkel in The American Journal of Sports Medicine
Footnotes
Submitted April 5, 2024; accepted May 31, 2024.
One or more of the authors has declared the following potential conflict of interest or source of funding: R.D.F. has received consulting fees from Smith & Nephew, Vericel, and Cannuflow; and research support from Smith & Nephew, DePuy Synthes Mitek Sports Medicine, and Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
An online CME course associated with this article is available for 1 AMA PRA Category 1 Credit™ at https://education.sportsmed.org/Public/Catalog/Home.aspx?CourseSearch=1&Criteria=9&Option=25. In accordance with the standards of the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, editors, and planners disclose to the learners all financial relationships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). Any and all disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy, authors, editors, and planners’ participation in this educational activity will be predicated upon timely submission and review of AOSSM disclosure. Noncompliance will result in an author/editor or planner to be stricken from participating in this CME activity.
References
Supplementary Material
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