Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

344. Surgical Treatment of Septic Arthritis in the Hand and Wrist

Asif M. Ilyas

DEFINITION

images Septic arthritis is defined as an infection within the closed space of a joint.

images It is usually acute and purulent secondary to a pyogenic bacterial infection.

images It causes irreversible damage to articular cartilage and therefore warrants prompt treatment with adequate drainage and an appropriate antibiotic regimen.

images Delay in making the diagnosis and initiating treatment has serious implications for prognosis.

ANATOMY

images The interphalangeal (IP) and metacarpophalangeal (MP) joints of the hand are hinge joints (FIG 1).

images The IP joint space is maximized in slight flexion and the MP joint in extension.

images The wrist joint includes the radiocarpal, midcarpal, and radioulnar joints. Septic arthritis may be present in all of these wrist joint spaces, concomitantly or separately, if there are no interosseous ligament perforations, as is the case in younger patients (see Fig 1).

PATHOGENESIS

images Septic arthritis may affect any joint of the hand or wrist.

images Septic arthritis does not have a gender or race predilection, but it is more common in adults than in children.

images

FIG 1  Anatomy of the interphalangeal, metacarpophalangeal, and wrist joints.

images The inoculation of the joint is most likely due to a penetrating injury (ie, lacerations, puncture wounds, and bites). Other causes include hematogenous seeding or contiguous spread.10

images At the distal IP joint, septic arthritis is common from penetrating trauma as well as contiguous infection from a mucous cyst, felon, paronychia, or suppurative flexor tenosynovitis.

images At the proximal IP joint, contiguous infection is most commonly related to a suppurative flexor tenosynovitis.

images At the MP joint, septic arthritis is most common after direct inoculation from a clenched fist injury or fight bite.

images Hematogenous spread can result from any concomitant or preceding infection of the body, including oral, upper respiratory, gastrointestinal, and genitourinary infections.

images The synovium is highly vascular and contains no limiting basement membrane, promoting easy access of blood contents to the synovial space.3

images The presence of bacteria within the joint induces a cellular and immunologic response that is detrimental to the joint. Bacteria rapidly replicate, producing toxins. The presence of bacteria stimulates an immunogenic response, resulting in the arrival of leukocytes, which produce proteolytic enzymes. Both the bacterial toxins and leukocytic enzymes destroy the articular cartilage of the joint by degrading proteoglycans and eventually injuring the underlying chondrocytes.

images Multiple risk factors can predispose a patient to septic arthritis6 (Table 1).

images Any disorder that results in an immunocompromised state can predispose to septic arthritis.

images Rheumatoid arthritis, in particular, poses a high risk. This risk is related to a variety of factors including general debilitation, immunosuppressive medication, tumor necrosis factor blockers (eg, infliximab or etanercept) and chronic joint injury.

images

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images In patients with rheumatoid arthritis, a diagnosis of septic arthritis may be delayed because of misinterpretation of a rheumatoid flare. A high index of suspicion must be maintained when evaluating for septic arthritis in patients with rheumatoid arthritis.9

images Virtually any microbial pathogen is capable of causing pyogenic septic arthritis (Table 2).

images Staphylococcus aureus and Streptococcus spp. are the most common offending organisms.

images Gram-negative, anaerobic, and polymicrobial infections also are possible, especially in IV drug abusers and immunocompromised patients.

images Specific bacterial pathogens are related to certain circumstances, eg, Eikenella corrodens in human bite wounds, Pasteurella multocida after domestic animal bites, Neisseria gonorrhoeae infections in sexually active young patients, and fungal and mycobacterial infections in immunocompromised patients.

NATURAL HISTORY

images The combination of the growing bacterial load and the ensuing inflammatory response results in a growing effusion that causes synovial ischemia, pressure necrosis of the cartilage, and infiltration of the bacteria into both the subchondral bone and overlying skin.

images Bacterial infiltration out of the joint can result in secondary osteomyelitis, suppurative flexor tenosynovitis, and skin breakdown with spontaneous drainage.

PATIENT HISTORY AND PHYSICAL FINDINGS

images Patients will complain of pain and swelling.

images Systemic signs of joint infection may include fevers, chills, malaise, and tachycardia.

images The patient should be asked about a history of penetrating trauma; human, animal, or insect bites; recent joint aspirations; recent infections elsewhere; and the presence of an immunocompromising condition.

images On examination, patients will manifest a painful swollen joint, with overlying erythema and warmth.

images The most important physical examination finding is exquisite pain with motion, in contrast to a noninfectious effusion or overlying cellulitis.

images Medical professionals at the triage level may attempt to perform a regional block for pain relief. This must be prevented, because it will mask the condition.

images Attempted active digital motion will result in significant guarding, and passive flexion and extension should induce exquisite tenderness.

images Physical examination of the wrist often is less dramatic than that of the digits. The joint typically is held in a neutral position.

images Active wrist motion also will induce guarding and passive flexion, and extension should induce exquisite tenderness.

images Passive pronation and supination may help evaluate involvement of the distal radioulnar joint.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Laboratory studies should include white blood cell count (WBC), erythrocyte sedimentation rate, C-reactive protein, and blood cultures.

images The WBC usually is not elevated, but the erythrocyte sedimentation rate and C-reactive protein levels are consistently elevated (unless the patient is immunocompromised).

images Diagnosis of a septic arthritis is best accomplished by joint aspiration and analysis.

images If infection is present, increased fluid will be present in the joint.

images Joint aspirates should be sent for a cell count with differentiation, Gram stain, crystal analysis, glucose, and cultures (aerobic, anaerobic, fungal, and mycobacterial; Table 3).

images Diagnosis can be made most reliably with a joint fluid WBC count greater than 50,000 (and a differential of 75% or more segmented neutrophils); a Gram stain confirming the presence of bacteria; or positive cultures.5

images A low WBC count with a high percentage of neutrophils (>90%) may indicate an early septic arthritis.11

images A joint glucose of 40 mg/dL or less compared with the fasting blood glucose level also suggests a septic process.7

images Crystal analysis is necessary to rule out the presence of gout or pseudogout, because they also can present similarly, including an elevated WBC count in the aspirate.

images The role of imaging studies early in the course of the septic process is limited. Radiographs may reveal joint distention, presence of foreign bodies, osteomyelitis, air in the soft tissues, and chondrocalcinosis—characteristic of both gout and pseudogout (FIG 2A). Later radiographs will reveal joint destruction.

images MRI is effective in diagnosing early septic arthritis and in differentiating it from osteomyelitis or overlying tenosynovitis (FIG 2B).

images

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FIG 2  A. Radiograph showing chondrocalcinosis of the triangular fibrocartilage complex from chronic pseudogout. B. Coronal T2-weighted MRI of a metacarpophalangeal joint with underlying septic arthritis. Note the normal bone signal but the presence of high signal within the joint from the fluid and surrounding soft tissue inflammation.

DIFFERENTIAL DIAGNOSIS

images Rheumatoid arthritis

images Crystalline arthropathies: gout, pseudogout

images Seronegative arthropathies: systemic lupus erythematosus, psoriatic arthritis, Reiter syndrome, ankylosing spondylitis, rheumatic fever

images Lyme disease

images Cellulitis

images Osteomyelitis

images Suppurative flexor tenosynovitis

NONOPERATIVE MANAGEMENT

images If septic arthritis is detected or suspected early enough, antibiotics alone have been suggested in the medical literature to be sufficient to eradicate the infection.3

images In cases where comorbid conditions contraindicate surgery, serial aspiration of the involved joint can be done to decrease the bacterial load, decompress the joint, and allow medical management with antibiotics to treat the infection.

images This technique has been shown to be less effective than open surgical drainage in large joints and, therefore, would be even less reliable in small joints.4

SURGICAL MANAGEMENT

images Septic arthritis usually is considered a surgical pathology that warrants prompt treatment.

images Open and arthroscopic techniques are available for surgical drainage of the wrist.

Preoperative Planning

images Arrangements for instruments, irrigation fluid, drains, sutures, and assistants should be made in advance of surgery.

Positioning

images Approaches to the hand and wrist can be accomplished with the patient supine and the operative extremity extended on a hand table with the surgeon and assistants seated.

images The hand table should be stable and well-secured, and should allow adequate space for both the operative limb and the surgeon’s elbow and forearm, to minimize surgeon fatigue and enhance stability.

images Tourniquet use is advised to obtain a bloodless field and clear visualization of anatomic structures.

images The limb usually is exsanguinated via gravity with elevation before inflating the tourniquet to avoid proximal spread of the bacteria.

images A small-joint wrist arthroscopy tower should be used. This will provide positioning and application of traction during arthroscopy and also facilitate conversion to an open procedure if necessary. Additionally, small-joint arthroscopy equipment, including a 30-degree 2.7-mm camera, should be used.

Approach

images Multiple approaches to a joint are available. The choice of which approach to use should be based on ease of the approach while still allowing adequate joint exposure for débridement and minimizing contiguous spread of infection.

images All surgical approaches of the hand and wrist warrant a sound understanding of surface anatomy, surgical anatomy, internervous planes, and surgical technique.

TECHNIQUES

ASPIRATION OF INTERPHALANGEAL OR METACARPOPHALANGEAL JOINTS

images  Prepare the skin with an antiseptic wash, but avoid placing local anesthesia before the aspiration, because it may mask the location of the joint space.

images  As large a needle as possible should be used, preferably 18 or 20-gauge.

images  A syringe no larger than 3 or 5 mL should be used, because larger syringes cause too great a vacuum aspiration and collapse the joint, making them, therefore, less effective for aspiration.

images  The joint space can be identified just radial or ulnar to the extensor mechanism on the dorsal surface.

images The needle should be inserted in a dorsal-to-volar direction with a 30to 45-degree angle toward the midline.

images A palpable “pop” or sensation of entering the joint should be felt, and the joint should be aspirated.

images Distraction of the joint can sometimes aid entry.

images If there is resistance to aspiration, the needle should be redirected while maintaining suction on the syringe.

SURGICAL DRAINAGE OF INTERPHALANGEAL OR METACARPOPHALANGEAL JOINTS

images  For the MP joint, a dorsal longitudinal incision is made (TECH FIG 1A). The extensor mechanism is exposed and also incised longitudinally to expose the capsule.

images Alternatively, the capsule can be exposed by incising the ulnar sagittal band.

images  The joint is exposed by incising the capsule dorsal to the collateral ligaments.

images  For the proximal IP joint, a midaxial incision is preferred to avoid injury to the central slip and creation of a septic boutonniere deformity (TECH FIG 1B).

images The neurovascular bundle may be identified and retracted volarly. The dorsal sensory branches are at risk and should be retracted with the dorsal flap.

images The extensor mechanism, including the lateral bands, is identified and retracted dorsally, thereby exposing the capsule laterally. The accessory collaterals (volar to the proper collaterals) are released to allow entry into the joint.

images  The distal IP joint can be approached through a midaxial incision or through a dorsal “H” incision and the terminal tendon retracted laterally, exposing the joint dorsal to the collateral ligaments.

images Injury to the terminal tendon can result in a mallet finger and possible late swan-neck deformity.

images  Obtain cultures and thoroughly irrigate and débride the joint with gravity cystoscopy tubing or a bulb syringe.

images In-line traction on the digit will help expose the joint space.

images  Inspect the joint surfaces for articular damage.

images  Leave a small wick in the joint to prevent premature closure of the joint capsule, and reapproximate the extensor mechanism using a monofilament suture. Avoid using deep braided sutures in the face of an infection.

images  Loosely close the skin around the wick with one or two 4-0 nylon sutures.

images  Place the hand in a volar splint for comfort and emphasize that the patient should keep it elevated.

images

TECH FIG 1  A. Sample incisions for open dorsal drainage of the interphalangeal, metacarpophalangeal, and radiocarpal joints. B. Sample midaxial incision for open drainage of the interphalangeal joints.

ASPIRATION OF THE WRIST

images  Prepare the skin with an antiseptic wash but avoid placing local anesthesia pre-aspiration, because it may mask the location of the joint space.

images  As large a needle as possible should be used, preferably 18-gauge.

images  A syringe no larger than 5 or 10 mL should be used.

images Larger syringes cause too great a vacuum on aspiration and collapse the joint, and are, therefore, less effective for aspiration.

images  The joint space can be identified just distal to Lister’s tubercle on the dorsum of the wrist. The needle should be angled approximately 10 degrees volar to accommodate for the normal volar tilt of the radius.

images Alternatively, the joint may be easily entered through the dorsal ulnocarpal space, just distal to the triangular fibrocartilage complex.

images  A palpable pop or sensation of entering the joint should be felt and the joint should be aspirated. If there is resistance to aspiration then the needle should be redirected while maintaining suction on the syringe.

ARTHROSCOPIC DÉBRIDEMENT OF THE WRIST

images  Secure the hand and wrist in a sterile small-joint arthroscopy tower. Apply 5 to 10 pounds of traction.

images  Identify and mark the dorsal surface anatomy of the wrist. Specifically, palpate the dorsal and distal surface of the radius, ulna, distal radioulnar joint, and Lister’s tubercle. These landmarks will guide safe establishment of portals and maximize visualization (TECH FIG 2).

images  The 3–4 portal is the main “viewing” portal and should be established first to visualize the radiocarpal joint. Begin by identifying the soft spot just distal to Lister’s tubercle. The portal is bordered by the third and fourth dorsal compartments.

images An 18-gauge needle is directed just distal to Lister’s tubercle and should be angled about 10 degrees volar to accommodate for the normal volar tilt of the radius. The joint is then insufflated with 5 to 10 mL of normal saline.

images Create the portal with a 3-mm longitudinal skin incision using a no. 11 blade directed superiorly. Spread the soft tissue bluntly with a curved hemostat down to the joint, avoiding inadvertent penetration of the capsule.

images Direct a blunt-tipped cannula and trocar into the joint, again angling about 10 degrees volar just distal to Lister’s tubercle. Avoid plunging the cannula uncontrolled into the joint, because this may cause iatrogenic articular cartilage injury.

images Replace the trocar with the camera.

images

TECH FIG 2  Dorsal surface anatomy of the wrist. The 3–4 and 4–5 portals are marked. The dashed lines represent approximate location of the radial sensory nerve on the radial side and the dorsal ulnar sensory nerve on the ulnar side.

images  Cultures can be taken through the cannula.

images  Systematically explore the radioscaphoid, radiolunate, and ulnocarpal joints for turbid fluid.

images In addition, evaluate the scapholunate ligament and triangular fibrocartilage complex for tears that may allow the infection to communicate with the midcarpal and distal radioulnar joints, respectively.

images  Establish a second “working” portal. Arthroscopic equipment such as the shaver and probe will be used through this portal. A 25-gauge needle is directed into the proposed site under direct arthroscopic visualization before making the skin incision.

images The 4–5 portal is identified just ulnar to the fourth dorsal compartment and just distal to the distal radioulnar joint (see Tech Fig 2).

images Alternatively, a 6-R or 6-U portal can be used and can be identified just radial or ulnar, respectively, to the sixth dorsal compartment. Diligent blunt dissection with a curved hemostat must be performed before inserting the blunt cannula and trocar to avoid inadvertent injury to the dorsal ulnar sensory nerve.

images  The joint can be both visualized and washed through the camera cannula in the viewing portal and drained through the working portal with a cannula. Drainage can be applied to gravity or suction.

images  The joint can be further débrided with the aid of a shaver with suction placed through the working cannula.

images Devitalized tissues and synovial shavings can be taken through the shaver.

images  Thorough arthroscopic débridement of the wrist should include visualization and irrigation of the midcarpal joint as well.

images Palpate a soft spot about 1 cm distal to the 3–4 portal.

images Place a 25-gauge needle first, and insufflate the joint with 5 mL of normal saline.

images Direct a blunt cannula and trocar into the midcarpal joint just radial to the base of the capitate.

images  After thorough visualization, irrigation, and débridement of the wrist, insert a small Hemovac drain through the working portal cannula.

images  Remove the arthroscopic equipment. Close the portals with 4-0 nylon stitches.

images  Place the wrist in a volar splint for comfort, and encourage limb elevation and active finger motion.

OPEN SURGICAL DRAINAGE OF THE WRIST

images  A dorsal longitudinal incision should be placed just ulnar to Lister’s tubercle (TECH FIG 3A). The incision should be approximately 4 cm in length, with about two thirds distal to the tubercle.

images  Alternatively, a transverse incision may be used. Although more cosmetic, it may not provide adequate exposure.

images  Once the extensor retinaculum is exposed with blunt dissection, the distal third is released perpendicular to the fibers and ulnar to the third dorsal compartment.

images  The interval between the third and fourth extensor compartments is bluntly dissected, and the joint capsule is exposed (TECH FIG 3B).

images  The joint capsule is incised longitudinally, and limited flaps are raised subperiosteally off the dorsal distal radius, like an inverted T (TECH FIG 3C).

images  Cultures are taken, and synovial tissue should be sent for culture and histology.

images  The joint should be thoroughly débrided and irrigated with gravity cystoscopy tubing or a bulb syringe.

images Pulse lavage should be avoided due to its potential to cause additional soft tissue injury.

images The joint should be ranged during irrigation to maximize the effect of the lavage.

images  The joint surfaces are inspected for articular damage.

images  Leave a small wick or drain in the joint and loosely close the skin around the wick.

images Primary closure of the joint risks reaccumulation of pus.

images Typically, two to three loosely placed 4-0 nylon sutures will be sufficient.

images  Place the wrist in a volar splint for comfort and encourage limb elevation.

images

TECH FIG 3  A. Incision for open drainage of the wrist. B. The distal third of the extensor retinaculum is released and the interval between the third and fourth dorsal compartment developed. C. The capsule is arthrotomized with an inverted T.

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POSTOPERATIVE CARE

images Empiric IV antibiotics are initiated immediately after obtaining cultures and then later tailored to the results of laboratory cultures and sensitivities.

images IV antibiotics should be continued for 2 weeks or at least through symptom resolution, followed by oral antibiotics.8

images The duration of antibiotics is the subject of some controversy. This should be determined on a case-by-case basis, with consideration of surgical findings, virulence of the offending bacterial pathogen, and the response to treatment.

images Early range of motion (active and active-assisted) in diluted povidone-iodine soaks is initiated three times daily to provide mechanical lavage of the joint and to prevent premature wound closure.

images The wick or drain is removed 1 or 2 days postoperatively.

images As symptoms resolve, the soaks are discontinued to allow the wound to heal, and progressive range of motion exercises are initiated.

images If symptoms do not improve within 2 days, then a repeat surgical drainage should be considered.

OUTCOMES

images The results of surgical treatment of septic arthritis are not well-documented in the literature, and it is difficult to predict the outcome even during the course of treatment.

images Functional outcome is most closely correlated to the duration of symptoms before treatment is initiated.10

images Some loss of motion and joint stiffness are expected, even in cases treated with early surgical drainage and rehabilitation.1,10,1214

images Some joint space narrowing usually is seen following treatment, and significant arthrosis and ankylosis may occur in severe cases or when treatment has been delayed.

COMPLICATIONS

images Joint stiffness, arthrosis, osteomyelitis, and secondary tendon adhesions

images Salvage options for postseptic arthritis include arthrodesis, resection arthroplasty, or amputation.

images Implant arthroplasty is controversial and is not generally recommended for a previously infected joint.

REFERENCES

1.     Boustred AM, Singer M, Hudson DA, Bolitho GE. Septic arthritis of the metacarpophalangeal and interphalangeal joints of the hand. Ann Plast Surg 1999;42:623–628.

2.     Glass K. Factors related to the resolution of treated hand infections. J Hand Surg Am 1982;7:388–394.

3.     Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med 1985; 312:764–771.

4.     Leslie B, Harris J III, Driscoll D. Septic arthritis of the shoulder in adults. J Bone Joint Surg Am 1989;71:1516–1522.

5.     Li SF, Cassidy C, Chang C, et al. Diagnostic utility of laboratory tests in septic arthritis. Emerg Med J 2007;24:75–77.

6.     Linscheid R, Dobyns J. Common and uncommon infections of the hand. Orthop Clin North Am 1975;6:1063–1104.

7.     Moran G, Talan D. Hand infections. Emerg Med Clin North Am 1993;11:601–619.

8.     Murray P. Septic arthritis of the hand and wrist. Hand Clin 1998; 14:579–587.

9.     O’Dell JR. Anticytokine therapy: a new era in the treatment of rheumatoid arthritis. N Engl J Med 1999;340:310–312.

10. Rashkoff E, Burkhalter W, Mann R. Septic arthritis of the wrist. J Bone Joint Surg Am 1983;65:824–828.

11. Shmerling RH, Delbanco TL, Tosteson ANA, et al. Synovial fluid tests: What should be ordered? JAMA 1990;264:1009–1014.

12. Sinha M, Jain S, Woods DA. Septic arthritis of the small joints of the hand. J Hand Surg Br 2006;31:665–672.

13. Willems C. Treatment of purulent arthritis by wide arthrotomy followed by immediate active mobilization. Surg Gynecol Obstet 1919; 28:546–554.

14. Wittels N, Donley J, Burkhalter W. A functional treatment method for interphalangeal pyogenic arthritis. J Hand Surg Am 1984;9:894–898.



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