A functional treatment method for interphalangeal pyogenic arthritis

Managing Small Joint Septic Arthritis of the Hand

Background: Current guidance for the management of septic arthritis is limited to large joints and, therefore, unspecific to the small joints of the hand, which may present differently, require different diagnostic approaches, and have different complications. The aim of this article was to review current treatment trends for the management of small joint septic arthritis (SJSA) of the hand and offer guidelines for its management. Methods: A systematic review was carried out according to PRISMA guidelines and a survey distributed to Fellows of the British Society for Surgery of the Hand to establish expert opinion. The review and survey were combined to present a set of specific SJSA of the hand infection guidelines. Results: All 20 included studies recommended physical drainage of infected joint fluid; subsequent lavage and early antibiotic therapy, with physiotherapist-guided joint mobilisation. Statistical analysis of the 77 responses to our survey revealed that (in order of preference) the diagnosis was made by history and examination, blood tests, joint aspiration and vital signs; and for interventions: joint elevation and intravenous antibiotics; then joint washout repeated within 48 hours, if necessary. Conclusions: Small joint infection differs from large joint infection because it is difficult to obtain joint aspirate without damaging or opening the joint. We, therefore, recommend utilising exclusion blood tests, imaging and the clinical picture to establish the diagnosis and implement early treatment and rehabilitation. Level of Evidence: Level III.

[Infections of the Proximal and Distal Interphalangeal Joint: 4 weeks of Immobilisation between initial Surgery with Joint Resection and secondary Joint Fusion is sufficient]

BACKGROUND

In 2011 we published our treatment regime for infections of the interphalangeal joints of the hand with infection-related macroscopic cartilage damage. We recommended the resection of the infected joint followed by 6 weeks of immobilisation by external fixation before secondary arthrodesis. In 2013 we reduced the period of immobilisation to 4 weeks within a prospective study.

PURPOSE

This paper analyses the effect of a shortened immobilisation time of 4 instead of 6 weeks between joint resection and secondary joint fusion in bacterial infection of the proximal and distal interphalangeal joint.

PATIENTS AND METHODS

Between March 2013 and July 2014, 20 patients with an infection of an interphalangeal joint of the hand were treated by joint resection and secondary arthrodesis after a reduced time of immobilisation of 4 weeks. The patients were clinically and radiologically evaluated at median of 5,8 (4,7-10,5) months. The results were statistically analysed and compared with the previous study published 2011.

RESULTS

The reduced immobilisation period from 6 to 4 weeks did not result in a significant difference of revisions (p = 0.148). In 18 of 20 patients, the joint infection was reliably cured and the following arthrodesis consolidated. One patient required a revision surgery due to a persistent joint infection, a second patient got a revision surgery after arthrodesis because of a displaced implant. The range of motion of the infected finger was median 147.5 (30-220)°. Achieving a grip strength of 26 (4-64) kg, the affected hand reached 88.5 (47,8-223,1) % of the strength of the opposite side. The subjective functioning of the hand was good (DASH 37.9 (3.3-71.7), Krimmer-Score 2 (1-4)). We did not observe any persistent pain at rest (VAS 0 (0-3)) or under daily activities (VAS 1.3 (0-7)). 50 % of patients stated a sensitivity to cold. Our study of 2011 revealed similar results (ROM of the infected finger 142.5 (30-220)°, grip strength 95 (33-127)%, DASH-Score 23.3 (0-130), Krimmer Score 2 (1-4), VAS at rest 0 (0-7), VAS under stress 4.5 (0-9), sensitivity to cold in 41 % of 27 patients).

CONCLUSION

A decreased immobilisation period from 6 to 4 weeks between joint resection and secondary arthrosis for infections of the interphalangeal joints of the hand do not lead to a negative outcome. The described therapeutical regime results in reliable cure of the bacterial joint infection with a good function of the finger and only minor subjective discomfort.

Septic Joints: Finger and Wrist

Infections in the joints of the hand and wrist carry the risk of significant morbidity. Common presenting symptoms include joint redness, swelling, and pseudoparalysis that occurs several days following a penetrating trauma. Diagnostic workup should be expedited, including a laboratory evaluation and arthrocentesis. Imaging, including radiographs, ultrasound, computed tomography, and/or MRI, are helpful tools in diagnosis. Once infection is identified, prompt surgical debridement and antibiotics are required. Once the infection has been managed, hand therapy is initiated to decrease the risk of stiffness. Stiffness is the most common complication following infection; additional reported complications include arthritis, ankylosis, and amputation."

Techniques for Continuous Irrigation of Septic Joints of the Hand

Septic arthritis of the small joints of the hand usually occurs secondary to bacterial inoculation through penetrating injury to the joint, or direct spread of infection from paronychia, felon, or pyogenic flexor tenosynovitis. Surgical treatment involves drainage and irrigation and may involve debridement if there is an open wound. We describe a method of continuous irrigation of septic joints of the hand postoperatively in the ward setting using an intravenous cannula placed within the joint and connected to an intravenous giving set with delivery of physiological fluid using a pump driver. Modifications of the technique are described for distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints and illustrated in each joint by 3 case studies. In addition to the irrigation, intravenous antibiotics were administered. All patients healed well with a full return of joint motion, no radiologic change, and a mean QuickDASH score of 4.8 at a mean follow-up duration of 3.6 months. This is a safe and simple technique that can be performed in patients with suspected or confirmed septic arthritis and carries minimal morbidity.

Septic Arthritis of the Small Joints of the Hand

Twenty-five patients with sepsis of 26 hand joints were treated by urgent debridement, antibiotics and early hand therapy. We reviewed 15 patients (16 joints) in a clinic and three patients by postal questionnaire after a mean follow-up of 54 (range 10–94) months. Of the 26 involved joints, 14 had restricted motion at discharge. Stiffness increased with increase in delay between onset and treatment. At final review, one joint with painful degenerative changes had been fused. Seven patients had regained full movements. The remaining six had some stiffness but, nevertheless, had undergone significant improvement in the ranges of movement. There were two cases with radiological joint degeneration in this group of six patients. Three patients had mild, intermittent pain. No patient had significant disability. While there is significant loss of motion after this joint pathology in the early recovery period, overall motion and function appears to improve over the longer term.

Catheter irrigation for treatment of pyogenic closed space infections of the hand

We studied 29 patients admitted to San Francisco General Hospital with flexor tenosynovitis (6 patients), pyogenic arthritis (17 patients), and deep space infections (6 patients). All patients underwent catheter irrigation of the infected space for at least 48 hours postoperatively. In 23 patients no further operative procedures were required. Infection was controlled without amputation in all patients. Median hospital stay was the same for patients with tenosynovitis, pyogenic arthritis, and deep space infections (8 days). Thirteen of 17 patients followed for at least one month, including 7 of 9 patients with pyogenic arthritis, were found to have regained at least 50% of baseline motion. In this series the outcome of treatment for pyogenic arthritis was comparable to that for tenosynovitis. We believe that catheter irrigation should be considered as a treatment option in pyogenic arthritis. A prospective trial comparing the efficacy of treatment modalities for pyogenic arthritis is indicated.