Corticosteroids as an adjunct to antibiotics and surgical drainage for the treatment of pyogenic flexor tenosynovitis

Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis

BACKGROUND

Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment.

METHODS

A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach.

RESULTS

Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores.

CONCLUSIONS

Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

[Pyogenic Flexor Tenosynovitis]

Pyogenic flexor tenosynovitis (PFT) is still the most serious infections of the hand. If the typical cardinal signs of PFT according to Kanavel exist, the indication for surgery should be made immediately. The consequential damage of a delayed surgery with enormous restrictions on the movement of the fingers due to the destruction of the sliding layers and massive adhesions are so serious that conservative therapy attempts are very difficult to justify. The results of Hand therapy after delayed surgery are often disappointing. The rapid surgical intervention and the early opening and relief as well as the irrigation of the tendon sheath can end the disease, the destruction of the sliding layers and the severe pain almost immediately. Quick recognition and quick action are important. With early intervention, normal hand function can often be completely restored.

Optimizing Treatment of Hand Infections: Is MRSA Coverage Always Necessary?

Multiple publications have highlighted the prevalence of methicillin resistant Staphylococcus aureus (MRSA) as a cause of hand infections. We hypothesized that these publications have shifted the empiric treatment of hand infections. The aim of this study was to identify the current standard of care, the most common causative bacteria, and factors leading to extended length of stay for hand infection patients at a suburban hospital to improve treatment and establish an optimized care protocol.

Methods

Retrospective cohort analysis was conducted to identify all patients admitted for hand infections over an 8-year period. A comprehensive chart review of each patient's hospital course was completed.

Results

A total of 70 patients were included. Maximum white blood cell count ≥ 12 was associated with a significantly longer hospital length of stay (9.1 days versus 5.4 days) compared to WBC values < 12 (P < 0.05). Also, 11 out of 23 (47.8%) underwent two or more incision and drainages (I&D's), compared with patients with maximum WBC < 12. Vancomycin use as an empiric antibiotic was widespread (68 patients, 97.1%), despite only 14 (20%) having MRSA positive cultures. Univariate analysis identified a significant increased likelihood for increased length of stay (P < 0.05) and rise in creatinine (P < 0.05) in patients with an initial vancomycin trough level > 20.

Conclusions

This analysis of hand infection treatment in a suburban hospital demonstrates the incidence of MRSA hand infections may not be universally high across institutions. Each hospital should review its own data to optimize hand infection treatment and its associated costs.

Development of a Murine Model of Pyogenic Flexor Tenosynovitis

BACKGROUND

Pyogenic flexor tenosynovitis is a debilitating infection of the hand flexor tendon sheath with high morbidity despite standard treatments of empiric antibiotics with irrigation and debridement. In vivo studies in the available literature have used avian models, but these models are difficult to scale and maintain. The purpose of this study was to demonstrate the plausibility of a murine model of pyogenic flexor tenosynovitis utilizing bioluminescence imaging and tissue analysis at harvest.

METHODS

A 2-μL inoculate of bioluminescent Xen29 Staphylococcus aureus or sterile phosphate-buffered saline solution (sPBS) was administered to the tendon sheath of 36 male C57BL/6J mice. The infectious course was monitored by bioluminescence imaging (BLI) via an in vivo imaging system, gross anatomic deformity, and weight change. The infected hind paws were harvested at 4 time points: 24 hours, 72 hours, 1 week, and 2 weeks for histological analysis using Alcian blue, hematoxylin, and Orange-G staining. Two-way analysis of variance with the Sidak multiple comparison test was used to assess differences in bioluminescence and weight at each time point.

RESULTS

The infected cohort displayed significantly elevated bioluminescence values, had reductions in weight, and exhibited swelling of the infected digit throughout the course of infection. By day 4, most infected mice saw a substantial decrease in BLI signal intensity; however, 2 infected mice exhibited persistent BLI intensity through day 14. Histological analysis of the infected cohort showed tissue disorganization and the presence of a cellular infiltrate in and around the flexor tendon sheath.

CONCLUSIONS

A murine model of pyogenic flexor tenosynovitis is possible and can serve as an experimental platform for further investigation of the pathophysiology of pyogenic flexor tenosynovitis.

CLINICAL RELEVANCE

This animal model can be utilized in elucidating the basic molecular and/or cellular mechanisms of pyogenic flexor tenosynovitis while simultaneously evaluating novel therapeutic strategies.

Pyogenic Flexor Tenosynovitis: Evaluation and Management

Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring to ensure clinical improvement.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT) is a common closed-space infection of the flexor tendon sheaths of the hand, which remains one of the most challenging problems facing hand surgeons. PFT goes by several names including septic or suppurative flexor tenosynovitis. Adequate treatment requires timely diagnosis and often prompt surgical treatment. However, despite prompt treatment, and regardless of the protocol used, complication rates as high as 38% have been reported in the literature. Moreover, even with successful eradication of the infection, a significant proportion of patients will suffer from continuing pain, swelling, stiffness, loss of composite flexion, weakness, and recurrence potentially requiring amputation. This review will focus on current evidence-based antimicrobial and surgical treatment strategies to maximize treatment outcomes.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT)is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity. Management of PFT, regardless of the pathogen, includes prompt administration of empirical intravenous antibiotics and often surgical treatment. However, currently, there is no standardized treatment algorithm for PFT in regards to the need for, timing, or type of surgical treatment. Many utilize a combination of surgical decompression and sheath irrigation. However, despite prompt treatment, and regardless of the protocol used, complication rates can be high, leading to impaired function and even amputation of the affected digit. Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen. This paper reviews the background, microbiology, and treatment options and controversies surrounding PFT.

Rethinking Pyogenic Flexor Tenosynovitis: Biofilm Formation Treated in a Cadaveric Model

Introduction  Pyogenic flexor tenosynovitis (PFT) of the hand remains a challenging problem that often requires surgical irrigation and parenteral or oral antibiotics. The authors hypothesize that the pathophysiology and microenvironment of PFT can be likened to that of periprosthetic joint infections (PJIs), in which bacteria thrive in a closed synovial space with limited blood supply. As such, they postulate that PFT is also facilitated by bacterial attachment and biofilm formation rendering standard treatments less effective. In this study, they evaluate infected tendons for the presence of biofilm and explore new treatment strategies. Methods  Fresh human cadaveric hand tendons were harvested and divided into 0.5-cm segments. Samples were sterilized and inoculated with 1 × 10 ⁴ CFU/mL green fluorescent Staphylococcus aureus (GFP-SA) for 48 hours at 37°C. After saline washing to remove plank tonic bacteria, samples were treated for 24 hours with (1) saline irrigation, (2) antibiotics (vancomycin), (3) corticosteroids, or (4) antibiotics/corticosteroid combined. Samples were visualized using confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM). Results  Following bacterial challenge, CLSM revealed heterogeneous green fluorescence representing bacterial attachment with dense biofilm formation. SEM at > 3,000X, also demonstrated bacterial colonization in grape-like clusters consisted with a thick matrix characteristic of biofilm. Bacterial load by direct colony counting decreased by 18.5% with saline irrigation alone, 42.6% with steroids, 54.4% with antibiotics, and 77.3% with antibiotics/steroids combined ( p  < 0.05). Conclusion   Staphylococcus aureus readily formed thick biofilm on human cadaveric tendons. The addition of both local antibiotics and corticosteroids resulted in greater decreases in biofilm formation on flexor tendons than the traditional treatment of saline irrigation alone. We suggest rethinking the current treatment of PFT and recommend considering a strategy more analogous to PJI management with the adjunctive use of local antibiotics, corticosteroids, and mechanical agitation.

A systematic review of the management of acute pyogenic flexor tenosynovitis

Pyogenic flexor tenosynovitis (PFT) is an aggressive closed-space infection that can result in severe morbidity. Although surgical treatment of pyogenic flexor tenosynovitis has been widely described, the role of antibiotic therapy is inadequately understood. We conducted a literature review of studies reporting on acute pyogenic flexor tenosynovitis management. A total of 28 case series articles were obtained, all of which used surgical intervention with varied use of antibiotics. Inconsistencies among the studies limited summative statistical analysis. Our results showed that use of antibiotics as a component of therapy resulted in improved range of motion outcomes (54% excellent vs. 14% excellent), as did using catheter irrigation rather than open washout (71% excellent vs. 26% excellent). These studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. As broad-spectrum antibiotics have changed the management of other infectious conditions, we must more closely evaluate consistent antibiotic use in pyogenic flexor tenosynovitis management.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Biomechanical effects of steroid injections used to treat pyogenic flexor tenosynovitis

BACKGROUND

A recent study from our laboratory has demonstrated improved range of motion in the toes of broiler chickens afflicted with pyogenic flexor tenosynovitis when treated with local antibiotic and corticosteroid injections, without surgical drainage. However, the use of corticosteroids as an adjunct treatment raised peer concern, as steroids are thought to have deleterious effects on tendon strength. The purpose of this study was to compare the tensile strength of the aforementioned steroid treated tendons, to a group of tendons administered with the current standard treatment: systemic antibiotics, surgical drainage and no corticosteroids.

METHODS

Twenty-three tendons' structural and material properties were investigated (fifteen receiving the standard treatment, eight receiving the steroid treatment). The measurements from each group were interpreted via Student's unpaired t-test and a post-hoc power analysis.

RESULTS

The steroid treated tendons did demonstrate a trend toward decreased mechanical properties when compared with the standard treatment group, but the results were not statistically significant.

CONCLUSIONS

Treatment of septic tenosynovitis with local corticosteroid and local antibiotic injections resulted in better digital motion, without a significant loss of tendon strength, over a twenty-eight day recovery period.

Flexor tendon sheath infections of the hand

Flexor tendon sheath infections of the hand must be diagnosed and treated expeditiously to avoid poor clinical outcomes. Knowledge of the sheath's anatomy is essential for diagnosis and to help to guide treatment. The Kanavel cardinal signs are useful for differentiating conditions with similar presentations. Management of all but the earliest cases of pyogenic flexor tenosynovitis consists of intravenous antibiotics and surgical drainage of the sheath with open or closed irrigation. Closed irrigation may be continued postoperatively. Experimental data from an animal study have shown that local administration of antibiotics and/or corticosteroids can help lessen morbidity from the infection; however, additional research is required. Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. Patients with medical comorbidities or those who present late with advanced infection can expect poorer outcomes, including severe digital stiffness or amputation.