Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis

Arthroscopy Is at Least as Effective as Arthrotomy for Treatment of Septic Arthritis in Adults: A Systematic Review of Large and Intermediate Joints

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.

Arthroscopy or arthrotomy for native knee septic arthritis: A systematic review

Purpose

Septic arthritis of any joint is an orthopaedic emergency which requires prompt diagnosis and treatment. The knee is the commonest joint afflicted, and the primary objective of any treatment is complete source control. This commonly takes the form of antibiotic therapy and a washout of the infected joint by means of arthroscopy or arthrotomy. The primary aim of this review is to investigate if arthroscopic washout for native knee septic arthritis confers a lower risk of repeat procedure than arthrotomy.

Methods

A systematic review and meta-analysis was conducted of the MEDLINE, SCOPUS and the Cochrane Library data bases. The primary outcome of interest was requirement for repeat washout with all-cause complications, length of inpatient stay and mortality secondary outcomes.

Results

A total of 17,140 subjects were included for analysis of the primary outcome, and the overall rate of repeat procedure was 14.6%. No statistical difference was found between arthroscopy and arthrotomy for repeat washout (risk ratio 0.86 [95% confidence interval, CI: 0.72-1.02], I 2 = 36%). Eligible studies found in favour of arthroscopy for all-cause complication rate (risk ratio 0.75 [95% CI: 0.6-0.93], I 2 = 84%) and length of stay in hospital (mean difference -1.98 days [95% CI: -3.43 to -0.53], I 2 = 84%). No statistical difference was found for the mortality rate (risk ratio 1.17 [95% CI: 0.52-2.63], I 2 = 57%).

Conclusion

Our analysis found arthroscopy and open arthrotomy to be equivocal for repeat surgical washout in native knee septic arthritis. All-cause complication rate and length of inpatient stay were favourable for arthroscopy with no difference noted between mortality rates.

Level of Evidence

Level III.

Editorial Commentary: Arthroscopic Irrigation and Debridement is an Effective Treatment for Acute Septic Arthritis of Native Joints

Arthroscopic irrigation and debridement has long been known to be an effective treatment for acute septic arthritis of native joints. Systematic review shows that when compared to open irrigation and debridement, arthroscopy yields comparable hospital length of stay complication, reoperation, and readmission rates, as well as better patient-reported outcomes compared to open arthrotomy. However, reoperation rates are heterogeneously defined in the literature, not to mention that unplanned return to surgery likely suggests inadequate prior irrigation and debridement of an infection, whereas a planned repeat washout may be a surgeon's intention and practice for septic arthritis. Most of all, this condition should be managed urgently.