SLR - June 2019 - Ashmi H. Patel
Native Joint Septic Arthritis: Comparison of Outcomes with Medical and Surgical Management
Reference: Harada K, McConnell I, DeRycke E, Holleck J, Gupta S. Native Joint Septic Arthritis: Comparison of Outcomes with Medical and Surgical Management. South Med J. 2019 Apr; 112(4), 238–243.
Scientific Literature Review
Reviewed By: Ashmi H. Patel, DPM
Residency Program: Kaiser Permanente Vallejo, North Bay Consortium, Vallejo, CA
Podiatric Relevance: Septic arthritis (SA) in native joints is estimated to have an incidence of four to 12/100,000 patient-years and is known to be a medical emergency requiring hospitalization, immediate surgical washout and IV antibiotics. The incidence of SA appears to be rising, likely due to the increase in the aging population. Despite early recognition and widespread use of antibiotics, mortality is estimated to be 2 percent to 14 percent, and approximately one third of surviving patients experience functional impairment from joint deterioration. Management guidelines for native joint infections are vague because of the lack of clinical data to guide clinical treatment. Early joint drainage and systemic antibiotics are the standard of care to prevent irreversible damage to the joint; however, no guidelines exist for choosing the joint drainage method.
Methods: A 10-year chart review was conducted in patients hospitalized for SA in a veteran population to compare outcomes based on management: medical (bedside closed-needle joint aspiration) versus surgical (arthrotomy/arthroscopy). Inclusion criteria included positive synovial fluid culture, positive blood culture from patient with clinical features of SA when synovial fluid cultures were negative or negative cultures but clinical evidence of infection with purulent joint fluid (synovial fluid WBC > 100 kg/mL) without evidence of synovial fluid crystals. Demographic, clinical, diagnostic and outcome data were also collected.
Results: Sixty-one patients met inclusion criteria. Forty-six percent had diabetes mellitus, 43 percent had preexisting factors of concern, 11.5 percent were active intravenous drug users, 21 percent were taking immunosuppressive medications and one had confirmed human immunodeficiency virus disease. There was no statistical difference in risk factors between medically and surgically managed patients. Forty-one patients were managed surgically (15 arthroscopy, 24 arthrotomy and two had both) and 20 received closed-needle aspiration. There were no statistically significant differences in long-term outcomes between the two groups at 12 months. Patients managed medically were more likely to experience full recovery at three months and were less likely to need short-term rehabilitation.
Conclusions: Medical management of native SA by serial bedside closed-needle aspiration may be a more adequate management strategy than a surgical approach that is most commonly performed. This study found that medically managed patients had a higher likelihood of recovering from native joint SA within three months and a lower likelihood of requiring short-term rehabilitation; however, outcomes at 12 months was similar. Medical management is a more cost-effective approach and can be a better alternative in the elderly population with significant comorbidities, but larger sample size studies will need to be performed to provide more evidence to develop practice guidelines in management of native joint infections.