SLR - August 2022 - Joshua Manning, DPM
Reference: Ramamurti P, Agarwal AR, Gu A, et al. Increased risk of 90-day surgical-site infection and hospital readmission but not reoperation after open arthrotomy when compared with arthroscopy for septic ankle arthritis. Arthroscopy. 2022;38(6):1999-2006.e1.Level of Evidence: 3
Scientific Literature Review
Reviewed By: Joshua Manning, DPM
Residency Program: Mount Auburn Hospital, Cambridge, MA
Podiatric Relevance: Septic joints are a surgical emergency, and septic arthritis of the ankle carries substantial morbidity. Without prompt treatment it can lead to osteomyelitis, cartilage destruction and ultimately loss of function for the patient in the affected joint. Prompt treatment requires irrigation and debridement coupled with immobilization and intravenous antibiotics. Open and arthroscopic irrigation and debridement have been used effectively to surgically address septic ankle arthritis. This study found no difference in surgical reoperation rates between arthroscopic and open techniques, and found a significant increase in surgical site infections and hospital readmission rates in cases where an open technique was utilized.
Methods: Patients were identified with an all payer insurance database specifically targeting patients with open or arthroscopic debridement for septic ankle arthritis. A power calculation was performed to identify proper numerical significance. The diagnosis of septic ankle arthritis and a 90 day follow up was used as inclusion criteria. Patients were excluded if they failed to meet the 90 day follow up, is a previous ankle procedure was performed within six months, if a simultaneous procedure was performed such as hardware removal, or if there was a superimposed soft tissue or osseous infection.
Results: Nine hundred sixty-two (962) patients met inclusion criteria, 794 (82.4 percent) underwent open arthrotomy and 168 (17.46 percent) underwent arthroscopic debridement. Univariate analysis found no difference in reoperation rate within 90 days (p = .047) and found patients undergoing open arthrotomy had higher rates of surgical site infections (7.2 percent vs 2.3 percent, p = .014), and hospital readmissions (47.7 percent vs 35.12 percent, p = .004) as compared to arthroscopic techniques. Multivariate analysis controlling for confounding variables confirmed this statistical difference.
Conclusions: This study is limited by use of an insurance database to identify patients, the exclusion of patients with superimposed infection, and its inability to identify if effective antibiotic coverage was empirically started before culture and sensitivity was obtained. Proper arthroscopic technique is critical in providing thorough visualization to allow for accurate debridement to provide complete evacuation of infected and devitalized tissue. Followed by extensive irrigation, this study finds arthroscopic irrigation and debridement an efficacious treatment for ankle septic arthritis and holds less risk of surgical site infection and readmission as compared to open techniques.