Current surgical practice for septic arthritis of the knee in the United States

Survival and risk factor analysis in patients with septic arthritis: a retrospective study of 192 cases

BACKGROUND

Septic arthritis (SA) presents a complex clinical challenge, often resulting in significant morbidity and mortality. This study aimed to (1) assess overall mortality rates and (2) identify potential factors contributing to increased mortality risk in patients with SA.

METHODS

This retrospective study on SA patients treated at a German university hospital between January 1, 2011, and December 31, 2021. Patients were identified using International Classification of Diseases (ICD)-10 codes for septic arthritis, specifically "M00.-". The study evaluated mortality rates and analyzed comorbidities, pathogens, and other potential risk factors. Kaplan-Meier survival curves and odds ratios (OR) were calculated to assess mortality risk.

RESULTS

In a cohort of 192 patients diagnosed with SA, 64 patients (33.3%) died during a mean follow-up period of 54.4 ± 42 months. The overall mortality rate was 17.5% at one year, 19.9% at two years, and 28.3% at five years. Patients aged 65 years or older, as well as those with arterial hypertension, congestive heart failure, chronic renal disease, chronic liver disease, malignancy, steroid use and immunosuppression showed significantly higher mortality rates (p < 0.05). Chronic renal disease (OR = 2.80), malignancy (OR = 3.40), and chronic heart failure (OR = 2.62) were identified as significant notably risk factors for mortality.

CONCLUSION

This study highlights a notably high mortality rate among vulnerable patients with SA, particularly those with pre-existing comorbidities. Recognizing and addressing these risk factors early could improve patient outcomes. These results unterscore the need for close monitoring of SA patients, particularly those with chronic organ conditions, and timely intervention for sepsis to reduce mortality risk.

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.

Genetic Testing Technology Assisting in the Diagnosis and Treatment of Multiple Suppurative Arthritis and Extensive Migratory Skin and Soft Tissue Infections Caused by Disseminated Staphylococcus aureus Disease: A Case Report and Review

Staphylococcus aureus (S. aureus) infection is readily disseminated, yet the multiple septic arthritis and extensive migratory skin and soft tissue infections it causes are uncommon and challenging to treat. The infection can be life-threatening, with a mortality rate of 15-31%. Early, targeted antibiotic therapy is critical to improve prognosis. However, routine cultures are time-consuming and have low positivity rates, which may lead to errors in antibiotic regimen selection, depriving patients of optimal treatment. Genetic testing technologies, such as macrogenomic next-generation sequencing (mNGS) and digital polymerase chain reaction (dPCR), are now emerging as powerful tools for early pathogen diagnosis as well as pathogen diagnosis of target detectors with low microbial loads. In this study, we report a 53-year-old man who was admitted to the ICU for treatment of septic shock. The causative agent was targeted earlier as S. aureus by mNGS, and the shock was corrected more quickly with targeted antibiotic medication. However, he later developed multiple septic arthritis and an extensive migratory skin soft tissue infection with persistent fever, and at one point a gram-negative bacterial infection was suspected, and the antibiotic regimen was incorrectly changed. Blood dPCR suggested that the causative organism was still methicillin-sensitive S. aureus (MSSA), with no drug resistance gene detected, and the anti-infective regimen was readjusted, and the patient eventually recovered and was discharged from the hospital. We present this rare case and review related studies to validate the superiority of genetic testing technology in pathogen diagnosis, which deserves further application.

Osteo-NeT: An Automated System for Predicting Knee Osteoarthritis from X-ray Images Using Transfer-Learning-Based Neural Networks Approach

Knee osteoarthritis is a challenging problem affecting many adults around the world. There are currently no medications that cure knee osteoarthritis. The only way to control the progression of knee osteoarthritis is early detection. Currently, X-ray imaging is a central technique used for the prediction of osteoarthritis. However, the manual X-ray technique is prone to errors due to the lack of expertise of radiologists. Recent studies have described the use of automated systems based on machine learning for the effective prediction of osteoarthritis from X-ray images. However, most of these techniques still need to achieve higher predictive accuracy to detect osteoarthritis at an early stage. This paper suggests a method with higher predictive accuracy that can be employed in the real world for the early detection of knee osteoarthritis. In this paper, we suggest the use of transfer learning models based on sequential convolutional neural networks (CNNs), Visual Geometry Group 16 (VGG-16), and Residual Neural Network 50 (ResNet-50) for the early detection of osteoarthritis from knee X-ray images. In our analysis, we found that all the suggested models achieved a higher level of predictive accuracy, greater than 90%, in detecting osteoarthritis. However, the best-performing model was the pretrained VGG-16 model, which achieved a training accuracy of 99% and a testing accuracy of 92%.

Efficacy of Lavage by Tube under Local Anesthesia versus Arthroscopic Treatment of Acute Septic Arthritis of Native Knee

Although arthroscopic treatment is a minimally invasive surgery that effectively treats septic arthritis of the knee joint, it requires general or regional anesthesia. This study aimed to compare the clinical results of lavage after tube insertion versus arthroscopic treatment. Patients treated with arthroscopic treatment were included in group I (n = 76), while those treated with lavage by tube were included in group II (n = 34). We investigated the following in all patients: demographics, underlying disorders, initial serum white blood cell (WBC) count, C-reactive protein (CRP) level, synovial fluid WBC and polymorphonuclear cell counts, causative organism, initial Kellgren-Lawrence grade, lavage number, interventional delay, hospitalization days, CRP normalization time, and Western Ontario McMaster Universities Osteoarthritis index scores for clinical outcomes at 3 months postoperative. The mean interventional delay was significantly greater in group I (23.6 ± 15.6 h vs. 8.7 ± 9.3 h, p < 0.001). The lavage by tube featured a significantly shorter interventional delay time than arthroscopy, while the CRP decrease rate did not differ between groups. Moreover, lavage by tube showed no significant differences in outcomes, including laboratory results and functional outcomes at 3 months postoperative.

Raised initial total white cell count and lower post-operative decline of C reactive protein increases the risk of secondary surgery in septic arthritis of the native knee

PURPOSE

Septic arthritis is an orthopaedic emergency with high morbidity and mortality. The aim of this study is to determine the risk factors associated with secondary surgery for septic arthritis of the native knee joint.

METHODS

This is a retrospective study reviewing all patients who underwent surgery for septic arthritis of the knee from 2012 to 2019 in a single institution. A total of 117 patients were recruited. Patients were divided into 2 groups: Group I (79/117, 67.5%) underwent one surgery and Group II (38/117, 32.5%) underwent more than one surgery.

RESULTS

Patients with a raised initial total white (TW) cell count of > 20 × 10⁹/L had a significantly higher risk of secondary surgery. (Adjusted hazard ratio 2.42, p < 0.05) A decline of CRP level of less than 20% within 24 h from initial operation was also a risk for secondary surgery. (Adjusted hazard ratio 0.34, p < 0.01) Patients in group II also had significantly higher post-operative median TW cell count and neutrophil count. There was no significant difference in the offending microbe, surgical approach, and duration of operation from initial presentation between the groups.

CONCLUSIONS

Patients with septic arthritis of the native knee joint who present with raised initial total white cell count of > 20 × 10⁹/L and decline of CRP level of less than 20% within 24 h from initial operation are at higher risk of secondary operation. In these patients, more aggressive treatment strategies and appropriate counselling on the risks of repeated surgery are recommended.

LEVEL OF EVIDENCE

Level IV.