In the March 15, 2017 issue of The Journal, Johns et al. report results from a Level III cohort study comparing arthroscopic vs open irrigation for control of acute native-knee sepsis. The authors collected information on more than 160 patients with knee sepsis over a 15-year period, which is a large cohort of patients with this relatively unusual clinical problem.
The data show a cumulative success rate of 97% with arthroscopic treatment after 3 irrigations and debridements vs 83% success in the arthrotomy group after the same number of procedures—a clinically important difference. Significantly fewer arthroscopic procedures were required for successful treatment, relative to open procedures, and post-procedure median knee range of motion was significantly greater in the arthroscopic group (90°) than in the open treatment group (70°).
The fact is that arthroscopic instruments allow a greater volume of irrigation fluid to be instilled with better access to the posterior recesses of the knee. With an open arthrotomy, it is more difficult to irrigate with high volumes, and the posterior recesses of the knee are not well accessed. It seems clear that arthroscopic management of acute knee sepsis should be the standard of care for these reasons, as well as because the technique is minimally invasive in terms of soft tissue stripping and incision size.
Treating infections of major-weight bearing joints is following a trend seen in surgical management of many orthopaedic conditions—smaller exposures with use of adjunctive visualization techniques.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
The issue is whether treatment of septic conditions by multiple interventions is a valid strategy. Three interventions would mean that there were 2 failures.
“Do it right the first time” could be the imperative. It has been suggested that it can be achieved through a high index of suspicion, a process of thorough evaluation (based almost routinely on contrast MRI), and meticulous surgical debridement.Treatment by irrigation would remain an option for early, less severe cases.
The principle of multiple debridements has been reserved for combat casualty care.
Evaluation was based on the following outcomes:
“The primary outcome was the need to return to the operating room. The secondary outcomes were the total number of operations required, the range of motion assessed postoperatively, the length of inpatient stay, and mortality.”
Further evaluation is deemed necessary: Condition of joint cartilage, incidence of chondrolysis and late osteoarthritis (with endpoint TKA).
Is it beyond imagination that multiple revision surgery in septic conditions is a misconception leading to suffering and possibly harm to the patient?
Sincerely,
A. Ludwig Meiss
_ _ _
l.meiss@gmail.com
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