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Acute septic arthritis results from bacterial invasion of a joint space, which can occur
through hematogenous spread, direct inoculation from trauma or surgery, or contiguous
spread from an adjacent site of osteomyelitis or cellulitis. Despite in-depth research into
the pathophysiology and treatment of acute septic arthritis, the morbidity and mortality
are still significant, especially in patients at the extremes of age. Even with the currently
available treatment regimens and antibiotics, serious complications may result. Delay in
diagnosis and failure to begin treatment promptly are the most common reasons for late
complications of infection. Studies now focus on identifying specific types of bacterial
etiologies and predisposing risk factors and on the host’s response to the infection,
particularly interleukin-1 (IL-1) and how it affects the destruction of articular cartilage.
Acute septic arthritis can occur at any age, but young children and elderly individuals are
most susceptible. An immature immune system, immune compromise for any reason,
neoplasms, alcoholism, diabetes mellitus, rheumatoid arthritis, systemic lupus
erythematosus, malnutrition, chronic hepatic or renal failure, intravenous drug use, and
previous joint trauma or arthritis predispose an individual to septic arthritis and alter the
normal bacterial etiology. Therefore a thorough history and physical examination should
be done.
Septic arthritis occurs most frequently in adults; however, the most serious sequelae from
infection occur in children, especially if a hip joint is involved and treatment has been
delayed. Age-dependent anatomical variables may be responsible for the serious
complications in children, such as destruction of the epiphysis and associated avascular
necrosis from increased intracapsular pressure and septic effusion.
In adults, Neisseria gonorrhoeae is the most common infecting organism. This infection
commonly occurs in young adults and has a slightly different presentation than other
types of infectious arthritis. Often the infection is polyarticular and may be associated
with a papular rash. Joint cultures often are negative, but cultures from the pharynx or
urethra may be positive. Gonococcal arthritis generally has a favorable outcome when
treated with appropriate antibiotics, and drainage usually is not necessary. The most
common nongonococcal cause of septic arthritis in adults is Staphylococcus aureus. As in
children, adults typically have monoarticular involvement, and the infecting organism
spreads by the hematogenous route. The hips and knees are the most frequently affected
sites.
Hematogenous spread of infection occurs frequently because the vascular spaces of the
synovium lack a basement membrane, allowing the contents of the vascular space
relatively easy access to the joint space. Polyarticular disease is seen more frequently in
adults with rheumatoid arthritis.
If the diagnosis is made early and the involved joint is superficial, such as the elbow or
ankle, aspiration should be performed and repeated if necessary, appropriate antibiotics
should be administered, the joint should be splinted in a position of function, and the
patient should be observed for a decrease in pain, swelling, and temperature and for
improved joint mobility. Infections caused by less virulent organisms usually respond
promptly to treatment. If the response is not favorable and repeat aspiration does not
show a decrease in the synovial leukocyte count within 24 to 48 hours, open surgical
drainage is necessary. If purulent material is deeply situated in a joint, such as the
shoulder or hip, open surgical drainage should be carried out. Arthroscopic drainage is a
good alternative to open drainage in many instances, especially for infections involving
the knee, elbow, shoulder, or ankle.
Initial antibiotic treatment is empirically based on the patient’s age and the risk factors.
Empirical antibiotic therapy should be used until culture and sensitivity results are
available. Although some infections clear up within 7 days, antibiotic regimens often
should be continued for 4 to 6 weeks, depending on the clinical course.
As the infection resolves, therapy to restore normal joint function is begun, including
functional splinting initially to prevent deformity, isometric muscle strengthening, and
active range-of-motion exercises. Salter, Bell, and Keeley have shown the beneficial
effects of continuous passive motion in inhibiting the formation of adhesions and pannus
and in promoting better nutrition for the cartilage during the healing phase. Patients being
treated for infectious arthritis often have varying degrees of deformity, and treatment with
traction, dynamic splints, serial casting, and passive exercises may be useful.
In the residual stage the infection has completely subsided but the joint or joints involved
are left with deformity or limitation of motion, and treatment is directed at correction and
functional restoration of the joint. However, the possibility of reactivating the infection
should be considered when any necessary procedure is undertaken at this stage.
With current techniques of bone grafting, internal fixation, and external fixation,
definitive surgery in many instances can be performed earlier, and rehabilitation of the
joints and soft tissues can thus be started earlier. The condition of the soft tissues
surrounding a nonunion must be considered in treatment planning. Unyielding scar
tissues, especially on the concave side of a deformity,may result in skin necrosis; deep
scarring may prevent bone transport or grafting; and the need for skin grafting or flap
coverage may influence treatment selection. Soft tissue contractures must be considered
if treatment of the nonunion will result in lengthening of the extremity.
In patients with histories of vascular injuries or those with weak or absent peripheral
pulses, an arteriogram may be indicated to evaluate vascular status. A significant vascular
abnormality may limit treatment methods and fracture healing. Vascular abnormalities
should be corrected.
Any nerve injuries should be carefully evaluated; if possible, the nerve should be
repaired. Occasionally an extremity must be shortened to gain length in repairing a nerve
defect. To avoid nerve damage the Ilizarov technique may be considered for gradual
lengthening and treatment of the nonunion. When the nerves are so damaged that
sensation and muscle power in a lower extremity are permanently lost, amputation
usually is the practical choice.
1. ‘‘Elephant foot’’ nonunions. These are hypertrophic and rich in callus. They result
from insecure fixation, inadequate immobilization, or premature weight-bearing
in areduced fracture with viable fragments.
2. ‘‘Horse hoof’’ nonunions. These are mildly hypertrophic and poor in callus. They
typically occur after a moderately unstable fixation with plate and screws. The
ends of the fragments show some callus, insufficient for union, and possibly a
little sclerosis.
3. Oligotrophic nonunions. These are not hypertrophic, and callus is absent. They
typically occur after major displacement of a fracture, distraction of the
fragments, or internal fixation without accurate apposition of the fragments.
In the second type the nonunion is avascular (atrophic) or inert and is incapable of
biological reaction. Studies of strontium 85 uptake in these nonunions indicate a poor
blood supply in the ends of the fragments.
Avascular nonunions are subdivided as follows:
Reduction of fragments. When the fragments are in good position but are separated by
fibrous tissue, extensive dissection usually is undesirable; leaving periosteum, callus, and
fibrous tissue intact about the major fragments preserves their vascularity and stability,
and, after a bridging graft or grafts have united with the fragments, the intervening
fibrous tissue and callus ossify.
Displaced, and especially bayonet, nonunions of any long bone can be reduced by
gradual traction in a simple pin fixator before closed intramedullary nailing. In
cooperative patients posttraumatic shortening usually can be corrected rapidly; we have
been able to obtain lengthening of up to 1 cm per day in divided increments. The external
fixator is applied for a few days to restore length, the fixator is removed, and closed
intramedullary nailing is performed. We have had no problems with infections after a
brief period of external fixation. Alternatively, an Ilizarov frame can be used to restore
length, appose fragments, and stabilize the fragments until union.
Plating and bone grafting of displaced nonunions of most long bones require a more
extensive operation. Scar tissue about the nonunion must be excised so that the grafts can
be covered by relatively normal tissue. The fragments are then mobilized, preserving
their normal soft tissue attachments as much as possible, their rounded ends are resected
so that contact will be maximal, their medullary canals are cleared of fibrous tissue to aid
in medullary osteogenesis, and they are then apposed as closely as possible.
Bone grafting. For many years, the most frequently used method of treatment of
nonunions has been bone grafting, and numerous techniques have been described.
Autogenous bone graft, allograft bone, or synthetic bone substitute, used alone or in
conjunction with internal fixation, may help to stimulate bone formation.
Onlay bone graft. Massive cortical grafts combine fixation and osteogenesis in treating
nonunions of the long bones.
Dual onlay graft. Because union in congenital pseudar throsis of the tibia is hard to
obtain. Two cortical onlay grafts are placed opposite each other on the host bone across
the nonunion and are fixed with the same set of screws.
Cancellous insert grafts. Nicoll described a technique of bridging gaps in long bones
with solid blocks of cancellous bone and fixing the fragments with metal plates. This
procedure has been useful in patients with defects less than 2.5 cm long.
External fixation. The Ilizarov external fixator is a labor intensive but very effective tool
in the treatment of nonunions, especially those associated with defects, shortening, and
deformities. More traditional type pin external fixators, using the Ilizarov principles, also
can be used in the management of nonunions, especially when complicated by infection.
Recently, hybrid circular frames attached to uniplanar external fixators have decreased
some of the problems associated with this demanding technique. External fixation can be
used for temporary or definitive stabilization. One advantage of external fixation is that it
is relatively noninvasive and does not disturb soft tissues surrounding the nonunion.
Other advantages are its ability to correct deformity and provide stable fixation.
Nonunions may be complicated by infection, poor soft tissue quality, short periarticular
fragments, or significant deformity.
The skin over the bone is made as nearly normal as possible. Three operations may be
necessary to provide this type of skin. In the first the wound is thoroughly saucerized, and
all foreign and infected or devitalized materials are removed to provide a vascular bed.
Any gross overlapping and displacement of the fragments are corrected through the
wound. Fixing the fracture internally has some advantages, but the use of foreign
materials in an infected fracture may be unwise. With rare exceptions an intramedullary
nail should not be used. If plates and screws are used, drainage almost always persists
until they are removed, but they do allow the fracture to become stabilized by fibrous
tissue in satisfactory position. Steinmann pins can be inserted through the bone proximal
and distal to the fracture and incorporated in a cast; the cast can then be windowed for
dressing the wound. An external fixator also can be used. This method is safer, but
fixation is less secure than when a plate is used. Antibiotics are used both parenterally
and locally after surgery. After 4 to 7 days, when a thin layer of granulation tissue has
covered the wound, a split-thickness skin graft is applied. The split graft is replaced by a
full-thickness pedicled skin graft 4 to 6 weeks after the wound has healed from the
operation. A local rotation flap or vascularized free flap can be used to fill the soft tissue
defect left by the debridement. In our experience infections can be more easily controlled
when new, highly vascular, soft tissue is used to cover the fracture, especially infected
nonunions of the distal tibia. Bone grafting is deferred until the graft has completely
healed and has become stabilized. In some patients the fracture may then unite, and
grafting is unnecessary.
When the clinical signs of infection have subsided, the skin over the bone is good, and
nonunion persists, bone grafting must be considered. There may never be a safe time to
graft the nonunion, for whether an infection has been completely eradicated or is merely
quiescent cannot be surely determined; yet a time must be selected, or the operation must
be abandoned. The character and duration of the infection, the time of the last drainage,
and the general condition of the extremity all must be considered.
When an infection has been active chiefly in the soft tissues or about sequestra, the risk
of reactivating it by surgery is much less than when it has involved the cortex and
medullary canal of the major fragments; when it has been prolonged and destructive, all
the surrounding structures are presumed to have been deeply penetrated, and a dormant
infection is likely. Pocketed in cortical bone, bacteria may lie dormant for years, only to
become active again after surgery or some other trauma. This danger is inherent in the
treatment of ununited open fractures and must be accepted. The use of antibiotics before
and after surgery has reduced the danger, since they can often control an infection within
the limits of a vascular area, but they cannot be expected to sterilize an avascular area
that they cannot penetrate. Although the length of time since the last drainage is not in
itself a reliable index of safety, reconstructive operations usually should be delayed until
at least 6 months after all signs of infection have disappeared.
Controlling infection before attempting bone grafting always has been a sound clinical
principle in the conventional treatment of nonunions. However, there are exceptions to
this principle, especially in the tibia. Jones and Barnett, Freeland and Mutz, Jones,
Marmor, and others have reported successful bone grafting in tibial nonunions even in the
presence of draining sinuses. In sequestration or gross infection, the bone is saucerized
through an anterior approach, the incision is closed, and the infection is treated with
antibiotics by irrigation and suction
The first step is restoration of bony continuity. This takes absolute priority over treatment
of the infection. The nonunion is exposed through the old scar and sinuses. The ends of
the fragments are then decorticated subperiosteally, forming many small osteoperiosteal
grafts; any grafts that become detached are discarded. Next all devitalized and infected
bone and soft tissues are removed. Then the fragments are aligned and stabilized, usually
by an external fixation device. Compression is applied across the nonunion if possible.
Weber and Eech then insert autogenous cancellous bone grafts. Internal fixation with a
plate is used only when drainage has already ceased, and then the approach is away from
the area of old drainage, or when no other method of fixation is possible and the infection
is mild. When the fracture already has been firmly fixed with a plate or intramedullary
nail, the fixation is not disturbed and the operation is carried out as described, except
decortication is omitted when an intramedullary nail has been used. Finally a tube for
suction drainage is inserted, and as much of the wound as possible is closed; any
remaining open area is covered by iodoform gauze. Systemic antibiotics are given.
If necessary for union, a second decortication with or without the addition of cancellous
iliac bone grafts is carried out. After the nonunion has healed, any residual sequestra are
removed and split-thickness skin grafts are applied to any remaining defect in the skin.
Ilizarov method. Combinations of several of the methods described for infection can be
used for treatment of the separate components of a complex nonunion, but the Ilizarov
method allows simultaneous treatment of all components, including angular, rotary, and
translational deformities, shortening, and segmental bone loss (Figure 52-13). Although
dramatic results can be obtained, this method is technically demanding and requires
thorough training and experience. Its use is not recommended except by surgeons
knowledgeable in its biological basis and the techniques required for its safe, effective
application. The development of hybrid circular frames attached to uniplanar external
fixators has decreased some of the problems associated with this demanding technique.
Reference:
Williams KD Infectious Arthritis in Campbell's Operative Orthopaedics, Terry J. Canal
ed, Mosby CD online, 1999; Chapter 15