65: Arthroscopic Treatment for Septic Arthritis

Procedure 65 Arthroscopic Treatment for Septic Arthritis



William B. Geissler, Daniel C.M. Williams



Indications




image Arthroscopic synovectomy has been shown to be beneficial in patients with symptomatic, refractory reactive arthritis.


• Arthroscopy will allow for diagnosis and treatment of suspected joint infection.

• Arthroscopy assists in distinguishing between infectious and noninfectious inflammatory arthritis.

image Arthroscopy allows for not only continuous irrigation of joint space but also débridement of infected material.


• Smaller incisions and quicker return to use of wrist are desired by the patient as well as the surgeon.


Examination/Imaging



Clinical Examination




image Examine the entire wrist for swelling, redness, warmth, and pain.


image The range-of-motion examination will produce exquisite pain with both active and passive motion.


image Hematogenous spread will manifest with systemic signs of infection, which may include fever, chills, tachycardia, and diaphoresis.


image Evaluation with laboratory tests should be done and should include white blood cell count (WBC), erythrocyte sedimentation rate, and C-reactive protein levels.


image Joint fluid can be obtained at the initiation of the procedure and should be evaluated with Gram staining, culture and sensitivity, WBC count, and crystal analysis.



Imaging




image Radiographs should be obtained and are useful for determining foreign bodies, soft tissue gas, and osteomyelitis.


image Magnetic resonance imaging can also be obtained and can give a better view of joint effusion, soft tissue fluid collections, and bone involvement.



Surgical Anatomy




image Structures to be identified and marked are Lister tubercle, articular margins, and the radius and ulna.


image Tendons that should be identified are the extensor digitorum communis (EDC), the extensor digiti minimi (EDM), and the extensor carpi ulnaris (ECU).


image Portal sites 3-4, 4-5, radial and ulna midcarpal, and 6U are marked before starting the procedure.



Positioning




image A sterile traction tower is used to suspend the elbow flexed at 90 degrees.


image The index and long finger are placed in finger traps, and a 10-lb weight is applied through the traction tower (Fig. 65-1).


image A gravity inflow system is used instead of the typical infusion pump system to help decrease the chance of disseminating infected fluid into the surrounding soft tissue structures.


image An arthroscope, 30-degree angled lens, camera, and full radius joint shaver setup are needed for this procedure.


image

FIGURE 65-1



Exposures




image Extremity exsanguination is generally contraindicated because of the joint infection. In some situations a tourniquet may be used to allow better visualization of the wrist joint. If a tourniquet is used, the arm is elevated to let the blood drain before tourniquet inflation.


image The anatomic landmarks are identified before starting the procedure. The portal sites are then marked, which are the radiocarpal, 3-4, 6R, 6U, and radial and ulna midcarpal portals.


image The 6R portal is located by palpating the ECU tendon. The portal is made just radial to the tendon.


image The 3-4 portal is located by palpating the concavity between the extensor pollicis longus and EDC tendons just distal to Lister tubercle in line with the radial border of the long finger (Fig. 65-2).


image The radial midcarpal portal is located about 1 cm distal to the 3-4 portal, and the ulna midcarpal portal is located about 1 cm distal to the 6R portal in line with the midaxis of the ring finger.


image

FIGURE 65-2



Procedure




Step 1




image Inflow is initially placed through the 6U portal. The joint is inflated.

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 89: Total Wrist Fusion

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 65: Arthroscopic Treatment for Septic Arthritis

Full access? Get Clinical Tree
Get Clinical Tree app for offline access