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Arthroscopic surgery for septic arthritis of the hip joint in 4 adults
Arthroscopic Surgery for Septic Arthritis of the Hip Joint in 4 Adults Yasuhiro Yamamoto, M.D., Takatoshi Ide, M.D., Nobuaki Hachisuka, M.D., Shingo Maekawa, M.D., and Noriya Akamatsu, M.D.
Purpose: Arthroscopic surgery for septic coxarthritis has not become a well-established technique despite its minimally invasive nature. The authors performed arthroscopic surgery and intraoperative high-volume irrigation on 4 adult patients with septic coxarthritis. This minimally invasive procedure was successful in treating these patients, and there was no recurrence of arthritis or other complications. The purpose of this article is to introduce this 3-directional-approach method of arthroscopic surgery for septic coxarthritis. Type of Study: Case study of arthroscopic surgery for septic arthritis of the hip joint in 4 adults. Methods: There were 3 women and 1 man with an average age of 58 years. The length of time from onset of symptoms to surgery averaged 36 days. One patient had diabetes; another had subarachnoid hemorrhage and was being treated with steroidal drugs. The etiologic agent was found to be Staphylococcus aureus infection in 2 patients, Serratia sp. in 1 patient, and group-B Streptococcus in 1 patient. Three-directional-approach arthroscopic surgery and intraoperative high-volume irrigation were performed using 20 to 25 L of physiologic saline on the 4 patients. Continuous postoperative intra-articular irrigation was not performed. Results: Inflammatory reactions subsided within 4 weeks of surgery in 3 of the 4 patients and within 6 weeks in the other patient. At the time of the final examination, the postoperative follow-up period ranged from 1 to 6 years and none of the patients had ankylosis of the hip joint. Conclusions: Three-directionalapproach arthroscopic surgery in combination with intraoperative large-volume irrigation is an effective technique for treating septic arthritis of the hip joint because the joint can be preserved and it is less invasive than other open arthrotomy techniques. Key Words: Septic arthritis—Hip joint—Arthroscopy.
W
hen treating adult patients with septic arthritis, it is important to remove any pus and to perform debridement and lavage at an early stage. In the hip joint, this is usually done by open arthrotomy and drainage. However, as these procedures may require dislocation of the femoral head, there is a risk of complications such as aseptic necrosis of the femoral head or dislocation of the hip joint. Additionally, this
From the Department of Orthopaedic Surgery, Yamanashi Medical University, Yamanashi, Japan. Address correspondence and reprint requests to Yasuhiro Yamamoto, M.D., Department of Orthopaedic Surgery, Yamanashi Medical University, 1110 Shimokato, Tamaho-cho, Nakakomagun, Yamanashi 409-3821, Japan. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 0749-8063/01/1703-2401$35.00/0 doi:10.1053/jars.2001.20664
290
kind of invasive procedure obliges patients to endure long-term bed rest and hospitalization. In contrast, arthroscopic surgery for septic arthritis of the knee joint has become a well-established technique because of its minimally invasive nature and accelerated rehabilitation. To the best of our knowledge, there have been reports published on only 2 adults and 1 child undergoing arthroscopic surgery for septic arthritis in the hip. In every case, an arthroscope was inserted only from the lateral or anterolateral side, and either a drainage tube was placed or continuous intra-articular irrigation was performed after surgery. In contrast, the 3-directional-approach method we describe facilitates the performing of intra-articular debridement and high-volume irrigation during surgery. This also allows the surgical wounds to be
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 290 –297
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS
291
FIGURE 1. The 3-directionalapproach arthroscopic surgery. (Reprinted with permission.2)
closed immediately after surgery, achieving satisfactory results.
METHODS Three-directional-approach arthroscopic surgery was performed on the 4 patients described below using the method of Ide et al.1 Three arthroscopes are inserted into the hip joint from 3 different directions: anterior, lateral, and anterolateral. Arthroscopy of the hip in most cases requires general or spinal anesthesia and a traction table. In the 3-directional-approach method, 2 arthroscopes are inserted to examine and irrigate the hip joint, and a surgical instrument is inserted through the third portal to perform arthroscopic surgery. In other words, the lateral compartment can be operated on
by means of anterolateral instrumentation with anterior inspection. Similarly, the medial compartment is operated on using either anterolateral instrumentation with anterior inspection, or anterior instrumentation with anterolateral inspection. The anterior compartment is operated on by anterolateral instrumentation with lateral inspection and the femoral neck compartment by anterior instrumentation with anterolateral inspection. As a result, almost all areas of the hip joint can be examined and debrided (Fig 1). Intraoperative high-volume irrigation was performed using 20 to 25 L of physiologic saline (average, 23 L). However, continuous postoperative intraarticular irrigation was not performed. Seven days after surgery, the patients’ involved legs were put in indirect traction of 2 to 3 kg in the 30° abduction position of the hip joint. Exercises for the hip joint
TABLE 1. Patient Data Case
Age (yr)
Sex
Duration of Symptoms
Culture Result
Comorbidity
1 2 3 4
50 57 46 83
F M F F
19 d 99 d 7d 14 d
Serratia sp. S. aureus Group-B Streptococcus S. aureus
SAH, steroidal drug
Abbreviations: SAH, subarachnoid hemorrhage; DM, diabetes mellitus.
DM, steroidal drug
Follow-up 72 18 18 18
mo mo mo mo
292
Y. YAMAMOTO ET AL.
FIGURE 2. Case 1: A 50-year-old woman with septic arthritis of the left hip joint. (A) At initial visit, (B) 6 years after surgery. (Reprinted with permission.2)
were commenced, and weight bearing was permitted 3 weeks after surgery. RESULTS
FIGURE 3. Case 1: Arthroscopic finding of the left hip joint with the anterior approach. The forceps are being inserted through the anterolateral portal. (Reprinted with permission.2)
Four patients underwent arthroscopic hip surgery for hematogenous septic arthritis. There were 3 women and 1 man with an average age of 58 years (range, 42 to 83 years). The length of time from onset of symptoms to surgery averaged 36 days (range, 7 to 99 days). One patient had diabetes and another patient had subarachnoid hemorrhage. The latter was being treated with steroidal drugs. The etiologic agent was found to be Staphylococcus aureus in 2 patients, Serratia sp. in 1 patient, and group-B Streptococcus in 1 patient (Table 1). After surgery, intravenous administration of 2 g cefazolin was given daily for a week, followed by daily oral administration of 300 mg Cefdinir (Fujisawa, Japan) for another week. Inflammatory reactions subsided within 4 weeks of surgery in 3 of the 4
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS
FIGURE 4.
293
Case 2: A 57-year-old man with septic arthritis of the right hip joint. (A) At initial visit, (B) 1 year after surgery.
patients and within 6 weeks in the other patient. The postoperative follow-up period ranged from 1 to 6 years (average, 2.2 years) and at the time of final examination, none of the patients had ankylosis of the hip joint. Case 1: A 50-Year-Old Woman
FIGURE 5. Case 2: Arthroscopic finding of detached cartilage in the right hip joint with the anterior approach. The forceps are being inserted through the anterolateral portal.
For the 7-week period before referral, this patient had been receiving steroidal drugs to treat a subarachnoid hemorrhage and thrombophlebitis of the leg in the neurosurgery department of our hospital. The patient began to experience pain in the left hip joint and was referred to our department 15 days later. An assessment of the patient’s condition revealed a slight fever of 37°C, an elevated white blood cell count (WBC) of 9,700/L, C-reactive protein (CRP) concentration of 6.3 mg/dL, and an erythrocyte sedimentation rate (ESR) of 80 mm/hour. A radiograph detected a bone defect in the lateral side of the left femoral head (Fig 2A), and arthrocentesis further con-
294
FIGURE 6.
Y. YAMAMOTO ET AL.
Case 3: A 42-year-old woman with septic arthritis of the right hip joint. (A) At initial visit, (B) 1 year after surgery.
firmed the presence of Serratia. On the 19th day of illness, arthroscopic surgery was performed to remove the proliferative synovial membrane, granulation tissue, and detached cartilage from the lateral side of the 2femoral head (Fig 3). However, a plain radiograph taken 9 weeks after surgery showed an enlarged bone defect; as a result, arthroscopic surgery was performed again 3 months after the initial surgery. A hematologic test did not show any abnormality. The postoperative course of this patient has been favorable. At present (6 years after surgery), the patient does not have coxalgia. However, she walks with a crutch because of hip joint contracture and reduced muscle force caused by left hemiplegia (Fig 2B).2 Case 2: A 57-Year-Old Man
FIGURE 7. Case 3: Arthroscopic finding of the right hip joint with the lateral approach. The cartilage fragment is being removed with forceps from the anterolateral portal.
This man was diagnosed as having septic arthritis of the right hip joint 65 days after onset at a different hospital. Despite intravenous administration of 2 g cefotiam and oral 200 mg minocycline (both admin-
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS istered daily for 2 weeks), coxalgia did not improve, and as a result the patient was transferred to our hospital. At the time of his transfer, the patient’s WBC was normal at 7,700/L, but moderate inflammatory reactions were confirmed: CRP of 3.7 mg/dL, and ESR of 45 mm/hour. A plain radiograph showed narrowing of the right hip joint space (Fig 4A), and arthrocentesis of the hip joint confirmed the presence of S. aureus. Arthroscopic surgery was performed on the 99th day of illness, and arthroscopy showed detached and damaged articular cartilage and marked proliferation of granulation tissue. Debridement of damaged tissue was performed, and the hip joint was irrigated using 22 L of physiologic saline (Fig 5). At 3 weeks after surgery, the results of hematologic and biochemical tests had normalized to a WBC of 5,200/ L, CRP of 0.3 mg/dL, and ESR of 12 mm/hour. A radiograph taken 1 year after surgery showed a deformed femoral head. However, the range of motion of the hip joint was not restricted, and the patient did not experience pain when walking (Fig 4B).
FIGURE 8.
295
Case 3: A 42-Year-Old Woman This patient visited our hospital because of a sudden onset of coxalgia. The sharp pain caused her to be in an iliopsoas position, and the results of hematologic and biochemical examinations showed inflammatory reactions: WBC of 16,200/L, CRP of 12.6 mg/dL, and ESR of 122 mm/hour. However, a plain radiograph revealed no abnormalities (Fig 6A). After arthrocentesis confirmed the presence of group-B Streptococcus, intramuscular injections of 200 mg gentamicin were administered daily until arthroscopic surgery was performed on day 7 of the illness. A proliferation of synovial membrane and some cartilage damage were observed and consequently removed. The joint was then irrigated with 20 L of physiologic saline (Fig 7). Three weeks after surgery, the results of a hematologic test had normalized to a WBC of 3,700/L, CRP of 0.3 mg/dL, and ESR of 14 mm/hour. At present (18 months after surgery), the
Case 4: An 80-year-old woman with septic arthritis of the right hip joint. (A) At initial visit, (B) 1 year after surgery.
296
Y. YAMAMOTO ET AL.
femoral head appears almost normal, and the patient does not have any particular complaint (Fig 6B). Case 4: An 80-Year-Old Woman This patient had been undergoing treatment for diabetes at a different hospital for 25 years. Coxalgia suddenly appeared 7 days before the initial examination at our hospital. Despite being treated with an intra-articular administration of a steroidal drug at a neighborhood clinic, the pain had become exacerbated. At this point, the patient was referred to our department. The patient was in an iliopsoas position, and severe inflammatory reactions were confirmed: WBC of 11,000/L, CRP of 24.5 mg/dL, and ESR of 105 mm/hour. A plain radiograph showed a narrowing of the joint space (Fig 8A). After arthrocentesis confirmed the presence of S. aureus, 2 g of cefazolin was administered intravenously daily for 7 days before the operation. Arthroscopic surgery was performed on the 14th day of the illness. The cartilage at the weightbearing area had become detached, a proliferation of synovial membrane and granulation tissue were observed, and all were consequently removed (Fig 9). The hip joint was then irrigated with 25 L of physiologic saline. At 3 weeks after surgery, the results of a hematologic test had normalized. At 18 months after surgery, the range of motion in the hip joint was
FIGURE 9. Case 4: Arthroscopic finding of the right hip joint with anterior approach. A proliferation of synovial membrane and granulation tissue were observed on the femoral head.
unrestricted. The patient experienced mild coxalgia only after walking for a long time (Fig 8B). DISCUSSION In adult patients, it is extremely difficult to achieve thorough synovectomy in hip joints with small-incision arthrotomy, and dislocation of the femoral head may be required. In such situations, there is a risk of complications such as aseptic necrosis of the femoral head or dislocation of the hip joint, and the recovery period may also be prolonged. Conversely, arthroscopic surgery is minimally invasive and offers several advantages. To the best of our knowledge, there have been reports published on only 2 adults and 1 child having arthroscopic surgery for septic arthritis: Blitzer,3 Bould et al.,4 and Chung et al.5 Blitzer and Chung et al. stated that the most important factor influencing the result was early treatment. In contrast, we performed arthroscopic surgery an average of 36 days after the initial onset of symptoms and favorable results were obtained. The difference between previous reports and ours exists in the following points. In every case, an arthroscope was inserted only from a single side. Chung et al. performed irrigation from the anterolateral side and pointed out that the main disadvantage of this approach was that the medial part of the joint and the femoral neck could not be easily viewed. On the other hand, with our technique, 3 arthroscopes are inserted from 3 different directions to allow for thorough debridement of diseased tissues. According to our experiment of hip arthroscopy on 355 joints,6 medial instrumentation with medial inspection makes it extremely difficult to sufficiently perform synovectomy around the cotyloid fossa. The most reliable techniques are anterolateral instrumentation with anterior inspection and anterior instrumentation with anterolateral inspection. On the other hand, some damage and detachment of cartilage was observed in the weight-bearing area of the femoral head in each of the 4 cases. Although the amount of cartilage damage cannot be quantified, it can be said that the patient who underwent arthroscopic examination on the seventh day of illness (case 3) showed only mild damage, whereas the patient who underwent arthroscopic examination on the 99th day of illness (case 2) showed extreme damage. The damage was particularly severe in the weight-bearing area of the femoral head. We believe that this cartilage damage is triggered by infection and exacerbated by mechanical stress.
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS The main causes of joint cartilage destruction in septic coxarthritis are a rise in intra-articular pressure and lysozymes. This is the main reason for the postoperative placement of a drainage tube, to release the intra-articular pressure and to irrigate the lysozymes. Bould et al.4 and Chung et al.5 placed a drainage tube, and Blitzer3 performed continuous intra-articular irrigation for 24 to 72 hours after surgery. However, it is our experience that an inverse flow of physiologic saline solution can occur from the sutured incision for 24 hours following arthroscopic examination. Therefore, we believe that placement of such a tube for decompression is unnecessary. Additionally, the 3-directional-approach method uses 2 portals to irrigate the hip joint, enabling a fast flow. An average of 23 L of physiologic saline solution is used during a 2-hour operation, which is a greater amount than Blitzer et al. achieved irrigating postoperatively. We believe this is an effective method for irrigating lysozymes. High-volume irrigation was performed during surgery, allowing the surgical wounds to be closed immediately thereafter, thus satisfactorily achieving the treatment objective. These points illustrate some of
297
the advantages of the 3-directional-approach method, which we recommended. CONCLUSIONS Three-directional-approach arthroscopic surgery in combination with intraoperative large-volume irrigation is an effective technique for treating septic arthritis of the hip joint because the joint can be conserved, and it is less invasive than other open arthrotomy techniques. REFERENCES 1. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery of hip joint. Arthroscopy 1991;7:204-211. 2. Maekawa S, Ide T, Hachisuka N, Akamatsu N. Septic coxarthritis treated with arthroscopic surgery [in Japanese]. Hip Joint 1994:20:186-191. 3. Blitzer CM. Arthroscopic management of septic arthritis of the hip. Arthroscopy 1993;9:414-416. 4. Bould M, Edward D, Villar RN. Arthroscopic diagnosis and treatment of septic arthritis of the hip joint. Arthroscopy 1993; 9:707-708. 5. Chung WK, Slater GL, Bates EH. Treatment of septic arthritis of the hip by arthroscopic lavage. J Pediatr Orthop 1993;13: 444-446. 6. Ide T, Akamatsu N. Arthroscopic synovectomy of the hip [in Japanese]. Kotu Kansetu Jintai 1992;5:811-820.
Purpose: Arthroscopic surgery for septic coxarthritis has not become a well-established technique despite its minimally invasive nature. The authors performed arthroscopic surgery and intraoperative high-volume irrigation on 4 adult patients with septic coxarthritis. This minimally invasive procedure was successful in treating these patients, and there was no recurrence of arthritis or other complications. The purpose of this article is to introduce this 3-directional-approach method of arthroscopic surgery for septic coxarthritis. Type of Study: Case study of arthroscopic surgery for septic arthritis of the hip joint in 4 adults. Methods: There were 3 women and 1 man with an average age of 58 years. The length of time from onset of symptoms to surgery averaged 36 days. One patient had diabetes; another had subarachnoid hemorrhage and was being treated with steroidal drugs. The etiologic agent was found to be Staphylococcus aureus infection in 2 patients, Serratia sp. in 1 patient, and group-B Streptococcus in 1 patient. Three-directional-approach arthroscopic surgery and intraoperative high-volume irrigation were performed using 20 to 25 L of physiologic saline on the 4 patients. Continuous postoperative intra-articular irrigation was not performed. Results: Inflammatory reactions subsided within 4 weeks of surgery in 3 of the 4 patients and within 6 weeks in the other patient. At the time of the final examination, the postoperative follow-up period ranged from 1 to 6 years and none of the patients had ankylosis of the hip joint. Conclusions: Three-directionalapproach arthroscopic surgery in combination with intraoperative large-volume irrigation is an effective technique for treating septic arthritis of the hip joint because the joint can be preserved and it is less invasive than other open arthrotomy techniques. Key Words: Septic arthritis—Hip joint—Arthroscopy.
W
hen treating adult patients with septic arthritis, it is important to remove any pus and to perform debridement and lavage at an early stage. In the hip joint, this is usually done by open arthrotomy and drainage. However, as these procedures may require dislocation of the femoral head, there is a risk of complications such as aseptic necrosis of the femoral head or dislocation of the hip joint. Additionally, this
From the Department of Orthopaedic Surgery, Yamanashi Medical University, Yamanashi, Japan. Address correspondence and reprint requests to Yasuhiro Yamamoto, M.D., Department of Orthopaedic Surgery, Yamanashi Medical University, 1110 Shimokato, Tamaho-cho, Nakakomagun, Yamanashi 409-3821, Japan. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 0749-8063/01/1703-2401$35.00/0 doi:10.1053/jars.2001.20664
290
kind of invasive procedure obliges patients to endure long-term bed rest and hospitalization. In contrast, arthroscopic surgery for septic arthritis of the knee joint has become a well-established technique because of its minimally invasive nature and accelerated rehabilitation. To the best of our knowledge, there have been reports published on only 2 adults and 1 child undergoing arthroscopic surgery for septic arthritis in the hip. In every case, an arthroscope was inserted only from the lateral or anterolateral side, and either a drainage tube was placed or continuous intra-articular irrigation was performed after surgery. In contrast, the 3-directional-approach method we describe facilitates the performing of intra-articular debridement and high-volume irrigation during surgery. This also allows the surgical wounds to be
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 290 –297
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS
291
FIGURE 1. The 3-directionalapproach arthroscopic surgery. (Reprinted with permission.2)
closed immediately after surgery, achieving satisfactory results.
METHODS Three-directional-approach arthroscopic surgery was performed on the 4 patients described below using the method of Ide et al.1 Three arthroscopes are inserted into the hip joint from 3 different directions: anterior, lateral, and anterolateral. Arthroscopy of the hip in most cases requires general or spinal anesthesia and a traction table. In the 3-directional-approach method, 2 arthroscopes are inserted to examine and irrigate the hip joint, and a surgical instrument is inserted through the third portal to perform arthroscopic surgery. In other words, the lateral compartment can be operated on
by means of anterolateral instrumentation with anterior inspection. Similarly, the medial compartment is operated on using either anterolateral instrumentation with anterior inspection, or anterior instrumentation with anterolateral inspection. The anterior compartment is operated on by anterolateral instrumentation with lateral inspection and the femoral neck compartment by anterior instrumentation with anterolateral inspection. As a result, almost all areas of the hip joint can be examined and debrided (Fig 1). Intraoperative high-volume irrigation was performed using 20 to 25 L of physiologic saline (average, 23 L). However, continuous postoperative intraarticular irrigation was not performed. Seven days after surgery, the patients’ involved legs were put in indirect traction of 2 to 3 kg in the 30° abduction position of the hip joint. Exercises for the hip joint
TABLE 1. Patient Data Case
Age (yr)
Sex
Duration of Symptoms
Culture Result
Comorbidity
1 2 3 4
50 57 46 83
F M F F
19 d 99 d 7d 14 d
Serratia sp. S. aureus Group-B Streptococcus S. aureus
SAH, steroidal drug
Abbreviations: SAH, subarachnoid hemorrhage; DM, diabetes mellitus.
DM, steroidal drug
Follow-up 72 18 18 18
mo mo mo mo
292
Y. YAMAMOTO ET AL.
FIGURE 2. Case 1: A 50-year-old woman with septic arthritis of the left hip joint. (A) At initial visit, (B) 6 years after surgery. (Reprinted with permission.2)
were commenced, and weight bearing was permitted 3 weeks after surgery. RESULTS
FIGURE 3. Case 1: Arthroscopic finding of the left hip joint with the anterior approach. The forceps are being inserted through the anterolateral portal. (Reprinted with permission.2)
Four patients underwent arthroscopic hip surgery for hematogenous septic arthritis. There were 3 women and 1 man with an average age of 58 years (range, 42 to 83 years). The length of time from onset of symptoms to surgery averaged 36 days (range, 7 to 99 days). One patient had diabetes and another patient had subarachnoid hemorrhage. The latter was being treated with steroidal drugs. The etiologic agent was found to be Staphylococcus aureus in 2 patients, Serratia sp. in 1 patient, and group-B Streptococcus in 1 patient (Table 1). After surgery, intravenous administration of 2 g cefazolin was given daily for a week, followed by daily oral administration of 300 mg Cefdinir (Fujisawa, Japan) for another week. Inflammatory reactions subsided within 4 weeks of surgery in 3 of the 4
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS
FIGURE 4.
293
Case 2: A 57-year-old man with septic arthritis of the right hip joint. (A) At initial visit, (B) 1 year after surgery.
patients and within 6 weeks in the other patient. The postoperative follow-up period ranged from 1 to 6 years (average, 2.2 years) and at the time of final examination, none of the patients had ankylosis of the hip joint. Case 1: A 50-Year-Old Woman
FIGURE 5. Case 2: Arthroscopic finding of detached cartilage in the right hip joint with the anterior approach. The forceps are being inserted through the anterolateral portal.
For the 7-week period before referral, this patient had been receiving steroidal drugs to treat a subarachnoid hemorrhage and thrombophlebitis of the leg in the neurosurgery department of our hospital. The patient began to experience pain in the left hip joint and was referred to our department 15 days later. An assessment of the patient’s condition revealed a slight fever of 37°C, an elevated white blood cell count (WBC) of 9,700/L, C-reactive protein (CRP) concentration of 6.3 mg/dL, and an erythrocyte sedimentation rate (ESR) of 80 mm/hour. A radiograph detected a bone defect in the lateral side of the left femoral head (Fig 2A), and arthrocentesis further con-
294
FIGURE 6.
Y. YAMAMOTO ET AL.
Case 3: A 42-year-old woman with septic arthritis of the right hip joint. (A) At initial visit, (B) 1 year after surgery.
firmed the presence of Serratia. On the 19th day of illness, arthroscopic surgery was performed to remove the proliferative synovial membrane, granulation tissue, and detached cartilage from the lateral side of the 2femoral head (Fig 3). However, a plain radiograph taken 9 weeks after surgery showed an enlarged bone defect; as a result, arthroscopic surgery was performed again 3 months after the initial surgery. A hematologic test did not show any abnormality. The postoperative course of this patient has been favorable. At present (6 years after surgery), the patient does not have coxalgia. However, she walks with a crutch because of hip joint contracture and reduced muscle force caused by left hemiplegia (Fig 2B).2 Case 2: A 57-Year-Old Man
FIGURE 7. Case 3: Arthroscopic finding of the right hip joint with the lateral approach. The cartilage fragment is being removed with forceps from the anterolateral portal.
This man was diagnosed as having septic arthritis of the right hip joint 65 days after onset at a different hospital. Despite intravenous administration of 2 g cefotiam and oral 200 mg minocycline (both admin-
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS istered daily for 2 weeks), coxalgia did not improve, and as a result the patient was transferred to our hospital. At the time of his transfer, the patient’s WBC was normal at 7,700/L, but moderate inflammatory reactions were confirmed: CRP of 3.7 mg/dL, and ESR of 45 mm/hour. A plain radiograph showed narrowing of the right hip joint space (Fig 4A), and arthrocentesis of the hip joint confirmed the presence of S. aureus. Arthroscopic surgery was performed on the 99th day of illness, and arthroscopy showed detached and damaged articular cartilage and marked proliferation of granulation tissue. Debridement of damaged tissue was performed, and the hip joint was irrigated using 22 L of physiologic saline (Fig 5). At 3 weeks after surgery, the results of hematologic and biochemical tests had normalized to a WBC of 5,200/ L, CRP of 0.3 mg/dL, and ESR of 12 mm/hour. A radiograph taken 1 year after surgery showed a deformed femoral head. However, the range of motion of the hip joint was not restricted, and the patient did not experience pain when walking (Fig 4B).
FIGURE 8.
295
Case 3: A 42-Year-Old Woman This patient visited our hospital because of a sudden onset of coxalgia. The sharp pain caused her to be in an iliopsoas position, and the results of hematologic and biochemical examinations showed inflammatory reactions: WBC of 16,200/L, CRP of 12.6 mg/dL, and ESR of 122 mm/hour. However, a plain radiograph revealed no abnormalities (Fig 6A). After arthrocentesis confirmed the presence of group-B Streptococcus, intramuscular injections of 200 mg gentamicin were administered daily until arthroscopic surgery was performed on day 7 of the illness. A proliferation of synovial membrane and some cartilage damage were observed and consequently removed. The joint was then irrigated with 20 L of physiologic saline (Fig 7). Three weeks after surgery, the results of a hematologic test had normalized to a WBC of 3,700/L, CRP of 0.3 mg/dL, and ESR of 14 mm/hour. At present (18 months after surgery), the
Case 4: An 80-year-old woman with septic arthritis of the right hip joint. (A) At initial visit, (B) 1 year after surgery.
296
Y. YAMAMOTO ET AL.
femoral head appears almost normal, and the patient does not have any particular complaint (Fig 6B). Case 4: An 80-Year-Old Woman This patient had been undergoing treatment for diabetes at a different hospital for 25 years. Coxalgia suddenly appeared 7 days before the initial examination at our hospital. Despite being treated with an intra-articular administration of a steroidal drug at a neighborhood clinic, the pain had become exacerbated. At this point, the patient was referred to our department. The patient was in an iliopsoas position, and severe inflammatory reactions were confirmed: WBC of 11,000/L, CRP of 24.5 mg/dL, and ESR of 105 mm/hour. A plain radiograph showed a narrowing of the joint space (Fig 8A). After arthrocentesis confirmed the presence of S. aureus, 2 g of cefazolin was administered intravenously daily for 7 days before the operation. Arthroscopic surgery was performed on the 14th day of the illness. The cartilage at the weightbearing area had become detached, a proliferation of synovial membrane and granulation tissue were observed, and all were consequently removed (Fig 9). The hip joint was then irrigated with 25 L of physiologic saline. At 3 weeks after surgery, the results of a hematologic test had normalized. At 18 months after surgery, the range of motion in the hip joint was
FIGURE 9. Case 4: Arthroscopic finding of the right hip joint with anterior approach. A proliferation of synovial membrane and granulation tissue were observed on the femoral head.
unrestricted. The patient experienced mild coxalgia only after walking for a long time (Fig 8B). DISCUSSION In adult patients, it is extremely difficult to achieve thorough synovectomy in hip joints with small-incision arthrotomy, and dislocation of the femoral head may be required. In such situations, there is a risk of complications such as aseptic necrosis of the femoral head or dislocation of the hip joint, and the recovery period may also be prolonged. Conversely, arthroscopic surgery is minimally invasive and offers several advantages. To the best of our knowledge, there have been reports published on only 2 adults and 1 child having arthroscopic surgery for septic arthritis: Blitzer,3 Bould et al.,4 and Chung et al.5 Blitzer and Chung et al. stated that the most important factor influencing the result was early treatment. In contrast, we performed arthroscopic surgery an average of 36 days after the initial onset of symptoms and favorable results were obtained. The difference between previous reports and ours exists in the following points. In every case, an arthroscope was inserted only from a single side. Chung et al. performed irrigation from the anterolateral side and pointed out that the main disadvantage of this approach was that the medial part of the joint and the femoral neck could not be easily viewed. On the other hand, with our technique, 3 arthroscopes are inserted from 3 different directions to allow for thorough debridement of diseased tissues. According to our experiment of hip arthroscopy on 355 joints,6 medial instrumentation with medial inspection makes it extremely difficult to sufficiently perform synovectomy around the cotyloid fossa. The most reliable techniques are anterolateral instrumentation with anterior inspection and anterior instrumentation with anterolateral inspection. On the other hand, some damage and detachment of cartilage was observed in the weight-bearing area of the femoral head in each of the 4 cases. Although the amount of cartilage damage cannot be quantified, it can be said that the patient who underwent arthroscopic examination on the seventh day of illness (case 3) showed only mild damage, whereas the patient who underwent arthroscopic examination on the 99th day of illness (case 2) showed extreme damage. The damage was particularly severe in the weight-bearing area of the femoral head. We believe that this cartilage damage is triggered by infection and exacerbated by mechanical stress.
ARTHROSCOPIC TREATMENT OF SEPTIC COXARTHRITIS The main causes of joint cartilage destruction in septic coxarthritis are a rise in intra-articular pressure and lysozymes. This is the main reason for the postoperative placement of a drainage tube, to release the intra-articular pressure and to irrigate the lysozymes. Bould et al.4 and Chung et al.5 placed a drainage tube, and Blitzer3 performed continuous intra-articular irrigation for 24 to 72 hours after surgery. However, it is our experience that an inverse flow of physiologic saline solution can occur from the sutured incision for 24 hours following arthroscopic examination. Therefore, we believe that placement of such a tube for decompression is unnecessary. Additionally, the 3-directional-approach method uses 2 portals to irrigate the hip joint, enabling a fast flow. An average of 23 L of physiologic saline solution is used during a 2-hour operation, which is a greater amount than Blitzer et al. achieved irrigating postoperatively. We believe this is an effective method for irrigating lysozymes. High-volume irrigation was performed during surgery, allowing the surgical wounds to be closed immediately thereafter, thus satisfactorily achieving the treatment objective. These points illustrate some of
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the advantages of the 3-directional-approach method, which we recommended. CONCLUSIONS Three-directional-approach arthroscopic surgery in combination with intraoperative large-volume irrigation is an effective technique for treating septic arthritis of the hip joint because the joint can be conserved, and it is less invasive than other open arthrotomy techniques. REFERENCES 1. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery of hip joint. Arthroscopy 1991;7:204-211. 2. Maekawa S, Ide T, Hachisuka N, Akamatsu N. Septic coxarthritis treated with arthroscopic surgery [in Japanese]. Hip Joint 1994:20:186-191. 3. Blitzer CM. Arthroscopic management of septic arthritis of the hip. Arthroscopy 1993;9:414-416. 4. Bould M, Edward D, Villar RN. Arthroscopic diagnosis and treatment of septic arthritis of the hip joint. Arthroscopy 1993; 9:707-708. 5. Chung WK, Slater GL, Bates EH. Treatment of septic arthritis of the hip by arthroscopic lavage. J Pediatr Orthop 1993;13: 444-446. 6. Ide T, Akamatsu N. Arthroscopic synovectomy of the hip [in Japanese]. Kotu Kansetu Jintai 1992;5:811-820.