- Email: [email protected]
Arthroscopic treatment of septic arthritis of the elbow
J Shoulder Elbow Surg (2012) 21, 1001-1005
www.elsevier.com/locate/ymse
Arthroscopic treatment of septic arthritis of the elbow Kimberly I.M. van den Ende, MD, Scott P. Steinmann, MD* Department of Orthopedics, Mayo Clinic, Rochester, MN, USA Hypothesis: Septic arthritis of the elbow is a serious orthopedic concern associated with high morbidity and mortality rates, traditionally treated with open exposure of the elbow joint. This study was performed to describe the outcome of arthroscopic treatment of septic elbow arthritis. Methods: From May 2000 through January 2008, 12 patients with septic elbow arthritis were treated arthroscopically at the Mayo Clinic, Rochester, Minnesota, a large medical center. We reviewed the patients’ medical records concerning variables such as history and clinical findings, previous elbow history, surgical procedure, cultured organism, and follow-up. Using the Oxford Elbow Score and the Mayo Elbow Score, we examined current level of pain, function, and social-psychological aspects. Six patients died before initiation of this study and were therefore only studied retrospectively. Results: Septic elbow arthritis without pre-existing elbow problems shows excellent outcomes after arthroscopic treatment, with scores for absence of pain, function, social-psychological well-being, and range of motion of 97.9%, 100%, 95.8%, and 100%, respectively. When elbows were treated arthroscopically within 2 days after the onset of clinical symptoms suggesting bacterial elbow arthritis, maximum scores of 100% were noted for all aspects. Positive elbow history before infection and reoperation were associated with poor outcome scores, with 62.5%, 85.4%, and 50% for absence of pain, function, and social-psychological well-being, respectively. Conclusion: Septic elbow arthritis occurs often in the debilitated, immunocompromised patient. Arthroscopic intervention is a reasonable alternative to open treatment. In this small series, the acutely septic elbow was successfully treated in the majority of patients, although the overall patient mortality rate remains high. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Elbow; arthritis; septic; arthroscopy
Septic arthritis remains a significant concern to orthopedic surgeons, and it is associated with a mortality rate of 10% to 13%. The most commonly involved joint in adults is the knee, comprising more than 30% to 50% of the cases. It is remarkable that bacterial arthritis of the elbow, Mayo Clinic Institutional Review Board approval was received for this study (08-003515). *Reprint requests: Scott P. Steinmann, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail address: [email protected] (S.P. Steinmann).
accounting for 3% to 9%, is rarely reported, especially because it can be related to moderate functional disability and even death.3,4,7,8,11,14 Weston et al14 studied the clinical features and outcome of septic arthritis in a UK Health District study. They found that, besides age greater than 65 years, confusion, and involvement of multiple joints, infection of the elbow joint was associated independently with significantly higher mortality rates. In the study of Kelly et al,8 all patients with infection of the elbow recovered, but all were left with a loss of joint function.
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.07.019
1002 Essential treatment of the infected joint is thorough drainage. As a minimally invasive procedure, arthroscopy is an attractive option.8,9,11,13 Jerosch et al5,6 treated 2 septic elbows arthroscopically in their study of 12 infected joints, with good results. To our knowledge, there is no study focusing on the arthroscopic treatment of septic elbow arthritis. The purpose of this study was, therefore, to describe the outcome of elbow arthroscopy in treating infection of the elbow.
Materials and methods From May 2000 through January 2008, 12 patients with septic arthritis of the elbow joint were treated arthroscopically at the Mayo Clinic, Rochester, Minnesota. Of the patients, 11 were men and 1 was a woman; the mean age at the time of surgery was 63 years (range, 34-81 years). Two patients had multiple infected joints, one of whom died of sepsis and hemodynamic collapse in the hospital within 7 days of hospitalization. Five additional patients died before the initiation of this study. The mean follow-up time of the surviving patients was 39 months (range, 5-80 months). We reviewed the patients’ medical records and recorded the following variables: age, sex, history and clinical findings, previous elbow history and/or treatment, surgical procedures, surgical findings, cultured organism, antibiotic treatment, complications, and follow-up. An elbow questionnaire was also sent to the patients who were still living at the time of this study to obtain current outcomes in terms of pain, function, and social-psychological aspects. This elbow questionnaire was created by combining the Oxford Elbow Score (OES)2 and the Mayo Elbow Score (MES).10 We obtained approval for this study from our Institutional Review Board for Human Research. Patients included in this study had a confirmed diagnosis of septic elbow arthritis based on a positive bacterial culture of the elbow joint and/or obvious gross purulence aspirated from the elbow. In addition, they were treated arthroscopically; patients treated with open elbow surgery were excluded. The surgical technique for arthroscopic treatment involved standard arthroscopic technique and setup as previously described.1,12 General endotracheal anesthesia was administered. The patient was placed in the lateral decubitus position, with the arm secured in an arm holder, positioning the elbow just higher than the shoulder to ensure free access to the joint. A nonsterile tourniquet was applied and inflated after elevation of the hand. The anterolateral portal was established first over the radiocapitellar joint, with care taken to avoid the radial nerve. We then established the anteromedial portal using an inside-out technique with direct visualization, carefully protecting the areas of the median nerve and the ulnar nerve. After this was done, debridement with a motorized shaver (4.8 mm; Arthrex, Naples, FL, USA) of purulent synovium, as well as loose pieces of bone and cartilage, was performed. Suction was not used to avoid injury to the neurovascular structures. Multiple cultures were obtained of pieces of synovium and samples of purulence. Then, the anterior joint was thoroughly irrigated with 3 to 6 L of saline solution. After this was completed, attention was turned toward the posterior compartment. A posterolateral portal was created for the arthroscope, and through a direct posterior portal, debridement of the posterior aspect of the joint was then performed with
K.I.M. van den Ende, S.P. Steinmann a motorized shaver. Sometimes drains were placed through the portal sites depending on the surgeon. All patients remained as inpatients and received empiric intravenous antibiotic treatment after surgery. The antibiotic was adjusted based on the culture results.
Results All patients presented with pain, local signs of inflammation (swelling, redness, warmth), and fever. The infection developed after elbow surgery in 5 patients, after a skin wound in 3 patients (from a fall, an ulcer, and a cat scratch, respectively), and in 4 immunosuppressed patients (of whom 1 also belonged to the postoperative group), and in 1 patient, the elbow became infected in a setting of septic pneumococcal meningitis. The main organism cultured was Staphylococcus aureus (5 cases). In 4 cases, no microorganism was cultured from elbow material (obvious gross pus aspirated from the elbow joint confirmed the diagnosis of elbow arthritis). These patients had all received antibiotic therapy before elbow debridement surgery. Other bacteria cultured were b-hemolytic Streptococcus group B and G, Streptococcus pneumoniae, and Staphylococcus coagulase-negative bacteria (Table I). All patients were treated with arthroscopic debridement and irrigation. In 3 cases, drains were placed to allow egress of fluid. In 9 cases, the portals were closed with nonabsorbable monofilament sutures. There was no correlation between use of drains or suture closure of the wounds with recurrence of infection or other complications. Nine patients underwent elbow surgery once, and two needed reoperation because of recurrence of elbow infection. One patient needed 2 reoperations, but this could not avert his severe illness from worsening and he died of septic hemodynamic collapse within 1 week of hospitalization. All patients received broad-spectrum intravenous antibiotics initially, followed by specific intravenous antibiotic treatment based on the culture results. The mean duration of intravenous antibiotic treatment after primary elbow arthroscopy was 4 weeks (range, 3-14 weeks), omitting our patient who died within 1 week. One patient was prescribed lifelong suppressive antibiotics after reoperation; however, acute signs and symptoms of infection resolved after second debridement surgery. Examining the follow-up results from the surviving patients by scoring the OES and the MES gives us an idea of both subjective and objective outcomes. Subjective postoperative results are mainly based on pain scores and social-psychological impact, whereas objective postoperative results can be seen in daily life function and range of motion of the elbow joint. Four of six patients have an excellent MES, of which three have an excellent subjective outcome as well (Table II). Five patients had full range of motion of the elbow joint at follow-up. Three patients in our follow-up group had a history of elbow complaints before the elbow infection (because of
Arthroscopic treatment of septic elbow arthritis Table I Patient 1)
1003
Etiology of infection and causative organisms Sex
Age (y)
Setting/cause
Elbow history
Organism
M
57
Fall on elbow Partially treated septic elbow arthritis
d
2)
M
49
Chronic inflammatory arthritis
3)
M
64
Postoperative elbow arthroscopy (18 d) Immunocompromised
4)
M
81
Immunocompromised
d
5)
M
48
d
6)
M
59
Severe rheumatoid arthritis
MRSA
7
M
34
Immunocompromised After wrist and elbow surgery (6 d) Chronic elbow ulcer (after elbow operation) Meningitis/bacteremia
No elbow growth under AB (pyogenic aspiration, BC showing b-hemolytic Streptococcus group B) Staphylococcus coagulasenegative b-Hemolytic Streptococcus group B b-Hemolytic Streptococcus group G S aureus
Multiple joint infections during childhood
8
F
45
Immunocompromised
9
M
63
10
M
43
Postoperative, after septic olecranon bursitis (110 d) Cat scratch
Multiple recurrent joint infections Chronic elbow osteomyelitis/ septic joint d
No elbow growth under AB (pyogenic aspiration, BC showing S pneumoniae) No growth under AB (pyogenic aspiration) S aureus
11
M
42
12
M
47
Postoperative elbow arthroscopy (11 d) Postoperative elbow arthroscopy (14 d)
d
Osteoarthritis
No growth under AB (pyogenic aspiration, BC showing Staphylococcus coagulasenegative) S aureus
Osteoarthritis
S aureus
AB, Antibiotic therapy; BC, blood culture; MRSA, methicillin-resistant Staphylococcus aureus. ) Died before initiation of study.
osteoarthritis or chronic osteomyelitis) and therefore had undergone elbow surgery. Their elbows were all infected postoperatively with S aureus. Two of them needed a reoperation because of recurrence of infection or incomplete eradication. These 3 patients show moderate postoperative results for absence of pain, function, and social-psychological wellbeing: 62.5%, 85.4%, and 50%, respectively. The 3 patients in whom septic elbow arthritis developed without pre-existing elbow problems show excellent outcomes after arthroscopic treatment, scoring 97.9%, 100%, 95.8%, and 100% for absence of pain, function, social-psychological well-being, and range of motion, respectively. In addition, the best outcomes were seen when they were operated on within 2 days of onset of pain and swelling (OES and MES of 100%).
Discussion Septic arthritis of the elbow is uncommon in otherwise healthy persons. There is significant morbidity and mortality
in patients in whom a septic elbow develops, given that 6 of our 12 patients died not long after their elbow infection (mean, 3 months; range, 1 week to 10 months). Of these 6 patients, 5 were aged 64 years or younger; therefore, age is not likely to be the reason for death. Three died of multiple myeloma and two died of sepsis (partly) related to the bacterial infection of the elbow. There are 3 possible conclusions that can be drawn from this study: (1) septic elbow arthritis may be more likely to develop in patients with comorbid conditions, (2) septic elbow arthritis deteriorates the patient’s prognosis, or (3) the presence of septic arthritis of the elbow is a marker for generalized poor prognosis and/or condition. Our study affirms the notable result reported by Weston et al14 that higher mortality rates are associated with infection of the elbow joint. The 3 patients with a moderate total OES had a history of elbow complaints before the elbow infection (osteoarthritis or chronic osteomyelitis); therefore, their moderate postoperative outcome might also be because of the preoperative condition of their elbow. Unfortunately, there are no scores or measures documented before infection;
70 66.67
100 95-100 93.75 64.46
hence, no conclusions can be drawn from this. Nevertheless, in this study, we have seen that arthroscopic treatment of septic elbows in patients without a history of elbow complaints results in excellent outcome scores for pain, function, range of motion, and social-psychological wellbeing. Open exposure of the elbow joint has been the traditional technique of treating joint sepsis; however, there is limited information in the literature on this specific treatment. Weston et al14 did find a difference between open surgical drainage and closed (percutaneous) drainage with regard to morbidity. Open surgical drainage was associated with poor outcome (odds ratio, 3.74), whereas closed drainage showed better results (odds ratio, 0.41) in the surviving patients. To examine whether elbow arthroscopydbeing minimally invasivedalso results in lower morbidity rates than open procedures, a study comparing open surgery with arthroscopy is necessary. Early and adequate arthroscopic drainage of the infected elbow joint should theoretically limit further cartilaginous and soft-tissue damage. The best outcomes for pain, function, social-psychological well-being, and range of motion were found in the elbows treated within 2 days after the onset of clinical symptoms suggesting bacterial elbow arthritis. Prior elbow complaints and reoperation were associated with worsening outcome scores.
100
Conclusion Septic elbow arthritis occurs often in the debilitated, immunocompromised patient. Arthroscopic intervention is a reasonable alternative to open treatment. In this small series, the acutely septic elbow was successfully treated in the majority of patients, although the overall patient mortality rate remains high.
Disclaimer
1d After elbow arthroscopy for OA 12
d
62.5
37.5
Full 20 -30 loss in extension Full 100 87.5
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References OA, Osteoarthritis. ) Section of OES. y Section of MES.
1 mo 4d 10 11
d After 2 d
93.75 56.25
87.5 50
100 100 66.67 Full Full Full 100 100 68.75 1d 2d 3.5 mo
Meningitis, bacteremia Immunocompromised Postoperative, after septic olecranon bursitis Cat scratch After elbow arthroscopy for OA 7 8 9
d d After 2 mo
100 100 68.75
100 100 62.5
Total OES Range of motiony Function) Etiology/setting Patient
Delay in surgical intervention
Follow-up and results of OES and MES (surviving patients) Table II
Reoperation
Pain)
Social-psychological well-being)
100 100 70
K.I.M. van den Ende, S.P. Steinmann Total MES
1004
1. Adams JE, Steinmann SP. Arthroscopy for elbow arthritis. Tech Shoulder Elbow Surg 2007;8:120-5. doi:10.1097/BTE.0b013e31809 86ee7 2. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J, et al. The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery. J Bone Joint Surg Br 2008;90: 466-73. doi:10.1302/0301-620X.90B4.20290
Arthroscopic treatment of septic elbow arthritis 3. Garcıa-De La Torre I. Advances in the management of septic arthritis. Infect Dis Clin North Am 2006;20:773-88. doi:10.1016/j.idc.2006.09.005 4. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001;40:24-30. 5. Jerosch J, Hoffstetter I, Schr€oder M, Castro WH. Septic arthritis: arthroscopic management with local antibiotic treatment. Acta Orthop Belg 1995;61:126-34. 6. Jerosch J, Schr€ oder M, Schneider T. Good and relative indications for elbow arthroscopy. A retrospective study on 103 patients. Arch Orthop Trauma Surg 1998;117:246-9. 7. Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum 1997;40:884-92. 8. Kelly PJ, Martin WJ, Coventry MB. Bacterial (suppurative) arthritis in the adult. J Bone Joint Surg Am 1970;52:1595-602.
1005 9. Mehta P, Schnall SB, Zalavras CG. Septic arthritis of the shoulder, elbow, and wrist. Clin Orthop Relat Res 2006;451:42-5. doi:10.1097/ 01.blo.0000229322.30169.29 10. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: Saunders; 1993. p. 74-83. 11. Ross JJ. Septic arthritis. Infect Dis Clin North Am 2005;19:799-817. doi:10.1016/j.idc.2005.07.004 12. Steinmann SP. Elbow arthroscopy: where are we now? Arthroscopy 2007;23:1231-6. doi:10.1097/BTE.0b013e3180986ee7 13. Vispo Seara JL, Barthel T, Schmitz H, Eulert J. Arthroscopic treatment of septic joints: prognostic factors. Arch Orthop Trauma Surg 2002; 122:204-11. doi:10.1007/s00402-001-0386-z 14. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991. Ann Rheum Dis 1999;58:214-9.
www.elsevier.com/locate/ymse
Arthroscopic treatment of septic arthritis of the elbow Kimberly I.M. van den Ende, MD, Scott P. Steinmann, MD* Department of Orthopedics, Mayo Clinic, Rochester, MN, USA Hypothesis: Septic arthritis of the elbow is a serious orthopedic concern associated with high morbidity and mortality rates, traditionally treated with open exposure of the elbow joint. This study was performed to describe the outcome of arthroscopic treatment of septic elbow arthritis. Methods: From May 2000 through January 2008, 12 patients with septic elbow arthritis were treated arthroscopically at the Mayo Clinic, Rochester, Minnesota, a large medical center. We reviewed the patients’ medical records concerning variables such as history and clinical findings, previous elbow history, surgical procedure, cultured organism, and follow-up. Using the Oxford Elbow Score and the Mayo Elbow Score, we examined current level of pain, function, and social-psychological aspects. Six patients died before initiation of this study and were therefore only studied retrospectively. Results: Septic elbow arthritis without pre-existing elbow problems shows excellent outcomes after arthroscopic treatment, with scores for absence of pain, function, social-psychological well-being, and range of motion of 97.9%, 100%, 95.8%, and 100%, respectively. When elbows were treated arthroscopically within 2 days after the onset of clinical symptoms suggesting bacterial elbow arthritis, maximum scores of 100% were noted for all aspects. Positive elbow history before infection and reoperation were associated with poor outcome scores, with 62.5%, 85.4%, and 50% for absence of pain, function, and social-psychological well-being, respectively. Conclusion: Septic elbow arthritis occurs often in the debilitated, immunocompromised patient. Arthroscopic intervention is a reasonable alternative to open treatment. In this small series, the acutely septic elbow was successfully treated in the majority of patients, although the overall patient mortality rate remains high. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Elbow; arthritis; septic; arthroscopy
Septic arthritis remains a significant concern to orthopedic surgeons, and it is associated with a mortality rate of 10% to 13%. The most commonly involved joint in adults is the knee, comprising more than 30% to 50% of the cases. It is remarkable that bacterial arthritis of the elbow, Mayo Clinic Institutional Review Board approval was received for this study (08-003515). *Reprint requests: Scott P. Steinmann, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail address: [email protected] (S.P. Steinmann).
accounting for 3% to 9%, is rarely reported, especially because it can be related to moderate functional disability and even death.3,4,7,8,11,14 Weston et al14 studied the clinical features and outcome of septic arthritis in a UK Health District study. They found that, besides age greater than 65 years, confusion, and involvement of multiple joints, infection of the elbow joint was associated independently with significantly higher mortality rates. In the study of Kelly et al,8 all patients with infection of the elbow recovered, but all were left with a loss of joint function.
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.07.019
1002 Essential treatment of the infected joint is thorough drainage. As a minimally invasive procedure, arthroscopy is an attractive option.8,9,11,13 Jerosch et al5,6 treated 2 septic elbows arthroscopically in their study of 12 infected joints, with good results. To our knowledge, there is no study focusing on the arthroscopic treatment of septic elbow arthritis. The purpose of this study was, therefore, to describe the outcome of elbow arthroscopy in treating infection of the elbow.
Materials and methods From May 2000 through January 2008, 12 patients with septic arthritis of the elbow joint were treated arthroscopically at the Mayo Clinic, Rochester, Minnesota. Of the patients, 11 were men and 1 was a woman; the mean age at the time of surgery was 63 years (range, 34-81 years). Two patients had multiple infected joints, one of whom died of sepsis and hemodynamic collapse in the hospital within 7 days of hospitalization. Five additional patients died before the initiation of this study. The mean follow-up time of the surviving patients was 39 months (range, 5-80 months). We reviewed the patients’ medical records and recorded the following variables: age, sex, history and clinical findings, previous elbow history and/or treatment, surgical procedures, surgical findings, cultured organism, antibiotic treatment, complications, and follow-up. An elbow questionnaire was also sent to the patients who were still living at the time of this study to obtain current outcomes in terms of pain, function, and social-psychological aspects. This elbow questionnaire was created by combining the Oxford Elbow Score (OES)2 and the Mayo Elbow Score (MES).10 We obtained approval for this study from our Institutional Review Board for Human Research. Patients included in this study had a confirmed diagnosis of septic elbow arthritis based on a positive bacterial culture of the elbow joint and/or obvious gross purulence aspirated from the elbow. In addition, they were treated arthroscopically; patients treated with open elbow surgery were excluded. The surgical technique for arthroscopic treatment involved standard arthroscopic technique and setup as previously described.1,12 General endotracheal anesthesia was administered. The patient was placed in the lateral decubitus position, with the arm secured in an arm holder, positioning the elbow just higher than the shoulder to ensure free access to the joint. A nonsterile tourniquet was applied and inflated after elevation of the hand. The anterolateral portal was established first over the radiocapitellar joint, with care taken to avoid the radial nerve. We then established the anteromedial portal using an inside-out technique with direct visualization, carefully protecting the areas of the median nerve and the ulnar nerve. After this was done, debridement with a motorized shaver (4.8 mm; Arthrex, Naples, FL, USA) of purulent synovium, as well as loose pieces of bone and cartilage, was performed. Suction was not used to avoid injury to the neurovascular structures. Multiple cultures were obtained of pieces of synovium and samples of purulence. Then, the anterior joint was thoroughly irrigated with 3 to 6 L of saline solution. After this was completed, attention was turned toward the posterior compartment. A posterolateral portal was created for the arthroscope, and through a direct posterior portal, debridement of the posterior aspect of the joint was then performed with
K.I.M. van den Ende, S.P. Steinmann a motorized shaver. Sometimes drains were placed through the portal sites depending on the surgeon. All patients remained as inpatients and received empiric intravenous antibiotic treatment after surgery. The antibiotic was adjusted based on the culture results.
Results All patients presented with pain, local signs of inflammation (swelling, redness, warmth), and fever. The infection developed after elbow surgery in 5 patients, after a skin wound in 3 patients (from a fall, an ulcer, and a cat scratch, respectively), and in 4 immunosuppressed patients (of whom 1 also belonged to the postoperative group), and in 1 patient, the elbow became infected in a setting of septic pneumococcal meningitis. The main organism cultured was Staphylococcus aureus (5 cases). In 4 cases, no microorganism was cultured from elbow material (obvious gross pus aspirated from the elbow joint confirmed the diagnosis of elbow arthritis). These patients had all received antibiotic therapy before elbow debridement surgery. Other bacteria cultured were b-hemolytic Streptococcus group B and G, Streptococcus pneumoniae, and Staphylococcus coagulase-negative bacteria (Table I). All patients were treated with arthroscopic debridement and irrigation. In 3 cases, drains were placed to allow egress of fluid. In 9 cases, the portals were closed with nonabsorbable monofilament sutures. There was no correlation between use of drains or suture closure of the wounds with recurrence of infection or other complications. Nine patients underwent elbow surgery once, and two needed reoperation because of recurrence of elbow infection. One patient needed 2 reoperations, but this could not avert his severe illness from worsening and he died of septic hemodynamic collapse within 1 week of hospitalization. All patients received broad-spectrum intravenous antibiotics initially, followed by specific intravenous antibiotic treatment based on the culture results. The mean duration of intravenous antibiotic treatment after primary elbow arthroscopy was 4 weeks (range, 3-14 weeks), omitting our patient who died within 1 week. One patient was prescribed lifelong suppressive antibiotics after reoperation; however, acute signs and symptoms of infection resolved after second debridement surgery. Examining the follow-up results from the surviving patients by scoring the OES and the MES gives us an idea of both subjective and objective outcomes. Subjective postoperative results are mainly based on pain scores and social-psychological impact, whereas objective postoperative results can be seen in daily life function and range of motion of the elbow joint. Four of six patients have an excellent MES, of which three have an excellent subjective outcome as well (Table II). Five patients had full range of motion of the elbow joint at follow-up. Three patients in our follow-up group had a history of elbow complaints before the elbow infection (because of
Arthroscopic treatment of septic elbow arthritis Table I Patient 1)
1003
Etiology of infection and causative organisms Sex
Age (y)
Setting/cause
Elbow history
Organism
M
57
Fall on elbow Partially treated septic elbow arthritis
d
2)
M
49
Chronic inflammatory arthritis
3)
M
64
Postoperative elbow arthroscopy (18 d) Immunocompromised
4)
M
81
Immunocompromised
d
5)
M
48
d
6)
M
59
Severe rheumatoid arthritis
MRSA
7
M
34
Immunocompromised After wrist and elbow surgery (6 d) Chronic elbow ulcer (after elbow operation) Meningitis/bacteremia
No elbow growth under AB (pyogenic aspiration, BC showing b-hemolytic Streptococcus group B) Staphylococcus coagulasenegative b-Hemolytic Streptococcus group B b-Hemolytic Streptococcus group G S aureus
Multiple joint infections during childhood
8
F
45
Immunocompromised
9
M
63
10
M
43
Postoperative, after septic olecranon bursitis (110 d) Cat scratch
Multiple recurrent joint infections Chronic elbow osteomyelitis/ septic joint d
No elbow growth under AB (pyogenic aspiration, BC showing S pneumoniae) No growth under AB (pyogenic aspiration) S aureus
11
M
42
12
M
47
Postoperative elbow arthroscopy (11 d) Postoperative elbow arthroscopy (14 d)
d
Osteoarthritis
No growth under AB (pyogenic aspiration, BC showing Staphylococcus coagulasenegative) S aureus
Osteoarthritis
S aureus
AB, Antibiotic therapy; BC, blood culture; MRSA, methicillin-resistant Staphylococcus aureus. ) Died before initiation of study.
osteoarthritis or chronic osteomyelitis) and therefore had undergone elbow surgery. Their elbows were all infected postoperatively with S aureus. Two of them needed a reoperation because of recurrence of infection or incomplete eradication. These 3 patients show moderate postoperative results for absence of pain, function, and social-psychological wellbeing: 62.5%, 85.4%, and 50%, respectively. The 3 patients in whom septic elbow arthritis developed without pre-existing elbow problems show excellent outcomes after arthroscopic treatment, scoring 97.9%, 100%, 95.8%, and 100% for absence of pain, function, social-psychological well-being, and range of motion, respectively. In addition, the best outcomes were seen when they were operated on within 2 days of onset of pain and swelling (OES and MES of 100%).
Discussion Septic arthritis of the elbow is uncommon in otherwise healthy persons. There is significant morbidity and mortality
in patients in whom a septic elbow develops, given that 6 of our 12 patients died not long after their elbow infection (mean, 3 months; range, 1 week to 10 months). Of these 6 patients, 5 were aged 64 years or younger; therefore, age is not likely to be the reason for death. Three died of multiple myeloma and two died of sepsis (partly) related to the bacterial infection of the elbow. There are 3 possible conclusions that can be drawn from this study: (1) septic elbow arthritis may be more likely to develop in patients with comorbid conditions, (2) septic elbow arthritis deteriorates the patient’s prognosis, or (3) the presence of septic arthritis of the elbow is a marker for generalized poor prognosis and/or condition. Our study affirms the notable result reported by Weston et al14 that higher mortality rates are associated with infection of the elbow joint. The 3 patients with a moderate total OES had a history of elbow complaints before the elbow infection (osteoarthritis or chronic osteomyelitis); therefore, their moderate postoperative outcome might also be because of the preoperative condition of their elbow. Unfortunately, there are no scores or measures documented before infection;
70 66.67
100 95-100 93.75 64.46
hence, no conclusions can be drawn from this. Nevertheless, in this study, we have seen that arthroscopic treatment of septic elbows in patients without a history of elbow complaints results in excellent outcome scores for pain, function, range of motion, and social-psychological wellbeing. Open exposure of the elbow joint has been the traditional technique of treating joint sepsis; however, there is limited information in the literature on this specific treatment. Weston et al14 did find a difference between open surgical drainage and closed (percutaneous) drainage with regard to morbidity. Open surgical drainage was associated with poor outcome (odds ratio, 3.74), whereas closed drainage showed better results (odds ratio, 0.41) in the surviving patients. To examine whether elbow arthroscopydbeing minimally invasivedalso results in lower morbidity rates than open procedures, a study comparing open surgery with arthroscopy is necessary. Early and adequate arthroscopic drainage of the infected elbow joint should theoretically limit further cartilaginous and soft-tissue damage. The best outcomes for pain, function, social-psychological well-being, and range of motion were found in the elbows treated within 2 days after the onset of clinical symptoms suggesting bacterial elbow arthritis. Prior elbow complaints and reoperation were associated with worsening outcome scores.
100
Conclusion Septic elbow arthritis occurs often in the debilitated, immunocompromised patient. Arthroscopic intervention is a reasonable alternative to open treatment. In this small series, the acutely septic elbow was successfully treated in the majority of patients, although the overall patient mortality rate remains high.
Disclaimer
1d After elbow arthroscopy for OA 12
d
62.5
37.5
Full 20 -30 loss in extension Full 100 87.5
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References OA, Osteoarthritis. ) Section of OES. y Section of MES.
1 mo 4d 10 11
d After 2 d
93.75 56.25
87.5 50
100 100 66.67 Full Full Full 100 100 68.75 1d 2d 3.5 mo
Meningitis, bacteremia Immunocompromised Postoperative, after septic olecranon bursitis Cat scratch After elbow arthroscopy for OA 7 8 9
d d After 2 mo
100 100 68.75
100 100 62.5
Total OES Range of motiony Function) Etiology/setting Patient
Delay in surgical intervention
Follow-up and results of OES and MES (surviving patients) Table II
Reoperation
Pain)
Social-psychological well-being)
100 100 70
K.I.M. van den Ende, S.P. Steinmann Total MES
1004
1. Adams JE, Steinmann SP. Arthroscopy for elbow arthritis. Tech Shoulder Elbow Surg 2007;8:120-5. doi:10.1097/BTE.0b013e31809 86ee7 2. Dawson J, Doll H, Boller I, Fitzpatrick R, Little C, Rees J, et al. The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery. J Bone Joint Surg Br 2008;90: 466-73. doi:10.1302/0301-620X.90B4.20290
Arthroscopic treatment of septic elbow arthritis 3. Garcıa-De La Torre I. Advances in the management of septic arthritis. Infect Dis Clin North Am 2006;20:773-88. doi:10.1016/j.idc.2006.09.005 4. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001;40:24-30. 5. Jerosch J, Hoffstetter I, Schr€oder M, Castro WH. Septic arthritis: arthroscopic management with local antibiotic treatment. Acta Orthop Belg 1995;61:126-34. 6. Jerosch J, Schr€ oder M, Schneider T. Good and relative indications for elbow arthroscopy. A retrospective study on 103 patients. Arch Orthop Trauma Surg 1998;117:246-9. 7. Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum 1997;40:884-92. 8. Kelly PJ, Martin WJ, Coventry MB. Bacterial (suppurative) arthritis in the adult. J Bone Joint Surg Am 1970;52:1595-602.
1005 9. Mehta P, Schnall SB, Zalavras CG. Septic arthritis of the shoulder, elbow, and wrist. Clin Orthop Relat Res 2006;451:42-5. doi:10.1097/ 01.blo.0000229322.30169.29 10. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: Saunders; 1993. p. 74-83. 11. Ross JJ. Septic arthritis. Infect Dis Clin North Am 2005;19:799-817. doi:10.1016/j.idc.2005.07.004 12. Steinmann SP. Elbow arthroscopy: where are we now? Arthroscopy 2007;23:1231-6. doi:10.1097/BTE.0b013e3180986ee7 13. Vispo Seara JL, Barthel T, Schmitz H, Eulert J. Arthroscopic treatment of septic joints: prognostic factors. Arch Orthop Trauma Surg 2002; 122:204-11. doi:10.1007/s00402-001-0386-z 14. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991. Ann Rheum Dis 1999;58:214-9.