- Email: [email protected]
Bedside Washout of a Septic Shoulder in the Emergency Department: A Case Report
INFECTIOUS DISEASE/CASE REPORT
Bedside Washout of a Septic Shoulder in the Emergency Department: A Case Report Leonard Bunting, MD, RDMS*; Kenneth Kuper, MD *Corresponding Author. E-mail: [email protected].
We present a case of successful bedside irrigation of a septic joint in the emergency department. Complicating factors prevented the patient from undergoing operative management. With a simple 2 catheter technique the authors irrigated the patient’s septic shoulder at the bedside. The patient’s pain and range of motion improved immediately following the technique. The patient had complete recovery without open drainage. With further investigation, definitive management of septic joints could begin in the emergency department. [Ann Emerg Med. 2016;-:1-4.] 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.01.011
INTRODUCTION For emergency medicine practitioners, septic joints are rare but obvious diagnoses. Unfortunately, identifying the condition can be challenging because of lack of reliable physical examination findings or definitive serum markers.1 Instead we must rely on a strong clinical suspicion and a low threshold for joint aspiration with fluid analysis.2 Traditional management involves administering antibiotics and consulting outside services for drainage.3 However, any delay to drainage exposes the patient to potential complications2 and continued pain.4 To our knowledge, we present the first published case of an emergency medicine provider performing bedside drainage and irrigation of an infected joint. CASE REPORT A 46-year-old, black, right-handed man with a history of hypertension, chronic renal failure with hemodialysis, and multiple myeloma (undergoing chemotherapy and steroid therapy) presented to the emergency department (ED) from his hemodialysis center with complaints of not feeling well. He completed a course of dialysis during which he began complaining of generalized fatigue and vomited once. He was sent into the ED for further evaluation. The patient refused to answer most questions. He repeatedly stated, “I just don’t feel well.” He admitted to feeling tired and weak. He denied any pain, fevers, or chills. The results for the remainder of his review of systems were negative. He denied illicit drug use. Physical examination revealed a cachectic man who appeared older than his stated age. Vital signs on presentation Volume
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were blood pressure 146/89 mm Hg, pulse rate 81 beats/ min, respiratory rate 14 breaths/min, and temperature 37 C (98.6 F). He was lethargic, but awakened to questioning. His cardiovascular and abdominal examination results were normal. Extremity examination revealed a functioning fistula in his right anterior upper extremity. Focused examination of his right shoulder showed moderate tense swelling of his deltoid and posterior shoulder. There was no erythema, induration, or open wounds. The patient refused to move his shoulder, and attempted passive range of motion was unsuccessful and elicited intense pain. He had normal motion and appearance of his elbow, wrist, and hand. His distal right extremity was neurovascularly intact. With a working diagnosis of septic arthritis of the right shoulder, an evaluation was initiated, including laboratory studies and radiographs. An intravenous line was placed and the patient received 6 mg of morphine, 3 g of ampicillin/sulbactam, and 1 g of vancomycin. Laboratory study results were significant for a total WBC count of 1,000/cu mm, with an absolute neutrophil count of 600/cu mm, hemoglobin level of 9.2 g/dL, platelet count of 94,000/cu mm, blood urea nitrogen of 42 mg/dL, creatinine level of 3.95 mg/dL, and lactic acid level of 2.6 mmol/L. Radiographs of his chest and right shoulder were interpreted by radiology as normal. Given the concern for septic arthritis, bedside ultrasonography (Edge with HFL-38 probe in MSK mode; Sonosite, Bothell, WA) was performed of the posterior shoulder to evaluate for a glenohumeral joint effusion. The examination revealed an anechoic fluid collection that communicated with the glenohumeral joint and extended medially along the supraspinatus muscle, inferiorly along Annals of Emergency Medicine 1
Bunting & Kuper
Bedside Washout of Septic Shoulder
the humerus, superiorly to the acromion, and laterally to the midpoint of the deltoid. The collection was surrounded by an echogenic capsule and had maximum dimensions of 10 cm transversely and sagittally. To confirm the cause of the effusion, joint aspiration was performed under ultrasonographic guidance. Although lethargic, the patient was competent and written consent was obtained. The posterior shoulder was prepped and draped in a sterile fashion. The probe was placed in a sterile cover and sterile ultrasonographic gel was applied to the area. A 27-gauge needle was used to infiltrate local anesthetic at the puncture site. An 18-gauge needle was then introduced under in-plane ultrasonographic guidance into the joint capsule. Aspiration of 10 mL of grossly purulent fluid (Figure 1) confirmed the diagnosis of septic arthritis. After consultation with orthopedics, the patient was sent to the operating suite. He returned a short time later after the attending anesthesiologist and orthopedist evaluated him and determined he was too ill to undergo surgery. They cited his low WBC count, lethargy, and concern about concurrent infection in his ipsilateral dialysis shunt. The orthopedist recommended computed tomography (CT)–guided joint drainage, but interventional radiology was not available and would not be for approximately 12 hours. After further discussion with the attending orthopedist, the decision was made to perform bedside joint irrigation.
As with the earlier procedure, two 16-gauge angiocatheters were inserted into the joint capsule under ultrasonographic guidance (Figure 2) and held in place with Tegaderm (3M, St. Paul, MN). One was placed below the lateral edge of the acromion and directed into the deepest pocket of the glenohumeral joint. The other was placed from caudal to cranial into the inferior portion of the joint capsule. An additional 30 mL of purulent fluid was initially withdrawn. When further aspiration was not possible, 1-L sterile saline solution bags were attached to the superior angiocatheter with standard intravenous-line tubing and hung above the patient on an adjustable intravenous-line pole. The inferior angiocatheter was attached to intravenous-line tubing that was cut and hung to drain dependently into a basin. Saline solution was run by gravity into the joint through the superior port and drained through the inferior one. The fluid was initially purulent but cleared over time. When the effluent cleared, the joint was gently passively manipulated, which yielded additional purulence. The procedure was aborted after less than 1 hour once movement of the joint yielded no additional purulent fluid. A total of 3 L of normal saline solution was used to achieve this endpoint. Three times during the procedure, the drainage port stopped draining and required back flushing to unclog. The patient tolerated the procedure well without any sedation or additional analgesia.
Figure 1. Ultrasound image demonstrating an inplane needle guidance from a lateral approach into the posterior glenerohumeral joint and resultant purulent fliud. The needle (arrowhead) is placed in the anechoic joint effusion (E) erupting from between the glenoid (G) and humerus (H). Right panel demonstrates the resulting purulent fluid.
2 Annals of Emergency Medicine
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Bunting & Kuper
Bedside Washout of Septic Shoulder
Figure 2. Angiocatheter placement for bedside shoulder irrigation. Note the purulence in the drainage port.
After the procedure, the patient had decreased pain and increased range of motion. After irrigation, he had painless partial internal and external rotation and 30 degrees of abduction, flexion, and extension of the shoulder passively. Active range of motion was not tested. The patient was admitted to an oncology floor and followed by orthopedics and infectious diseases. The fluid aspirated from his shoulder had a WBC count of 67,000/mL and eventually grew methicillin-susceptible Staphylococcus aureus. He remained afebrile and his WBC count increased to a normal range on hospital day 3. The patient had repeated right shoulder drainages under CT guidance for reaccumulation of fluid on hospital days 3 and 7 that yielded 30 and 20 mL of fluid, respectively. The patient continued to improve, and he was discharged to inpatient rehabilitation, receiving intravenous cefazolin through a peripherally inserted central catheter on hospital day 14. According to the patient’s primary care physician, his right shoulder examination result and range of motion were normal 3 months later, with no further intervention.
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DISCUSSION Diagnosing septic joints through aspiration is part of the core training in emergency medicine. If the same technique were also used to treat a septic joint when orthopedics presence was not promptly available, the patient could be saved the pain, delay, and cost of additional procedures. We present the first case report, to our knowledge, of a successful ultrasonographically guided, closed-joint irrigation performed by an emergency physician. The complaint of a painful, swollen joint is an uncommon but potentially dangerous presentation in EDs. Although some causes of this complaint are benign, the diagnosis of septic arthritis must not be missed. Prompt identification and initiation of treatment is critical because within days of onset, damage to cartilage may be irreparable and the mortality rate can reach 15%.5 Septic arthritis has an annual incidence of 10 per 100,000 in the United States.6 However, some populations are at a higher risk, with the incidence in patients receiving hemodialysis at 500 cases per 100,000 patients.7 The knee is the most common site, followed by the hip, shoulder, ankle, and wrist.7,8 In the United States, S aureus is the most common pathogen and is encountered in 44% of positive cultures.9 Certain areas have reported increased rates of methicillin-resistant S aureus, including our location (Detroit), where rates reach up to 65%.10,11 The treatment of septic arthritis is incomplete without the removal of purulent material from the joint space, and modern thought on the treatment of sepsis mandates timely source control. The most efficient and definitive therapy to achieve a sterile joint remains a topic of debate.12-14 Arthrotomy, arthroscopy, or closed needle aspiration have been mainstay treatments to achieve removal of purulent material, but evidence is lacking about which approach is superior.11 Smith et al12 performed the only randomized prospective study comparing these techniques in Malawi. A total of 61 children who presented with signs of septic arthritis of the shoulder were randomized to needle aspiration or arthrotomy. They found no difference in short- or long-term outcomes between the groups. Their cohort had only 7% S aureus and 79% Salmonella on final growths; because virulence patterns differ in microbes, their findings may not be generally applicable. Indwelling catheters have also been used successfully to treat septic arthritis. In a prospective cohort of 52 patients, Griffet et al13 placed an indwelling catheter under fluoroscopic guidance for washout and drainage of septic joints. The procedure was successful in clearing infection in all cases. The necessity to use fluoroscopic placement may have increased
Annals of Emergency Medicine 3
Bunting & Kuper
Bedside Washout of Septic Shoulder
time to treatment because the mean time to drainage was 10.5 hours. They also postulated that consecutive aspiration dehydrates the joint, thus devitalizing the articular cartilage, and leads to increased morbidity. A 2-catheter approach to perform shoulder joint washouts has been described in the treatment of calcific tendonitis in a robust cohort of 219 patients by Seraffini et al.15 Using two 16-gauge needles, investigators with considerable skill in ultrasonography irrigated and drained calcific deposits and injected steroids into the subacromial bursa.15 A technically similar approach was described by Yassa et al14 to successfully treat septic arthritis of the shoulder in a single patient, using a 2-catheter washout approach; however, fluoroscopy rather than ultrasonography was used in the treatment of this patient. Sterile saline solution was flushed from one catheter through the bursa to the other catheter until no purulent material drained with passive motion of the shoulder by the surgeon.14 Although this was our first attempt at closed joint irrigation, the lead author had significant experience draining and injecting other cavities under ultrasonographic guidance. The procedure was simple to perform with the 2-angiocatheter technique. A pigtail catheter was the preferred device for the drainage port, but one was not available at this procedure. Given the issue of the drainage port clogging during the procedure, we recommend a larger-diameter drainage port. A modification to consider would be using a suture-secured pigtail catheter as the drainage port and leaving it indwelling until the inpatient team deems it ready to remove. The need for repeated aspirations during our patient’s hospital stay should not be viewed as a failure. Frequent aspirations are sometimes necessary in the closed management of septic joints.16 The possibility that other services will perform additional procedures does not necessarily preclude the ED from initiating drainage to prevent delays. We describe a case of successful bedside aspiration and drainage of a septic joint. Although the technique was easy to perform and well tolerated, it likely represents the only time we will perform this technique in a nonresearch setting. This technique should not be considered standard of care and might well leave those performing it vulnerable to criticism or legal action if conducted without major extenuating circumstances. Training and experience with the technique would be required, as well as direct communication with an orthopedic consultant. The unique circumstances of this case made early intervention by the emergency physicians the best option for the patient, but
4 Annals of Emergency Medicine
such circumstances will be rare in most emergency medicine practice outside austere environments. Supervising editor: Alan E. Jones, MD Author affiliations: From the Department of Emergency Medicine, Wayne State University, Detroit, MI (Bunting); and St. John Hospital and Medical Center, Detroit, MI (Kuper). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES 1. Christopher CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18: 781-796. 2. Genes N, Chisolm-Straker M. Monoarticular arthritis update: current evidence for diagnosis and treatment in the emergency department. Emerg Med Pract. 2012;14:1-19. 3. Mathews CJ, Kingsley G, Field M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-445. 4. Freeman K, Dewitz A, Baker WE. Ultrasound-guided hip arthrocentesis in the ED. Am J Emerg Med. 2007;25:80-86. 5. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30. 6. Kaandorp CJ, Van Schaardenburg D, Krijnen P, et al. Risk factors for septic arthritis in patients with joint disease: a prospective study. Arthritis Rheumatol. 1995;38:1819-1825. 7. Al Nammari SS, Gulati V, Patel R, et al. Septic arthritis in haemodialysis patients: a seven-year multi-centre review. J Orthop Surg (Hong Kong). 2008;16:54-57. 8. Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. 2009;37:269-272. 9. Ross JJ, Saltzman CL, Carling P, et al. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis. 2003;36:319-327. 10. Moore CL, Osaki-Kiyan P, et al. USA600 (ST45) methicillin-resistant Staphylococcus aureus bloodstream infections in urban Detroit. Microbiology. 2010;48:2307-2310. 11. Mathews CJ, Coakly G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol. 2008;20:457-462. 12. Smith SP, Thyok M, Lavy CB, et al. Septic arthritis of the shoulder in children in Malawi. 2002;84:1167-1172. 13. Griffet J, Oborocianu I, Rubio A, et al. Percutaneous aspiration irrigation drainage technique in the management of septic arthritis. J Trauma. 2011;70:377-381. 14. Yassa R, Khan T, Zenios M. Minimally invasive washout of the shoulder for septic arthritis in children: a new technique. Ann R Coll Surg Engl. 2011;93:485-492. 15. Seraffini G, Sconfienza LM, Lacelli F, et al. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two needle US-guided percutaneous treatment. Radiology. 2009;252:157-164. 16. Brusch J. Septic arthritis treatment and management. Available at: http://emedicine.medscape.com/article/236299. Accessed December 9, 2015.
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no.
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Bedside Washout of a Septic Shoulder in the Emergency Department: A Case Report Leonard Bunting, MD, RDMS*; Kenneth Kuper, MD *Corresponding Author. E-mail: [email protected].
We present a case of successful bedside irrigation of a septic joint in the emergency department. Complicating factors prevented the patient from undergoing operative management. With a simple 2 catheter technique the authors irrigated the patient’s septic shoulder at the bedside. The patient’s pain and range of motion improved immediately following the technique. The patient had complete recovery without open drainage. With further investigation, definitive management of septic joints could begin in the emergency department. [Ann Emerg Med. 2016;-:1-4.] 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.01.011
INTRODUCTION For emergency medicine practitioners, septic joints are rare but obvious diagnoses. Unfortunately, identifying the condition can be challenging because of lack of reliable physical examination findings or definitive serum markers.1 Instead we must rely on a strong clinical suspicion and a low threshold for joint aspiration with fluid analysis.2 Traditional management involves administering antibiotics and consulting outside services for drainage.3 However, any delay to drainage exposes the patient to potential complications2 and continued pain.4 To our knowledge, we present the first published case of an emergency medicine provider performing bedside drainage and irrigation of an infected joint. CASE REPORT A 46-year-old, black, right-handed man with a history of hypertension, chronic renal failure with hemodialysis, and multiple myeloma (undergoing chemotherapy and steroid therapy) presented to the emergency department (ED) from his hemodialysis center with complaints of not feeling well. He completed a course of dialysis during which he began complaining of generalized fatigue and vomited once. He was sent into the ED for further evaluation. The patient refused to answer most questions. He repeatedly stated, “I just don’t feel well.” He admitted to feeling tired and weak. He denied any pain, fevers, or chills. The results for the remainder of his review of systems were negative. He denied illicit drug use. Physical examination revealed a cachectic man who appeared older than his stated age. Vital signs on presentation Volume
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were blood pressure 146/89 mm Hg, pulse rate 81 beats/ min, respiratory rate 14 breaths/min, and temperature 37 C (98.6 F). He was lethargic, but awakened to questioning. His cardiovascular and abdominal examination results were normal. Extremity examination revealed a functioning fistula in his right anterior upper extremity. Focused examination of his right shoulder showed moderate tense swelling of his deltoid and posterior shoulder. There was no erythema, induration, or open wounds. The patient refused to move his shoulder, and attempted passive range of motion was unsuccessful and elicited intense pain. He had normal motion and appearance of his elbow, wrist, and hand. His distal right extremity was neurovascularly intact. With a working diagnosis of septic arthritis of the right shoulder, an evaluation was initiated, including laboratory studies and radiographs. An intravenous line was placed and the patient received 6 mg of morphine, 3 g of ampicillin/sulbactam, and 1 g of vancomycin. Laboratory study results were significant for a total WBC count of 1,000/cu mm, with an absolute neutrophil count of 600/cu mm, hemoglobin level of 9.2 g/dL, platelet count of 94,000/cu mm, blood urea nitrogen of 42 mg/dL, creatinine level of 3.95 mg/dL, and lactic acid level of 2.6 mmol/L. Radiographs of his chest and right shoulder were interpreted by radiology as normal. Given the concern for septic arthritis, bedside ultrasonography (Edge with HFL-38 probe in MSK mode; Sonosite, Bothell, WA) was performed of the posterior shoulder to evaluate for a glenohumeral joint effusion. The examination revealed an anechoic fluid collection that communicated with the glenohumeral joint and extended medially along the supraspinatus muscle, inferiorly along Annals of Emergency Medicine 1
Bunting & Kuper
Bedside Washout of Septic Shoulder
the humerus, superiorly to the acromion, and laterally to the midpoint of the deltoid. The collection was surrounded by an echogenic capsule and had maximum dimensions of 10 cm transversely and sagittally. To confirm the cause of the effusion, joint aspiration was performed under ultrasonographic guidance. Although lethargic, the patient was competent and written consent was obtained. The posterior shoulder was prepped and draped in a sterile fashion. The probe was placed in a sterile cover and sterile ultrasonographic gel was applied to the area. A 27-gauge needle was used to infiltrate local anesthetic at the puncture site. An 18-gauge needle was then introduced under in-plane ultrasonographic guidance into the joint capsule. Aspiration of 10 mL of grossly purulent fluid (Figure 1) confirmed the diagnosis of septic arthritis. After consultation with orthopedics, the patient was sent to the operating suite. He returned a short time later after the attending anesthesiologist and orthopedist evaluated him and determined he was too ill to undergo surgery. They cited his low WBC count, lethargy, and concern about concurrent infection in his ipsilateral dialysis shunt. The orthopedist recommended computed tomography (CT)–guided joint drainage, but interventional radiology was not available and would not be for approximately 12 hours. After further discussion with the attending orthopedist, the decision was made to perform bedside joint irrigation.
As with the earlier procedure, two 16-gauge angiocatheters were inserted into the joint capsule under ultrasonographic guidance (Figure 2) and held in place with Tegaderm (3M, St. Paul, MN). One was placed below the lateral edge of the acromion and directed into the deepest pocket of the glenohumeral joint. The other was placed from caudal to cranial into the inferior portion of the joint capsule. An additional 30 mL of purulent fluid was initially withdrawn. When further aspiration was not possible, 1-L sterile saline solution bags were attached to the superior angiocatheter with standard intravenous-line tubing and hung above the patient on an adjustable intravenous-line pole. The inferior angiocatheter was attached to intravenous-line tubing that was cut and hung to drain dependently into a basin. Saline solution was run by gravity into the joint through the superior port and drained through the inferior one. The fluid was initially purulent but cleared over time. When the effluent cleared, the joint was gently passively manipulated, which yielded additional purulence. The procedure was aborted after less than 1 hour once movement of the joint yielded no additional purulent fluid. A total of 3 L of normal saline solution was used to achieve this endpoint. Three times during the procedure, the drainage port stopped draining and required back flushing to unclog. The patient tolerated the procedure well without any sedation or additional analgesia.
Figure 1. Ultrasound image demonstrating an inplane needle guidance from a lateral approach into the posterior glenerohumeral joint and resultant purulent fliud. The needle (arrowhead) is placed in the anechoic joint effusion (E) erupting from between the glenoid (G) and humerus (H). Right panel demonstrates the resulting purulent fluid.
2 Annals of Emergency Medicine
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no.
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Bunting & Kuper
Bedside Washout of Septic Shoulder
Figure 2. Angiocatheter placement for bedside shoulder irrigation. Note the purulence in the drainage port.
After the procedure, the patient had decreased pain and increased range of motion. After irrigation, he had painless partial internal and external rotation and 30 degrees of abduction, flexion, and extension of the shoulder passively. Active range of motion was not tested. The patient was admitted to an oncology floor and followed by orthopedics and infectious diseases. The fluid aspirated from his shoulder had a WBC count of 67,000/mL and eventually grew methicillin-susceptible Staphylococcus aureus. He remained afebrile and his WBC count increased to a normal range on hospital day 3. The patient had repeated right shoulder drainages under CT guidance for reaccumulation of fluid on hospital days 3 and 7 that yielded 30 and 20 mL of fluid, respectively. The patient continued to improve, and he was discharged to inpatient rehabilitation, receiving intravenous cefazolin through a peripherally inserted central catheter on hospital day 14. According to the patient’s primary care physician, his right shoulder examination result and range of motion were normal 3 months later, with no further intervention.
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DISCUSSION Diagnosing septic joints through aspiration is part of the core training in emergency medicine. If the same technique were also used to treat a septic joint when orthopedics presence was not promptly available, the patient could be saved the pain, delay, and cost of additional procedures. We present the first case report, to our knowledge, of a successful ultrasonographically guided, closed-joint irrigation performed by an emergency physician. The complaint of a painful, swollen joint is an uncommon but potentially dangerous presentation in EDs. Although some causes of this complaint are benign, the diagnosis of septic arthritis must not be missed. Prompt identification and initiation of treatment is critical because within days of onset, damage to cartilage may be irreparable and the mortality rate can reach 15%.5 Septic arthritis has an annual incidence of 10 per 100,000 in the United States.6 However, some populations are at a higher risk, with the incidence in patients receiving hemodialysis at 500 cases per 100,000 patients.7 The knee is the most common site, followed by the hip, shoulder, ankle, and wrist.7,8 In the United States, S aureus is the most common pathogen and is encountered in 44% of positive cultures.9 Certain areas have reported increased rates of methicillin-resistant S aureus, including our location (Detroit), where rates reach up to 65%.10,11 The treatment of septic arthritis is incomplete without the removal of purulent material from the joint space, and modern thought on the treatment of sepsis mandates timely source control. The most efficient and definitive therapy to achieve a sterile joint remains a topic of debate.12-14 Arthrotomy, arthroscopy, or closed needle aspiration have been mainstay treatments to achieve removal of purulent material, but evidence is lacking about which approach is superior.11 Smith et al12 performed the only randomized prospective study comparing these techniques in Malawi. A total of 61 children who presented with signs of septic arthritis of the shoulder were randomized to needle aspiration or arthrotomy. They found no difference in short- or long-term outcomes between the groups. Their cohort had only 7% S aureus and 79% Salmonella on final growths; because virulence patterns differ in microbes, their findings may not be generally applicable. Indwelling catheters have also been used successfully to treat septic arthritis. In a prospective cohort of 52 patients, Griffet et al13 placed an indwelling catheter under fluoroscopic guidance for washout and drainage of septic joints. The procedure was successful in clearing infection in all cases. The necessity to use fluoroscopic placement may have increased
Annals of Emergency Medicine 3
Bunting & Kuper
Bedside Washout of Septic Shoulder
time to treatment because the mean time to drainage was 10.5 hours. They also postulated that consecutive aspiration dehydrates the joint, thus devitalizing the articular cartilage, and leads to increased morbidity. A 2-catheter approach to perform shoulder joint washouts has been described in the treatment of calcific tendonitis in a robust cohort of 219 patients by Seraffini et al.15 Using two 16-gauge needles, investigators with considerable skill in ultrasonography irrigated and drained calcific deposits and injected steroids into the subacromial bursa.15 A technically similar approach was described by Yassa et al14 to successfully treat septic arthritis of the shoulder in a single patient, using a 2-catheter washout approach; however, fluoroscopy rather than ultrasonography was used in the treatment of this patient. Sterile saline solution was flushed from one catheter through the bursa to the other catheter until no purulent material drained with passive motion of the shoulder by the surgeon.14 Although this was our first attempt at closed joint irrigation, the lead author had significant experience draining and injecting other cavities under ultrasonographic guidance. The procedure was simple to perform with the 2-angiocatheter technique. A pigtail catheter was the preferred device for the drainage port, but one was not available at this procedure. Given the issue of the drainage port clogging during the procedure, we recommend a larger-diameter drainage port. A modification to consider would be using a suture-secured pigtail catheter as the drainage port and leaving it indwelling until the inpatient team deems it ready to remove. The need for repeated aspirations during our patient’s hospital stay should not be viewed as a failure. Frequent aspirations are sometimes necessary in the closed management of septic joints.16 The possibility that other services will perform additional procedures does not necessarily preclude the ED from initiating drainage to prevent delays. We describe a case of successful bedside aspiration and drainage of a septic joint. Although the technique was easy to perform and well tolerated, it likely represents the only time we will perform this technique in a nonresearch setting. This technique should not be considered standard of care and might well leave those performing it vulnerable to criticism or legal action if conducted without major extenuating circumstances. Training and experience with the technique would be required, as well as direct communication with an orthopedic consultant. The unique circumstances of this case made early intervention by the emergency physicians the best option for the patient, but
4 Annals of Emergency Medicine
such circumstances will be rare in most emergency medicine practice outside austere environments. Supervising editor: Alan E. Jones, MD Author affiliations: From the Department of Emergency Medicine, Wayne State University, Detroit, MI (Bunting); and St. John Hospital and Medical Center, Detroit, MI (Kuper). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES 1. Christopher CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18: 781-796. 2. Genes N, Chisolm-Straker M. Monoarticular arthritis update: current evidence for diagnosis and treatment in the emergency department. Emerg Med Pract. 2012;14:1-19. 3. Mathews CJ, Kingsley G, Field M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-445. 4. Freeman K, Dewitz A, Baker WE. Ultrasound-guided hip arthrocentesis in the ED. Am J Emerg Med. 2007;25:80-86. 5. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30. 6. Kaandorp CJ, Van Schaardenburg D, Krijnen P, et al. Risk factors for septic arthritis in patients with joint disease: a prospective study. Arthritis Rheumatol. 1995;38:1819-1825. 7. Al Nammari SS, Gulati V, Patel R, et al. Septic arthritis in haemodialysis patients: a seven-year multi-centre review. J Orthop Surg (Hong Kong). 2008;16:54-57. 8. Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. 2009;37:269-272. 9. Ross JJ, Saltzman CL, Carling P, et al. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis. 2003;36:319-327. 10. Moore CL, Osaki-Kiyan P, et al. USA600 (ST45) methicillin-resistant Staphylococcus aureus bloodstream infections in urban Detroit. Microbiology. 2010;48:2307-2310. 11. Mathews CJ, Coakly G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol. 2008;20:457-462. 12. Smith SP, Thyok M, Lavy CB, et al. Septic arthritis of the shoulder in children in Malawi. 2002;84:1167-1172. 13. Griffet J, Oborocianu I, Rubio A, et al. Percutaneous aspiration irrigation drainage technique in the management of septic arthritis. J Trauma. 2011;70:377-381. 14. Yassa R, Khan T, Zenios M. Minimally invasive washout of the shoulder for septic arthritis in children: a new technique. Ann R Coll Surg Engl. 2011;93:485-492. 15. Seraffini G, Sconfienza LM, Lacelli F, et al. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two needle US-guided percutaneous treatment. Radiology. 2009;252:157-164. 16. Brusch J. Septic arthritis treatment and management. Available at: http://emedicine.medscape.com/article/236299. Accessed December 9, 2015.
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