Post-operative septic arthritis after arthroscopy: modern diagnostic and therapeutic concepts

Abstract

Purpose: Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy.

Methods: Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention.

Results: A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis.

Conclusion: The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6-12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases.

Level of evidence: IV.

Keywords: Ankle; Antibiotics; Arthroscopy; Complication; Elbow; Hip; Joint infection; Knee; Shoulder; Wrist.

Fig. 1

Priority protocol for suspected joint infections. Depending on the amount of joint fluid, the user should start with priority 1 and then follow the list. This specific protocol allows for easy handling with information about the amount, the purpose, the tube, and the target institute for analysis

Fig. 2

a Early detected knee joint infection after arthroscopy (Gächter type I) with clear synovialitis, and b shoulder joint infection after arthroscopic irrigation, before debridement (Gächter type II) with clear synovialitis and petechial bleeding in the anterior joint compartment with fibrin deposits

Fig. 3

Algorithm for suspected joint infection after arthroscopy. In cases with indwelling implants, it is important to distinguish between an acute and chronic infection (see Table 4) in regard to implant preservation or removal (* in chronic cases mandatory, in acute cases helpful to identify implants and their position in case of surgery and subsequent removal if patient is not known to the presenting surgeon