Abstract
Introduction
Native knee septic arthritis is a rare condition with a potential for high morbidity if not promptly treated. Treatment involves surgical decompression of the affected joint along with systemic antibiotic therapy. The purpose of this study is to compare arthroscopic versus open irrigation and debridement for treatment of native knee septic arthritis.
Methods
A retrospective review was conducted at a single academic institution of all patients treated for native knee septic arthritis from January 2007 until August 2018 utilizing ICD and CPT codes. Patient demographics, type of surgical procedure, need for reoperation, laboratory values, length of stay, and comorbidities were compared.
Results
A cohort of sixty-six patients who underwent 85 surgeries were included. Among these surgeries, 52 (61%) were arthroscopic while 33 (39%) were open arthrotomies, and 21% required more than one operation. While not statistically significant, the odds of reoperation was higher for those that underwent arthroscopic compared to open irrigation and debridement on univariable (OR = 4.05, p = .08) and multivariable analysis (OR = 4.39, p = .10). Additionally, patients were more likely to require a longer hospital stay if they initially underwent arthroscopic rather than open debridement (RR = 1.31, p = .02).
Conclusion
Native knee septic arthritis can be treated with a single surgery in the majority of cases. In our sample, there was an increased odds of reoperation in those treated arthroscopically compared to open, though this finding was not statistically significant. We found longer length of stay for patients undergoing arthroscopic rather than open irrigation and debridement – even after controlling for multiple operations, culture status, sex, age, and comorbidities.
Keywords: Arthroplasty, Septic arthritis, Irrigation and debridement
1. Introduction
Native knee septic arthritis is a rare condition occurring more frequently in patients with underlying medical comorbidities, prior surgery of the affected joint, or direct trauma to the knee.1,2 Mortality related to septic arthritis is also rare, though secondary arthrosis, stiffness, persistent pain, and need for reoperations create potential for significant morbidity to this population.3 While decompression of infection in combination with antibiotic therapy has been the standard treatment, the form of knee joint drainage has been debated.4, 5, 6, 7, 8, 9, 10, 11, 12 Serial aspiration is supported by a few small studies, though the authors note such treatment should be done on a individual patient basis.4,5 Surgical management has been favored in clinical practice for patients that are medically stable enough for an operation.13
Arthroscopic and open irrigation and debridement have been compared in previous literature with conflicting results.7, 8, 9, 10, 11, 12,14, 15, 16, 17, 18 Several retrospective studies have found no difference in reoperation rates or complications11,14 and others favoring arthroscopic treatment due to the lower reoperation rate, decreased pain, and improved early range of motion.7,10,12,18 One small prospective randomized study found lower reoperation rates and decreased pain at 7 and 14 days post-operatively in the arthroscopy group, though the authors noted no difference in range of motion or return to ADLs.16 Three studies utilized the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, all of which found no difference in reoperation rates, although they did find a higher rate of minor adverse events in the arthrotomy group which was attributed to a higher rate of blood transfusion.8,15,17 However, one of these studies found a higher rate of major adverse events in the arthroscopy group, though this association attenuated on multivariable analysis.17 Another study used the Healthcare Cost and Utilization Project National Inpatient Sample (NIS) database and found no difference in major or minor complications, length of stay, or cost between arthroscopic and open groups.9
Given the lack of consensus in the literature, the purpose of this study was to perform a detailed retrospective review of patients that underwent surgical treatment for native knee septic arthritis over an 11-year period at one tertiary referral academic institution.
2. Methods
Institutional review board (IRB) review and approval was obtained. A retrospective review was conducted at a single academic institution of all patients treated for native knee septic arthritis from the inception of the electronic medical record in January 2007 until August 2018 utilizing ICD codes(ICD-9: 711.06; ICD-10 M00.861, M00.862, M00.869) and CPT codes(27310, 29871).
Inclusion criteria were patients with native knee septic arthritis who underwent surgical treatment. Patients were excluded if they did not undergo an operation, underwent surgery for any reason other than a septic joint, had a traumatic arthrotomy, were less than 18 years of age, had osteomyelitis or neighboring necrotizing fasciitis, had presence of a prosthesis or implant, or had a recent ligament reconstruction or tendon repair. Patients who underwent their initial surgery prior to transfer to our hospital were included in the group corresponding to the procedure performed at the outside institution.
All patients included were diagnosed with septic arthritis of the knee based on clinical presentation, serum laboratory values and joint aspirate results, including Gram stain which was obtained following aspiration. They were all indicated for operative intervention by the attending orthopedic surgeon. Patients either underwent arthroscopic only or open irrigation and debridement; the type of operation performed, and need for operation, was decided upon by the attending orthopaedic surgeon. The procedures were performed by 20 board certified and fellowship trained orthopaedic surgeons. Following the procedure, standard of care drainage and irrigation was performed in all cases until further converted to simple drainage. All patients were treated with appropriate antibiotic therapy with the guidance of an infectious disease specialist who determined type of antibiotic, length of time for intravenous antibiotic use, and transition to oral antibiotic as is standard of care. Those that failed to improve after the initial surgery or acutely worsened underwent repeat irrigation and debridement at the discretion of the attending surgeon and standard of care.
Direct chart review was performed to obtain demographic data, body mass index(BMI), mortality, length of stay, reoperation, type of reoperation, synovial fluid white blood cell counts, synovial fluid crystal analysis, aspiration and surgical specimen culture results, blood culture results, erythrocyte sedimentation rate(ESR), C-reactive protein(CRP), serum white blood cell(WBC) count and comorbidities composing Charlson Comorbidity Index. The time spent at the outside hospital was not included in our length of stay analysis as this data was not available in the majority of patients. All patients were discharged per standard of care, with goals achieved and in agreement with the infectious disease specialist, primary care management team, orthopaedic team, physical and occupational therapist, and any other members involved in the patients care at our university hospital.
2.1. Statistical analysis
Patient demographics are displayed as valid counts and proportions for nominal characteristics while quantitative characteristics are displayed using the mean and standard deviation; these summaries are stratified by patients’ operation type (i.e., open versus arthroscopic).
Univariable and multivariable generalized estimating equations (GEE models) were used to estimate the odds of reoperation as a function of patients' procedure type, previous washout status, culture positivity status, Charlson comorbidity score, sex, age, and BMI. These models specified a binomial distribution with logit link for the reoperation response. For the multivariable model, the explanatory variable of interest was the procedure type and, due to the sparse event rate, only one additional covariate (culture status) was included because it improved the model's information criterion (QICu; Hardin & Hilbe, 2013; Peduzzi et al., 1996).
Univariable and multivariable GEE models were also used to estimate the length of stay as a function of patients' demographic characteristics and comorbidities. For these models, we specified a negative binomial distribution with log link for the dependent variable (i.e., length of stay). As before, the multivariable model included patients' procedure type as the explanatory variable of interest and covariates were included if they further improved the model's information criterion (QICc). All analyses were completed using SAS version 9.4 (Cary, NC).
3. Results
Sixty-six patients contributed 85 surgeries to the study. Among these surgeries, 52 (61%) were arthroscopic while 33 (39%) were open arthrotomies. Overall, most patients identified as male (69%), non-Hispanic (86%), and White (71%). Less than half were culture positive (42%) and few required reoperation (21%). Patients were middle age (M = 59.61 (41–84), SD = 17.64) with an average body mass index of 29.68 (SD = 9.12) kg/m2. The median length of stay was 7 (IQR: 4–10) days, and the median Charlson comorbidity score was 3 (IQR: 1–7) which describes a sample with a 10-year survival probability of approximately 77% (Charlson et al., 1987).19 See Table 1.
Table 1.
Patient characteristics.
| Open (n = 33) | Scope (n = 52) | Total (N = 85) | |
|---|---|---|---|
| Male | 23 (70%) | 36 (69%) | 59 (69%) |
| Race (N = 84) | |||
| White | 17 (53%) | 43 (83%) | 60 (71%) |
| Black | 12 (38%) | 6 (12%) | 18 (21%) |
| Other | 3 (9.4%) | 3 (5.8%) | 6 (7.1%) |
| Hispanic Ethnicity | 2 (6.1%) | 10 (19%) | 12 (14%) |
| Culture positive (N = 84) | 15 (47%) | 20 (38%) | 35 (42%) |
| Reoperation | 3 (9.1%) | 15 (29%) | 18 (21%) |
| Median Charlson score (IQR) | 5 (2–7) | 3 (0–6) | 3 (1–7) |
| Mean Age (SD) | 60.52 (15.09) | 59.04 (19.21) | 59.61 (17.64) |
| Mean BMI (SD) (N = 48) | 28.56 (7.18) | 30.35 (10.17) | 29.68 (9.12) |
| Median LOS (IQR) | 6 (4–10) | 7 (4–12) | 7 (4–10) |
| Mean Aspirate WBC (SD) (N = 75) | 11.29 (0.78) | 10.84 (1.08) | 11.02 (0.99) |
| Mean Aspirate SEG% (SD) (N = 73) | 89.33 (16.51) | 88.58 (8.93) | 88.91 (12.79) |
| Mean Aspirate WBC (SD) (N = 75) | 109,318.44 (115,866.89) | 70,626.78 (45,603.30) | 88,167 (86,527.67) |
|
Median Aspirate WBC (Range) (N = 75) |
71,800 (532,800) | 60,000 (227,517) | 61,200 (535,517) |
| Mean ESR (SD) (N = 72) | 66.74 (36.86) | 64.91 (37.74) | 65.77 (37.07) |
| Mean CRP (SD)(N = 70) | 15.54 (10.25) | 14.04 (9.81) | 14.75 (9.98) |
Note: Unless otherwise noted, the valid number of surgeries is N = 85. BMI = Body mass index in (kg/m2). IQR = Interquartile range. LOS = Length of stay (in days). WBC = Natural logarithm of the white blood cell count. SEG = Segmented neutrophils (%).
In this sample, there was no significant difference in the odds of reoperation during inpatient stay between patients undergoing arthroscopic versus open irrigation and debridement on univariable (Odds Ratio or OR = 4.05, 95% CI: 0.86–19.09; p = .08) or multivariable analysis (OR = 4.39, 95% CI: 0.76–25.45; p = .10)(Table 2). The most common pathogen identified was methicillin sensitive staphylococcus aureus (n = 15/35 or 43%), followed by methicillin resistant staphylococcus aureus (n = 5/35 or 14%) (Table 3).
Table 2.
Odds of reoperation.
| Valid N | Unadjusted |
Adjusted |
|||
|---|---|---|---|---|---|
| Odds Ratio (95% CI) | p | Odds Ratio (95% CI) | p | ||
| Status: Scope vs Open | 85 | 4.05 (0.86–19.09) | .08 | 4.39 (0.76–25.45) | .10 |
| Culture Positive: Yes vs No | 84 | 2.05 (0.67–6.24) | .21 | 2.40 (0.69–8.31) | .17 |
| Charlson Comorbidity Score (per point increase) | 85 | 0.95 (0.81–1.11) | .54 | ||
| Sex: Male vs Female | 85 | 0.85 (0.27–2.69) | .78 | ||
| Age (per 5-year increase) | 85 | 0.90 (0.75–1.09) | .28 | ||
| BMI (per 5 kg/m2 increase) | 48 | 0.95 (0.68–1.33) | .77 | ||
Note: Valid N = Number of surgeries used for the unadjusted estimates. For the adjusted estimates, the number of surgeries = 84 with 18 (21%) events.
Table 3.
Cultured pathogens.
| Pathogen (Aspirate or Surgical) | Number |
|---|---|
| Methicillin Sensitive Staphylococcus Aureus (MSSA) | 15 (43%) |
| Methicillin Resistant Staphylococcus Aureus (MRSA) | 5 (14%) |
| Polymicrobial | 2 (5.7%) |
| Escherichia coli | 2 (5.7%) |
| Streptococcus agalactiae | 2 (5.7%) |
| Pseudomonas aeruginosa | 2 (5.7%) |
| Blastomycosis dermatitidis | 1 (2.9%) |
| Staphylococcus epidermitis | 1 (2.9%) |
| Corynebacterium | 1 (2.9%) |
| Streptococcus pneumoniae | 1 (2.9%) |
| Streptococcus pyogenes | 1 (2.9%) |
| Streptococcus viridans | 1 (2.9%) |
| Mycobacteria | 1 (2.9%) |
| Total | 35 |
Controlling for patients’ previous washout status, culture positivity status, Charlson comorbidity score, and sex, patients were more likely to require a longer hospital stay if they initially underwent arthroscopic rather than open debridement (Rate Ratio or RR = 1.31, 95% CI: 1.04–1.64; p = .02)(Table 4). Further, controlling for all other variables in the model, the length of inpatient hospitalization was approximately 50% longer for patients with multiple operations (RR = 1.50, 95% CI: 1.14–1.97; p = .004) and approximately 45% longer for patients with a positive culture status (RR = 1.45, 95% CI: 1.05–1.99; p = .02). Similarly, the duration of inpatient hospitalization increases by approximately 6% (95% CI: 0.01%–12%) for every 1-point increase in the Charlson comorbidity index score (p = .049). No deaths occurred in any patients in the perioperative period. There was no difference in discharge location (home, acute care facility, nursing facility) between the groups.
Table 4.
Rate of length of stay.
| Valid N | Unadjusted |
Adjusted |
|||
|---|---|---|---|---|---|
| Rate Ratio (95% CI) | P | Rate Ratio (95% CI) | p | ||
| Status: Scope vs Open | 85 | 1.20 (0.91–1.60) | .20 | 1.31 (1.04–1.64) | .02 |
| Operations: Multiple vs single | 83 | 1.51 (1.14–2.00) | .004 | 1.50 (1.14–1.97) | .004 |
| Culture Positive: Yes vs No | 84 | 1.46 (1.02–2.10) | .04 | 1.45 (1.05–1.99) | .02 |
| Charlson Comorbidity Score (per point increase) | 85 | 1.05 (0.99–1.11) | .06 | 1.06 (1.0001–1.12) | .049 |
| Sex: Male vs Female | 85 | 0.77 (0.49–1.20) | .25 | 0.76 (0.54–1.08) | .12 |
| Age (per 5-year increase) | 85 | 1.02 (0.98–1.06) | .32 | 0.98 (0.93–1.04) | .48 |
| BMI (per 5 kg/m2 increase) | 48 | 1.02 (0.93–1.12) | .70 | ||
Note: Valid N = Number of surgeries used for the unadjusted estimates. For the adjusted estimates, the number of surgeries = 83.
4. Discussion
Native knee septic arthritis can lead to significant morbidity and long-term complications when not diagnosed and treated in a timely fashion.10 There is lack of agreement in the literature regarding the optimal surgical treatment for native knee septic arthritis.4, 5, 6, 7, 8, 9, 10, 11, 12 While not statistically significant, the reoperation rate was higher in our sample of patients undergoing arthroscopic (29%) rather than open (9.1%) irrigation and debridement. Additionally, at least in this sample of patients, those with positive joint cultures experienced a higher rate of reoperation (29%) than culture negative patients (16%). The length of stay was longer in patients who underwent arthroscopic rather than open (RR = 1.31) debridement and was also higher in patients who had multiple operations, positive joint cultures, and high Charlson comorbidity scores.
Two recent retrospective studies found no statistically significant difference in reoperation rates between those treated arthroscopically or open for native knee septic arthritis.14,20 These results differ from other retrospective cohort studies that found lower reoperation rates in patients who initially underwent arthroscopic irrigation and debridement.10,12,18 Of note, Johns et al. reported higher overall reoperation rates than other similar literature, with 71% and 51% requiring repeat operation in open and arthroscopic groups, respectively. This difference may indicate difference in practice patterns or population (i.e., the study took place in Australia).18 Bohler et al. reported lower reoperation rates in those initially treated arthroscopically, although Charlson comorbidity scores were significantly higher for the open arthrotomy group. They did, however, perform subgroup analysis which maintained lower reoperation rates in those treated arthroscopically with smaller differences in Charlson comorbidity scores.12 Perez et al. performed a small prospective randomized study involving 22 patients and had no reoperation in those who initially underwent arthroscopic surgery and two reoperations in those who underwent open arthrotomy.16
This question has also been addressed with large database studies. Kerbel et al. utilized the NIS database and performed a matched cohort study comparing those with native knee septic arthritis who underwent open versus arthroscopic procedures finding no difference in major complications, reoperation rates, minor complications, length of stay, or cost. Of note, they excluded all patients that crossed over from one operation to the other.9 Several studies have used the NSQIP database to address similar questions. Johnson et al. found no difference in reoperation rates. However, they noted higher rates of minor adverse events in those that underwent open arthrotomy after multivariable analysis.8 Faour et al. found higher rates of blood transfusion in the open arthrotomy group but no difference in length of stay, venous thromboembolism, reoperation rates, readmission rates or mortality.15 Bovonratwet et al. performed a similar analysis using the NISQIP database. They found higher rates of blood transfusion and minor adverse events in the open arthrotomy group; with a higher rate of serious adverse events in the arthroscopically treated group. However, all three of these findings lost statistical significance after controlling for American Society of Anesthesiology (ASA) scores and age.17
In addition to large database findings, systemic reviews and meta-analysis have been conducted to compare the use of arthroscopy versus open arthrotomy in the treatment of septic knee. Acosta-Olivo et al. analyzed twenty studies with 10,249 patients and found the arthroscopic group to have significantly lower risk of re-infection, lower complications rates, and less hospital stay. Their subgroup analysis also showed a higher risk of re-infection in the open arthrotomy group.23 Liang et al. included thirteen trials into their analysis that found significantly higher range of motion and lower complication rate in the arthroscopy treated group. However, their analysis of operative time, mortality, and hospital length of stay showed equal efficacy between the arthroscopy and open arthrotomy groups with no significant difference.24
Factors contributing to a need for reoperation in those presenting with native knee septic arthritis have been reported. Stake et al. found increased risk of reoperation in patients of African American or Hispanic decent, higher serum white blood cells at presentation, bacteremia or concurrent infection at time of admission.21 Hyung Won et al. utilized the NIS database and found that patients with a history of intravenous drug use were more likely to die during hospitalization for septic arthritis and more likely to undergo repeat operation regardless of whether they underwent an arthroscopic or open procedure.22 Dave et al. and Wirtz et al. found worse outcomes and higher reoperation rates in those who underwent surgical intervention after a longer period of time from initiation of symptoms, however Lauper et al. found no association of timing of irrigation and debridement and rate of complications.3,10,14 All of these factors may be important when counseling patients, however they do not provide any suggestion on which operation should be performed. Jaffe et al. demonstrated that MRSA infection is a risk factor for reoperation in those treated with arthroscopy but not with open arthrotomy. Their results suggest that the surgeon should consider open arthrotomy in patients with positive MRSA cultures or history of MRSA infection.11
This study has several limitations. The retrospective design enabled us to achieve a larger sample in this study than would be feasible in a prospective study at our institution, however it limits the ability to randomize patients and create a strict protocol for diagnosis and management decisions. In the present study, diagnosis of a septic joint was made using criteria established in the literature including clinical symptoms, synovial white blood cell, polymorphonuclear percentage, and positive joint culture, however there were no strict criteria and results were interpreted on a case-by-case basis. For example, several patients were considered immunosuppressed due to medications or other diagnoses, and thus they were diagnosed with a septic joint with lower synovial WBCs in the setting of their overall clinical picture. Inability to control for surgeon bias is another limitation of this study. The type of surgery performed may be influenced by the subspecialty of the attending surgeon, and their threshold for reoperation may vary. Additionally, long term follow-up and patient reported outcome scores were not included in this study, consequently we are unable to comment on these results.
In conclusion, our study reports a longer length of stay for patients undergoing arthroscopic rather than open irrigation and debridement – even after controlling for multiple operations, culture status, sex, age, and comorbidities. While the reoperation rate was higher in our sample of patients undergoing arthroscopic debridement, this association was not statically significant. These results should be replicated with prospective investigations.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Institutional ethical committee approval
Full approval was granted by the Institutional Review Board for this project.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nicholas M Brown reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership. Nicholas M Brown reports a relationship with Corin Group USA that includes: consulting or advisory. Nicholas M Brown reports a relationship with DePuy Synthes that includes: consulting or advisory.
Acknowledgements
None.
References
- 1.Kaandorp C.J.E., Van Schaardenburg D., Kriejnen P., Habbema K.D.F., Van de Laar MAFJ: risk factors for septic arthritis in patients with joint disease. Arthritis Rheumatol. 1995;38:1819–1825. doi: 10.1002/art.1780381215. [DOI] [PubMed] [Google Scholar]
- 2.Hindle P., Davidson E., Biant L.C. Septic arthritis of the knee: the use and effect of antibiotics prior to diagnostic aspiration. annals. 2012;94:351–355. doi: 10.1308/003588412X13171221591015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lauper N., Davat M., Gjika E., et al. Native septic arthritis is not an immediate surgical emergency. J Infect. 2018;77:47–53. doi: 10.1016/j.jinf.2018.02.015. [DOI] [PubMed] [Google Scholar]
- 4.Goldenberg D.L., Brandt K.D., Cohen A.S., Cathcart E.S. Treatment of septic arthritis. Arthritis Rheumatol. 1975;18:83–90. doi: 10.1002/art.1780180116. [DOI] [PubMed] [Google Scholar]
- 5.John G Lane M.D., Mark H Falahee M.D., Edward M Wojtys M.D., Fred M Hankin M.D., Herbert Kaufer M.D. Clinical Orthopaedics and Related Research®; 1990. Pyarthrosis of the Knee; pp. 198–204. [PubMed] [Google Scholar]
- 6.Jeon Y.D., Moon J.Y., Son J.H., Kim J.M., Choi Y. The efficacy of arthroscopic debridement with continuous irrigation in failed arthroscopic debridement for septic arthritis of the knee. Journal of the Korean Orthopaedic Association. 2016;51:308–314. [Google Scholar]
- 7.Johns B., Loewenthal M., Ho E., Dewar D. Arthroscopic versus open treatment for acute septic arthritis of the knee in children. Pediatr Infect Dis J. 2018;37:413–418. doi: 10.1097/INF.0000000000001795. [DOI] [PubMed] [Google Scholar]
- 8.Johnson D.J., Butler B.A., Hartwell M.J., et al. Arthroscopy versus arthrotomy for the treatment of septic knee arthritis. J Orthop. 2020;19:46–49. doi: 10.1016/j.jor.2019.11.031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kerbel Y.E., Lieber A.M., Kirchner G.J., et al. In-hospital complications following arthrotomy versus arthroscopy for septic knee arthritis: a cohort-matched comparison. J Knee Surg. 2019:1–6. doi: 10.1055/s-0039-1693450. [DOI] [PubMed] [Google Scholar]
- 10.Wirtz D., Marth M., Miltner O., Schneider U., Zilkens K. Septic arthritis of the knee in adults: treatment by arthroscopy or arthrotomy. Int Orthop. 2001;25:239–241. doi: 10.1007/s002640100226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Jaffe D., Costales T., Greenwell P., Christian M., Henn R.F.3., III Methicillin-resistant Staphylococcus aureus infection is a risk factor for unplanned return to the operating room in the surgical treatment of a septic knee. J Knee Surg. 2017;30:872–878. doi: 10.1055/s-0037-1598079. [DOI] [PubMed] [Google Scholar]
- 12.Böhler C., Dragana M., Puchner S., Windhager R., Holinka J. Treatment of septic arthritis of the knee: a comparison between arthroscopy and arthrotomy. Knee Surg Sports Traumatol Arthrosc. 2015;24:3147–3154. doi: 10.1007/s00167-015-3659-8. [DOI] [PubMed] [Google Scholar]
- 13.Jarrett M.P., Grossman L., Sadler A.H., Grayzel A.I. The role of arthroscopy in the treatment of septic arthritis. Arthritis Rheumatol. 1981;24:737–739. doi: 10.1002/art.1780240522. [DOI] [PubMed] [Google Scholar]
- 14.Dave O.H., Patel K.A., Andersen C.R., Carmichael K.D. Surgical procedures needed to eradicate infection in knee septic arthritis. Orthopedics. 2016;39:50–54. doi: 10.3928/01477447-20151222-05. [DOI] [PubMed] [Google Scholar]
- 15.Faour M. Arthroscopic irrigation and debridement is associated with favourable short-term outcomes vs. open management: an ACS-NSQIP database analysis. Knee Surg Sports Traumatol Arthrosc. 2019;27:3304–3310. doi: 10.1007/s00167-018-5328-1. [DOI] [PubMed] [Google Scholar]
- 16.Peres L.R., Marchitto R.O., Pereira G.S., Yoshino F.S., Fernandes M.C., Matsumoto M.H. Arthrotomy versus arthroscopy in the treatment of septic arthritis of the knee in adults: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2015;24:3155–3162. doi: 10.1007/s00167-015-3918-8. [DOI] [PubMed] [Google Scholar]
- 17.Bovonratwet P., Nelson S.J., Bellamkonda K., et al. Similar 30-day complications for septic knee arthritis treated with arthrotomy or arthroscopy: an American College of surgeons national surgical quality improvement Program analysis. Arthrosc J Arthrosc Relat Surg. 2018;34:213–219. doi: 10.1016/j.arthro.2017.06.046. [DOI] [PubMed] [Google Scholar]
- 18.Johns B.P., Loewenthal M.R., Dewar D.C. Open compared with arthroscopic treatment of acute septic arthritis of the native knee. J Bone Joint Surg. 2017;99:499–505. doi: 10.2106/JBJS.16.00110. [DOI] [PubMed] [Google Scholar]
- 19.Charlson M.E., Pompei P., Ales K.L., MacKenzie C.R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40:373–383. doi: 10.1016/0021-9681(87)90171-8. [DOI] [PubMed] [Google Scholar]
- 20.Jaffe W.L., Dundon J.M., Camus T. Alignment and balance methods in total knee arthroplasty. J Am Acad Orthop Surg. 2018;26:709–716. doi: 10.5435/JAAOS-D-16-00428. [DOI] [PubMed] [Google Scholar]
- 21.Stake S., Scully R., Swenson S., et al. Repeat irrigation & debridement for patients with acute septic knee arthritis: incidence and risk factors. J Clinic Orthopaedic Trauma. 2020;11:S177–S183. doi: 10.1016/j.jcot.2019.12.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Won Oh D.H., Wurcel A.G., Tybor D.J., Burke D., Menendez M.E., Salzler M.J. Increased mortality and reoperation rates after treatment for septic arthritis of the knee in people who inject drugs. Clin Orthop Relat Res. 2018;476:1557–1565. doi: 10.1097/01.blo.0000534682.68856.d8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Acosta-Olivo C., Vilchez-Cavazos F., Blázquez-Saldaña J., Villarreal-Villarreal G., Peña-Martínez V., Simental-Mendía M. Comparison of open arthrotomy versus arthroscopic surgery for the treatment of septic arthritis in adults: a systematic review and meta-analysis. Int Orthop. 2021;(8):1947–1959. doi: 10.1007/s00264-021-05056-8. [DOI] [PubMed] [Google Scholar]
- 24.Liang Z., Deng X., Li L., Wang J. Similar efficacy of arthroscopy and arthrotomy in infection eradication in the treatment of septic knee: a systematic review and meta-analysis. Front Surg. 2022 Jan 13;8 doi: 10.3389/fsurg.2021.801911. [DOI] [PMC free article] [PubMed] [Google Scholar]