Septic Arthritis of the Hip: An Arthroscopic Technique for Irrigation and Debridement

Abstract

Septic arthritis of the hip poses significant diagnostic and therapeutic challenges, requiring prompt intervention to prevent long-term joint complications. This technique article shows a hip arthroscopic irrigation and debridement as a minimally invasive alternative to traditional open arthrotomy. Our findings indicate that a hip arthroscopic irrigation and debridement technique could be effective to eradicate infection of the hip while preserving hip stability and function.

Septic arthritis of the hip is a debilitating condition characterized by different clinical presentations. With the yearly incidence estimated to be approximately 4 to 10 per 100,000 patients worldwide, diagnosing this condition can be challenging.1, 2, 3, 4 Clinical features of septic arthritis include but are not limited to relatively rapid onset of hip joint pain, thigh pain, inability to bear weight, and fever. Delayed diagnosis can increase the likelihood of infection progression, cartilage destruction, and permanent joint dysfunction. Additionally, delayed diagnosis may lead to recurrent infection, necessitating subsequent open surgical debridement. Risk factors for septic arthritis of the hip can include hematogenous spread, as well as immunocompromised status, such as with HIV/AIDS, systemic lupus erythematosus, rheumatoid arthritis, and malignancy.⁵

For a native joint, open arthrotomy and hip arthroscopy are viable treatment options for an infected joint. Open arthrotomy is traditionally the primary option for the treatment of septic arthritis in pediatrics. In adults, however, this procedure is invasive and can potentially result in avascular necrosis, or hip instability.6, 7, 8 In contrast, hip arthroscopy may allow for increased joint access with less postoperative pain and more rapid rehabilitation.⁹ Here, we describe an arthroscopic hip irrigation and debridement (I&D) technique for septic arthritis of the hip (Video 1).

Patient Evaluation for Septic Arthritis

The clinical signs of septic arthritis may include fever, generalized sepsis, hip pain, swelling and warmth at the affected joint, and an inability to bear weight. When suspected, a workup should include evaluation of white blood cell count, blood cultures, C-reactive protein, erythrocyte sedimentation rate, and joint aspiration.¹⁰ Radiographs of the affected hip should also be obtained to evaluate for bony pathology (osteoarthritis, malignancy, avascular necrosis). A computed tomography scan may also show an effusion of the hip (Fig 1), while magnetic resonance imaging is warranted to rule out osteomyelitis if clinically suspected. A synovial fluid aspiration of the hip joint, evaluating for cell count, gram stain, culture, and crystals, is the gold standard for the diagnosis of septic arthritis. A cell count of >50,000 cells/mm³ is strongly suggestive of a septic joint process.¹¹ In our experience, ultrasound-guided hip aspiration provides direct visualization of the hip effusion (Fig 2), allows for an accurate aspiration, and leads to quicker time to diagnosis. If workup is conclusive, the patient is deemed to be a candidate for arthroscopic hip synovectomy and debridement. The indications and contraindications for this technique are shown in Table 1.

Fig 1.

Computed tomography scans showing a right hip effusion on an axial cut at the level of the mid-femoral neck (A), an axial cut at the level of the right hip joint (B), and a coronal cut of the right hip joint (C).

Fig 2.

Ultrasound-guided imaging of a right hip in long axis, showing a hip effusion.

Table 1.

Indications and Contraindications

Indications

•Anterior groin or hip pain with limited hip range of motion and an inability to bear weight

•Pyrexia

•Associated leukocytosis

•Elevated erythrocyte sedimentation rate or C-reactive protein level

•Hip imaging and/or joint aspiration results consistent with infection

Contraindications

•Osteomyelitis of proximal femur, pelvis, or acetabulum; tuberculous; or fungal infection

•Pre-existing joint replacement surgery

•Lack of standard hip arthroscopic equipment or traction table

•Lack of basic familiarity with arthroscopic hip access

Surgical Technique

Step 1: Positioning

General anesthesia is administered, followed by intravenous antibiotics, if an appropriate aspiration sample has been obtained preoperatively; otherwise, antibiotics are held until an intraoperative aspiration sample has been obtained. The patient is transferred supine to an operative postless traction table (Pivot Guardian; Stryker), and both feet are placed in well-padded boots. The operative table is internally rotated 15° to match average femoral version. The C-arm is positioned at the patient's contralateral side to come over to the operative hip for imaging.

Step 2: Examination Under Anesthesia

Under anesthesia, an examination and gentle manipulation are done to document hip range of motion, including flexion arc, flexion adduction internal rotation, and flexion abduction external rotation. In-line traction is then applied to the operative hip to achieve 1 to 1.5 cm of joint distraction, or until deemed safe for Seldinger “inside-out” technique access under fluoroscopic guidance. The affected extremity is then prepped and draped in the usual sterile fashion.

Step 3: Access and Diagnostic Scope

Surface anatomy landmarks are marked before aspiration and portal placement. These include the anterior superior iliac spine, greater trochanter, and a longitudinal line from the anterior superior iliac spine down the femur to demarcate the medial extent of the hip to avoid neurovascular structures. An anterolateral (AL) viewing portal is then established using the Seldinger technique under x-ray guidance with a 17-gauge spinal needle from the Portal Entry Kit (Stryker). If an aspiration has not been obtained at this point, the stylet is removed from the spinal needle, and an aspiration sample is obtained with a 30-cc syringe. After, a nitinol wire is advanced through the spinal needle, which is removed when an appropriate position of the nitinol wire is confirmed under fluoroscopy. The AL portal is then established with the arthroscopic cannula through the capsule. Care is taken to avoid injury to the femoral head and labrum. After establishing the AL portal using the Seldinger technique under direct visualization, a mid-anterior portal (MAP) is then established anteriorly. Diagnostic arthroscopy is performed to visualize the labrum, synovium, and peripheral compartment of the femoral head and rule out the presence of loose bodies (Fig 3A). Limited periportal capsulotomies (Fig 3B) are made with a Beaver blade to preserve the capsule.

Fig 3.

Intraoperative hip arthroscopy in the supine position, utilizing a 70° arthroscope with a right hip shown from the anterolateral portal. (A) A shaver used synovitis (SYN) of the affected right hip near the femoral head (FH). (B) periportal capsulotomy (PC). (C) Thermal stabilization with a radiofrequency ablator (RFA) of the labrum (L) and chondrolabral junction (CLJ) shown after synovectomy.

Step 4: Synovectomy of the Hip

A thorough synovectomy with a minimum 6 L of saline is carried out with gravity or with the use of a pump. Using a combination of shaver and radiofrequency ablation, synovectomy is completed along the course of the capsule at the head-neck junction, being careful not to complete an interportal capsulotomy. Similarly, debridement is furthered while developing the plane between the capsule and labrum from 3 o'clock to 9 o'clock along the acetabular rim. Any suture or implant insertion is avoided due to the infectious setting. Radiofrequency-guided labral stabilization is used to stabilize any cartilage or labral flaps at the chondrolabral junction in a careful manner (Fig 3C). A fractional psoas lengthening can be considered to allow fluid egress into the extracapsular space to widen the zone of irrigation. Similarly, while viewing from the MAP (Fig 4), the AL periportal capsulotomy is deepened—not widened—to expose part of the abductor/piriformis and also allow fluid egress into the short external rotator muscle territory, which may be involved as part of the septic process. After I&D has been performed, the hip is released from traction, and the complete normal suction seal effect is confirmed. The arthroscope is withdrawn, and skin portal sites are irrigated. Subcutaneous tissue is closed with nonabsorbable sutures, a 3-0 Monocryl, and the skin is closed with 3-0 Nylon and dressed in the usual fashion. Pearls and pitfalls of the described technique are summarized in Table 2.

Fig 4.

Intraoperative photo showing establishment of a spinal needle outflow at the mid-anterior portal (MAP) to allow gentle of lavage purulent material to improve visualization.

Table 2.

Pearls and Pitfalls

Pearls

•Initial spinal needle and portal entry should be performed with hip distraction under fluoroscopy to ensure proper trajectory to avoid iatrogenic injury.

•Use initial spinal needle for joint aspiration if not obtained.

•Air arthrogram might be absent in the presence of joint effusion from a septic process.

•Use of blunt cannulas will prevent iatrogenic injuries.

•A 70° arthroscope is recommended to allow complete visualization of the peripheral and central compartments.

•If visualization is obscured during dry scope placement in the initial portal by purulent material, the mid-anterior portal trajectory can be established with the spinal needle under fluoroscopy, and gentle outflow can be obtained to lavage the joint with the mid-anterior portal spinal needle stylet removed until adequate visualization is obtained.

•Document concurrent hip pathology found at the time of arthroscopy for future counseling.

•Periportal capsulotomies prevent the need for suture closure of an interportal capsulotomy to prevent a nidus for infection.

Pitfalls

•Avoid completing an interportal capsulotomy to avoid capsular destabilization.

•Avoid use of suture anchor placements as nonabsorbable sutures can serve as a nidus for infection.

•Avoid performing a full impingement decompression surgery as this may widen the exposure and necessitate implant usage for capsular closure.

Rehabilitation Protocol

Patients are weightbearing as tolerated with the use of crutches for the first 2 to 4 weeks until gait is normalized. Given the absence of labral repair and minimal capsular violation, immediate active assisted hip range of motion is encouraged. To avoid adhesive capsulitis, family member– and physical therapy–assisted hip circumductions are encouraged. The use of a continuous passive motion is optional. Early core and pelvic stabilization exercises are emphasized. Formal supervised physical therapy is continued for 3 months or until the patient achieves full range of motion, strength, and stability.

Discussion

Septic arthritis of the hip is a rare but debilitating condition that can affect the hip and lead to potential long-term hip disability if not acutely recognized and treated promptly. The gold standard of treatment for septic arthritis of the hip is open arthrotomy of the hip and I&D. Open arthrotomy, while effective, may pose significant risks, including avascular necrosis, capsular disruption, enlarged incisions, and prolonged rehabilitation. There has been a broader shift toward minimally invasive procedures, and an increasing number of arthroscopic hip procedures are performed among orthopaedic surgeons. We show the viability of a hip arthroscopic I&D technique as a minimally invasive approach for treating septic arthritis of the hip. Compared to traditional open arthrotomy, this approach offers advantages, such as reduced surgical morbidity, preservation of hip stability with a limited periportal capsulotomy, and enhanced recovery time.¹² The ability to directly visualize and debride infected tissue and synovium while maintaining capsular integrity is a critical benefit of arthroscopic management compared to open arthrotomy.

While arthroscopy presents several advantages, it is not without limitations (Table 3). Hip arthroscopy is technically demanding and has a steep learning curve to master safe access and operative treatment of intra-articular pathology. When using arthroscopy for the treatment of septic arthritis, visualization within the hip joint may also be obstructed in cases with dense purulent material, necessitating the establishment of portals under fluoroscopic guidance to allow appropriate lavage to improve visualization. This article highlights a technique for safe hip arthroscopic access, debridement of purulent material, and irrigation of the hip joint in settings of septic arthritis. Often, a single-stage I&D could be effective to eradicate infection of the hip joint. However, the patient must be closely monitored after surgery for clinical signs of infection, since in some cases, elective and/or indicated repeat I&D procedures should be thoughtfully considered.

Table 3.

Advantages and Disadvantages

Advantages

•Smaller incision than open I&D

•May provide shorter hospitalization than open arthrotomy

•Utilizing small interportal capsulotomy minimizes risk of postoperative capsular destabilization and instability

•Improved visualization of intra-articular structures and allows assessment of concurrent hip pathology

•Ease of performing synovial debridement and the ability to obtain biopsy specimens

Disadvantages

•Gold standard for I&D remains open arthrotomy

•Hip arthroscopy can be technically challenging for those who do not commonly perform hip arthroscopy

•Requires specialized equipment

•Requires fluoroscopy

•Cannot be performed if a previous total hip arthroplasty or suspected altered anatomy

•Costs—increased use of disposable equipment

I&D, irrigation and debridement.

This study shows that an arthroscopic hip I&D is a safe, effective, and minimally invasive alternative to open arthrotomy for the treatment of septic hip arthritis. Advantages of arthroscopy include improved visualization, precise debridement, reduced surgical morbidity, and decreased risk of joint capsular destabilization. Prompt diagnosis and treatment are necessary to avoid long-term hip morbidity in patients, and arthroscopic I&D of the hip is a viable option in select patients.

Disclosures

All authors (F.A., P.R., M.A.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

This surgical video highlights the step-by-step procedure for an arthroscopic hip irrigation and debridement (I&D) for septic arthritis of the hip. Our video highlights how to position a patient for hip arthroscopy supine on a postless hip arthroscopy table and perform an examination under anesthesia. The video also shows how to gain access to the hip using the Seldinger technique while also using access techniques to collect an aspiration sample in the setting of a septic hip. The latter half of this video showcases the steps for creating a limited periportal capsulotomy, followed by a hip synovectomy and footage of an I&D performed.