Treatment for septic arthritis in any joint consists of drainage, irrigation, and debridement of affected synovium and necrotic debris. The elimination of infection, restoration of mobility, and maintenance of joint function define the success of the treatment. The extent of the procedure required to attain these goals in the hip joint can be variable, and depends on myriad factors related to the organism, host, and duration of the process. The appropriate surgical intervention for the treatment of hip joint sepsis should be determined on a case-by-case basis. In combination with intravenous antibiotics, successful treatment has been reported with methods as simple as repeated arthrocentesis,112 and as extensive as Girdlestone hip resection followed by delayed hip arthroplasty. Arthrotomy is and will remain the "gold standard" definitive procedure for septic hip arthritis, but hip arthroscopy has a definite role that undoubtedly will expand as the procedure and technology evolve.
Arthroscopic management of pyarthrosis is well established in all joints accessible to the instrumentation, and has been reported in the hip for both pediatric and adult patients. Early diagnosis of a hip joint infection and then identification of the organism by aspiration are of paramount importance in determining the appropriateness of arthroscopic intervention and treatment. The timing of the diagnosis, early or late, will usually predict the success of the intervention. Identification and treatment within the first week of symptom onset increases the potential for a successful outcome. Relatively healthy patients infected with low-virulence organisms have an increased chance for a cure if treated early. Chung et al have described successful, uncomplicated arthroscopic lavage for acute bacterial sepsis in the hips of nine children. The ar-throscopic treatment combined with intravenous antibiotics was effective in ablating septic disease in all nine patients.113 Debilitated patients with concomitant disease, and infection with more virulent organisms like Staphylococcus aureus, gram-negatives, or anaerobes carry a much less favorable prognosis. Formal arthrotomy in these situations is the preferred treatment if the procedure can be tolerated medically. If not, hip arthroscopy may provide a viable initial alternative in the prevention of sepsis, buying time to allow optimization of the patient medically before arthrotomy is attempted. Bould et al presented a case report demonstrating the diagnostic and treatment capabilities of hip arthroscopy in the adult population.114 Blitzer reported on four patients with septic arthritis of the hip and one with suspected septic arthritis who were treated with arthroscopic irrigation, de-bridement, and drainage. The patients were free of infection an average of 20.4 months post arthroscopy.115
In all joints, especially the hip, arthroscopic treatment of infection is indicated for the treatment of acute sepsis. Ar-throscopy is not indicated and is not a substitute for open de-bridement in the face of bony involvement, sequestrum, abscess formation, extracapsular extension, and recurrent or chronic infection, or when local infection has spread to the hip joint. The success or failure of arthroscopic treatment for hip joint sepsis rest completely with the surgeon's selection of appropriate patients and technical ability to perform the procedure. The technique involves lavage and synovial de-bridement, followed by postoperative closed-tube drainage and irrigation. If extensive infection with capsular destruction or bone involvement is encountered at the time of arthros-copy, conversion to limited or formal arthrotomy should be performed so that wide debridement can be achieved. In the right situation, arthroscopy results in much lower perioperative morbidity than open arthrotomy and allows for a more expedient, successful result by shortening rehabilitation and restoring early mobility.
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