What are the guidelines for performing and managing a joint arthrotomy?

Joint Arthrotomy: Guidelines for Performing and Managing

Joint arthrotomy should be performed via open surgical approach rather than arthroscopy for septic arthritis, as it allows for more extensive debridement and has lower reinfection rates compared to arthroscopic approaches. 1

Definition and Indications

Joint arthrotomy is a surgical procedure involving incision into a joint capsule to access the joint space directly. The primary indications include:

• Septic arthritis requiring debridement
• Prosthetic joint infection management
• Traumatic arthrotomy with joint contamination
• Severe joint deformity requiring surgical correction
• Failed arthroscopic procedures requiring open access

Preoperative Considerations

Patient Optimization

• Nicotine use: Delay surgery for nicotine cessation or reduction to minimize surgical risks 1
• Diabetes management: Improve glycemic control before proceeding with surgery 1
• Obesity: While not a reason to delay surgery, patients should be educated about increased surgical risks 1

Preoperative Planning

• Identify causative organisms through joint aspiration when infection is suspected
• Obtain appropriate imaging (radiographs, CT scans) to assess joint damage
• Prepare appropriate antibiotics for perioperative administration

Surgical Technique

Open Arthrotomy

1. Make an appropriate surgical incision based on the joint involved
2. Dissect through soft tissue layers to expose the joint capsule
3. Incise the joint capsule to access the joint space
4. Perform thorough debridement of infected or damaged tissue
5. Irrigate the joint space with copious amounts of solution
6. Consider antibiotic-impregnated cement or devices for infected cases
7. Close the wound in layers with appropriate drainage

Key Technical Considerations

• Ensure adequate exposure of the joint for complete visualization
• Remove all infected tissue, foreign bodies, and debris
• Obtain multiple tissue samples for culture before administering antibiotics
• Consider polyethylene liner exchange in prosthetic joint infections

Management of Specific Conditions

Septic Arthritis

• Open arthrotomy is preferred over arthroscopy for septic arthritis due to more thorough debridement capabilities 1, 2
• Arthroscopy has been associated with worse outcomes compared to open arthrotomy in infection cases 1
• Success rates for debridement without prosthesis removal range from 14-100% 1

Prosthetic Joint Infection (PJI)

Follow a structured approach based on infection timing and prosthesis stability:

1. Early postoperative infection (<30 days) or acute hematogenous infection:

   • Debridement with prosthesis retention if well-fixed
   • Open arthrotomy with polyethylene liner exchange

2. Chronic infection with loose prosthesis:

   • Two-stage exchange (removal of components, placement of antibiotic spacer, later reimplantation)
   • Success rate approximately 87% 1

3. Failed debridement or multiple failed exchanges:

   • Consider permanent resection arthroplasty for non-ambulatory patients or those with limited bone stock 1
   • Amputation as last resort in severe cases 1

Postoperative Management

Antibiotic Therapy

• Administer appropriate antibiotics based on culture results
• Continue antibiotics for adequate duration based on organism and infection site

Rehabilitation

• Early mobilization as tolerated to prevent stiffness
• Progressive weight-bearing based on procedure performed and joint stability
• Physical therapy to restore range of motion and strength

Complications and Their Management

Infection

• Persistent infection may require repeat debridement or more aggressive surgical intervention
• Consider antibiotic modification based on culture results

Joint Stiffness

• Early range of motion exercises
• Consider manipulation under anesthesia if conservative measures fail

Wound Complications

• Regular wound assessment
• Prompt intervention for dehiscence or drainage

Special Considerations

Traumatic Arthrotomy

• All periarticular injuries should be evaluated for traumatic arthrotomy 3
• Prompt diagnosis and management can mitigate high morbidity and mortality
• Management includes orthopedic consultation, wound irrigation, tetanus prophylaxis, and antibiotics 3

Outpatient vs. Inpatient Procedures

• For elective arthroplasty, outpatient procedures have shown lower rates of adverse events with no increased readmission rates compared to inpatient procedures 4
• Patient selection is crucial for outpatient management

Common Pitfalls and How to Avoid Them

1. Inadequate debridement: Ensure thorough exploration of all joint recesses
2. Missed diagnosis of traumatic arthrotomy: Maintain high suspicion for joint penetration with periarticular injuries
3. Delayed treatment of infection: Prompt surgical intervention is essential for septic arthritis
4. Inappropriate surgical approach: Select the correct approach based on joint involved and pathology
5. Inadequate antibiotic coverage: Obtain cultures before antibiotics when possible and adjust therapy based on results

By following these guidelines, surgeons can optimize outcomes for patients requiring joint arthrotomy while minimizing complications and improving functional recovery.