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Risk Factors for Failure of a Single Surgical Debridement in Adults with Acute Septic Arthritis (JBJS 2015)

Screenshot-2015-05-20-00.12.34-e1432095302195-73x98 Risk Factors for Failure of a Single Surgical Debridement in Adults with Acute Septic Arthritis (JBJS 2015) Journal Club



Background
– Acute septic arthritis urgent condition, usually able to be treated with single debridement / irrigation.
– Risk factors for development of septic arthritis known
– DM, RA, IVDA, immunosuppression, socioeconomic status
– No published data regarding risk of failure of single surgical debridement
 
Methods
– retrospective review of septic arthritis cases from 2000-2011 identified from billing database
– extensive demographic / medical data collected
– excluded patients non treated by ortho service, prior history of septic arthritis, current osteomyelitis, prior fracture surgery with arthrotomy, prior arthroplasty, prior implanted foreign body
– diagnosis based on one of following: + gram stain from aspirate, + culture from aspirate, NCC > 50K
– treated by either open (68%) or arthroscopic (32%) debridement
– antibiotics generally held prior to surgery
– ID consult obtained in all patients
– failure defined as one of following: gross purulence, increased pain, decreased ROM, persistent fevers, elevation inflammatory markers
– followed by ortho / ID as outpatient
– created regression model after identifying significant variables
 

Results
– Unable to determine difference between open and arthroscopic debridement
– 52 joints failed single debridement, 82 joints successful with single debridement
– NCC, WBC were found to differ between groups
– CRP trended toward but did not reach significance (p=0.07)
– joint aspirations without positive culture more likely be successful with single debridement
– staph aureus, especially MRSA, more common in joints failing single debridement
– larger joints (knee, shoulder, hip) more likely to fail than smaller joints (elbow, ankle, wrist)

Ultimately identified five independent predictors of failed single debridement: Inflammatory arthropathy, large joint involvement, NCC > 85 x109 on aspiration, staph aureus (not MRSA), DM 

Conclusion
-Strengths: adds prognostic value when counseling patients with acute septic arthritis, particularly those with identified risk factors
-Limitations:  retrospective nature leads to bias, nonstandard antibiotic protocol due to patient allergies etc, small sample size; unable to determine whether “planned” second debridement in at risk patient improves outcomes
-Overall impression:  Probably won’t change practice in short term.  Improves ability to counsel patients.  Does give credence to risk factors you’d inherently expect to lead to failure.  Future prospective studies could determine which patients are at risk for failure of single debridement and plan treatment accordingly.

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