Fulfilling the wisdom 'ubi pus, ibi evacua' (where pus, there evacuate), surgery has been deemed pivotal in OM, SA and OM+SA. Trepanation of bone is often performed in OM, and routine arthrotomy is recommended at least in hip and shoulder arthritis, because of the fear of hyperpressure and cartilage destruction in these tightly encapsulated joints.[1,31] Interestingly, this view has been based solely on retrospective analyses, and no prospective study has demonstrated its validity.[5–8] As intra-articular pressure is regulated by the position of the joint during aspiration,[32,33] some new thinking is warranted also in this respect regarding SA.
In a prospective, randomized study on 61 shoulder arthritides, mostly caused by Salmonella spp., arthrotomy showed no advantage over aspiration, when antibiotics were given orally for 6 weeks. A cohort from Israel showed favorable results with repeated ultrasound-guided aspirations in septic hip arthritis. In our own retrospective analysis there were 62 septic hips of which no more than 12 (21%) underwent arthrotomy. However, most children were older than 2 years, the median age was 7 years and the history of disease was 1–5 days – all factors which might have lowered the need for arthrotomy. Neonates and children presenting late in disease likely warrant a different approach. Aspirations or needle-joint lavages performed blindly without ultrasonographic or fluoroscopic control will be more likely to fail or give a negative result. Also, refraining from initial arthrotomy requires the patient to be kept under continuous observation and a 24-h immediate access to operating theater is required should complications develop.
Expert Rev Anti Infect Ther. 2011;9(12):1125-1131. © 2011 Expert Reviews Ltd.