Mayo Surgeons Review Surgical Treatment of Wrist Septic Arthritis

With newer ways of performing surgery, surgeons often have a choice between using the traditional open incision versus the minimally invasive arthroscopic approach. In this article, surgeons from the Rochester, Minnesota Mayo Clinic discuss how these two methods compare when treating septic arthritis of the wrist.

Septic arthritis refers to infection that has developed inside the joint, sometimes extending into the surrounding soft tissue structures. Surgery is done to wash out the infection and clean out any remaining damaged tissue. A sample of synovial fluid is taken from the joint and sent to the lab to identify the infectious organisms. Once the culture has been analyzed, the most appropriate antibiotic can be prescribed.

This type of surgery called irrigation and debridement is considered a surgical emergency when septic arthritis has been diagnosed. The goal is to prevent destruction of the joint, spread of the infection to the bones (a condition called osteomyelitis), and necrosis (death of the wrist bones).

Irrigation and debridement for septic arthritis usually involves two of the wrist joints: the radiocarpal joint (between the forearm bone on the thumb side and the base of the thumb) and the midcarpal joints (bones that form the mid-section of the wrist). A saline solution is used to gently flush affected areas, then the surgeon scrapes away any signs of infection or damage from the infection.

Arthroscopy allows for a smaller incision than the open incision method. Patients are usually released from the
hospital sooner and end up having fewer operations when this approach is used. But sometimes arthroscopy is contraindicated — in other words, it shouldn’t be done. The open incision method is used in those cases. Contraindications to arthroscopic wrist irrigation and debridement for septic arthritis include:

  • Previous surgery was done on the wrist
  • There is osteomyelitis of the bones
  • Infection has spread to other parts of the wrist that can’t be seen or reached with an arthroscope
  • Severe joint destruction is already present
  • Joint is too small to enter with a scope (e.g., infant or small child)

    The surgeon must always be aware of the potential for arthroscopic surgery to miss areas of infection or bone osteomyelitis. Failure to remove even a tiny portion of these infected areas will mean the infection can continue to spread and cause more problems.

    If fixation was used to hold the wrist in place during previous surgery (metal plate, screws, pins), infection can get under, around, or on the hardware. The arthroscope can’t show the surgeon these areas. And if surgery was already done on that same wrist, scar tissue and altered anatomy can prevent the surgeon from inserting the scope correctly without damaging nerves, blood vessels, bones, or soft tissue structures that have shifted from their normal anatomic location.

    To aid surgeons in performing arthroscopic wrist surgery, the authors provide color photos of the surgical set up (including patient in place and placement of television monitor for viewing by the surgeon). A special traction tower is used to hold the hand, wrist, and forearm in place during the procedure.

    A device called a finger trap applies traction to the wrist through the fingers. The set up makes sure there is equal pressure applied to all four fingers There is a photo of the assembled lens, camera, and light source. And a step-by-step description of the procedure is also included.

    The surgeons are careful to draw right on the patient’s skin an outline of the bones, tendons, and best spot for the scope to enter the joints. They provide specific directions for the placement of holes called portals where the scope can be inserted to give the best view but without damage to any of the structures. Angle of entry for each portal is described, amount of irrigation and technique to use, and even where and how to take photos of the joint structures are all points included in this review of surgical techniques.

    The authors conclude that the arthroscopic technique works best for patients with just one area of infection. When there are multiple sites of infection, an open procedure is advised. Patients do well with either approach but the chances of repeat operations are greater when there are multiple sites involved requiring open incision surgery. Length of hospitalization, potential for post-operative problems or complications, and costs are all greater for open incision surgery.