Purulent arthritis

The term "purulent arthritis" is understood to mean various forms of nonspecific inflammatory and necrotic processes occurring in the joint cavity and in paraarticular tissues. Purulent arthritis of large joints in the structure of purulent surgical diseases is 12-20%. Until now, their treatment presents considerable difficulties, as indicated by a high percentage of recurrences of the disease, which is 6.1-32.3%.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],

What causes purulent arthritis?

Any pyogenic microbes penetrated into the joint cavity can cause inflammation of the joint or joint as a whole, purulent arthritis. The most frequent pathogens are Staphylococcus aureus, E. Coli, Streptococcus spp., Enterobacter. Microbiological studies more often reveal the growth of associations of Gram-negative and Gram-positive microorganisms with high microbial contamination of articular fluid and surrounding tissues (up to 108-109 microbial bodies per 1 g of tissue). Gram-negative microorganisms predominate (Pseudomonas aeruginosa and Acinetobacter).

There are purulent arthritis of large joints of exogenous and endogenous origin. Exogenous purulent arthritis develops after open joint damage (posttraumatic and gunshot), after injection and surgical treatment of closed injuries and various orthopedic diseases (post-injection and postoperative). Endogenous purulent arthritis is a complication of various diseases and a secondary manifestation of sepsis.

The vast majority of patients on purulent arthritis of large joints have post-traumatic disease. In gunshot wounds of large joints purulent complications are observed more often (32-35%) than with open fractures of another genesis (14-17%). After surgical and injective interventions, they develop in 6-8% of cases. Postinjection purulent arthritis of large joints is rare. As a rule, it occurs after the introduction of steroid drugs (most often the Kenalog) into the joint cavity for deforming arthrosoarthritis, rheumatoid polyarthritis and diabetic osteoarthropathy. Post-traumatic purulent arthritis in half the cases affects the ankle joint. In the group of patients with postinjection arthritis, knee joint damage predominates.

The duration and severity of the course of purulent arthritis are the reason for the persistent loss of ability to work of patients in 40-45% of cases. In the general structure of disability, purulent arthritis of large joints is 11.7-12.5%.

The prerequisites for the development of infection in the joint are a violation of its tightness and the presence of fluid cavities, surrounded by a synovial membrane with a rich capillary network. Depending on the stage of development of the inflammatory process, arthritis can occur in the form of synovitis (inflammation of only the synovial membrane), paraarticular flegmon, panarthritis, chondritis and osteoarthritis. Inflammation of the synovium can be purulent or serous. When the inflammatory process spreads to the articular cartilage and bone tissue, purulent-destructive osteoarthritis, para-articular phlegmon, epiphyseal osteomyelitis, panartrite is formed.

Symptoms of purulent arthritis

Purulent arthritis manifests itself in different ways, its symptoms depend on the prevalence of the process. Isolated bursitis and defeat of the synovial membrane are manifested mainly by pain and soreness in palpation. Active movements are limited due to pain, the joint increases in volume, the skin folds are smoothed out; determine hyperthermia and flushing of the skin. The destruction of the ligamentous apparatus leads to pathological mobility or dislocation of the joint. The main diagnostic method is puncture of the joint with subsequent examination of the punctate. The stage of development of purulent arthritis and the extent of lesion of pararticular tissue are determined by clinical methods and using a set of the same objective criteria as in osteomyelitis. It should be noted that in inflammatory joint diseases, MRI has a higher sensitivity than CT. Arthroscopy has great diagnostic capabilities in determining the degree of damage to intraarticular structures.

Classification

Depending on the ways of penetration of microorganisms purulent arthritis can be primary - as a result of joint damage, and secondary - during the transition of the inflammatory process from the surrounding or distant foci of inflammation. Three types of arthritis are distinguished by the amount of tissue damage:

Purulent arthritis without destructive changes in the joint elements:

• without defeat of paraarticular tissue;
• with purulent inflammation and purulent-necrotic wounds of the paraarticular region.

Purulent arthritis with destructive changes in the capsule, ligaments and cartilage:

• without defeat of paraarticular tissue;
• with purulent inflammation and purulent-necrotic wounds of the pararticular region;
• with purulent fistulas of the paraarticular region.

Purulent osteoarthritis with destructive changes of articular cartilage and osteomyelitis of bones:

• without defeat of paraarticular tissue;
• with purulent inflammation and purulent-necrotic wounds of the pararticular region;
• with purulent fistulas of the paraarticular region.

The defeat of soft tissues can be represented by the following forms: paraarticular flegmon, purulent-necrotic and purulent-granulating wounds in the region of the large joint, festering fistulas of the paraarticular region. Extensive tissue damage determines the nature of the primary lesion during the trauma, the size of the primary purulent focus and the volume of surgical interventions (submerged metalloesteosynthesis complicated by a purulent infection, and numerous surgical treatments that inevitably led to an increase in the initial size of the wounds).

[11], [12]

Treatment of purulent arthritis

Purulent arthritis is treated, as well as osteomyelitis.

Surgery

The tactics of surgical treatment are based on the principles of the method of active surgical management of purulent wounds. It consists of the following main components:

• puncture of the joint;
• flow-aspiration drainage of the joint cavity with perforated tubes followed by long-term washing of the joint cavity with solutions of antiseptics and antibiotics;
• radical surgical treatment of purulent focus with excision of all non-viable soft tissues and resection of necrotic sites;
• local treatment of the wound of the para-articular region with multicomponent ointments on a polyethylene glycol basis or under conditions of a controlled abacterial environment;
• additional physical methods of wound treatment: a pulsating stream of antiseptics and antibiotics, low-frequency ultrasound exposure through solutions of antibiotics and proteolytic enzymes;
• early plastic wound closure and replacement of a soft tissue defect with full-layer vascularized grafts;
• reconstructive osteo-plastic surgery.

Analysis of the results of treatment at the previous stages showed that the complexity of treatment was due to the following factors:

• difficulty in determining the nature and extent of damage to a large joint and surrounding tissues by traditional methods of diagnosis;
• the severity of the lesion and the difficulty of combating the purulent infection in the cavity, due to the anatomical and functional features of its structure;
• the use of a large number of palliative operations designed only for the drainage of the cavity, even with destructive forms of lesion;
• unsuccessfully chosen and long-term immobilization in multi-stage treatment, which significantly worsens the functional results in the treatment of purulent arthritis without destructive changes;
• the severity of primary joint damage with post-injection forms of arthritis.

Surgical tactics and volume of surgical treatment are planned depending on the results of a comprehensive examination of the patient. Depending on the surgical situation (volume, nature and characteristics of lesion structures), the basic principles of surgical treatment of purulent arthritis of large joints are used in one or more stages.

The method of treatment of purulent arthritis is chosen in accordance with the type of disease. With purulent arthritis without destructive changes in the joint elements (type I), synovitis and purulent exudate are observed in the joint cavity. After determining the amount of damage, puncture and drainage of the cavity of the large joint with a perforated silicone tube is performed. Both ends of the tube are removed to the skin through separate punctures. If necessary, depending on the configuration of the affected joint, several drainage tubes are used. In severe cases, drainage is performed under the supervision of ultrasound or CT. In the future, long-term flow-aspiration washing with solutions of antiseptics and antibiotics matched by the sensitivity of microorganisms is established. The average duration of washing the cavity is 20-25 days. It should be emphasized that prolonged flow-aspiration drainage is of paramount importance in the treatment of isolated arthritis, when it is still possible to preserve the anatomical and functional integrity of the affected joint. During this time, against the background of systemic antibiotic therapy, in the vast majority of cases, purulent arthritis can be eliminated. Treatment of purulent wounds and replacement of soft tissue defects in the pararticular region in patients with purulent inflammation and purulent-necrotic wounds of this region are carried out according to the principles of treatment of purulent wounds.

Surgical treatment of patients who have purulent arthritis and destructive changes in the capsule, ligaments and cartilage (type II) consists of extensive arthrotomy, excision of nonviable soft tissues, resection of the affected joint surfaces. Drainage of the cavity is carried out under visual control in the manner described above with the connection of a flow-aspiration system. Restoration of the capsule and full-blown skin is performed first or in the early days by one of the methods of plastic surgery. Immobilization or arthrodesis is performed using an orthosis or external fixation device.

The treatment of the heaviest contingent of patients in whom the purulent necrotic process covers all the elements of the joint and extends to the bones that make up the joint, causing their destruction and sequestration (type III), includes all the principles of the method of active surgical treatment of purulent arthritis. Surgical intervention consists in resection of the destroyed joint, wide opening of the purulent focus with excision of non-viable soft tissues and terminal resection of affected parts of bones within healthy tissues. After a radical surgical treatment of the purulent foci, extensive wound surfaces and bone defects are formed. After resection of articular surfaces, arthrodesis of the joint is produced using an external fixation device. If the bone defect is more than 3 cm, the dosed approach of the fragments of the bones is carried out, followed by their compression. The resulting defect of a long bone or limb shortening is corrected by the method of distraction osteosynthesis by Ilizarov.

Surgical treatment of purulent-necrotic wounds of the pararticular region, as well as excision of purulent fistula with scar-modified skin integuments are accompanied by the formation of extensive wound surfaces and soft tissue defects. To close them and restore full skin in the pararticular areas, a variety of methods of plastic surgery are used - from wounds plasty with a free split skin flap in the nonfunctional zone to plastics with various blood-supply flaps, including microsurgical techniques. The nature of recovery operations depends on the size of the wound defects of soft tissues. Primary and early plastic surgery allows early closure of extensive wound surfaces with a full-blown skin. This creates optimal conditions for the normal functioning of the joint or the effective conduct of osteoplastic operations and the formation of bone callus.

The use of the method of active surgical treatment of purulent arthritis makes it possible to eliminate a purulent focus, to restore the ability of the affected limb to recover. In recent years in the treatment of severe arthritis with intact articular cartilage and a limited inflammatory process, arthroscopic technique has become effective. This technology allows to abandon open arthrotomy and early synovectomy in a significant part of patients, which leads to better results in who has purulent arthritis.