Purulent arthritis

The term "purulent arthritis" refers to various forms of non-specific inflammatory and necrotic processes occurring in the joint cavity and in paraarticular tissues. Purulent arthritis of large joints accounts for 12-20% of all purulent surgical diseases. To date, their treatment has been very difficult, as evidenced by the high percentage of relapses of the disease, amounting to 6.1-32.3%.

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

What causes purulent arthritis?

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

A distinction is made between purulent arthritis of large joints of exogenous and endogenous origin. Exogenous purulent arthritis develops after open joint injuries (post-traumatic and gunshot), after injection and surgical treatment of closed injuries and various orthopedic diseases (post-injection and post-operative). Endogenous purulent arthritis is a complication of various diseases and a secondary manifestation of sepsis.

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

The duration and severity of purulent arthritis are the cause of persistent loss of working capacity in patients in 40-45% of cases. In the overall structure of disability, purulent arthritis of large joints accounts for 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 the synovial membrane only), paraarticular phlegmon, panarthritis, chondritis and osteoarthritis. Inflammation of the synovial membrane can be purulent or serous. When the inflammatory process spreads to the articular cartilage and bone tissue, purulent-destructive osteoarthritis, paraarticular phlegmon, epiphyseal osteomyelitis, panarthritis are formed.

Symptoms of purulent arthritis

Purulent arthritis manifests itself in different ways, its symptoms depend on the prevalence of the process. Isolated bursitis and damage to the synovial membrane manifest themselves mainly in pain and tenderness upon palpation. Active movements are limited due to pain, the joint increases in volume, skin folds are smoothed out; hyperthermia and hyperemia of the skin are determined. Destruction of the ligamentous apparatus leads to pathological mobility or dislocations of the joint. The main diagnostic method is a puncture of the joint with subsequent examination of the puncture. The stage of development of purulent arthritis and the extent of damage to paraarticular tissues are determined by clinical methods and using a set of the same objective criteria as in osteomyelitis. It should be noted that in inflammatory diseases of the joints, MRI has a higher sensitivity than CT. Arthroscopy has greater diagnostic capabilities in determining the degree of damage to intra-articular structures.

Classification

Depending on the routes of penetration of microorganisms, purulent arthritis can be primary - as a result of damage to the joint, and secondary - when the inflammatory process moves from surrounding or distant foci of inflammation. According to the volume of tissue damage, three types of arthritis are distinguished:

Purulent arthritis without destructive changes in the joint elements:

• without damage to paraarticular tissues;
• with purulent inflammation and purulent-necrotic wounds of the paraarticular region.

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

• without damage to paraarticular tissues;
• with purulent inflammation and purulent-necrotic wounds of the paraarticular region;
• with purulent fistulas of the paraarticular region.

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

• without damage to paraarticular tissues;
• with purulent inflammation and purulent-necrotic wounds of the paraarticular region;
• with purulent fistulas of the paraarticular region.

Soft tissue damage may be represented by the following forms: paraarticular phlegmon, purulent-necrotic and purulent-granulating wounds in the area of a large joint, purulent fistulas of the paraarticular area. The extent of tissue damage determines the nature of the primary injury during the trauma, the size of the primary purulent focus and the volume of surgical interventions (immersion metal osteosynthesis complicated by purulent infection and numerous surgical treatments that inevitably led to an increase in the original size of the wounds).

[ 11 ], [ 12 ]

Treatment of purulent arthritis

Purulent arthritis is treated in the same way as osteomyelitis.

Surgical treatment

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:

• joint puncture;
• flow-aspiration drainage of the joint cavity with perforated tubes followed by long-term rinsing of the joint cavity with antiseptic and antibiotic solutions;
• radical surgical treatment of the purulent focus with excision of all non-viable soft tissues and resection of necrotic areas;
• local treatment of wounds in the paraarticular region with multicomponent ointments based on polyethylene glycol or in a controlled abacterial environment;
• additional physical methods of wound treatment: pulsating stream of antiseptics and antibiotics, low-frequency ultrasound exposure through solutions of antibiotics and proteolytic enzymes;
• early plastic closure of the wound and replacement of the soft tissue defect with full-layer vascularized flaps;
• reconstructive bone plastic surgeries.

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

• the difficulty of determining the nature and extent of damage to a large joint and surrounding tissues using traditional diagnostic methods;
• the severity of the lesion and the difficulty of combating 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 cavity drainage, even in destructive forms of damage;
• poorly chosen and prolonged immobilization during multi-stage treatment, which significantly worsens the functional results in the treatment of purulent arthritis without destructive changes;
• severity of primary joint damage in post-injection forms of arthritis.

Surgical tactics and the scope of surgical treatment are planned depending on the results of a comprehensive examination of the patient. Depending on the surgical situation (scope, nature and features of the damage to structures), the basic principles of surgical treatment of purulent arthritis of large joints are applied in one or several stages.

The treatment method for purulent arthritis is selected based on the type of disease. In purulent arthritis without destructive changes in the joint elements (type I), synovitis and purulent exudate are observed in the joint cavity. After determining the extent of the lesion, a puncture and drainage of the cavity of a large joint is performed with a perforated silicone tube. Both ends of the tube are brought out to the skin through separate punctures. If necessary, depending on the configuration of the affected joint, several drainage tubes are inserted. In severe cases, drainage is performed under ultrasound or CT control. Subsequently, long-term flow-aspiration drainage is established with antiseptic and antibiotic solutions selected based on the sensitivity of microorganisms to them. The average duration of cavity lavage is 20-25 days. It should be emphasized that long-term 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 antibacterial therapy, in the overwhelming majority of cases, the phenomena of purulent arthritis can be eliminated. Treatment of purulent wounds and replacement of soft tissue defects in the paraarticular region in patients with purulent inflammation and purulent-necrotic wounds in this area is carried out according to the principles of treatment of purulent wounds.

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

Treatment of the most severe contingent of patients, in whom the purulent-necrotic process covers all 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 of resection of the destroyed joint, wide opening of the purulent focus with excision of non-viable soft tissues and end resection of the affected areas of the bones within healthy tissues. After radical surgical treatment of the purulent focus, extensive wound surfaces and bone defects are formed. After resection of the articular surfaces, arthrodesis of the joint is performed using an external fixation device. If the bone defect is over 3 cm, a dosed approximation of bone fragments is performed with their subsequent compression. The resulting defect of the long bone or shortening of the limb is corrected using the Ilizarov distraction osteosynthesis method.

Surgical treatment of purulent-necrotic wounds of the paraarticular area, as well as excision of purulent fistulas with cicatricially altered skin are accompanied by the formation of extensive wound surfaces and soft tissue defects. To close them and restore full-fledged skin in the paraarticular areas, various methods of plastic surgery are used - from wound plastic surgery with a free split skin flap in a non-functional zone to plastic surgery with various blood-supplied flaps, including microsurgical techniques. The nature of the restorative operations depends on the size of the resulting wound defects of the soft tissues. Primary and early plastic surgeries allow for early closure of extensive wound surfaces with full-fledged skin. This creates optimal conditions for normal joint functioning or effective osteoplastic surgery and callus formation.

The use of the method of active surgical treatment of purulent arthritis allows to eliminate the purulent focus, restore the support ability of the affected limb. In recent years, arthroscopic techniques have been effectively used in the treatment of severe arthritis with intact articular cartilage and a limited inflammatory process. This technology allows to refuse open arthrotomy and early synovectomy in a significant part of patients, which leads to better results for those with purulent arthritis.