You are in: eMedicine Specialties > Orthopedic Surgery > SYSTEMIC DISEASES Aspiration Techniques and Indications for Surgery, Septic ArthritisArticle Last Updated: Oct 23, 2003AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Nadera Sweiss, MD, Assistant Professor, Department of Medicine, Section of Rheumatology, University of Chicago Hospitals Nadera Sweiss is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine Coauthor(s): Eric S Millstein, MD, Staff Physician, Department of Surgery, Section of Orthopedics and Rehabilitation, University of Chicago Hospitals; Gregory L Primus, MD, Staff Physician, Department of Orthopedic Surgery, University of Chicago Hospitals and Health System; Tammy Olsen Utset, MD, MPH, Assistant Professor of Internal Medicine, Director of Lupus Clinic, Section of Rheumatology, University of Chicago; James Curran, MD, Professor, Department of Medicine, Pritzer School of Medicine, University of Chicago; Chin Lee, MD, Fellow, Department of Rheumatology, University of Chicago Editors: Jegan Krishnan, MBBS, FRACS, PhD, Chair, Senior Clinical Director, Department of Orthopedic Surgery, Flinders Medical Centre and Repatriation General Hospital, Flinders University of South Australia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jerome D Wiedel, MD, Chair, Professor, Department of Orthopedics, University of Colorado Health Sciences Center; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: synovial fluid, acute monoarthritis, chronic monoarthritis, polyarticular arthritis, infectious arthritis, gonococcal arthritis, rheumatoid arthritis, RA, infection INTRODUCTIONSection 2 of 11
  Historically, synovial fluids have been classified as noninflammatory (WBC count 50-1000), inflammatory (WBC count 1000-75,000), septic (WBC count>100,000), or hemorrhagic. However, septic synovial fluid can have cell counts as low as a few thousand early in the infectious process; thus, differentiation of inflammatory and septic joints is not truly possible based on cell counts alone. When a patient presents with an acute or chronic monoarthritis, infectious arthritis should be considered. In one study of 77 patients with septic arthritis, the peripheral blood leukocyte count was within the reference range in 55% of the patients, and, in 13% of the cases, the erythrocyte sedimentation rate (ESR) was less than 20 mm/h. The diagnostic value of the synovial fluid leukocyte count in an individual case is poor. Counts below 25,000/mm3 are observed commonly in infectious arthritis. Thus, the key diagnostic test when septic arthritis is suggested is arthrocentesis with analysis and culture of synovial fluid. Patients may present with polyarticular involvement, so the presence of multiple inflamed joints does not rule out infectious arthritis. Polyarticular involvement is the rule in certain types of arthritis, such as gonococcal arthritis and rheumatoid arthritis (RA). The important message for the physician is to be aggressive in looking for infectious arthritis. If septic arthritis is suggested, aspirate. In skilled hands, the discomfort and morbidity of joint aspiration are minimal. The speed of diagnosis is the most important determinant of the outcome.
The following sections discuss the different aspiration techniques and indications for surgery for the major joints. The pathophysiology/epidemiology of septic arthritic conditions that are prevalent within the individual joints is also discussed below. HIPSection 3 of 11
Pathophysiology/epidemiology Septic arthritis of the hip is relatively uncommon (20-25%). In one study of 45 adults with septic arthritis of the hip, Staphylococcus was the usual organism found. Infection with tubercle bacillus, Brucella, Neisseria gonorrhoeae has been reported to cause hip monoarthritis. Septic arthritis of the hip presents a diagnostic dilemma in children more often than in adults, as it is often difficult to distinguish from toxic synovitis or an early presentation of other hip pathology. Workup with laboratory values, radiographs, and aspiration should be aggressive with any suggestion of sepsis. In children, joint sepsis is often associated with metaphyseal osteomyelitis due to the anatomy of the area around the physeal circulation. These patients usually present with a nonspecific limp or failure to use the affected limb. Prompt diagnosis and treatment of this pathology are important to prevent devastating complications including osteonecrosis, dislocation, growth disturbance, and advanced osteoarthritis. Aspiration technique The anterior, lateral, or medial approach may be used to aspirate the hip joint. As the hip joint is deep, aspiration under fluoroscopic guidance helps to assist with intracapsular needle placement. In addition, this technique allows for contrast arthrography to confirm joint penetration in difficult cases. Ultrasound-guided aspiration is a useful technique that is more accessible and avoids radiation exposure in infants and toddlers. In these young patients, sedation may be necessary to perform a useful arthrocentesis. With the patient in the supine position, insert an 18-gauge spinal needle approximately 2 cm distal and 2 cm lateral to the intersection of the femoral artery and the inguinal ligament. Direct the needle posteromedially at an angle of 60° until bone is reached. Confirm the position of the needle using image intensification or ultrasound. A lateral approach also may be used, inserting the needle just anterior and inferior to the tip of the greater trochanter. With the hip internally rotated, advance the needle in a proximal and medial direction toward the femoral neck. In young children, the hip may be aspirated using the adductor, or medial, approach. The hip is flexed and abducted and the needle is placed inferior to the proximal adductor longus tendon, aiming toward the femoral head. In all techniques, small volumes of dilute radio-opaque dye (or air in the case of infants) may be used to confirm intracapsular needle placement. Indications for surgery While sepsis of the native hip joint in adults is uncommon, this condition is observed with relative frequency in infants and toddlers. When evaluating a young child with acute onset hip or thigh pain, care must be taken to rule out this diagnosis using laboratory values and aspiration. The diagnosis of purulent arthritis of the hip is an absolute indication for surgical drainage, as repeat aspiration is arduous for the surgeon and uncomfortable for the patient. Standard approaches to the hip joint are appropriate for drainage of septic arthritis. In children, the preferred approach for most surgeons is the anterior Smith-Petersen approach. In adults, additional options include the anterolateral Watson-Jones and the posterolateral approaches, depending on surgeon comfort level. Operative technique The anterior Smith-Petersen approach uses the superficial interval between the sartorius and tensor fascia lata (TFL) and the deep interval between the rectus femoris and gluteus medius. In small children, this is the preferred approach, as it minimizes the risk of vascular injury to the femoral head and dislocation; in addition, the landmarks in small children are identified more easily anteriorly. The anterolateral Watson-Jones approach uses the superficial interval between the gluteus medius and the TFL; the deep dissection requires partial release of the abductor mechanism and detachment of the reflected head of the rectus femoris, followed by capsulotomy. The posterolateral approach splits the fibers of the gluteus maximus and detaches the external rotators to expose the posterior capsule. With all approaches, the capsule is left open after copious lavage; the muscular interval and skin are closed over drains. Young children are placed in abduction in a spica cast with a window for dressing changes until the wound is healed. Adults are permitted protected weightbearing as tolerated after the drains are removed. KNEESection 4 of 11
Pathophysiology/epidemiology Septic arthritis of the knee joint is common. The knee is involved in 40-50% of cases with septic arthritis. Hematogenous spread is the most common route by which the bacteria enter the knee joint. In children, an infected knee can result from a metaphyseal osteomyelitis site that ruptures through the cortex and tracts down into the joint. This phenomenon is rare in adults. Staphylococcus aureus is the most common cause of nongonococcal septic arthritis. Other common organisms include streptococci and gram-negative organisms. Disseminated gonococcal infections usually affect the knees as the disease progresses to its monoarthritis or oligoarthritis form. The presence of tenosynovitis is a strong diagnostic clue. Viruses known to cause arthritis of the knees include Parvovirus B19, hepatitis B (causes an immune complex–mediated arthritis), rubella, human immunodeficiency virus (HIV), and alphaviruses. The most prevalent joint manifestation of septic arthritis affected by the tick-born spirochete Borrelia burgdorferi of Lyme disease is chronic monoarthritis of the knee. Uncommon infectious agents include Mycobacterium tuberculosis, Candida albicans, and Coccidioides and Blastomyces organisms. Since knee arthroscopy is the most common orthopedic procedure, iatrogenic inoculation is not uncommon. Joint infections range from 0.04-4.0% after arthroscopy procedures. Intra-articular steroids, increased operative time, multiple excisional procedures, or shortened equipment sterilization times all are associated with increased infection risk. The most common organisms causing postarthroscopy infections are S aureus, S epidermidis, and gram-negative organisms. Joint infections after intra-articular corticosteroids injections are a well recognized, but extremely rare, complication, with a risk of less than 0.01%. Joint infections from arthrocentesis procedures usually present within one week and are the direct result of bacterial inoculation or from bacteria invading the injection site. Prosthetic joints carry an infection rate of less than 2% for early infections ( <1 y) and 0.60% for late infections, Usually the result of intra-operative inoculations or postoperative bacteremias. Increased risk occurs with RA, psoriasis, prior joint infection, concurrent distal infection, steroid therapy, prolonged operative time, large bone grafts, and delayed wound healing. If joint pain, fever, and erythema occur within 2 weeks of a surgical procedure, evaluate for a possible joint infection. Early prosthetic infections usually are caused by S aureus (50%), mixed infections (33%), gram-negative organisms (10%), and anaerobes (5%). Late infections are usually caused by staphylococcal and streptococcal species. Differential diagnoses
Workup
Aspiration technique Arthrocentesis with a large-bore needle (18- to 20-gauge) should be performed within 12 hours of suspicion. A Gram stain and culture should be attained with the caveat that these samples are found to be positive in only 50-70% of cases. The procedure should adhere to strict aseptic technique, and suitable local anesthetics, sedatives, and analgesics should be administered. The most common means to access the knee joint is from the lateral side at the level of the superior pole of the patella. The needle is advanced through the lateral retinaculum into the joint. Another common approach is through the medial joint line (see Image 5). Foul-smelling synovial fluid or the presence of gas within the joint or surrounding soft tissue on radiographs suggests anaerobic infection. Medical treatment Hospitalize all patients with suspected infected joints. Acute infection should be treated with antibiotics according to current epidemiologic trends. Duration should be a course of 4-6 weeks of intravenous therapy. Intra-articular administration of antibiotics has not been proven efficacious, and it carries the risk of reactive chemical synovitis. In cases of chronic infection, aggressive treatment with long-term antibiotics is recommended in patients who are not candidates for surgery. Indications for surgery Needle aspiration of purulent exudate is the primary method of drainage. Daily joint aspirations are usually required until the joint cultures are negative. The knee joint is probably the most amenable joint to repeated aspirations. Most cases of uncomplicated septic arthritis of the knee can be treated satisfactorily by repeated closed needle aspirations. A surgical approach to drainage should be considered in the following situations:
Minimally invasive surgery (arthroscopic drainage, arthroscopic irrigation) is helpful in breaking down loculations, draining purulent material, debriding necrotic tissue, and providing irrigation. In one study from Switzerland, 76 patients with septic arthritis (78 affected joints) were treated with a combination of arthroscopic irrigation and debridement (I&D) and antibiotic therapy. The knee was treated most commonly (62), followed by the shoulder (10), ankle (5), and hip (1). The combination of arthroscopic irrigation and systemic antibiotic treatment resulted in cure in 91% of the affected joints. Arthroscopic staging of the initial joint infection may have prognostic and therapeutic implications. Arthrotomy is reserved for selected cases that fail the arthroscopic approach. Activity Joints with acute infections should be rested during initial workup. The knee can be immobilized in balanced suspension and light traction, which helps to prevent muscle spasms. When local signs of inflammation have subsided, the knee can begin to be mobilized. Continuous passive motion (CPM) devices are often employed. This approach has been shown to decrease adhesion formation, improve cartilage nutrition, and enhance clearance of purulent exudates. Rehabilitation exercises such as isometric and active range of motion (AROM) and passive range of motion (PROM) should begin as soon as possible to prevent muscle atrophy. When the patient has achieved good range of motion (ROM), isotonic and isokinetic exercises can be initiated. Weight bearing on the joint should not be attempted until the joint has been rehabilitated fully. Medication See antibiotic coverage in Septic Arthritis. Follow-up The most common complication of the septic joint is failure to resolve the infection and progression of articular cartilage damage, severe degenerative changes, and profound functional loss. These changes often lead to arthroplasty or arthrodesis. Prognosis In general, the prognosis is proportional to the virulence of the offending pathogen (gonococcal infections have best treatment outcome while S aureus and gram-negative bacilli have the least favorable), the duration of infection prior to diagnosis and treatment, and the general premorbid condition of the patient, including systemic diseases or previous arthritis. The knee is the most likely of all the joints to experience complete or nearly complete recovery. ANKLESection 5 of 11
Pathophysiology/epidemiology Eight percent of cases of monoarticular septic arthritis involve the ankle. Septic arthritis of the ankle is associated with a high degree of morbidity and mortality. As is the case with all joints, the most common origin of septic arthritis of the ankle is hematogenous spread. The ankle joint, however, is very susceptible to soft tissue infections in the foot such as cellulitis, tenosynovitis (especially extensor-tendon sheaths), and abscesses. Incidence of infection increases dramatically in systemic diseases such as RA, systemic lupus erythematosus (SLE), gout, and diabetes mellitus (DM). The most common organisms infecting the ankle joint are S aureus, S epidermidis, and gram-negative organisms. Neisseria gonorrhoeae usually affects the ankle joint as a fleeting migratory polyarthritis and tenosynovitis before it evolves into a persistent monoarthritis or oligoarthritis. Viruses that may be involved include Parvovirus B19, hepatitis B, rubella, and alpha viruses. Differential diagnoses
Procedures Arthrocentesis with a large-bore needle (18- to 20-gauge) should be performed within 12 hours of suggested infection. A Gram stain and culture should be attained, with the caveat that these tests are found to be positive in only 50-70% of cases. The procedure should adhere to strict aseptic technique, and suitable local anesthetics, sedatives, and analgesics should be administered. The most common and safest means to aspirate the ankle joint is an anterolateral approach (see Image 7, anterior approach see Image 6). The insertion point of the needle should be 2.5 cm proximal and 1.3 cm anterior to the tip of the lateral malleolus, just lateral to the peroneus tertius tendon. Medical treatment Hospitalize all patients with suspected infected joints. Acute infection should be treated with antibiotics according to current epidemiologic trends. The duration should be a course of 4-6 weeks of intravenous therapy. Intra-articular administered antibiotics have not been proven efficacious. In addition, this route of administration carries the risk of reactive chemical synovitis. In patients with chronic infection who are not surgical candidates, aggressive treatment with long-term antibiotics is recommended. Surgical treatment Needle aspiration of purulent exudates, 1-2 times a day, is the primary method of drainage. The ankle is a joint amenable to repeated aspirations. However, because the ankle is prone to undergo excessive swelling, fluctuations may be difficult to locate. As is the case with all joints, if signs of local sepsis do not abate and synovial fluid analysis does not move to normal within 2 days after treatment, open surgical drainage is indicated. If the purulent fluid becomes too thick to aspirate, open surgical drainage is indicated. The safest and most successful means to surgically drain the ankle joint is through a posterolateral approach. Place the foot in dorsiflexion, and make an incision 5 cm proximal to the tip of the lateral malleolus just lateral to the Achilles tendon. This incision is extended distally and curves along the superior border of the calcaneus for 2.5 cm. Care must be taken to protect the sural nerve and small saphenous vein. The anterolateral approach to drain the ankle involves longitudinal incisions 5-7.5 cm over the joint and 1.3-2.5 cm anterior to the lateral malleolus. If purulent material persists in the medial aspect of the ankle joint, an anteromedial or posteromedial approach may be performed as well. Arthroscopic debridement and lavage is becoming more common in the treatment of the septic ankle. The ankle is flushed with 8-10 Liters of saline and the drain tubes are left for 36-48 hours. Postoperative treatment includes closing the wound loosely over drains. Because of the narrow confines of the ankle joint, closed suction irrigation is not employed. Arthrotomy for prosthesis removal with meticulous debridement of all cement, abscesses, and devitalized tissues may be necessary, which is then followed by prolonged antibiotics. For chronic persistent infections, excision arthroplasty, which may or may not include fusion, may be indicated. The appropriateness for arthrodesis depends on the extent of infection and the quality of remaining bone stock. Activity Acute joint infections should be rested during initial workup. When local signs of inflammation have subsided, the ankle can begin to be mobilized. After surgical drainage, the foot is stabilized in a posterior splint in the neutral position with the ankle at 90°. The ankle is kept immobilized until the wound is healed, with progression to weightbearing and AROM exercises. Follow-up
Prevention Adequate antibiotic prophylaxis is necessary before surgical procedures. Strict aseptic techniques for all diagnostic and surgical procedures, regular inspections, and frequent dressing changes are necessary for prevention of infection. Complications
Prognosis Patients with a septic ankle joint are less likely to recover completely without any permanent impairment than individuals without infection. SHOULDERSection 6 of 11
Pathophysiology/epidemiology Septic arthritis of the shoulder is uncommon, with 10-15% of cases of septic arthritis involving the shoulder. Hematogenous spread or direct inoculation is usually responsible for infection of glenohumeral joint and/or subacromial/subdeltoid bursa and acromioclavicular joint. Septic arthritis is a rare ( <1%) complication of arthroscopic surgery; slightly higher incidence is noted following open procedures including rotator cuff repair, open reduction and internal fixation (ORIF), and arthroplasty. Purulent arthritis of the glenohumeral joint is most commonly diagnosed in the following types of patients:
Diagnosis of septic arthritis is often delayed days to months after the onset of symptoms, due to nonspecific signs and symptoms in a debilitated population. At least 50% of patients have positive blood cultures and many have remote source of infection. Aspiration technique Aspiration of the glenohumeral joint can be accomplished from an anterior or posterior approach. Use an 18-gauge needle for all aspirations to allow for egress of viscous fluid. A spinal needle may be needed in obese or muscular patients. Aseptic technique should be followed for all aspirations, and local anesthesia may be used to infiltrate the skin only. The posterior approach is often more effective as it replicates the creation of the posterior arthroscopy portal. Insert the needle 2 cm inferior and 2 cm medial to the posterolateral corner of the acromion. Direct the needle toward the coracoid process (palpated anteriorly) until the tip pierces the capsule. When using the anterior approach, insert the needle at the point midway between the coracoid and the anterolateral corner of the acromion (see Image 4). Direct the needle posterior and slightly inferior. Frequently, it is necessary to rule out septic arthritis of the acromioclavicular (AC) joint or an infected subacromial bursa as well. Some authors advocate aspirating these areas routinely as part of the evaluation for septic arthritis, as these diagnoses can be elusive. The AC joint is a subcutaneous structure that can be aspirated directly from a superior or anterior approach. The bursa begins deep to the AC joint and extends laterally over the rotator cuff, more anterior than posterior. Aspiration of the bursa should be performed from the site of maximum fluctuance (anterior, posterior, or direct lateral). Indications for surgery Glenohumeral sepsis is often diagnosed at a late stage in this debilitated patient population. When the diagnosis is finally confirmed, treatment can be complicated by advanced joint destruction including synovitis, purulent loculations, osteomyelitis, erosion of the rotator cuff, and extra-articular extension. Therefore, recurrent aspiration may not be the optimal mode of treatment for this joint, especially considering the technical difficulty of shoulder arthrocentesis (in addition to the patient's discomfort). The literature regarding optimal treatment algorithms is confusing at best, with reports in medical journals championing conservative treatment and those in orthopedic journals claiming superior results with early operative drainage. Furthermore, even among those who recommend surgery, debate continues regarding the efficacy of arthroscopic versus open debridement. Some generalizations, however, can be made, including the following:
* No formal guidelines define this timeframe, though several studies suggest that patients diagnosed within 1 month of symptoms have a more favorable prognosis. Operative technique An arthroscopic I&D procedure is performed in either the beach chair or lateral decubitus position, depending on the comfort level of the surgeon. Standard anterior and posterior portals are used in either position. The posterior portal is accessed first. The skin is entered at a point 2 cm inferior and medial to the posterolateral corner of the acromion. A spinal needle, followed by the cannula, is passed through the palpable interval between the teres minor and infraspinatus and is directed toward the coracoid. Once the joint has been entered, the inflow is connected and the camera is inserted. The anterior portal then is established under direct visualization, using either the inside-out (using a Wissinger rod) or outside-in technique (with a spinal needle). This portal is established percutaneously at a point midway between the coracoid and the anterolateral corner of the acromion. The instruments should enter the capsule in the triangle bordered by the intra-articular biceps tendon, the superior border of the subscapularis and the anterior rim of the glenoid. The joint is then irrigated with several liters of fluid and a complete diagnostic arthroscopy is performed. If an adequate specimen has not been sent already for culture, fluid and tissue samples should be obtained for the laboratory prior to irrigation and administration of antibiotics. A thorough synovectomy and debridement of necrotic tissue follows. The posterior cannula can then be removed and placed with the trocar into the subacromial space for further I&D. As stated above, arthroscopic treatment of the septic shoulder may need to be supplemented with open exploration of the biceps tendon anteriorly. A limited deltopectoral approach allows for drainage of any purulence that has escaped the joint along the biceps sheath. For those surgeons uncomfortable with arthroscopic I&D and those patients with periarticular abscesses, osteomyelitis, virulent organisms, postoperative infections, or retained hardware, open arthrotomy with aggressive debridement is the treatment of choice. Most surgeons prefer the standard deltopectoral approach, followed by opening of the rotator interval. It should be noted that the rotator cuff is likely to be torn, degenerated, or scarred, resulting in abnormal anatomy. After synovectomy and thorough irrigation with several liters of fluid, the joint is closed over a drain with a monofilament absorbable suture. Many recommend antibiotic impregnated polymethylmethacrylate (PMMA) cement and other antibiotic delivery systems, though proof of their necessity remains debated. Postoperative care and rehabilitation Antibiotics are chosen based on the organism or organisms cultured from samples in consultation with an infectious disease specialist. While no standardized evidence exists for duration or mode of antibiotic delivery, a combination of IV and oral antibiotics are usually given for a total of 4-6 weeks. Response to treatment should be assessed with serial physical examinations and CRP laboratory values. PROM exercises should begin as soon as the patient is comfortable and able to tolerate them. ELBOW AND WRISTSection 7 of 11
ElbowEpidemiology and pathophysiology Septic arthritis usually occurs less frequently in the elbow (5-10%) than in larger joints. An exception is an infection due to N gonorrhoeae, which tends to involve the smaller joints, such as the hands, wrists, and elbows, although the larger joints also can be are affected. The pathogens and mechanisms of infection are like those in most other joints. In patients with total elbow prostheses, the infection rate was approximately 7% in a study of 164 primary total elbow arthroplasties. The important preoperative risk factors for subsequent postoperative infections included prior elbow surgeries, a previous infection near the region of the elbow, psychiatric disorders, spontaneous drainage from the surgical site after 10 days following elbow replacement, or any reason for reoperation. Aspiration technique Arthrocentesis or injection of the elbow is performed with the posterolateral approach (see Image 3). For this approach, the patient is positioned with the elbow in the flexed position at 90° and lying on a flat firm surface with comfortable support for the elbow. The site of entry is in the palpable depression lying in the triangle created by the olecranon, the radial head, and the lateral epicondyle. The needle is advanced through the skin aiming toward the antecubital fossa. Indications for surgery Once the diagnosis of a septic elbow has been established and the appropriate antibiotic regimen started, repeated arthrocentesis should be performed as needed to help reduce the bacterial load and intra-articular pus. Elbow arthroscopy is necessary when arthrocentesis fails to obtain an appropriate amount of joint aspirate for diagnosis. The clinical results of repeated needle arthrocentesis are similar to those that accompany arthroscopy and arthrotomy in more accessible joints such as the elbow. However, if the infection fails to improve with antibiotics and repeated arthrocentesis within 5-7 days, arthroscopy or arthrotomy should be performed for drainage and debridement. The threshold for surgical intervention should be lower in patients with comorbid conditions, such as individuals with prosthetic elbow implants, DM, RA, immunocompromised states, or other systemic illnesses. Operative technique The medial and/or lateral approach can be used to drain the elbow.
WristPathophysiology/epidemiology Septic arthritis of the wrist joint is relatively uncommon. Only 10% of cases with septic arthritis involve the wrist. Penetrating trauma such as human and animal bites are the most common causes. The most common organism is S aureus. Streptococcal species, N gonorrhoeae, Pasteurella multocida, Eikenella corrodens, Mycobacterium marinum, Streptobacillus moniliformis, and Mycobacterium avium intracellulare have been reported in specific clinical settings. The presence of calcium pyrophosphate crystals in the synovial fluid does not exclude the diagnosis of septic arthritis. Previous reports of pseudogout associated with septic arthritis have suggested that the presence of abundant calcium pyrophosphate crystals in synovial fluid should always raise the possibility of concurrent sepsis. Aspiration technique Aspiration of the wrist joint can be accomplished from several sites on the dorsum of the wrist (see Images 1-2). The most common site of aspiration is between the first and the second extensor compartments at the radiocarpal level. The procedure includes the following steps:
Indications for surgery
Operative technique
ACKNOWLEDGMENTSection 8 of 11
The authors would like to thank Dr. Curran for his expertise in demonstrating joint aspiration. ACKNOWLEDGMENTSSection 9 of 11
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Lawrence Pottenger to the development and writing of this article. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Aspiration Techniques and Indications for Surgery, Septic Arthritis excerpt Article Last Updated: Oct 23, 2003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
