Surgical Treatment of Septic Arthritis Technique

Updated: Mar 28, 2022
  • Author: Gabriel Munoz, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Approach Considerations

Adequate drainage of a septic joint is the cornerstone of successful treatment. S aureus is the most prevalent and most virulent organism involved; without drainage, rapid destruction of the joint proceeds quickly. Methicillin-resistant S aureus (MRSA) is a growing cause of septic arthritis, particularly in elderly patients and in healthcare-associated infections. [35, 36]

In many cases, needle aspiration can serve as the initial diagnostic and therapeutic intervention. If rapid improvement is not achieved, however, open drainage and lavage (arthroscopically or via arthrotomy) are strongly recommended. Head-to-head comparisons have not yet provided decisive answers regarding the benefits of one surgical modality over another. [16, 5]

Arthroscopic drainage and lavage can be used either initially or after initial needle decompression fails to provide relief of infection. It is a good procedure for decompression of elbows, knees, and ankles.

A retrospective review of 46 cases of septic arthritis in 46 patients found arthroscopic treatment to be indicated in all patients who have septic arthritis of native joints. [37]  Johns et al found arthroscopic treatment to be preferable to open treatment in both adult and pediatric patients with acute septic arthritis of the knee. [38, 39]  

Arthrotomy is the best procedure for bacteria deeply embedded in a joint and for loculations. It is especially helpful for drainage of shoulders and hips. Böhler et al found open arthrotomy to be superior to arthroscopy for septic arthritis of the shoulder. [40]

In a retrospective 8-year cohort study from a Spanish center (N = 63), Flores-Robles et al compared the functional results of initial medical treatment (ie, arthrocentesis) of native-joint septic arthritis (n = 49) with those of initial surgical treatment (ie, arthroscopy or arthrotomy; n = 14). [41]  Although he authors did not find initial surgical treatment to be superior to initial medical treatment, they noted that about half of the patients with shoulder and hip infections that were initially treated medically required surgery eventually, which suggested that surgery might be the preferred initial approach in such cases.


Drainage of Hip

The anterior Smith-Petersen approach uses the superficial interval between the sartorius and the tensor fasciae latae (TFL) and the deep interval between the rectus femoris and the gluteus medius. In small children, this is the preferred approach because it minimizes the risk of vascular injury to the femoral head and dislocation; in addition, the landmarks in small children are more easily identified 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 the 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.

In a prospective, controlled study comparing open arthrotomy and arthroscopic drainage for the treatment of early septic arthritis of the hip in children, arthroscopic drainage was found to be effective and was associated with fewer days in the hospital than arthrotomy was (3.8 days and 6.4 days, respectively). At follow-up, 70% of the 10 patients in the arthrotomy group had excellent results, and 90% of the 10 patients in the arthroscopy group had excellent results. [42]


Drainage of Knee

Minimally invasive surgery (arthroscopic drainage and arthroscopic irrigation) is helpful in breaking down loculations, draining purulent material, debriding necrotic tissue, and providing irrigation. Arthroscopic staging of the initial joint infection may have prognostic and therapeutic implications. Arthrotomy is reserved for selected cases that fail the arthroscopic approach.

In a 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 joint most commonly treated was the knee (62 instances), followed by the shoulder (10), the ankle (five), and the hip (one). The combination of arthroscopic irrigation and systemic antibiotic treatment resulted in cure in 91% of the affected joints.

In a study from Austria that included 70 patients with septic arthritis of the knee who were treated with either arthrotomy or arthroscopy, Böhler et al reported a significantly lower reinfection rate and a better functional outcome in the arthroscopy group as compared with the arthrotomy group. [43]



Drainage of Ankle

Needle aspiration of purulent exudates, once or twice a day, is the primary method of ankle drainage. The ankle is a joint amenable to repeated aspirations. However, because it is also prone to excessive swelling, fluctuations may be difficult to locate. As 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.

Surgical drainage of the ankle joint is most safely and successfully accomplished via the posterolateral approach. With the foot in dorsiflexion, an incision is made 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 the small saphenous vein.

The anterolateral approach to draining the ankle involves making 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 taken as well.

Arthroscopic debridement and lavage are becoming more common in the treatment of the septic ankle. [44] The ankle is flushed with 8-10 L of saline, and the drainage tubes are left in place 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 of arthrodesis depends on the extent of infection and the quality of remaining bone stock.


Drainage of Shoulder

An arthroscopic irrigation and debridement procedure is performed in either the beach chair or the lateral decubitus position, depending on the surgeon’s comfort level. In either position, standard anterior and posterior portals are used.

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 the infraspinatus and is directed toward the coracoid. Once the joint has been entered, the inflow is connected and the camera inserted.

The anterior portal then is established under direct visualization by means of either the inside-out technique (using a Wissinger rod) or the outside-in technique (using 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 before irrigation and administration of antibiotics. A thorough synovectomy and meticulous debridement of necrotic tissue follow. The posterior cannula can then be removed and placed with the trocar into the subacromial space for further irrigation and debridement.

Arthroscopic treatment of the septic shoulder may have to be supplemented with open exploration of the biceps tendon anteriorly. A limited deltopectoral approach allows drainage of any purulence that has escaped the joint along the biceps sheath.

For surgeons who are uncomfortable with arthroscopic irrigation and debridement and for patients who have 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. A systematic review by Memon et al did not find either arthroscopic surgery or open arthrotomy to be superior to the other for the management of shoulder septic arthritis. [45]

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 such approaches have not been proved to be necessary.


Drainage of Elbow

For lateral drainage of the elbow, the approach is as follows:

  • An incision is made over the lateral epicondyle and extended 5 cm proximally and 2.5 cm distally
  • The triceps is separated from the extensor carpi radialis longus anteriorly, and the joint capsule is exposed
  • The capsule is incised carefully, and the pus is evacuated
  • The joint is irrigated with saline, and the skin is closed loosely over drains
  • The posterior compartment can be drained through the same incision by dissecting posteriorly on the humerus and elevating the attachment of the triceps from the lateral surface of the bone
  • Injury to the radial nerve should be avoided

For posterior drainage, the approach is as follows:

  • Parallel longitudinal incisions are made on each side of the olecranon and continued proximally for 7.5 cm
  • The incisions are deepened through the medial lateral border of the triceps aponeurosis into the posterior compartment of the joint
  • Injury to the ulnar nerve should be avoided
  • After treatment, the elbow is splinted at 90° and the forearm is kept in neutral rotation; active range-of-motion (AROM) exercises are started after wound healing

Drainage of Wrist

For lateral wrist drainage, the approach is as follows:

  • A 5-cm incision is made between the abductor pollicis longus and extensor pollicis brevis tendon volarly and the extensor pollicis longus tendon dorsally
  • The incision is deepened into the anatomic snuffbox, avoiding injury to the radial nerve
  • The radial collateral ligament and the synovium are incised to evacuate the pus
  • The joint is irrigated, and the skin is closed loosely over drains

For medial drainage, the approach is as follows:

  • A 5-cm incision is made over the ulnar head between the tendons of the flexor and the extensor carpi ulnaris
  • The ulnar collateral ligament and the synovium are exposed and incised distal to the ulnar styloid

For dorsal drainage, the approach is as follows:

  • A dorsal longitudinal incision is made either between the extensor pollicis longus and the extensor indicis proprius tendon or between the extensor carpi ulnaris and the extensor digiti quinti proprius tendon
  • The dorsal carpal ligament is incised, and the joint is entered
  • After treatment, the wrist is splinted in the position of function; AROM exercises are started after wound healing

Postoperative Care

Generally, nonweightbearing status should be maintained postoperatively, with splinting in a position of function. Once signs of infection diminish, frequent passive range-of-motion (PROM) exercises should commence. As soon as infection clears, patients should gradually advance from functional splinting to isometric muscle strengthening and, finally, to AROM exercises.


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 (eg, isometric, AROM, and PROM exercises) should begin as soon as possible to prevent muscle atrophy. When the patient has achieved good range of motion, isotonic and isokinetic exercises can be initiated. Weightbearing on the joint should not be attempted until the joint has been rehabilitated fully.


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.


Antibiotics are chosen on the basis of the organism or organisms cultured from samples in consultation with an infectious disease specialist. Although there is no evidence to support a standardized duration or mode of antibiotic delivery, it is usual to give a combination of intravenous (IV) and oral antibiotics for a total of 4-6 weeks. Response to treatment should be assessed with serial physical examinations and assessment of C-reactive protein (CRP) values.

PROM exercises should begin as soon as the patient is comfortable and able to tolerate them.



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 result in arthroplasty [46] or arthrodesis [47] and, in the worst case, amputation. Irreversible destruction of the joint occurs in a large percentage of patients despite proper treatment.

Secondary infection in open wounds is the most common complication for open drainage techniques. In patients with compromised immune systems or debilitating diseases, infections from open wounds may spread into soft tissues and tissue planes.