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135

Treatment of Suppurative by Percutaneous Catheter Drainage

#{149}.:.

Jordan B. Renner1’2 Michelle W. Age&

154:135-138,

Septic must

arthritis

CB 751 0, University Hill, Chapel

of North Carolina at Chapel Hill, NC 27599-7510. Address reprint

requests to J. B. Renner. 2 Department of Medical Allied Health Professions,

University

of North

Carolina

Chapel Hill, NC 27599-751 0. 0361-803X/90/1541-0135 © American Roentgen Ray Society

at Chapel

Hill,

January

is a grave

be eradicated

antibiotic

joint

be decompressed

may

therapy

or as reported

Materials

and Methods

Five

were

patients

1990

disease.

completely

adequate aspirations, catheters.

Presented at the annual meeting of the American Roentgen Ray Society, New Orieans, LA, May 1989. 1 Department of Radiology, Schcol of Medicine,

.

.

Percutaneous catheter drainage to treat suppurative arthritis was performed in five joints in five patients. Joints drained included the hip in two cases and one case each of a hip joint prosthesis, an ankle joint, and a glenohumeral joint. Organisms isolated from the joints included Staphylococcus aureus in one hip joint and the hip prosthesis, and Haemophilus influenzae in the ankle joint. Specific organisms were not isolated in the other hip joint or in the shoulder joint. Systemic antibiotic therapy was used in all five patients, and in two patients gentamicin was instilled through the catheters. Joint infection was managed successfully with catheter drainage and antibiotics in three patients. In all three cases, the range of motion was restored and the patients became free of pain after catheter drainage. These three patients remained asymptomatic at follow-up ranging from 3 weeks to 9 months. In two patients, percutaneous drainage failed. In one patient, the catheter positions could not be maintained and the catheters repeatedly became dislodged. In the other, superimposed osteomyelitis necessitated surgical debridement. No complications occurred. Our experience suggests that suppurative arthritis can be successfully treated with drainage of the joint via a percutaneous catheter in combination with antibiotic therapy. AJR

Received May 18, 1989; accepted after revision August 22, 1989.

Arthritis

referred

lfjoint

and

and prompt surgically,

here,

for

function

quickly.

and complete through

by means

aspiration

is to be preserved,

Successful the

use

of drainage

of fluid

to

treat

aspirated included two hips, one in an IV drug abuser who debridement in the same joint for suppurative arthritis (Fig. CS-level quadriplegia (Fig. 2); a prosthetic hip in a patient (Fig. 3); an ankle in a patient with an episode of bacteremia a shoulder in a patient with systemic lupus erythematosus ditis,

nephritis,

and

formation

of multiple

abscesses

(Fig.

treatment

drainage of repeated

the infection requires

both

of the joint.

The

percutaneous

via percutaneously

suspected

pyarthrosis.

placed

Joints

had previously undergone surgical 1) and the other in a patient with with severe rheumatoid arthritis after plasmapheresis (Fig. 4); and complicated by cerebritis, pericar-

5).

Each joint was entered from the approach most likely to facilitate gravity-aided drainage. Organisms isolated from the joint aspirates included Staphylococcus aureus from the drug abuser’s hip and the prosthetic hip and Haemophilus influenzae from the ankle. Specific organisms were not isolated in the quadriplegic patient or in the patient with lupus. After purulent material was aspirated from the joint, a pigtail catheter was inserted by using a modified Seldinger technique [1]. Once the needle entered the joint, a guidewire was inserted, followed by dilators and a pigtail catheter. Catheters used included two 5.5-French catheters (Electro-Catheter Corp., Rahway, NJ), sutured in position in the patient with lupus, an 8.3French self-retaining catheter (Cook, Bloomington, IN) in the drug abuser, and 6-French self-

RENNER

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136

AND

AGEE

AJA:154,

January

1990

Fig. 1.-34-year-old

male IV drug abuser had had partial resection of the femoral head for osteomyelitis and pyarthrosis. He presented with hip pain 6 aureus was aspirated from hip. Anteroposterior radiograph of hip after placement of 8.3-French pigtail catheter shows catheter positioned over partially resected femoral head. 13 days of catheter drainage and antibiotic therapy resufted in sterilization of joint aspirate and restoration of range of motion. Patient remained asymptomatic 4 months after removal of catheter. months

after

surgery,

Fig. 2.-27-year-old

and Staphylococcus

male quadriplegic

in whom abdominopelvic

CT scan revealed

and although aspiration of joint yielded pus, no organism was isolated from cuftures. contrast material through catheter opacified hip joint as well as fistulous tract (arrow)

22 days of catheter drainage, osteomyelitis

of femoral head and acetabulum

an air/fluid A 6-French

level in hip. Patient pigtail

was already

receiving

antibiotics,

catheter was placed percutaogously. Injection of with a greater trochanteric abscess cavity. Despite

communicating necessitated surgical debridement.

Fig. 3.-46-year-old man with rheumatoid arthritis previously had undergone 14 joint replacements. He presented with hip pain, and Staphylococcus aureus was aspirated from hip. Initially, joint was drained surgically, but 9 days after surgery, patient again became febrile, and pus containing grampositive cocci was aspirated from joint. 6-French catheter was placed in hip. contrast injection opacified joint and a greater trochanteric abscess cavity. Patient was ambulating fully after 5 days of catheter drainage and antibiotic therapy, at which time joint aspirates were sterile. No recurrent joint infection

was noted on follow-up 9 months later.

(average, throughout

1 4 days). Systemic antibiotic the catheter treatment.

therapy

was

continued

Results In three through

drainage.

Fig. 4.-62-year-old

woman

with renal failure had Haemophilus

influen-

zae bacteremia after plasmapheresis. Ankle pain developed, and pus containing gram-negative reds was aspirated from ankle and subtalar

joints. A 6-French pigtail catheter was placed in posterior recess of ankle joint. Contrast injection opacified both ankle and subtalar joints. Catheter drainage was continued for 12 days, after which joint aspirate was sterile and range of motion was restored. Patient remained asymptomatic 3 weeks after removal of catheter.

catheters

(Medi-tech,

Inc.,

Watertown,

MA)

was

use of antibiotic

included

treated

satisfactorily

therapy

and catheter

the prosthetic

hip joint, the

hip that had been surgically

and the drug abuser’s

for an earlier bout of suppurative

arthritis.

Catheter

drainage was completed in 5-1 3 days (average, 1 0 days). In each case, catheter drainage and antibiotic therapy resulted in restoration of range of motion of the affected joint, sterilization of the joint aspirate, and resolution of the patients’ joint symptoms. At follow-up, ranging from 3 weeks to 9 months, the patients remained asymptornatic. In two cases, the catheter treatment failed. In one of these cases,

osteomyelitis

of the femoral

head

and acetabulum

in

the quadriplegic patient necessitated surgical debridement. In the patient with lupus, the catheter positions could not be stabilized adequately, the catheters were dislodged repeatedly, and surgical drainage was required. The percutaneous catheter was tolerated well by all patients,

retaining

the infection

These joints

ankle joint,

treated

cases,

the combined

and no catheter-related

complications

occurred.

in the remaining

patients. In all patients, a constant, low-pressure suction bulb (Jackson-Pratt reservoir, American V. Mueller, Chicago, IL) was applied to the catheter, and in the drug abuser and the patient with rheumatoid arthritis, gentamicin was intermittently delivered directly into the joint through the catheter. Catheters were left in place for 5-22 days

Discussion Successful treatment relief of pain, restoration

of bacterial septic of joint motion,

arthritis results and prevention

in of

AJA:154,

January

CATHETER

1990

DRAINAGE

IN SUPPURATIVE

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tion

ARTHRITIS

fail to eradicate

137

the

infection

[9],

when

the

infected

joint

is deep, such as the hip, or when the inflammatory debris or articular loculations prevent adequate aspiration [8, 1 0]. The results of needle aspiration are comparable to, if not better than, those associated with surgical drainage [8]. Patients treated surgically vs those receiving nonsurgicaljoint drainage may differ in the infecting organism, the duration of symptoms before initiation of therapy, the presence of any coexisting medical or surgical disease, and the inability to treat deep joints with repeated aspirations easily [8]. It appears, however,

Fig. 5.-21-year-old woman with complicated systemic lupus erythematosus developed multiple abscesses and was receiving multiple antibiotics. Serosanguinous fluid was aspirated from subdeltoid bursa, and although pus was aspirated from glenohumeral joint, no organism was isolated. Two catheters were placed in shoulder girdle. One catheter (arrow) entered glenohumeral joint via a posterior approach. Second cath-

eter drained subdeltoid/subacromial bursa. Catheters were securely sutured in place, but repeatedly dislodged in patient’s room. surgical drainage of glenohumeral joint was required 19 days after placement of cathe-

that

the sequelae of osteoarthrosis and ankylosis [2]. This requires appropriate antibiotic therapy, immobilization of the joint, and drainage of the affected articulation. Appropriate antibiotic therapy must include systemic

decompression

and treated with months). The joint

long-term effusion

of the

five

reinfections

through

noninfected

fluid

time

[3-5].

In these

any

human

isolated

studies,

organism.

antibiotics

Several

investigated

included penicillin G, phenoxymethyl penicillin, nafcillin, cephaloridine, cloxacillin, tetracycline, erythromycin, and lincomycin in the first study [3], ampicillin, methicillin, penicillin, and cephalothin in the second [4], and ampicillin and kanamycin

in the

third

[5].

Administration

was

oral,

intramuscular,

and IV, depending on the antibiotic being administered. In each of these studies, articular antibiotic concentrations equalled or exceeded serum concentrations and, except for erythromycin [3], were in excess of the antibiotic concentrations required for inhibition or killing of the organisms usually causing suppurative arthritis. Nelson [4] suggested that, because of altered synovial permeability to the passage of antibiotic molecules in the setting of synovial inflammation, the peak serum antibiotic concentration may precede the peak articular concentration, but this and other studies mdicate that effective articular antibiotic levels can be reached without the use of intraarticular antibiotic instillation. Furthermore, the intraarticular administration of antibiotics may be counterproductive

because

they

may

produce

a chemical

[6, 7]. Decompression of the infected joint is required if joint function is to be preserved [8]. Undrained pus retards the effectiveness of antibiotics. Joint effusion and inflammatory debris destroy the articular cartilage and lead to degenerative osteoarthrosis or ankylosis [8]. Traditionally, decompression synovitis

of septic

arthritis

has

been

repeated needle aspiration age has been advocated

performed

of the infected when antibiotic

surgically

or through

joint. Surgical draintherapy and aspira-

subsequently

not

(average, syndrome”

managed

arthroscopic

collections,

biotics

toward

may

2

lavage

success-

in four

and

after

synovial centesis with yttrium-90 in one. Percutaneously placed catheters have been used widely and effectively in the management of a variety of infected and

investigators have studied the intraarticular concentrations of antibiotics attainable through systemic administration of anti-

directed

joint

antibiotic therapy and the “inflammatory

was

a second

eter drainage of joint Sanders and Staple angiocatheter into an pain decreased after

treatment

of a septic

were resolved in 36 (78%) joints after the initial arthroscopic treatment. Five patients had a persistent articular infection, and five others became reinfected after initial success. Each fully,

ters.

surgical

be mandatory. A recent multicenter study reported the use of arthroscopic debridement and drainage of septic knees [1 1 ]. In this study, 46 septic knees were drained and lavaged arthroscopically

the

joint

A letter

fluid

was

clear

by Proubasta

of one

infected

but limited

experience

with

cath-

infections has been reported [1 2, 13]. [1 2] placed an 1 8-gauge translumbar infected shoulder joint. Their patient’s 1 0 days of catheter drainage, at which and

the

catheter

et al. [1 3] reported

hip and

one

infected

was

removed.

catheter

shoulder.

drainage

In their

report,

the

affected joints showed “no further abnormality” at a minimum of 6 months follow-up. These authors reported no complications. In two

of our five

cases,

percutaneous

drainage

failed.

Our

failure in one case due to repeated dislodgment of the catheters emphasizes the importance of maintaining catheter stability. In our other failed case, osteomyelitis of the femoral head and acetabulum required surgical debridement of the affected osseous structures. Our success with percutaneously placed catheters to treat suppurative arthritis in three cases, including a hip joint, a hip joint prosthesis, and an ankle/subtalar joint is promising. Hip joint infections in other series are associated with poor eventual results or, in the case of prosthetic joints, obligatory prosthesis removal and joint revision [8, 1 4, 1 5]. Our numbers are small, but the ability to manage an infected prosthetic joint or a deep joint infection nonoperatively may present a practical and attractive treatment option. Successful percutaneous catheter drainage obviates any morbidity

associated

with

uous drainage of the joint, intraarticular administration

guidance, portion

the catheter of the joint.

of catheter

dude

placement.

infection

surgical

drainage.

It allows

contin-

lavage of the joint, and if desired, of antibiotics. Under fluoroscopic

can be placed in the most dependent

We have Possible

of the joint

encountered

no complications

complications,

due to the presence

however,

in-

of a foreign

138

RENNER

AND

development of a fistulous tract, or particularly in a joint a delicate capsule such as the shoulder, capsular rupture if lavage volumes are too great [12].

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5. Baciocco EA, lIes AL. Ampicillin and kanamycin concentrations in joint fluid. Clin Pharmacol Ther 1971:12:858-863 6. Argen AJ, Wilson CH, Wood P. Suppurative arthritis, clinical features of 42 cases. Arch Intern Med 1966; 117:661-666

The Society a clinical

pediatric careers

for Pediatric or laboratory

imaging. in pediatric

be submitted

purpose,

Radiology

(SPR) project

and

radiology is Feb.

methods,

to the

SPR.

Eligible

and pediatric radiologists. 1 1 990. The application ,

materials,

planned

Education

is requesting that

The purpose of these grants imaging. On completion, the

for presentation

in diagnostic of applications

1 4. Chartier Y, Martin WJ, Kelly PJ. treatment of 77 patients. Ann Intern 1 5. Kelly PJ, Martin WJ, Coventry MB. adult. J Bone Joint Surg 1970;52A:

Research

research

of the diffusion

analysis

will

involve

Grants

grant

applications

some

aspect

of

is to stimulate and advance results of the research must applicants The deadline must include procedure,

Louis,

Washington

University

MO 631 1 0. For information

Medical

Center,

by telephone:

across

of septic modes of a general diagnosis

Bacterial arthritis: experiences Med 1959:50:1462-1474 Bacterial (suppurative) arthritis 1595-1602

include

trainees

for submission a statement proposed

of

budget

details, and background discussion. Copies of the curricula vitae of all investigators should be appended. The maximal amount to be awarded for any one grant is $5000. Send applications to William H. McAlister, M.D., Dept. of Radiology,

of penicillin

cavities. J Lab Clin Med 1946:31:535-543

13. Proubasta IA, Celaya Fl, Cadafalch JA, Palacio AH. Percutaneous drainage of septic joints (letter). AJR 1988;1 51 :1057

1971:284:349-353

for

CB. A study

ofjoint

January 1990

8. Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES. Treatment arthritis: comparison of needle aspiration and surgery as initial joint drainage. Arthritis Rheum 1975:18:83-90 9. Manshady BM, Thompson GA, Weiss JJ. Septic arthritis in hospital 1966-1 977. J Rheumatol 1980:7:523-530 1 0. Bayer AS. Nongonococcal bacterial septic arthritis: an update on and management. Postgrad Med 1980:67:157-165 1 1 . Thiery JA. Arthroscopic drainage in septic arthritides of the mulicenter study. Arthroscopy 1989:5:65-69 1 2. Sanders TA, Staple TW. Percutaneous catheter drainage of septic joint. Radiology 1983:147:270-271

1 . Seldinger SI. Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radio! 1953:39:368-376 2. O’Meara PM, Bartal E. Septic arthritis: process, etiology, treatment outcome. Orthopedics 1988;1 1 :623-628 3. Parker RH, Schmid FR. Antibacterial activity of synovial fluid during treatment of septic arthritis. Arthritis Rheum 1971:14:96-104 4. Nelson JD. Antibiotic concentrations in septic joint effusions. N EnglJ Med

Radiology

HL, O’Neil

the serous membranes

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AJA:154,

7. Hirsh HL, Feffer

body, with

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AGEE

51 0 5. Kingshighway, (31 4) 454-6229.

St.

knee:

a

shoulder

catheter in the in the