Management of Latent Septic Ankle Arthritis Through StagedArthroscopic Ankle Arthrodesis Utilizing External Fixation

Mark A. Prissel, DPM (PGY-III)1

Devin C. Simonson, DPM (PGY-II)1

Thomas S. Roukis, DPM, PhD, FACFAS2

1Gundersen Medical Foundation, La Crosse, WI2Gundersen Health System, La Crosse, WI

Management of septic arthritis is a surgical emergency requiring a protocol-driven approach including high-volume joint lavage, extensive débridement, deep culture procurement and prolonged sensitivity-driven parenteral antibiotics.1-6 With concomitant osteomyelitis, in addition to the above, a staged approach utilizing antibiotic loaded polymethylmethacrylate cement beads (AL-PMMA) and de�nitive management with joint arthrodesis is recommended.1

PURPOSE

LITERATURE REVIEWNo standardized approach to the management of septic ankle arthritis exists.1-8

CASE STUDYA 66-year old uncontrolled diabetic woman was referred 11-days after initial presentation with a known right septic ankle. One year prior, she underwent trimalleolar ankle fracture ORIF performed elsewhere, complicated by �ve-months of delayed incisional healing (Figure 1). Prior to referral, she underwent two ankle joint aspirations which yielded multi-drug resistant Staphylococcus epidermitis. Additionally, radiographs, CT scan, WBC-labeled bone scintigraphy and laboratory work-up demonstrated failed �xation, septic arthritis and osteomyelitis.

We performed the protocol-driven approach, as stated in the purpose section, to treat the septic ankle and hardware removal with bone biopsy procurement that con�rmed septic arthritis and acute osteomyelitis (Figure 2). Eight-weeks following the index procedures, she underwent removal of AL-PMMA and arthroscopic ankle arthrodesis utilizing external �xation that was removed 10-weeks later (Figure 3). Clinical surveillance with serial radiographs demonstrated successful arthrodesis. She ambulates with an AFO and remains infection-free on suppressive antibiotics 17-months postoperatively (Figure 4).

RESULTS

ANALYSIS and DISCUSSION

A positive outcome was achieved, despite treatment delays with known septic arthritis. Clinical acumen and appropriate use of diagnostic tests should be utilized to initiate prompt treatment for this surgical emergency. Protocol-driven staged treatment for septic ankle arthritis followed by arthroscopic arthrodesis utilizing external �xation o�ers a viable limb-salvage approach.1

References1. Mankovecky MR, Roukis TS. Arthroscopic synovectomy, irrigation and débridement for the treatment of septic ankle arthrosis: a systematic review and case series. J Foot Ankle Surg. In Press Corrected Proof; 2014.2. Bo�eli TJ, Thompson JC. Arthroscopic management of septic ankle Joint: case report of a stage-guided treatment. J Foot Ankle Surg 52:113-117, 2013.3. Parisien JS, Sha�er B. Arthroscopic management of pyarthrosis. Clin Orthop 275:243-247, 1982.4. Stuz G, Kuster MS, Kleinstück F, Gächter A. Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthosc 8:270-274, 2000.5. Lee CH, Chen YJ, Ung SWN, Hsu RWH. Septic arthritis of the ankle joint. Chang Gung Med J 23:420-426, 2000.6. Shadrick D, Mendicinio RW, Catanzariti AR. Ankle joint sepsis with subsequent osteomyelitis in an adult patient. J Foot Ankle Surg 50:354-360, 2011.7. Manadan AM, Block JA. Daily needle aspiration versus surgical lavage for the treatment of bacterial septic arthritis in adults. Am J Ther 11:412-415, 2004. 8. Jerosch J, Ho�stetterI, Schröder M, Castro WHM. Septic arthritis: arthroscopic management with local antibiotic treatment. Acta Orthop Belg 61(2):127-134, 1995.

Figure 1: Preoperative imaging: Anterior-posterior (AP) (A), mortise (B) and lateral (C) weightbearing radiographs demonstrating previous hardware from trimalleolar ankle fracture repair, fragmentation and nonunion of the posterior malleolus, persistent syndesmotic diastasis and grossly edematous soft- tissues; �ndings con�rmed as osteomyelitis via technetium-99m (blood pooled, D; delayed, E) and 24-hour delayed indium-111 labeled WBC (F) bone scintigraphy.

Figure 4: One year follow-up postoperative weightbearing radiographs (A-C) and clinical photographs (D-F) demonstrating stable osseous union and healed soft-tissue envelope without recurrent infection.

Figure 2: Arthroscopic images from initial débridement: (A) initial joint inspection noted gross amounts of purulent coagulum; (B) culture procurement with swab; (C) grasper employed to obtain tissue sample for pathologic and microbiologic analysis; (D) shaver utilized for joint synovectomy and débridement; (E) arthroscopic débridement of syndesmosis; (F) grasper utilized to obtain devitalized bone segment for pathologic analysis; (G) visualization of joint surface post-débridement; (H) insertion of AL-PMMA cement beads.

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Figure 3: Arthroscopic (A-F), immediate post-operative radiographic (G,H) and clinical photographic (I-K) images from joint staged arthrodesis: (A) retrieval of AL-PMMA cement beads; (B) tibiotalar joint exploration con�rming no persistent infection; (C) denuding of cartilage and subchondral plate; (D,E) microfracture awl utilized for further joint preparation; (F) �nal joint preparation prior to �xation; AP (G) and lateral (H) radiograph with Calandruccio type external �xation device; (I-K) clinical veri�cation of neutral position and alignment of ankle arthrodesis following application of external �xator.

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E I J KF

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