Surgical Treatment for Septic Ankle Arthritis: A Comparison of Arthrotomy and Arthroscopy

Abstract

Category: Ankle; Arthroscopy Introduction/Purpose: Ankle joint septic arthritis can result in substantial morbidity involving cartilage destruction, bone erosion, osteomyelitis and loss of function. Operative intervention is the preferred method of irrigation and debridement, and options include both open arthrotomy and arthroscopic debridement. Prior studies have established both ankle arthroscopy and arthrotomy as effective management strategies for the treatment of ankle septic arthritis. However, no prior research has compared open arthrotomy verses arthroscopy to treat septic arthritis of the ankle, and it is unclear if one approach is superior to the other. The purpose of this study is to compare the rate of reoperation and 90-day perioperative complications between arthroscopy and open arthrotomy for the treatment of septic ankle arthritis using a national all-payer claims database. Methods: Patients who were diagnosed with septic arthritis in a native ankle and underwent irrigation and debridement through arthroscopy or arthrotomy were identified in the 2010-2019 PearlDiver database using International classification of diseases (ICD) and current procedural (CPT) codes. Demographic characteristics including age, gender and Elixhauser comorbidities were obtained for each cohort. The rate of reoperation, defined as a proxy for failure of initial intervention, was the primary outcome. Secondary outcomes including readmission, surgical site infection (SSI) and other 90-day complications were compared between the two cohorts. Univariate analysis using chi-square tests and student T-tests were performed to analyze any differences in patient demographics, comorbidities and complications. Multivariate analysis through logistic regression was subsequently conducted to account for any confounding variables and covariates. Results: In total, 331 patients undergoing arthroscopy and 886 patients undergoing arthrotomy for septic ankle arthritis were identified. On univariate analysis, the incidence of reoperation was higher in the open arthrotomy cohort (12.30%) compared to the arthroscopy cohort (9.37%), however this result was not statistically significant (p=.153). There was also no statistically significant difference between the two cohorts in superficial SSI incidence (3.95% vs. 2.42%, p=.197), readmission rates (36.79% vs. 34.14%, p=.0.391). However, the incidence of renal failure was higher in the open arthrotomy cohort (17.83%) compared with the arthroscopy cohort (12.39%) (p=.022). On multivariate analysis, the incidence of reoperation was higher for those undergoing ankle arthrotomy (OR 1.421; 95% CI 0.937-2.255; p=.108) relative to arthroscopy, however this result was not statistically significant (Table 1). The incidence of renal failure was higher in the open arthrotomy cohort after multivariate analysis (OR 1.615; 95% CI 1.113-2.393; p=0.014). Conclusion: This study demonstrated similar 90-day rates of reoperation, postoperative complications and readmissions, suggesting that arthrotomy and arthroscopy have similar efficacy in treating septic ankle arthritis. Although renal failure was more prevalent in the cohort undergoing open arthrotomy, differences in the primary endpoint of reoperation/repeat washout rates were non-significant. Based on these findings, deciding between these two operative approaches may be determined by patient specific risk factors and factors not elicited by this study including surgeon comfort with the technique, rather than the treatment modality itself.