There is no report of athroscopic treatment for septic arthritis of the ankle in infants. We report a case of successful management of septic arthritis of the ankle in a three-month-old boy by arthroscopic washout. Arthroscopic washout may be a useful treatment for septic arthritis in young infants when performed early after onset

AM El-Sayed

CL Wang

D Daniel

DM Sammer

DP Forward

G Stutz

JB Howard

JD Nelson

JL Esterhai Jr

JL Vispo Seara

JS Parisien

L Balabaud

MA Glazebrook

Masanori Wako

P Riegels-Nielsen

R Gillespie

RW Armstrong

S Nade

Satoshi Ochiai

Tetsuo Hagino

English

PubMed

Springer - Publisher Connector

CASE REPORT Open Access
Arthroscopic washout of the ankle for septic
arthritis in a three-month-old boy
Tetsuo Hagino1*, Masanori Wako2 and Satoshi Ochiai1
Abstract
There is no report of athroscopic treatment for septic arthritis of the ankle in infants. We report a case of successful
management of septic arthritis of the ankle in a three-month-old boy by arthroscopic washout. Arthroscopic
washout may be a useful treatment for septic arthritis in young infants when performed early after onset.
Background
Septic arthritis of the ankle is relatively rare, constituting
10 to 15% of all septic arthritis cases in adults [1], and 4
to 13% of cases in children [2-4]. Like septic arthritis of
other sites, the important factors influencing the prog-
nosis of septic arthritis of the ankle include early treat-
ment after onset, administration of appropriate
antibiotics, and adequate sterilization of the joint. Espe-
cially in infants, treatment delay or inappropriate treat-
ment may result in cartilage destruction, avascular
necrosis and physeal injury [5,6], with an increased risk
of severe deformation and functional impairment. In the
past, septic arthritis was managed by repeated needle
aspirations or arthrotomy. Recently, arthroscopic treat-
ment has become widely used, both in adults and chil-
dren [7-11]. Several studies that compared the treatment
results of arthroscopic surgery and open surgery for sep-
tic arthritis confirmed that arthroscopic procedure is an
effective method in treating isolated and uncomplicated
arthritic joints, resulting in shorter hospital stay and
fewer operations [12-14]. Arthroscopic procedure is
especially valuable due to the less invasiveness to the
articular cartilage and epiphyses. However, there is no
report of arthroscopic treatment for septic arthritis of
the ankle in infants. In this report, we describe a case of
successful management of septic arthritis of the ankle in
an infant by arthroscopic washout.
Case presentation
A 3-month-old male in-patient was referred to our
department from the pediatric department for investiga-
tion of suspected septic arthritis of the left ankle.
Three days before referral, the patient developed fever
and slight swelling of the left ankle during the night.
The next day, he was not able to move the left ankle,
and was brought to the emergency outpatient of the
pediatric department in our hospital. He had a past his-
tory of bronchiolitis 10 days before onset of ankle symp-
toms, and was treated with oral Rokitamycin (140 mg/
day) for one week, resulting in resolution of coughing
and other respiratory symptoms. He had no history of
injection in the left leg and trauma. There were also no
factors related to immunodeficiency. At the initial exam-
ination by the pediatrician, his body temperature was
37.6°C. Slight swelling and heat were found in the ankle,
but a plain radiograph showed no abnormality. Blood
tests showed a white blood cell count of 14,330/mm3
and C-reactive protein of 2.6 mg/l. From the local and
systemic findings, the pediatrician suspected septic
arthritis. The patient was hospitalized for observation.
Splint fixation of the left ankle, cooling, and intravenous
infusion of first generation cephalosporin (600 mg/day)
were started. However, swelling and heat deteriorated.
On the second hospital day, the patient was referred to
our orthopedic department.
At the first examination by orthopedic surgeons, ultra-
sonography and magnetic resonance imaging of the left
ankle joint showed joint fluid collection. From the
symptoms and examination findings, septic arthritis was
diagnosed and emergency arthroscopic surgery was con-
ducted. Ultrasonographic examination was performed
before operation to confirm the joint gap, anterior tibial
* Correspondence: tmhagino@amber.plala.or.jp
1The Sports Medicine and Knee Center, Department of Orthopaedic Surgery,
Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi 400-8533, Japan
Full list of author information is available at the end of the article
Hagino et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:21
http://www.smarttjournal.com/content/3/1/21
© 2011 Hagino et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
tendon and anterior tibial artery. Arthroscopic surgery
was conducted in a supine position under general
anesthesia. A slight traction was applied to the foot
manually. While confirming the position of the joint gap
from the image intensifier, a 22-gauge injection needle
was inserted from the medial side of the anterior tibial
tendon. After confirming that a turbid joint fluid was
aspirated, a 5-mm longitudinal incision was made at the
same site, and dissected bluntly until reaching inside the
joint. Then an arthroscope measuring 1.9 mm in dia-
meter was inserted. After washing with Ringer’s solu-
tion, a 30° wrist arthroscope was inserted to observe
intraarticular changes. While mild hyperplasia of the
synovial membrane and debris were observed, irregular-
ity of the articular cartilage was absent (Figure 1).
Under arthroscopic visualization, the joint was washed
thoroughly until all debris and turbid fluid were
removed. A total of 1500 ml of Ringer’s solution was
used for the washout. Since arthroscopic washout
appeared to achieve adequate debridement, no drain
was placed after the surgery. The portal was closed with
surgical tape. After operation, a splint was applied. One
day after surgery, the fever subsided and movement of
the left ankle joint became active. Culture of the joint
fluid yielded methicillin-resistant Staphylococcus aureus
(MRSA). Therefore, antibiotic infusion was changed to
vancomycin (180 mg/day) on day 2 after surgery. The
splint was removed 3 weeks after operation and the
patient was discharged on the 31st postoperative day
(Figure 2). At the last follow-up six years after the
operation, there was no relapse and the patient had no
pain and was able to walk without limping.
We obtained consent from the patient’s parents to
publish this case report.
Discussion
In general, septic arthritis is managed by needle aspira-
tion as the sole drainage method or by arthrotomy.
However, many reports have shown that needle aspira-
tion alone does not achieve adequate clinical result, and
several animal studies have verified that needle aspira-
tion is inadequate to manage septic arthritis [15,16].
Forward and Hunter [17] first reported arthroscopic
washout as a new technique to treat septic arthritis of
the shoulder in infants. Arthroscopic washout was per-
formed under direct arthroscopic vision, with the advan-
tage that complete clearance of pus allowed assessment
of the inflammation and the damage to articular carti-
lage. In addition, if arthroscopic washout alone is not
adequate, supplemental treatments can be conducted
depending on the arthroscopic findings, such as adding
a portal to perform debridement.
Recent reports using a staging system based on
arthroscopic findings have proven that the prognosis
worsens as the stage advances [10,11]. This evidence
supports the necessity of treatment based on intraarticu-
lar findings, and that needle aspiration alone may not be
sufficient under certain intraarticular conditions.
In the present case, arthroscopy was conducted in the
small ankle joint of a 3 month-old infant. Intraarticular
observation was possible using an arthroscope 1.9 mm
in diameter. The postoperative course has been good
cosmetically and functionally. From our experience,
arthroscopic washout which is minimally invasive and
allows complete washout of the joint is a very useful
treatment for septic arthritis of the ankle in infants.
However, arthroscopic debridement for treating septic
arthritis would be most effective if performed early after
onset. Since the risk of articular cartilage damage is
Figure 1 Arthroscopic findings of the ankle joint in a 3 month-old infant with septic arthritis of the ankle. A: Arthroscopic findings at
the beginning of surgery showed debris (arrow) in the joint space. B: Arthroscopic findings after washout showed no irregularity of the articular
cartilage.
Hagino et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:21
http://www.smarttjournal.com/content/3/1/21
Page 2 of 3
increased with the progress of time, in cases where there
is a delay in diagnosis and treatment initiation, it is
important not to unnecessarily insist on arthrosopic sur-
gery but to consider also open surgery depending on the
clinical condition.
Consent
Written informed consent was obtained from the patient
for publication this case report and the images.
Author details
1The Sports Medicine and Knee Center, Department of Orthopaedic Surgery,
Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi 400-8533, Japan.
2Department of Orthopaedic Surgery, Faculty of Medicine, University of
Yamanashi, Yamanashi, Japan.
Authors’ contributions
All authors co-wrote the paper and discussed the results for the manuscript
preparation. All authors have read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 2 March 2011 Accepted: 1 October 2011
Published: 1 October 2011
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doi:10.1186/1758-2555-3-21
Cite this article as: Hagino et al.: Arthroscopic washout of the ankle for
septic arthritis in a three-month-old boy. Sports Medicine, Arthroscopy,
Rehabilitation, Therapy & Technology 2011 3:21.
Figure 2 The clinical course of the present case. BT: body temperature, CEZ: cephalosporin, VCM: vancomycin, WBC: white blood cell count,
CRP: C-reactive protein.
Hagino et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2011, 3:21
http://www.smarttjournal.com/content/3/1/21
Page 3 of 3


Arthroscopic washout of the ankle for septic arthritis in a three-month-old boy

Abstract There is no report of athroscopic treatment for septic arthritis of the ankle in infants. We report a case of successful management of septic arthritis of the ankle in a three-month-old boy by arthroscopic washout. Arthroscopic washout may be a useful treatment for septic arthritis in young infants when performed early after onset.</p

Hagino Tetsuo

Wako Masanori

Ochiai Satoshi

Directory of Open Access Journals

Sports Medicine Arthroscopy Rehabilitation Therapy & Technology

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Acute septic arthritis in infancy and childhood.

Allard JP: Evidencebased indications for ankle arthroscopy. Arthroscopy

Antibiotic treatment insufficient for established septic arthritis. Staphylococcus aureus experiments in rabbits. Acta Orthop Scand

Arthroscopic management of pyarthrosis. Clin Orthop Relat Res

Arthroscopic treatment of septic joints: prognostic factors. Arch Orthop Trauma Surg

Arthroscopic washout of the shoulder for septic arthritis in infants. A new technique.

CC: Septic arthritis in children: relationship of causative pathogens, complications, and outcome.

Gachter A: Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthrosc

Gelb I: Adult septic arthritis. Orthop Clin North Am

JD: Residual effects of septic arthritis in infancy and childhood. JAMA

Lavage of septic joints in rabbits: effects of chondrolysis.

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Arthroscopic washout of the ankle for septic arthritis in a three-month-old boy

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