Introduction
Materials and methods
Data sources and study selection
Database | Search strategy |
---|---|
PubMed | (Septic Arthritis[tiab] OR Suppurative Arthritis[tiab] OR infect* Arthritis[tiab] OR Pyogenic Arthritis[tiab] OR Bacterial Arthritis[tiab] OR Arthritis, Infectious[MeSH]) AND (Arthrotomy[tiab] OR Open[tiab] OR Arthroscop*[tiab] OR Arthroscopy[MeSH]) AND (Knee*[tiab] OR Knee Joint[MeSH] OR Knee[MeSH]) |
MEDLINE (1946 onwards) | #1(Septic Arthritis or Suppurative Arthritis or infect* Arthritis or Pyogenic Arthritis or Bacterial Arthritis).mp |
#2infectious arthritis.mp. or exp *Arthritis, Infectious/ | |
#3(Arthroscop* or Arthrotomy or Open).mp | |
#4arthroscopy.mp. or exp *Arthroscopy/ | |
#5exp *Knee/ or exp *Knee Joint/ or knee.mp | |
#61 or 2 | |
#73 or 4 | |
#85 and 6 and 7 | |
Embase (1980 onwards) | #1(Septic Arthritis or Suppurative Arthritis or infect* Arthritis or Pyogenic Arthritis or Bacterial Arthritis).mp |
#2limit 1 to abstracts | |
#3exp *infectious arthritis/ | |
#4(Arthroscop* or Arthrotomy or Open).mp | |
#5limit 4 to abstracts | |
#6exp *arthroscopy/ | |
#7Knee.mp. or exp *knee/ | |
#82 or 3 | |
#95 or 6 | |
#107 and 8 and 9 | |
Cochrane | #1Septic Arthritis OR Suppurative Arthritis OR infect* Arthritis OR Pyogenic Arthritis OR Bacterial Arthritis:ti,ab,kw |
#2Arthritis, Infectious | |
#3Arthroscop* OR Arthrotomy OR Open:ti,ab,kw | |
#4Arthroscopy | |
#5Knee*:ti,ab,kw | |
#6Knee37105 | |
#7Knee joint | |
#8#1 OR #2 | |
#9#3 OR #4 | |
#10#5 OR #6 | |
#11#7 AND #8 AND #9 | |
Web of Science (1900 onwards) | #1 ((((AB = (septic arthritis)) OR AB = (suppurative arthritis)) OR AB = (infectious arthritis)) OR AB = (pyogenic arthritis)) OR AB = (bacterial arthritis) |
#2 (((AB = (arthrotomy)) OR AB = (open)) OR AB = (arthrosc*)) OR AB = (arthroscopy) | |
#3 (AB = (knee)) OR AB = (knee joint) | |
#4 #1 AND #2 AND #3 | |
Scopus | TITLE-ABS-KEY ( ( septic AND arthritis OR suppurative AND arthritis OR infect* AND arthritis OR pyogenic AND arthritis OR bacterial AND arthritis OR arthritis, AND infectious) AND ( arthrotomy OR open OR arthroscop* OR arthroscopy) AND ( knee* OR knee AND joint OR knee)) |
Data extraction
Outcomes
Assessment of risk of bias and evidence quality
Data synthesis and analysis
Results
Article selection
Study characteristics
Study | Location | Study design | Evidence level(16) | Number of patients | Male (%) | Age (years) | Follow-up (months) | |||
---|---|---|---|---|---|---|---|---|---|---|
AW | OW | AW | OW | AW | OW | |||||
Peres (2016) [23] | Brazil | RCT | 1 | 10 | 11 | 7 (70.0) | 7 (63.6) | 42 (11–66)¶ | 45.4 (19–74)¶ | Min 24 |
Balabaud (2007 [24] | France | Cohort | 3 | 21 | 19 | 31 (77.5) | 31 (77.5) | 49 ± 20 (19–81)¶ | 22 ± 2 (12–96)¶ | |
Böhler (2016) [25] | Austria | Cohort | 3 | 41 | 29 | 27 (65.9) | 19 (65.5) | 49 (30–64)¥ | 71 (65–78)¥ | 12¥ (12–15) |
Johns (2017) [26] | Australia | Cohort | 3 | 119 | 42 | 80 (67.2) | 28 (66.7) | 57.5 (15.8)¥ | 65.8 (16.0)¥ | - |
Kalem (2018) [27] | Turkey | Cohort | 3 | 13 | 11 | 8 (61.5) | 6 (54.5) | 56.6 ± 14.9¶ | 59.5 ± 17.2¶ | 6 |
Sabater-Martos (2021) [28] | Spain | Cohort | 3 | 12 | 15 | 18 (66.7) | 64.8 (30–89) | Min 12 | ||
Wirtz (2001) [29] | Germany | Cohort | 3 | 27 | 24 | 25 (49.0) | 59.7 (21–94)¶ | 26.4¶ |
Study | Microbiological diagnosis | Presence of risk factors | ||
---|---|---|---|---|
AW | OW | AW | OW | |
Peres [23] | Negative 11 (52.4%) | Idiopathic 10 (47.6%) | ||
Chronic renal failure (CRF) 3 (14.3%) | ||||
S. aureus 6 (28.7%) | Repetition arthrocentesis 5 (23.8%) | |||
S. epidermidis 2 (9.5%) | Pyoderma 2 (9.5%) | |||
S. agalactiae 1 (4.7%) | ||||
Klebsiella species 1 (4.7%) | ||||
Balabaud [24] | Negative 3 (7.5%) | Idiopathic 29 (72.5%) | ||
Methicillin-sensitive S. aureus (MSSA) 12 (30.0%) | Diabetes mellitus (DM) 4 (10.0%) | |||
Alcohol abuse 5 (12.5%) | ||||
Methicillin-resistant S. aureus (MRSA) 4 (10.0%) | CRF 1 (2.5%) | |||
Psoriasis 1 (12.5%) | ||||
S. epidermidis 7 (17.5%) | ||||
Other staphylococci 7 (17.5%) | ||||
Gram-negative pathogens 4 (10.0%) | ||||
Böhler [25] | – | Rheumatoid arthritis (RA) 4 (9.8%) DM 7 (17.1%) | RA 0 DM 10 (34.5%) | |
Johns [26] | Negative 23 (19.3%) | Negative 4 (9.5%) MSSA 16 (38.1%) MRSA 1 (2.4%) Streptococci 11 (26.2%) Gram negative 5 (11.9%) | None 45 (37.8%) DM 15 (12.6%) Liver disease 14 (11.8%) Intravenous drug use (IVDU) 11 (9.2%) CRF 14 (11.8%) RA 8 (6.7%) | None 10 (23.8%) DM 8 (19.0%) Liver disease 8 (19.0%) IVDU 6 (14.3%) CRF 3 (7.1%) RA (1 (2.4%) |
MSSA 41 (34.5%) MRSA 4 (3.4%) Streptococci 18 (15.1%) | ||||
Gram negative 8 (6.7%) | ||||
Kalem [27] | MSSA 1 (7.7%) | MSSA 1 (9.1%) | DM 4 (30.8%) | DM 5 (45.5%) |
MRSA 2 (18.2%) | IVDU 3 (23.1%) | |||
Liver disease 0 RA 1 (7.7%) | ||||
IVDU 0 Liver disease 2 (18.2%) | ||||
RA 1 (9.1%) | ||||
Sabater-Martos [28] | Negative 4 (33.3%) | Negative 8 (53.3%) | American Society of Anaesthesiologists (ASA) I 2 (16.7%) | ASA I 0 |
ASA II 9 (60.0%) | ||||
S. aureus 4 (33.3%) | S. aureus 4 (2.7%) | |||
ASA III 6 (40.0%) | ||||
ASA II 4 (33.3%) | ||||
ASA III 6 (50.0%) | ||||
S. epidermidis 1 (8.3%) | S. epidermidis 1 (6.7%) | |||
Streptococcus 2 (16.7%) | Streptococcus 2 (13.3%) | |||
Wirtz [29] | Negative 13 (25.5%) | – | ||
Positive 38 (74.5%) (most often SA) |
Assessment of risk of bias
Study | ||||||||
---|---|---|---|---|---|---|---|---|
Bias arising from the randomisation process | Bias due to departures from intended interventions | Bias due to missing data | Bias in measurement of outcomes | Bias in selection of reported results | Overall bias | |||
RoB-2 [17] | ||||||||
Peres [23] | Low | Low | Low | Some concerns | Low | Some concerns | ||
ROBINS-1 [18] | Bias due to confounding | Bias in selection of participants | Bias in measurement of interventions | |||||
Balabaud [24] | Moderate | Moderate | Low | Low | Low | Low | Low | Moderate |
Böhler [25] | Moderate | Moderate | Low | Low | Low | Low | Low | Moderate |
Johns [26] | Moderate | Moderate | Low | Low | Low | Low | Low | Moderate |
Kalem [27] | Serious | Moderate | Low | Low | Low | Low | Moderate | Serious |
Sabater-Martos [28] | Moderate | Low | Low | Low | Low | Low | Low | Moderate |
Wirtz [29] | Serious | Moderate | Low | Low | Low | Low | Low | Serious |
Patient-reported outcome measures
Study | Functional outcome assessed | Scale descriptor | Reported result | Comments | |
---|---|---|---|---|---|
AW | OW | ||||
RCT | |||||
Peres [23] | Lysholm Knee Scoring Scale (LKSS) | Assesses eight clinical domains, producing an overall score between 0 and 100 (< 65 poor, 65–83 fair, 84–94 good, 95–100 excellent) [31] | 93.8¶ ± 2.3 — equates to ‘good’ score | 87.2¶ ± 5.5 — equates to ‘good’ score | Difference non-significant |
Cohort study | |||||
Balabaud [24] | Bussiere and Beaufils functional scale (BBFS) | Considers patient-reported pain and ROM and is reported as an ordinal scale (excellent, good, fair, poor) [32] | ‘Good’ in 15/21 knees | ‘Good’ in 4/19 knees | Difference non-significant |
Sabater-Martos [28] | Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) | Considers pain (0–20), stiffness (0–8) and functional impairment (0–68), with lower scores reflecting superior states [33] | 17¶ ± 15.4—equates to ‘slight difficulties’ | 16.1¶ ± 15.9—equates to ‘slight difficulties’ | Difference non-significant |
Wirtz [29] | Larson score | Considers seven clinical domains (pain, walking, function, ROM, strength, flexion contracture, laxity), producing a score between 0 and 100 (< 60 poor, 60–69 fair, 70–84 good, 85–100 excellent) [34] | 74¶ ± 17.5—equates to ‘good’ score | 61¶ ± 18.5—equates to ‘fair’ score | Difference only significant if operated on within 5 days of symptom onset (favours AW) |
Range of movement
Study | Reported result | Comments | |
---|---|---|---|
AW | OW | ||
Böhler [25] | 110 ± 8.5¶ | 95 ± 30¶ | Difference reaches statistical significance (p < 0.001) |
Johns [26] | 90 ± 6.7¶ | 70 ± 25.5¶ | Difference reaches statistical significance (p = 0.016) |
Kalem [27] | 100¥ | 100¥ | Difference non-significant |
Wirtz [29] | 106 ± 5¶ | 77 ± 35¶ | Difference significant if operated on within 5 days of symptom onset |
Secondary outcomes
Study | Synovectomy at index procedure | Further procedure | Comment | ||||
---|---|---|---|---|---|---|---|
AW | OW | AW | Timeframe; details | OW | Timeframe; details | ||
RCT | |||||||
Peres [23] | 10 (100%) | 11 (100%) | 0 | - | 2 (18.2%) | Within 7 days; 2 OW | Difference non-significant |
Cohort study | |||||||
Balabaud [24] | 1 (4.8%) If severe swelling/effusion | 13 (68.4%) | 6 (28.6%) | ‘Early’ (not specified) 5 OW/synovectomy, 1 open arthrolysis | 3 (15.8%) | ‘Early’ (not specified) 1 OW, 1 OW/synovectomy, 1 arthrodesis | - |
Böhler [25] | Not specified (done at surgeon’s discretion) | Not specified (done at surgeon’s discretion) | 2 (4.9%) | Median 3.0 days (within 3 months); no details of procedure | 6 (20.7%) | Median 3.0 days (within 3 months); no details of procedure | Higher following OW (p = 0.041) |
Johns [26] | - | 60 (50.4%) | Timeframe not specified; 51 AW, 9 OW | 30 (71.4%) | Timeframe not specified; 2 AW, 28 OW | Higher following OW (p = 0.02) | |
Kalem [27] | - | 2 (15.4%) | Timeframe not specified (within 6 months) No details of procedure | 4 (36.4%) | Timeframe not specified (within 6 months); no details of procedure | - | |
Sabater-Martos [28] | 12 (100%) | 15 (100%) | 5 (42.7%) | Timeframe not specified No details of procedure | 2 (13.3%) | Timeframe not specified No details of procedure | - |
Wirtz [29] | 27 (100%) | - | 2 (7.4%) | Timeframe not specified; 2 AW | 4 (16.7%) | Timeframe not specified; 1 OW, 3 arthrodesis | - |
Quality of evidence
Patients or population: Adult patients with septic arthritis of the native knee joint Intervention: Arthroscopic washout (AW) Comparison: Open arthrotomy washout (OW) | ||||||
---|---|---|---|---|---|---|
Outcomes | Illustrative comparative risks | Relative effect | Number of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
AW | OW | |||||
Lysholm Knee Scoring Scale [32] | The mean score was 93.8 points | The mean score was 6.6 points lower | - | 21 (1 RCT) | ⨁⨁⨁O1 | AW may result in a superior LKSS, however, difference non-significant |
Bussiere and Beaufils functional scale [33] | Function regarded as ‘good’ in 71.4% | Function regarded as ‘good’ in 21.1% | - | 40 (1 cohort study) | ⨁⨁OO2 | AW may result in a superior BBFs, however, difference non-significant |
Western Ontario and McMaster Universities Osteoarthritis Index [34] | The mean score was 17 points | The mean score was 0.9 points lower | - | 27 (1 cohort study) | ⨁⨁OO3 | AW may result in a superior WOMAC, however, difference non-significant |
Larson score [35] | The mean score was 74 points | The mean score was 13 points lower | - | 51 (1 cohort study) | ⨁OOO4 | AW may result in a superior Larson score, however, difference non-significant |
Range of movement | The mean ranged from 90 to 106° | The mean ranged from 70 to 95° | Mean difference 20.18° | 282 (4 cohort studies) | ⨁OOO5 | AW associated with superior post-operative ROM |
Need for further intervention | Rates of reoperation ranged from 4.0 to 50.4% in the observational studies, 0 in the RCT | Rates of reoperation ranged from 13.3 to 71.4% in the observational studies, 18.2% in the RCT | OR 0.64 | 384 (6 cohort studies, 1 RCT) | ⨁OOO6 | AW may be associated with lower re-operation requirement, however, difference non-significant |