JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Douglas M. Sammer and Alexander Y. Shin
Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist
J Bone Joint Surg Am 2009; 91: 1387-1393 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Drs. Shin and Sammer respond to Dr. Strauch
Alexander Y. Shin, MD, Douglas M. Sammer, MD   (15 July 2009)
[Read Letter to the Editor] Standard of treatment?
Robert J. Strauch, MD   (16 June 2009)

Drs. Shin and Sammer respond to Dr. Strauch 15 July 2009
Previous Letter to the Editor Top
Alexander Y. Shin, MD,
Professor and Consultant of Orthopaedic Surgery
Mayo Clinic, Rochester, Minnesota,
Douglas M. Sammer, MD

Send letter to journal:
Re: Drs. Shin and Sammer respond to Dr. Strauch

Shin.Alexander{at}mayo.edu Alexander Y. Shin, MD, et al.

We would like to thank Dr. Strauch for his comments. As the purpose of our study was to compare open irrigation and debridement (I&D) with arthroscopic I&D, we did not evaluate or discuss needle aspiration as a treatment for septic arthritis of the wrist. Additionally, since there are no high-quality randomized controlled trials comparing surgical I&D with needle aspiration, an argument can be made that there is no definitive gold standard for treating septic arthritis of the wrist. However, the predominant opinions in the hand surgery literature are that prompt surgical drainage is the primary treatment for septic arthritis of the wrist. For example, Rashkoff et al. (1) suggested that, “any treatment short of arthrotomy in the face of the diagnosis is ill-advised". Stevanovic and Sharpe called septic arthritis in the hand and wrist a, “surgical emergency” and suggested that serial aspiration is “therapeutically unpredictable” (2). Dr. Strauch’s comments highlight the divide between the surgical and medical literature. While there are some articles that support needle aspiration for the treatment of septic arthritis, these are predominantly found in the rheumatologic literature (3,4). There are likely multiple reasons for this difference, but one possible explanation is that rheumatologists tend to treat a different part of the spectrum of septic arthritis than do hand surgeons. Regardless, a prospective randomized comparison of the three methods (open I&D, arthroscopic I&D, and needle aspiration) would certainly provide more information about the respective roles for each approach. However, because of the low incidence of septic arthritis in the wrist, this would be logistically difficult, and would likely require a multi-center effort.

References

1. Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg Am. 1983;65:824-8.

2. Stevanovic MV, Sharpe F. Acute infections in the hand. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, editors. Green’s operative hand surgery. 5th ed. Philadelphia: Elsevier; 2005. p 77-81.

3. Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, Walker D, Coakley G. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-5.

4. Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES. Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum. 1975;18:83-90.
Standard of treatment? 16 June 2009
Next Letter to the Editor Top
Robert J. Strauch, MD
Columbia University Medical Center, New York, New York

Send letter to journal:
Re: Standard of treatment?

robertjstrauch{at}hotmail.com Robert J. Strauch, MD

To the Editor:

I read with interest the article by Drs. Sammer and Shin in which they compare arthroscopic and open treatment of septic arthritis of the wrist(1). However, I would raise the point that the authors' statement in the opening paragraph that, "...open irrigation and debridement remains the standard of treatment for the (septic) wrist", is not supported by the current medical literature to date(2).

While the shoulder and hip are not amenable to easy aspiration, aspiration of the wrist joint is usually a simple matter, often performed by non-surgeons as well as orthopaedic surgeons. To date, there have been no convincing studies supporting open or arthroscopic drainage of the septic wrist compared with needle aspiration. In my own practice, I have been quite satisfied using needle aspiration and intravenous antibiotics for the successful treatment of the majority of patients with septic arthritis of the wrist. Therefore, while arthroscopic drainage of the septic wrist may be superior to open drainage, it may not be superior to needle aspiration alone--a point not discussed anywhere in the article.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References:

1.Douglas M. Sammer and Alexander Y. Shin Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist J Bone Joint Surg Am 2009; 91: 1387-1393

2. Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, Walker D, Coakley G. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-5. Epub 2007 Jan 12.