by Dr. Jonathan Cedermaz
compiled by Tarun Yandamuri, MS3
Traumatic arthrotomies (TAs) can vary widely in severity. While large, contaminated TAs require operative intervention for irrigation and debridement (I&D), smaller, minimally contaminated open joint injuries may be treated with bedside wound irrigation and closure. However, a missed or untreated TA is a risk for septic arthritis. The question is whether we can safely and efficiently diagnose and treat small TAs (< 5 cm in size) at the patient’s bedside without surgery.
The saline load test has traditionally been used to diagnose small TAs, but it can both be excruciating for patients as well as inconsistent in sensitivity (between 43% to 95% sensitive) depending on how much saline is utilized. The literature for using non-contrast CT scans in diagnosing small TAs is still growing. In addition, operations and CT scans are associated with higher healthcare costs.
Am I going to lose sleep for not obtaining a non-contrast CT scan on a small, non-contaminated knee laceration with no fracture?
McKnight, R. , Ruffolo, M. , Wally, M. , Seymour, R. , Jeray, K. , E. Matuszewski, P. , Weinlein, J. & Hsu, J. (2021). Traumatic Arthrotomies: Do They All Need the Operating Room?. Journal of Orthopaedic Trauma, 35 (11), 612-618.
A prospective observational multicenter study that was conducted at multiple Level I trauma centers. Patients with TAs were treated with operative versus nonoperative management decided by the attending surgeon. Operative treatment involved a formal I&D in the operating room. Nonoperative treatment involved bedside I&D, primary closure, and a single dose of antibiotics with or without an oral antibiotic regimen based on the surgeon’s discretion.
Enrolled 189 TA patients
64 Managed NonOP vs 125 Operatively
70% of the NonOp group had arthrotomies < 5 cm, and 95% had minimal to no contamination
1 septic joint in the NonOp group (1/64 or 1.5%)
4 days from TA to septic arthritis
3 other complications
Operative Group (OG) normally had arthrotomies > 5 cm and contaminated
7 septic joints in the OG (7/125 of 5.6%)
0–26 days from TA to septic arthritis (mean 15.3 days)
11 other complications
Comparison of TA locations by treatment method, highlighting the most common (elbow and knee)
Comparison of TA level of contamination by treatment method
Comparison of TA size by treatment method, highlighting small TAs (< 5 cm)
Significant variability between groups
No standardized protocol for who goes to OR or what antibiotics were given
No long term follow-up after 1 year
Subtle TAs are difficult to diagnose
Small, minimally contaminated TAs with no associated fracture have a low risk of complications, can safely be treated nonoperatively, and are associated with a significantly decreased cost of care.
Therefore, the standard of care may be to miss small TAs
All patients will get a thorough bedside irrigation of injuries overlying joints
All of these patients will get an X-ray
I will lose less sleep over small non contaminated injuries over the knee that have no fracture
McKnight RR, Ruffolo M, Wally MK, et al. Traumatic Arthrotomies: Do They All Need the Operating Room? Journal of Orthopaedic Trauma. 2021;35(11):612-618. doi:10.1097/BOT.0000000000002093
Nord RM, Quach T, Walsh M, Pereira D, Tejwani NC. Detection of Traumatic Arthrotomy of the Knee Using the Saline Solution Load Test. Journal of Bone and Joint Surgery American Volume. 2009;91(1):66-70. doi:10.2106/JBJS.G.01682
Tornetta P, Boes MT, Schepsis AA, Foster TE, Bhandari M, Garcia E. How Effective is a Saline Arthrogram for Wounds Around the Knee? Clinical Orthopaedics and Related Research. 2008;466(2):432-435. doi:10.1007/s11999-007-0006-5