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The Veterinary Record, April 11, 1998
Treatment of infectious arthritis of the radiocarpal joint of
cattle with gentamicin-impregnated collagen sponges
G. Hirsbrunner, A. Steiner
Veterinary Record (1998) 142, 399-402
Gentamicin-impregnated collagen sponges were used success-
fully in the treatment of chronic septic arthritis of the radio-
carpal joint in two cattle. Both animals were moderately to
severely lame and refractory to systemic antibiotics, and one
of them was refractory to joint lavage and local antibiotics.
The clinical diagnosis was confirmed by radiography and
arthrocentesis. Arthroscopy was performed under general
anaesthesia and, after debridement and lavage of the joint,
gentamicin-impregnated collagen sponges were placed intra-
articularly. Synovial fluid was sampled at 10 and 20 days after
surgery and radiographs were taken three months (case 1)
and two months (case 2) after surgery. The infection was elim-
inated from both animals and they recovered without residual
lameness.
INFECTIOUS arthritis of the radiocarpal joint is a common cause
of forelimb lameness in cattle (Verschooten and others 1974, Van
Huffel and others 1989). In calves, several other synovial struc-
tures are usually affected at the same time, owing to the
haematogenous spread of bacteria from a primary infectious site
(tertiary infections). In heifers and adult cattle, however, septic
arthritis of the radiocarpal joint is usually restricted to the affected
carpus, either as a result of direct inoculation of bacteria into the
joint cavity (primary infection) or the extension of an infection
from periarticular bone or soft tissue (secondary infection)
(Greenough and others 1981, Van Huffel and others 1989,
Munroe and Cauvin 1994).
Techniques recommended for the treatment of the condition
depend on the duration of inflammation and the efficacy of previ-
ous treatments. In acute and subacute cases (one week or less after
the onset of lameness), conservative treatment, including paren-
teral and intra-articular administration of antibiotics (if possible in
accordance with the results of sensitivity testing), parenteral
administration of non-steroidal anti-inflammatory drugs, and joint
lavage may be successful (Verschooten and others 1974, Munroe
and Cauvin 1994). In chronic cases (more than a week after the
onset of lameness), a more radical surgical approach is recom-
mended, consisting of arthrotomy, complete resection of affected
tissue, and subsequent immobilisation of the limb with a full limb
cast (Verschooten and others 1974). In severe cases with serious
bony destruction, radical surgical treatment with partial or com-
plete resection of the carpal row(s) and subsequent arthrodesis of
the carpal joint by immobilisation of the affected limb has been
recommended. This technique provided pain-free arthrodesis in 69
per cent of the cases of septic arthritis of the radiocarpal joint
operated on by Van Huffel and others (1989). Recently, the surgi-
cal removal of the infected tissue via arthrotomy or arthroscopy
and lavage of the affected synovial cavity with copious amounts
of fluid, followed by the implantation of gentamicin-impregnated
polymethylmethacrylate beads (Septopal; Merck Pharma-
ceuticals), has been used successfully to treat intrasynovial infec-
tions that had either proved refractory to conservative treatment or
showed signs of osteomyelitis adjacent to the affected joint. The
treated animals included 10 cattle and a three-week-old calf with
septic arthritis of the radiocarpal joint and subchondral osteolysis
of the distal radius. However, this technique has the disadvantages
that it may be difficult and time-consuming to implant the beads
into the joint pouches accurately, and that a second minor surgical
G. Hirsbrunner, Drmedvet, A. Steiner, PD, Drmedvet, MS, DiplECVS,
Clinic for Food Animals and Horses, University of Bern,
Bremgartenstrasse 109a, CH-3012 Bern, Switzerland
399
intervention is necessary to remove the beads (Butson and others
1996).
In humans, favourable results have been obtained in the treat-
ment of osteomyelitis and septic arthritis by the implantation of
absorbable gentamicin-impregnated collagen sponges (Garamycin;
Essex Chemie) at the time of surgical interventions (Letsch 1988,
von Hasselbach 1989a,b, Worschhauser and Ruter 1989). This
paper describes the use of arthroscopic debridement, arthroscopic
through-and-through lavage, and the subsequent implantation of
gentamicin-impregnated collagen sponges for the treatment of
chronic (>10 days) septic arthritis of the radiocarpal joint in a
seven-year-old cow and an 18-month-old heifer. Before treatment,
both animals had shown signs of osteolysis of bony structures
adjacent to the joint and had been refractory to standard conserva-
tive treatment.
Case reports
Case
A seven-year-old, 614 kg Holstein Friesian cow had been lame
in the right forelimb for 15 days for unknown reasons. It had been
treated intramuscularly with procaine penicillin G (30,000 iu/kg)
and flunixin meglumine (2-2 mg/kg) daily for five days, without
showing any improvement. When examined, its rectal temperature
was 38-8°C, pulse rate 80 beats/minute, respiratory rate 28
breaths/minute, and its appetite was poor. An orthopaedic exami-
nation revealed a moderate, mixed lameness of grade 3 (on a scale
of 0 = sound to 5 = non-weight bearing) with a soft tissue swelling
painful to palpation over the craniomedial aspect of the right car-
pus. A 'mixed' lameness can involve any combination of the
structures affected in swinging-limb or supporting-limb lameness
and is evident both when the limb is moving and when it is sup-
porting weight (Stashak 1987). The hair was clipped but no skin
lesion was evident. A reduced range of motion was obvious and
severe pain was elicited during passive flexion of the carpus. The
carpal region was examined radiographically in an anteroposteri-
or/lateromedial direction. Soft tissue swelling was evident on the
craniomedial aspect of the carpus, and discrete zones of irregular
radiolucency were visible on the mediodistal aspect of the radius
and on the os carpi radiale (Fig 1). Arthrocentesis of the radio-
carpal joint allowed several millilitres of turbid, purulent fluid to
drain out. This fluid was analysed for total nuclear cell count
(TNcc), with quantitative cell differentiation, and total protein
concentration; the results are summarised in Table 1. Bacterial
culture of the fluid yielded a negative result. On the basis of these
findings, chronic septic arthritis was diagnosed and osteolytic
zones on adjacent bony structures were suspected. The cow was
prepared for arthroscopy of the right radiocarpal joint.
Surgical treatment and aftercare. Two hours before surgery,
-
procaine penicillin G (Ilcocillin P; Ciba-Geigy) (30,000 iu/kg)
was administered intramuscularly. General anaesthesia was
induced with xylazine hydrochloride (Rompun; Provet) (0-2
mg/kg intramuscularly) and ketamine hydrochloride (Narketan;
Chassot) (2 mg/kg intravenously) and was maintained with
halothane and oxygen in a semi-closed circle system. The cow
was positioned on its left side. A torniquet was tightened around
the mid-radial region before routine aseptic preparation. A stab
incision was made on the craniolateral aspect of the radiocarpal
joint, between the extensor carpi radialis tendon and the common
digital extensor tendon, to introduce the arthroscope (Olympus).
The distending fluid was allowed to drain through a cannula
(internal diameter 4 mm) introduced into the craniomedial pouch
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400 The Veterinary Record, April 11, 1998

FIG 1: Anteroposterior radiograph of the right radiocarpal,joint of a FIG 2: Anteroposterior radiograph of the radiocarpal joint of case 1
cow wsith chronic septic arthritis (case 1). Discrete zones of irregular three months after surgery. Well organised periosteal reactions are
radiolucencv are visible on the mediodistal aspect of the radius and of visible on the distal aspect of the radius, of the os carpi radiale and
the os carpi radiale (arrows) ulnare, and of the os carpale IV (arrows)

of the joint medial to the extensor carpi radialis tendon. An entry tion of procaine penicillin G (30,000 iu/kg) daily for 20 days and
for instruments to remove fibrin clots and debride necrotic materi- oral phenylbutazone (Equipalazone; Griiub) (I g/100 kg oni the
al by the use ot a Ferris-Smith rongeur was created I cm cranio- day after surgery and 0(5 g/l00 kg every second day) for 10 days.
medial to the draininc cannula (Mcllwraith 1990). After thorough The cow's clinical conidition improved within five days after
debr-idemiient of the joint, including partial synovectomy cand surgery and the severity of- the lameness decreased from grade 3
lavage with 12 litres ot Ringer's solution, gentamicin-impregnated to grade 2. The arthrocentesis and analysis of synovial fluid were
collaren sponges were introduced through the sleeve of the repeated 10 days and 20 days after surgery (Table I). Twenty days
atrthroscope into the radiocarpal joint. The Garamycin implaznt is after surgery. radiology of the carpus revealed decreased soft tis-
available as 5 cmn x 5 cmn x 0.5 cm sponge, containing 50 mg gen- sue swelling on the craniomedial aspect of the carpus, and discrete
tarmicin sulphate on highly puritied collagen. or as a 10 cm x 10 periosteal reactions on the distal aspect of the radius, on the os
cim X 0(5 cim sponge cont.aining 200 mg gentamicin sulphate on carpi radiale and ulnare. and on the os carpale IV. When the cow
collagen. Fixe small sponges (250 mg gentamicin sulphate) were was discharged four weeks after surgery only slight joint disten-
implanted. Stab incisions were closed with simple inter-rupted sion and a grade 1 lameness were still evident.
sutul-es (PDS 0: Ethicon), and a pressure bandage was applied. The
banda.ge was changed two and 10 days after surgery and finally Follow-uipire.mnination. - Three months after surgery. the cow was
removed after 20 days. The cow was box rested for eight weeks. sound and no swelling or lameness was apparent. Radiographs
Postoperative treattment consisted of the intramuscular administra- showed minimal soft tissue swelling, and the periosteal reactions
were more distinct and the architecture of the new bone was well
organised (Fig 2).
TABLE 1: Total protein concentration and total nucleated cell count of
synovial fluid before and after treatment with gentamicin-impregnated
collagen implants in two cases of septic arthritis of the radiocarpal joint
in cattle Ccse 2
Before 10 days after 20 days after An 18-month-old. 417 kg Simmental heifer had become pro-
Measurement treatment treatment treatment
gressively more lame in the left forelimb over a period of five
Total protein (g/litre) days. for unknown reasons. It had been treated intramuscularly
Case 1 65 47 54 with procaine penicillin G (30,000 iu/kg) and orally with
Case 2 64 62 41 phenylbutazone (I g/l00 kg) daily for three days. When examined
Total nucleated cell its rectal temperature was 38 9'C. pulse rate 84 beats/minute, and
count (109 cells/litre) respiratory rate 60 breaths/minute. An orthopaedic examination
Case 1 93 6 (80%)* 40 5 (60%) 7.8 (60%) revealed a severe mixed lameness (grade 4 to 5) of the left fore-
Case 2 84 0 (90%) 66.2 (60%) 22 2 (60%)
limb, with a diffuse swelling painful to palpation over the left car-
Percentage of neutrophils pus, and a severely reduced range of motion at passive flexion of
 Downloaded from http://veterinaryrecord.bmj.com/ on July 7, 2015 - Published by group.bmj.com
The Veterinary Record, April 11, 1998
the carpus. Radiographic examination in an anteroposterior/latero-
medial direction revealed severe soft tissue swelling on the lateral
aspect of the left carpus and irregular bone architecture of the pro-
cessus styloideus of the ulna and the proximal aspect of the os
carpi ulnare. As in case 1, an arthrocentesis and analysis of syn-
ovial fluid confirmed the diagnosis of septic arthritis of the radio-
carpal joint (Table 1). Staphylococcus aureus (sensitive to peni-
cillin) was isolated from the synovial fluid.
Surgical treatment and aftercare. - The radiocarpal joint was
lavaged with 6 litres of Ringer's solution and sodium penicillin
(Penicillin G; Hoechst) (10 million iu) was administered locally
twice within four days. The heifer was also treated intramuscular-
ly with procaine penicillin G (30,000 iu/kg) daily for three weeks
and with gentamicin (Pargenta; Graub) (2-2 mg/kg) daily for five
days. In spite of the treatment, the lameness deteriorated progres-
sively and there was evidence of increased pain in the left carpal
region. Thirteen days after the onset of lameness, arthrocentesis of
the left radiocarpal joint confirmed the progressive deterioration;
the synovial fluid was purulent and laboratory analysis revealed
that the TNCC had increased from 36 x 109 cells/litre before treat-
ment, to 84 x 109 cells/litre (Table 1). As in case 1 the heifer was
treated by arthroscopic lavage, radical arthroscopic debridement,
and partial synovectomy of the radiocarpal joint. One large gen-
tamicin-impregnated collagen sponge containing 200 mg gentam-
icin sulphate was implanted. The surgical treatment, postoperative
care, and sampling of synovial fluid (Table 1) were identical to
case 1. Three weeks after surgery, the heifer was discharged from
the clinic with no signs of pain or lameness.
Follow-up examination. - Two months after surgery the heifer
was evaluated clinically and radiographs were taken of the left
carpal region. No lameness or soft tissue swelling were evident.
The radiographs revealed well organised periosteal reactions on
the distal radius, the processus styloideus of the ulna, and on all
the bones of the proximal carpal row.
Discussion
Diagnosis of septic arthritis relies on clinical examination, radi-
ology and arthrocentesis of the affected joint. Laboratory analysis
of synovial fluid includes total protein concentration and TNCC,
with quantitative differentiation of nucleated cells, and microbial
culture. According to Madison and others (1991), inflamed joints
with purulent synovial fluid must be presumed to be infected and
treated as such, even if bacteria cannot be isolated. Greenough and
Weaver (1997) consider synovial fluid with a TNCC exceeding 50
x 109 cells/litre or a total protein concentration exceeding 40
g/litre to be suggestive of sepsis, and fluid with a TNCC exceeding
100 x 109 cells/litre to be septic. However, Howard (1993) consid-
ered a TNCC exceeding 30 x 109 cells/litre to indicate sepsis. In
case 1 the synovial fluid was purulent and had a TNCC of 93-6 x
109 cells/litre with more than 80 per cent neutrophils. Despite the
negative culture result the cow was therefore considered to be a
case of septic arthritis.
Accepting a TNCC of 30 x 109 cells/litre or a total protein con-
centration of 40 g/litre as thresholds for sepsis, both of the affect-
ed joints would have been considered septic at 10 and 20 days
after the implantation of the sponges, despite the continuing
reduction in lameness and the clinically obvious progress of heal-
ing. The reasons for this finding remain unclear. It may be
hypothesised that neutrophils are attracted by the collagen present
in the joint, and that degradation products of collagen may con-
tribute to the high concentration of protein found after the admin-
istration of the sponges. Judgment of the progress of healing after
the intra-articular administration of the sponges should be based
on clinical indicators including the reduction in lameness and the
amelioration of the animal's general condition, rather than on the
results of the analysis of synovial fluid.
It may be difficult to isolate pathogens from synovial fluid
because of the temporary absence of bacteria or their presence in
insufficient numbers. The administration of antimicrobial agents
401
or the insensitivity of the culture medium may also be responsible
for a negative culture result (Van Pelt 1973, Verschooten and oth-
ers 1974, Madison and others 1991, Crabill and others 1996). A
variety of pathogens have been reported to be responsible for joint
infections. The most common organisms cultured from septic
arthritis in cattle are Actinomyces pyogenes, Escherichia coli,
S aureus, Streptococcus species and Salmonella species
(Greenough and others 1981). S aureus was isolated from case 2,
but the sample from case 1 was negative.
The recommended techniques for treating septic arthritis
involve the use of antibiotics or surgery, both with the purpose of
eliminating the infection. For antibiotic therapy to be successful it
is necessary for the antibiotic agents to cross the synovial mem-
brane, and their passage may be retarded by the thickened mem-
branes; moreover, some antibiotics, like the aminoglycosides,
have a narrow therapeutic range and may be nephrotoxic if the
systemic dose range is exceeded (Orsini 1984, Lloyd and others
1990). The local concentration of antibiotics may be increased by
injecting them through a needle into the affected joint cavity after
it has been lavaged. However, if pus and fibrin clots are present, it
is important to remove them by arthroscopy or arthrotomy,
because they may interfere with the antimicrobial agent and may
have a detrimental effect on the integrity of the surface of the joint
(Orsini 1984, Schneider and others 1992). The inflammatory reac-
tion of joints is characterised by hypertrophy and hyperplasia of
the cells lining the synovia, and a marked immune response,
which result in the accumulation of fibrin, neutrophils and exudate
containing mediators of inflammation that finally lead to irre-
versible damage to the articular cartilage (Van Pelt 1972,
Schneider and others 1992).
The persistence of infection at the surgical site is an important
reason for a failure of therapy, and it is therefore necessary to
maintain consistently high local concentrations of antibiotic after
the removal of septic material (Verschooten and others 1974). The
choice of gentamicin is justified by its broad antimicrobial spec-
trum and its mild adverse reaction on healthy joints after intra-
articular administration (Lloyd and others 1988, Butson and oth-
ers 1996).
In spite of the good results obtained by Butson and others
(1996), with gentamicin-impregnated polymethylmethacrylate
beads, absorbable gentamicin-impregnated collagen sponges were
preferred, on the basis of the favourable results described in the
human literature (von Hasselbach 1989a). Collagen as a carrier is
haemostatic, thus minimising postoperative effusion into the joint,
and is completely absorbed between nine days to three months
after implantation followed by drainage (Stemberger and others
1989, von Hasselbach 1989b). In the Garamycin preparation, the
gentamicin is not mechanically or chemically bound to the colla-
gen and its delivery is therefore dependent on local blood flow or
perfusion which determines the resorption time of the collagen.
This characteristic of Garamycin prevents the local concentration
of antibiotic from being sub-inhibitory, and therefore decreases
the risk of inducing resistant bacteria (von Hasselbach 1989a). It
is important to be aware of the fact that the resistance of bacteria
against aminoglycosides is relative, depending only on the con-
centration and elimination time of the antibiotic by bacterial enzy-
matic inactivation (Grimm 1989, von Hasselbach 1989b).
Comparative studies of gentamicin-impregnated polymethyl-
methacrylate beads and gentamicin-impregnated collagen sponges
in human beings revealed more resistance problems after implan-
tation of the beads because of the slow release of gentamicin.
Furthermore, the beads require a second surgical intervention to
remove them (Letsch 1988, Scherer and others 1989, von Hasselbach
1989b, Worschhauser and Ruter 1989). When the beads were
removed from human beings after an average implantation time of
11 months, it was found that they contained 40 per cent of the ini-
tial concentration of gentamicin (von Hasselbach 1989a). The
adaptability and flexibility of the gentamicin-impregnated colla-
gen sponges simplify their implantation, which does not require
an arthrotomy. Furthermore, the sponges do not interfere substan-
tially with the motion of the joint even if they are placed within a
narrow joint space, whereas drill tracts would be required for the
placement of the beads.
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402
To the authors' knowledge, complete healing of chronic septic
arthritis of the radiocarpal joint, without residual lameness or
impairment of gait, has not been reported in adult cattle. The
promising results described in the human literature, and the two
cases described here, therefore warrant further investigations on
the use of Garamycin for the treatment of severe orthopaedic
infections in cattle.
Acknowledgements. The Garamycin sponges were generously
- ORSINI, J. A. (1984) Journal of the American Veterinary Medical Association 185,
provided by Essex Chemie AG, Lucerne, Switzerland. The
authors thank Dr Urs Geissbuhler for the radiographic examina-
tions, and Professor Peter Tschudi for the analysis of synovial
fluid samples.
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The Veterinary Record, Aprl 11, 1998
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improve the superovulatory response in cows.
Fifteen Japanese black beef cows (five to 10 years old) with
regular oestrus cycles were selected from an experimental herd.
The experiment was conducted using a crossover design with each
cow being assigned to each of three groups at three-month inter-
vals within a one-year period. Each group received the same doses
of follicle stimulating hormone (FSH-R; Denka Pharmaceutical)
and each cow had two normal oestrus cycles before the onset of
the next superovulatory treatment.
Cows were superovulated between days 10 and 13 after sponta-
neous oestrus, since it has been found empirically that the optimal
time to begin superovulatory treatment is day 9 to 13 of the
oestrus cycle. In the day-I group, FSH injections were initiated one
day after the removal of the largest follicle from the ovaries by
ultrasound-guided follicular aspiration. In the day-3 group FSH
injections began three days after the removal of the largest folli-
cle. In the third group, the control group, the largest follicle was
not aspirated before the onset of superovulation. Superovulation
was induced with FSH at a total dose of 20 or 28 mg, given twice
daily over three or four days in decreasing doses and luteolysis
was induced with two injections of 12-5 mg prostaglandin F2cx
(Dinoprost; Daiichi Pharmaceutical) given at the time of the fifth
and sixth injections of FSH. Cows were inseminated twice with
frozen semen about 12 hours and 24 hours after standing oestrus.
Embryos were collected non-surgically seven days after the first
 Downloaded from http://veterinaryrecord.bmj.com/ on July 7, 2015 - Published by group.bmj.com

Treatment of infectious arthritis of the

radiocarpal joint of cattle with
gentamicin-impregnated collagen sponges
G. Hirsbrunner and A. Steiner

Veterinary Record 1998 142: 399-402

doi: 10.1136/vr.142.15.399

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