Knee Surgery, Sports Traumatology, Arthroscopy

https://doi.org/10.1007/s00167-018-5328-1

KNEE

Arthroscopic irrigation and debridement is associated with favourable

short-term outcomes vs. open management: an ACS-NSQIP database
analysis
Mhamad Faour1 · Assem A. Sultan1 · Jaiben George1 · Linsen T. Samuel1 · Gannon L. Curtis1 · Robert Molloy1 ·
Carlos A. Higuera2 · Michael A. Mont3

Received: 17 June 2018 / Accepted: 7 December 2018

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Abstract
Purpose  Septic arthritis of the knee is an orthopaedic emergency that is associated with marked morbidity and can poten-
tially be life threatening. Surgical debridement can be performed either arthroscopically or via an arthrotomy. The aim of
this study was to compare the 30-day complications and adverse outcomes between the two procedures.
Methods  Patients with a diagnosis of septic arthritis of the knee between 2011 and 2015 were identified using the ACS-
NSQIP database. The study population included 695 patients, who had knee septic arthritis and underwent either an arthro-
scopic irrigation or debridement (I&D) (n = 464) or open irrigation and debridement (n = 231). Preoperative data included
demographics, independent functional status, and comorbidities. Outcomes of interest included wound complications, infec-
tious complications, cardiovascular events, hospital readmissions, and reoperations, or any of the previous adverse events.
Results  Both cohorts were similar in most baseline characteristics. Bleeding requiring transfusion was significantly lower
in the arthroscopic (n = 13; 3.6%) compared to the open procedure (n = 31; 13.4%; p = 0.0001). Home discharge was signifi-
cantly higher in the arthroscopic irrigation and debridement group (n = 310; 67.5%) compared to the open group (n = 126;
55%; p = 0.0013). The overall incidence of adverse events was lower in the arthroscopic group (n = 158; 34%) compared to
the open group (n = 112; 49%; p = 0.0002). There was no difference in rates of infectious complications, thromboembolic
events, hospital readmission, reoperation, or mortality between the groups. Open irrigation and debridement was associated
with higher risk of bleeding requiring transfusion (OR = 3.79; 95% CI: 2.02–7.13; p = 0.0001), higher risk of incidence
of adverse events (OR = 1.46; 95% CI: 1.02–2.08; p = 0.039), and lower home discharge (OR = 3.79; 95% CI: 2.02–7.13;
p = 0.0001) within 30 days after the procedure.
Conclusion  Arthroscopic irrigation and debridement demonstrated favourable short-term outcomes. Patients who underwent
arthroscopic irrigation and debridement had lower rates of blood transfusions, lower rates of adverse events, and higher home
discharge rates compared to open irrigation and debridement. This study is the largest analysis comparing arthroscopic vs.
open irrigation and debridement in a national database sample. These findings conclude that arthroscopic debridement can
be an alternative first-line option in managing septic arthritis.
Level of evidence III.

Keywords  Septic arthritis · Knee · Irrigation and debridement · Arthroscopy · Arthrotomy · Outcomes · Complications ·
Infection · Arthroscopic · Open · I&D

Abbreviations OR Odds ratio

ACS-NSQIP American College of Surgeons National CI Confidence interval
Surgical Quality Improvement Program SD Standard deviation
I&D Incision and drainage BMI Body mass index
ICD-9 International Classification of Disease, 9th
edition
* Michael A. Mont CPT Current Procedural Technology code
rhondamont@aol.com UTI Urinary tract infection
Extended author information available on the last page of the article n.s. Non-significant

13
Vol.:(0123456789)

DVT Deep vein thrombosis
PE Pulmonary embolism
ASA American Society of Anesthesiologists
Introduction
Septic arthritis of the knee is an orthopaedic emergency that
is associated with significant morbidity and can potentially be
life threatening [1, 2]. Early management is essential to prevent
irreversible joint damage and articular cartilage destruction.
Studies have demonstrated that the outcome depends on the
type of infecting pathogen and the patient’s current health sta-
tus. It also depends on the time from diagnosis to treatment
initiation [3–5]. Diagnosis relies on clinical signs aided by hae-
matological investigations, imaging studies, and synovial fluid
aspiration and microbiological analysis. Treatment requires
emergency surgery, irrigation and debridement of the joint,
and intravenous antibiotics. Surgical irrigation removes debris
and decreases the intra-articular microbial burden [6–9].
To date, a controversy exists regarding the ideal and least
morbid approach to treat septic arthritis of the knee. Surgi-
cal debridement can be performed either arthroscopically
or via open arthrotomy. Both open and arthroscopic inci-
sion and drainage (I&D) procedures have been described in
the literature [10, 11]. Arthroscopic treatment demonstrated
more favourable outcomes with fewer subsequent irrigations
[11], shorter hospital stays, and better functional outcomes
[12, 13], while open approach may be preferred by some
surgeons to provide adequate and more definitive clearance
of the joint space.
While previous studies compared infection eradication
and functional outcomes between arthroscopic and open irri-
gation and debridement [10–13], to the best of the author’s
knowledge, no study has compared short-term adverse
outcomes. The purpose of this study was to compare the
adverse events and complications after arthroscopic and
open surgical irrigation and debridement for patients with
septic arthritis of the knee in terms of (1) wound complica-
tions, (2) systemic infectious complication, (3) recurrence of
joint infection, (4) hospital readmissions, (5) reoperations,
(6) bleeding, (7) home discharge, and (8) mortality within
30 days after the surgical intervention. This comparison
may help clinicians anticipate problems in the short-term
period, and guide choosing their management option, given
the current paucity of studies on the efficacy of arthroscopic
debridement.
Materials and methods
The American College of Surgeons National Surgical
Quality Improvement Program (ACS-NSQIP) database
was queried for this study. Trained reviewers from over
13
Knee Surgery, Sports Traumatology, Arthroscopy
700 contributing hospitals gathered data prospectively and
tracked patients for 30 days following surgery [14]. Method-
ology regarding the database has been described previously
[15, 16, 22].
881 patients were identified using the International classi-
fication of disease, 9th edition (ICD-9) code 711.06 who had
a diagnosis of septic arthritis of the knee between 2011 and
2015. We excluded 186 patients who underwent additional
procedures other than irrigation and debridement. The study
population included 695 patients with knee septic arthritis
who underwent either (Current Procedural Technology code
(CPT) 29871) arthroscopic (n = 464, 66.7%) or (CPT 27310)
open irrigation and debridement (n = 231, 33.2%). Preop-
erative data included demographics, independent functional
status, and comorbidities (see Table 1) [22].
Outcomes were separated into wound infection, recurrent
joint infection, infectious complications, bleeding required
transfusions, hospital readmission, reoperation, any of the
previous adverse events, and discharge disposition to home.
Wound infection included superficial and deep wound infec-
tion. Infection-related complications included systemic sep-
sis, pneumonia, and urinary tract infection (UTI). Bleeding
was recorded if at least 1 unit of packed or whole red blood
cells was given at any time between surgical start time and
72 h postoperatively. Thromboembolic events included deep
venous thrombosis (DVT) and pulmonary embolism (PE).
Comparing baseline characteristics in both cohorts, no
significant (n.s.) difference was found between the groups
in terms of age, sex, American Society of Anesthesiologists
(ASA) class, independent functional status, smoking status,
anaesthesia type, hospital length of stay, or medical comor-
bidities. However, the open irrigation and debridement
group had a higher percentage of African-American patients
(55 (24%) vs. 60(13%); p < 0.001), and a higher mean body
mass index (31.2 ± 8.6) compared to the arthroscopic irri-
gation and debridement group (29.2 ± 7.2; p = 0.003) (see
Table 1).
ACS-NSQIP is a publicly accessible database; therefore,
no IRB approval was required for this study.
Statistical analysis
Univariate analysis was performed using Chi-square or
Fisher’s exact tests for categorical variables and independ-
ent t tests for numerical values. Variables that were signifi-
cantly different after univariate analysis were included in
the multivariate regression models. These models were used
to control for confounding variables. Variables that were
less than 80% complete were excluded from the analysis
[17]. A significance of p ≤ 0.05 was used and all statistical
tests were two sided. For all analyses, we used STAT​GRA​
PHICS Centurion XVII software (Statpoint Technologies,
Inc.; Warrenton, Virginia).
Knee Surgery, Sports Traumatology, Arthroscopy

Table 1  Baseline characteristics Variable Open (n = 231) Arthroscopic p value

of patients undergoing open and (n = 464)
arthroscopic surgeries for septic
arthritis Age, mean ± standard deviation (SD) 59 ± 15 59 ± 18 n.s
Male sex (%) 65% 65% n.s
Race (%) < 0.001
 White 64% 67%
 African-American 55 (24%) 60 (13%)
 Others 12% 20%
ASA class (%) n.s
 1 3% 5%
 2 28% 34%
 3 56% 49%
 4 + 13% 12%
 Independent functional status (%) 88% 89% n.s
 Body mass index (BMI), mean ± standard 31.2 ± 8.6 29.2 ± 7.2 0.003
deviation
 Smoker (%) 26% 23% n.s
 General anaesthesia (%) 95% 92% n.s
Comorbidities (%) n.s
 0 53% 57%
 1 32% 28%
 > 1 15% 15%

Results complications, or any other adverse events after the proce-

The incidence of recurrent joint infection was similar
between open (n = 11, 4.8%), and arthroscopic irrigation
and debridement (n = 27, 5.8%; n.s.). In addition, the two
groups showed no difference regarding wound infections,
thromboembolic events, or infection-related complications
(n.s.) (see Table 2). Bleeding requiring transfusion was
lower (n = 18, 3.6%) in the arthroscopic compared to the
open procedure (n = 31, 13.4%; p = 0.0001). Home dis-
charge was higher in the arthroscopic I&D group (n = 310,
67.5%) compared to the open group (n = 126, 55%;
p = 0.0013). There was no difference between the cohorts
when considering hospital readmissions, reoperations,
or mortality. The overall incidence of any adverse event
was higher in the open group (n = 112, 49%) compared
to (n = 158, 34%) in the arthroscopic group (p = 0.0002).
Multivariate logistic regression analysis comparing
the outcomes showed that an open procedure was asso-
ciated with higher risk of bleeding requiring transfusion
[odds ratio (OR) = 3.79; 95% confidence interval (CI):
2.02–7.13; p = 0.0001], lower home discharge (OR = 3.79;
95% CI: 2.02–7.13; p = 0.0001), and higher risk of inci-
dence of adverse events within 30 days after the procedure
(OR = 1.80; 95% CI: 1.28–2.52; p = 0.0006). However,
the open procedure was not associated with higher risk of
recurrent joint infection, wound infection, infection-related
dure (see Table 3).
Discussion
In the present study, patients who underwent arthroscopic
irrigation and debridement had lower rates of blood transfu-
sions, lower rates of adverse events, and higher home dis-
charge rates compared to open irrigation and debridement
within 30 days after the procedure. Septic arthritis of the
knee is considered an orthopaedic emergency and associ-
ated with high rates of permanent impairment of joint move-
ment in up to 73% of patients and a mortality rate of up
to 20% [18]. Successful outcome requires early diagnosis,
joint decompression and debridement to reduce pressure
on the articular cartilage, joint lavage to clear necrotic and
inflammatory substances, appropriate antibiotic therapy,
and early rehabilitation. While open surgical irrigation and
debridement is considered the gold standard for surgical
management, arthroscopic irrigation and debridement pro-
cedures have gained popularity as a more favourable option
[3, 6, 7]. Open arthrotomy is still successfully used at many
institutions; however, there has been a recent shift toward
the use of arthroscopic irrigation and debridement. The
aim of this study was to compare short-term outcomes and
adverse events between open and arthroscopic irrigation and
debridement using a large national database (ACS-NSQIP).

13
 Knee Surgery, Sports Traumatology, Arthroscopy

Table 2  Univariate analysis Variable Open Arthroscopic (n = 464) p value

comparing the outcomes (n = 231)
between open and arthroscopic
procedures Any adverse event 112 (49%) 158 (34%) 0.0002
Bleeding required transfusion 31 (13.4%) 18 (3.6%) 0.0001
Home discharge 126 (55%) 310 (67.5%) 0.0013
Recurrent joint infection 11 (4.8%) 27 (5.8%) n.s
Wound infection 5 (2.2%) 9 (1.9%) n.s
 Superficial infection 0 (0%) 1 (0.2%) n.s
 Deep infection 5 (2.2%) 8 (1.7%) n.s
Infectious complications 39 (17%) 69 (15%) n.s
 Sepsis 35 (15.2%) 59 (12.7%) n.s
 Pneumonia 4 (1.7%) 14 (3.0%) n.s
 Urinary tract infection 3 (0.4%) 5 (0.7%) n.s
Thromboembolic event 6 (2.6%) 14 (3.0%) n.s
 Pulmonary embolism 0 (0%) 2 (0.4%) n.s
 Deep venous thrombosis 6 (2.6%) 12 (2.6%) n.s
Mortality 2 (0.9%) 8 (1.7%) n.s
Readmission 33 (14%) 51 (11%) n.s
Reoperation 32 (14%) 46 (10%) n.s

Table 3  Multivariate analysis comparing the outcomes between risk of blood transfusion and adverse events, and a lower
arthroscopic and open procedures likelihood of home discharge compared to arthroscopy.
Variable Odds ratio (95% CI) p value Few studies have compared short-term complications and
adverse outcomes between open and arthroscopic debride-
Any adverse event 0.56 (0.40–0.78) 0.0006 ment for septic arthritis of the knee. Bovonratwet et al.
Bleeding required transfusion 0.26 (0.14–0.50) 0.0001 [19] evaluated 30-day perioperative complications between
Home discharge 1.76 (1.25–2.47) 0.0012
open arthrotomy and arthroscopy for the treatment of septic
Recurrent joint infection 1.14 (0.54–2.40) n.s
knees. They found that arthroscopic procedures were associ-
Wound infection 0.83 (0.26–2.60) n.s
ated with a lower rate of minor complications, but a higher
Infectious complication 0.81 (0.52–1.26) n.s
rate of serious complications. However, multivariate analysis
Venous thromboembolic event 1.14 (0.43–3.05) n.s
revealed similar perioperative complications, reoperation,
Mortality 1.88 (0.37–9.30) n.s
and readmission for both open and arthroscopic debride-
Readmission 0.76 (0.47–1.22) n.s
ment of septic knees. Additionally, Bovonratwet et al. [19]
Reoperation 0.68 (0.42–1.10) n.s
reported a significant difference in mortality rate between
Covariates included were BMI and race (i.e. the variables significant open (1.2%) and arthroscopic procedures (5.6%; p = 0.027)
in univariate analysis) within 30 days after the procedure. Johns et al. [11] reported
Open I&D was used as a reference mortality was lower in the arthroscopic treatment group at
4.1% compared with 9.5% in the open treatment group, but
this was not significant.
In this analysis, arthroscopic debridement was associ- Compared to Bovonratwet et al. [19], the present study
ated with a significantly lower rate of bleeding that required had approximately double the cohort size of their study
blood transfusions (p = 0.0001) and a significantly higher (695 vs. 384 patients) which reinforce our observed find-
rate of discharge disposition to home (p = 0.0012). In addi- ings by adding study power. In addition, the present study
tion, arthroscopic debridement was associated with a lower had stricter patient selection criteria, as we have excluded
incidence of any adverse event (p = 0.053). The study also all patients who had any other procedures than irrigation and
showed no significant difference in infectious complications debridement (186 patients out of 881 initial study cohort),
(wound, joint, and systemic infections), thromboembolic which can be a potential confounder given the nature of the
events, reoperation, or hospital readmission between arthro- database. In Bovonratwet et al. [19] only 16 cases that under-
scopic and open interventions. After accounting for signifi- went other specific procedures were excluded, although
cantly different variables, multivariate logistic regression they used the same codes that we used to identify the ini-
analysis showed that open I&D was associated with a higher tial cohort. This can be a critical step in the study design

13
Knee Surgery, Sports Traumatology, Arthroscopy
when the data source is an administrative database as the
NSQIP, as aggressive patient inclusion and exclusion criteria
are vital, to account for potential confounders related to the
nature of these databases that do not capture the details of
surgical procedures. Furthermore, key findings in the present
study were also different from those demonstrated by Bovon-
ratwet et al. [19] who failed to demonstrate a statistically
significant difference in terms of any of the outcomes among
patients who underwent arthroscopic vs. open debridement
on multivariate analysis. In our study, open irrigation and
debridement was associated with a significantly higher risk
of bleeding requiring transfusion, any adverse event, and
lower odds of home discharge. In addition, we found no dif-
ferences in mortality within 30 days compared to Bovonrat-
wet et al. [19] which showed higher mortality with arthro-
scopic Irrigation and Debridement, a finding that may not
be clinically relevant.
There were several limitations to this study. The study
population was derived from a large national database of
more than 700 hospitals, which may impose a high degree
of heterogeneity in terms of patient’s demographics, access
to high-volume health centres, and management algorithms
among different hospitals. However, baseline characteris-
tic analysis demonstrated that patients in the two cohorts
of the study were similar in most baseline characteristics.
In addition, variables that were significantly different after
univariate analysis were included in the multivariate regres-
sion model. Another limitation was that patients were only
followed for 30 days post-operatively. However, this study
specifically aimed to determine any differences in short-term
outcomes in a large database setting, as previous studies have
investigated outcomes in the mid- and long terms. Addition-
ally, we were unable to include other relevant factors in our
analysis such as the responsible organism, the antibiotic
management, the number of procedures needed to eradicate
the infection, the type of open surgical approach, or to assess
the presence of concurrent septic arthritis of other joints,
which is associated with higher mortality and morbidity
[20]. Nevertheless, this is a limitation inherent to the data-
base and we were able to control for several other confound-
ers to decrease the risk of external bias. Another limitation
that is also inherent to the database is that details related
to the diagnosis such as contributing risk factors were not
retrievable. However, it is important to note that all patients
included in the present study were those who only had native
septic arthritis that are coded separately from other infec-
tion-related diseases, such as periprosthetic joint infections.
Also, this study excluded all patients who underwent other
procedures which should serve to limit any potential bias,
i.e. a patient encountering septic arthritis as a complication
from a procedure such as a ligament reconstruction. Despite
these limitations, this study provided important findings that
are very relevant to the clinical practice showing favourable
outcomes associated with arthroscopic vs. open irrigation
and debridement.
Most studies comparing open and arthroscopic debride-
ment for septic arthritis of the knee evaluated recurrence of
infection with repeated interventions. Arthroscopic debride-
ment yields efficient joint decompression and irrigation and
reduced operative morbidity. Johns et al. [11] evaluated 161
patients, who had native knee septic arthritis and repeat
irrigation was higher in the open procedure group (71%)
compared to the arthroscopic group (50%). After three irri-
gation procedures, the cumulative success rate was 97%
in the arthroscopic treatment group and 83% in the open
treatment group (p = 0.011). Böhler et al. [21] treated 70
patients with septic knee arthritis of which 41 were treated
arthroscopically and 29 with arthrotomy. The rate of second
surgical procedure due to early re-infection was significantly
higher for arthrotomy (20.7%) compared to arthroscopy
(2.5%). Aïm et al. [22] analysed 46 cases of septic arthritis
in 46 patients. Infection eradication was achieved in 93% of
patients. Functional outcomes have also been investigated
between the two procedures. Johns et al. [11] found that the
arthroscopic treatment yielded better post-operative range
of motion and shorter hospital length of stay. Böhler et al.
[21] also showed that knee range of motion was significantly
better in patients who underwent arthroscopic debridement.
Conclusions
Despite the established evidence and previous few short-
term studies, the present study remains the largest to com-
pare the two methods of treatment through analysis of a
national database. Arthroscopic irrigation and debridement
was associated with lower rates of bleeding requiring trans-
fusion, lower risk of adverse events, and higher rates of
home discharge after surgery compared to the open proce-
dure. Arthroscopic and open procedures had similar rates of
perioperative complications, mortalities, reoperations, and
hospital readmissions. Existing literature reported better out-
comes in terms of re-infection and restoration of functional
outcomes with arthroscopy [11, 21, 22]. Findings from this
study conclude that arthroscopic irrigation and debridement
should be considered an alternative first line of management
with favourable short-term outcomes in the management of
knee septic arthritis.
Acknowledgements  American College of Surgeons National Surgi-
cal Quality Improvement Program and the hospitals participating in
the ACS-NSQIP are the source of the data used herein; they have not
verified and are not responsible for the statistical validity of the data
analysis or the conclusions derived by the authors.
Author contributions  MF conceived of the study and drafted the
manuscript; JG participated in the design of the study and performed
13

the statistical analysis; AS participated in its design and coordination
and helped to draft the manuscript. LTS participated in its design and
coordination and helped to draft the manuscript; GLS participated in
its design and coordination and helped to draft the manuscript; RM
participated in its design and coordination; CAH participated in its
design and coordination; and MAM participated in its design and coor-
dination. All authors read and approved the final manuscript.
Funding  There is no funding source.
Compliance with ethical standards  Shen H-C, Lee C-H (2011) Treatment of septic knee arthritis:
Conflict of interest  Mhamad Faour, MD, declares that he has no com-
peting interests. Assem Sultan, MD, declares that he has no competing
interests. Jaiben George, MD, declares that he has no competing inter-
ests. Linsen T. Samuel, MD, MBA, declares that he has no competing
interests. Gannon L. Curtis, MD, declares that he has no competing
interests. Robert Molloy, MD: Stryker: paid consultant; Paid presenter
or speaker; research support. Zimmer: research support. Carlos A.
Higuera, MD: 3M: research support. American Association of Hip and
Knee Surgeons: Board or committee member. American Journal of Or-
thopedics: editorial or governing board. CD Diagnostics: research sup-
port. Cempra: research support. Cymedica: research support. Ferring
pharmaceuticals: research support. Journal of Hip Surgery: editorial
or governing board. Journal of Knee Surgery: Editorial or governing
board. KCI: paid consultant; paid presenter or speaker; research sup-
port. Mid-American Orthopaedic Association: board or committee
member. Musculoskeletal Infection Society: board or committee mem-
ber. OREF: research support. Orthofix, Inc.: research support. Pfizer:
paid consultant. PSI: stock or stock options. Stryker: research support.
TenNor Therapeutics Limited: paid consultant. Zimmer: paid consult-
ant; research support. Michael A. Mont, MD. AAOS: board or com-
mittee member. Abbott: paid consultant. Cymedica: paid consultant.
DJ Orthopaedics: paid consultant; research support. Johnson & John-
son: paid consultant; research support. Journal of Arthroplasty: edito-
rial or governing board. Journal of Knee Surgery: editorial or govern-
ing board. Mallinckrodt Pharmaceuticals: paid consultant. Microport:
IP royalties. National Institutes of Health (NIAMS & NICHD): re-
search support. Ongoing Care Solutions: paid consultant; research
support. Orthopedics: editorial or governing board. Orthosensor: paid
consultant; research support. Pacira: paid consultant. Peerwell: stock
or stock options. Performance Dynamics Inc.: paid consultant. Sage:
paid consultant. Stryker: IP royalties; paid consultant; research sup-
port. Surgical Techniques International: editorial or governing board.
TissueGene: paid consultant; research support.
Ethical approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
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Knee Surgery, Sports Traumatology, Arthroscopy

Affiliations

Mhamad Faour1 · Assem A. Sultan1 · Jaiben George1 · Linsen T. Samuel1 · Gannon L. Curtis1 · Robert Molloy1 ·

Carlos A. Higuera2 · Michael A. Mont3

Mhamad Faour Carlos A. Higuera

faourm@ccf.org higuerc@ccf.org
Assem A. Sultan 1
Department of Orthopaedic Surgery, Cleveland Clinic
sultana@ccf.org
Foundation, Cleveland, OH, USA
Jaiben George 2
Department of Orthopaedic Surgery, Cleveland Clinic
jaibengeorge@gmail.com
Florida, Weston, FL, USA
Linsen T. Samuel 3
Department of Orthopaedic Surgery, Lenox Hill Hospital,
samuell@ccf.org
New York, NY, USA
Gannon L. Curtis
gannoncurtis10@gmail.com
Robert Molloy
molloyr@ccf.org

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