Management of Native Joint Septic Arthritis, Serial Aspiration vs. Arthroscopic Washout During the COVID-19 Pandemic

Septic arthritis remains an orthopaedic emergency that requires prompt diagnosis and management. During the 2020 COVID-19 pandemic, British Orthopaedic Association (BOAST) guidelines dictated that medical treatment (closed-needle aspiration + antibiotic therapy) should be offered to patients as first-line management, and operative treatment (arthroscopic joint washout +/- synovectomy) be reserved for patients exhibiting signs of sepsis. Literature has previously shown that for native joint septic arthritis, operative treatment is not superior to medical treatment. During the COVID-19 'lock-down' period (March 2020 to June 2020), we prospectively followed the presentation, diagnosis, management and outcome of a total of six patients who presented with confirmed native joint septic arthritis. All six patients underwent initial medical management of their septic arthritis following their diagnostic aspiration, which involved serial closed-needle aspirations and antibiotic therapy as advised by our microbiology team. Four patients went on to have an arthroscopic washout at an average of eight days following admission (mean 2.5), prior to a consultant-led decision to proceed to arthroscopic washout. The decision for operative management was the patient's clinical deterioration based on physiological (fever, tachycardia) and biochemical (C-reactive protein (CRP), white blood cell (WBC)) parameters. All of the four patients that proceeded to operative treatment failed to provide culture yield at the time of arthroscopic washout. The mean time to discharge was 15.6 days, whilst the mean time to discharge following operative intervention was 12 days. One patient passed away during admission and one patient required a second arthroscopic washout. Medical management of septic arthritis may play a role in symptom control in the palliative setting or in patients where a general anaesthetic is undesirable. We found operative management to be therapeutic clinically, haemodynamically and biochemically as well as facilitative of a faster recovery and shorter inpatient stay.