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Arthroscopic Versus Open Treatment of Septic Wrist Arthritis: National Trends in Usage and Impact on Length of Stay, Reoperation, Postoperative Readmissions, and Complications
Department of Orthopedic Surgery, University of Virginia, Charlottesville, VADepartment of Plastic Surgery, University of Virginia, Charlottesville, VA
Department of Orthopedic Surgery, University of Virginia, Charlottesville, VADepartment of Plastic Surgery, University of Virginia, Charlottesville, VA
Department of Orthopedic Surgery, University of Virginia, Charlottesville, VADepartment of Plastic Surgery, University of Virginia, Charlottesville, VA
The purpose of this study was to use a national claims database to analyze trends in the usage of arthroscopic versus open irrigation and debridement of septic wrist arthritis and compare complication rates, readmission rates, and reoperation rates between the 2 treatment modalities.
Methods
The PearlDiver database was used to identify patients in the United States who underwent open or arthroscopic debridement for suspected septic wrist arthritis from 2010 to 2017. Data on patient demographics and comorbidities were obtained. Pearson’s chi-square tests were performed to compare the treatment modality to demographic data and the year of diagnosis. Univariate logistic regressions were used to measure differences in 90-day hospital readmission rates, 90-day complication rates, and 1-year reoperation rates.
Results
The database captured 1,145 patients who received treatment for septic arthritis of the wrist during this period. Among these, 212 (18.5%) patients underwent arthroscopic debridement and 933 (81.5%) patients underwent open debridement. Open management was more common in all ages; however, arthroscopic debridement was used more frequently in younger age groups. The proportion of open cases per year seemed to increase over the study period. In limited comparisons, no significant differences were observed in 90-day hospital readmission rates, 90-day complication rates, and 1-year reoperation rates.
Conclusions
Open irrigation and debridement was the preferred method for treatment of septic wrist arthritis in all age groups and time points in this study. No univariate differences were found between rates of readmission, complications, and reoperations between arthroscopic and open treatment modalities; however, more robust data and analyses are needed to better understand the differences between these approaches, especially across different patient groups.
Septic arthritis of the wrist is an uncommon condition that can have devastating consequences for the patient. It can cause rapid cartilage destruction; spread to adjacent tissues, resulting in abscess or osteomyelitis; and lead to sepsis.
Arthroscopy is frequently used in treating septic arthritis of larger joints and has several potential advantages, including reduced incision length, limited disruption of capsuloligamentous structures, less soft tissue injury, purported reduced postoperative pain, and superior intra-articular visualization.
Disadvantages include the need for specialized equipment, operating room personnel familiar with arthroscopy setup, and technical skill required to perform arthroscopy. Some authors suggest that open approaches can provide better exposure to facilitate a more definitive washout of the joint space. When comparing open versus arthroscopic management of septic arthritis involving the knee and shoulder, arthroscopic debridement has been demonstrated to be at least similarly effective in eradicating infection, with limited evidence to suggest superiority with certain functional outcomes.
Because arthroscopic approaches are being applied more frequently for diagnostic and reconstructive procedures of the wrist, they have become accepted alternatives to open debridement for septic arthritis. Given the relative infrequency of septic arthritis of the wrist compared with that of other joints, there is a paucity of studies providing direct comparison between open and arthroscopic treatment modalities.
To date, there is no evidence that suggests clear superiority of one technique over the other; however, some studies have demonstrated fewer reoperations and shorter hospital stays in patients treated arthroscopically for isolated septic wrist arthritis.
Our study examines the national usage of arthroscopic versus open approaches in treating septic wrist arthritis from 2010 to 2017. Additionally, we aimed to compare complication rates, readmission rates, and reoperation rates between the 2 modalities. We hypothesized that there would be an increasing trend in the usage of arthroscopy and that there would be no significant difference in the effectiveness of open and arthroscopic management of septic wrist arthritis, as measured by our outcome criteria.
Materials and Methods
A commercially available, proprietary, national insurance claims database, PearlDiver Patients Records Database (PearlDiver Inc), was queried to identify patients who underwent treatment for suspected intra-articular infection of the wrist from 2010 to 2017.
This database contains patient records from Medicare, Humana, and Mariner data sets, which are deidentified, anonymous, and compliant with the privacy rules of the Health Information Portability and Accountability Act, which exempted them from review by an institutional review board.
The database contains data on patient demographics, comorbidities, diagnoses, and procedural coding among several other data. This database may be queried via the International Classification of Diseases, Nineth Revision and Tenth Revision, and procedures or Current Procedural Terminology (CPT) codes. The database includes >122 million distinct US patients insured from 2010 to 2018. Patients can be tracked across all locations (inpatient, outpatient, etc.) throughout the database years. Data from 2018 were not included in this study because the information contained within the database was not present for the entirety of the year.
The International Classification of Diseases, Ninth and Tenth Revision codes were used to identify patients with reported pyogenic arthritis of the wrist. Patients who were subsequently managed surgically were selected using CPT codes for either arthroscopic or open management in the same claim (Table 1). Patients were excluded for absence of valid age or sex information. Patients were also excluded if they were not active in the database for 1 year after the CPT code for surgical management of the wrist was recorded. Patients were not excluded or differentiated on the basis of other concomitant sites of infection.
Table 1CPT or ICD-9/ICD-10 Codes Used to Query the Database for the Respective Definitions of Interest
These codes were used to identify patients with a diagnosis of septic wrist arthritis who subsequently underwent either open or arthroscopic irrigation and debridement. Presence of various medical comorbidities and occurrence of complications were also assessed using the respective ICD-9/ICD-10 codes listed.
CPT, Current Procedural Terminology; ICD-9, International Classification of Diseases, Ninth Revision; ICD-10, International Classification of Diseases, Tenth Revision.
∗ These codes were used to identify patients with a diagnosis of septic wrist arthritis who subsequently underwent either open or arthroscopic irrigation and debridement. Presence of various medical comorbidities and occurrence of complications were also assessed using the respective ICD-9/ICD-10 codes listed.
Our primary focus was to compare the use of open versus arthroscopic management for septic wrist arthritis during the study period. Secondary end points included rates of overall 90-day complications, 90-day hospital readmissions, and 1-year reoperations. The following complications were queried for: acute kidney injury, cardiac arrest, deep vein thrombosis, pneumonia, pulmonary embolism, blood transfusion, urinary tract infection, disruption of wound, hematoma, and nerve injury. Reoperations included any additional incision and debridement for septic arthritis of the wrist during the initial hospital admission or any subsequent admission. Demographic data, including age, sex, and comorbidities, were also extracted.
Demographic data were pooled to report descriptive statistics. Pearson’s chi-square tests were used to analyze differences in comorbidities, sex, age groups, and year of diagnosis between open and arthroscopic groups. Welch two-sample t tests were used for analysis of means for these groups. Univariate logistic regression analyses were used to evaluate the association between treatment modality and hospital readmission, complication, and reoperation rates. Odds ratios were calculated from the regression analyses with a corresponding 95% CI and P value. R Project for Statistical Computing software, available through the PearlDiver database, was used for all statistical analyses.
For all statistical calculations, a P value of <.05 was considered statistically significant.
Results
A total of 1,145 patients surgically treated for septic arthritis of the wrist were identified, and of these patients, 212 (18.5%) underwent arthroscopic debridement and 933 (81.5%) underwent open debridement as the index procedure (Table 2). In all age groups, open management was more common than arthroscopic management of septic wrist arthritis. However, the proportion of patients treated with arthroscopic management in the age groups of <40 years (P < .001), 40–49 years (P = .027), and 50–59 (P = .026) years was significantly greater than the proportion treated with open management in these age groups. Further, the proportion of patients treated with arthroscopic management in the age group of 70–79 years (P < .001) was significantly lesser than the proportion treated with open management, displaying a clear trend toward increased usage of arthroscopic debridement among younger patients (Table 2).
Table 2An Overview of Patient Demographic Factors and Medical Comorbidities of the Identified Patients Undergoing Arthroscopic Versus Open Surgical Intervention for Septic Wrist Arthritis
A significantly higher percentage of patients with congestive heart failure (P = .008), tobacco use (P = .019), and gout (P < .001) underwent arthroscopic management. A significantly higher percentage of patients with coronary artery disease (P = .009), hypertension (P < .001), and obesity (P = .013) underwent open management. Patients in the arthroscopic group had a mean Charlson Comorbidity Index of 2.08 ± 2.92, and those in the open group had a mean Charlson Comorbidity Index of 2.0 ± 2.77 (Table 2).
The percentage of open cases for septic arthritis of the wrist was significantly greater than the percentage of arthroscopic cases throughout the study period (2010 to 2017; P < .001). The relative usage of arthroscopy among patients identified in this database cohort declined nationally from 2010 to 2017 (Fig; Table 3).
Figure 1An illustration of the trend in the use of arthroscopic versus open management of septic wrist arthritis from 2010 to 2017. The y axis denotes the percentage of cases performed by year included in the study (x axis).
Table 3An Overview of the Number and Relative Percentage of Open Versus Arthroscopic Irrigation and Debridement Procedures Performed Each Year Included in the Study (2010–2017)
Among patients who were treated arthroscopically, 25 (11.8%) were readmitted within 90 days, compared with 89 (9.5%) readmitted after open treatment. Treatment type alone did not significantly impact the odds of 90-day hospital readmission (odds ratio, 1.26; 95% CI, 0.79–2.03; P = .32). Twenty-four (11.3%) patients in the arthroscopic group had a postoperative complication within 90 days of the index procedure, compared with 95 (10.18%) patients in the open group. The odds of 90-day complications with arthroscopic versus open treatment were also not statistically significant (P = .624). In patients treated with open wrist incision and debridement, there were 38 1-year reoperations among 15 (1.6%) patients. In the arthroscopically treated group, there were <11 patients with additional procedures; however, the specific number was not reported. Small-number events are not detailed in the PearlDiver database to protect patient confidentiality.
Discussion
Septic arthritis of the wrist is a surgical emergency that requires prompt operative intervention and antibiotic therapy. It is associated with high rates of morbidity and mortality.
However, there is no clear consensus on whether arthroscopic or open management leads to better outcomes. In our study, we investigated trends in the usage and clinical outcomes of open versus arthroscopic debridement for treating suspected septic arthritis of the wrist in a large, national insurance claims database. Open debridement of septic wrist arthritis was the preferred approach in most cases reported from 2010 to 2017. Although open management was more common in all age groups, there was relatively more frequent use of arthroscopic debridement in younger patients. Additionally, this study demonstrated no statistical difference in unadjusted analyses of the rates of 1-year reoperation, 90-day readmission, and 90-day complication between the 2 treatment modalities.
Historically, open irrigation and debridement of septic wrist arthritis has been considered the standard treatment modality.
Although this study confirmed the preferred usage of this standard nationally, it also showed some higher usage of arthroscopic debridement in younger patients. The nature of a database study precludes a definitive explanation for this finding because the surgeon’s rationale for each operative plan cannot be identified on a case-by-case basis. However, younger patients may be more likely to have better preserved joint space, which can make arthroscopy technically easier. Surgeons may also consider arthroscopic intervention to be less morbid and be more willing to attempt less-invasive techniques in younger, higher-demand patients in this scenario.
With regard to overall usage trends, although wrist arthroscopy has become a more common treatment modality in upper-extremity surgery, the relative incidence of arthroscopic management of septic arthritis was seen to decline over the study period (Fig). This finding is overall consistent with the finding in a study by Karelson et al,
who examined the rates of wrist arthroscopy between 1997 and 2016 and identified an increase of approximately 15% per year from 1997 to 2014, before observing a decline of 4% per year from 2014 to 2016. The exact reason for this trend in our study and the study by Karelson et al
remains unclear and is unexpected given that the indications for wrist arthroscopy are expanding and being more commonly reported in the literature. Between 1986 and 2012, the number of publications per year on wrist arthroscopy has more than tripled.
It is possible that the lack of increase in the frequency of arthroscopic debridement could be attributed to the steep learning curve for proficiency in wrist arthroscopy such that even hand surgeons not performing high volumes of wrist arthroscopy are still opting for open debridement. It is also possible that surgeons favor open debridement as they are often performing these procedures in an emergent manner after typical operating room hours and do not have staff familiar with the arthroscopic setup or procedure. Surgeons may also opt for an open arthrotomy when planning for evacuation of concomitant infection of nearby spaces, such as the carpal tunnel or extensor compartments, because this is a relative contraindication for arthroscopic management alone. Regardless of the reason, the results of this study demonstrate that open debridement of isolated septic wrist arthritis remains the more common approach.
To date, the only randomized trial comparing open versus arthroscopic debridement of septic arthritis included 40 wrists in 36 patients. In this study, Sammer and Shin
reported that arthroscopic debridement led to shorter hospital length of stay (LOS) and fewer reoperations in those with isolated wrist joint infection. In their study, the average LOS for patients with isolated septic arthritis was 16 days for patients treated in an open fashion and 6 days for patients treated arthroscopically.
also demonstrated a decreased likelihood of reoperation in patients undergoing arthroscopic rather than open debridement of isolated septic wrist arthritis; however, they did not observe this same trend in patients with multifocal infection. This result is consistent with our findings that because of the nature of the database used, patients with isolated infection could not be differentiated from patients with multifocal infection. The 1-year reoperation rate in our open treatment cohort was low (1.6%). All but one of the instances of repeat wrist debridement were through an open arthrotomy. There were <11 patients and procedures in the arthroscopic group; however, the exact number was not reported. Although statistics could not be applied, we know that the reoperation rate in the arthroscopically treated cohort was between 0% and 5.2%.
Contemporary evidence evaluating management of septic arthritis of other joints suggests relative parity between open and arthroscopic treatment. Recent systematic reviews of the management of septic knee and shoulder arthritis have reported open and arthroscopic debridement to be similarly effective in eradicating joint infection.
Considering this literature in the context of the findings of our study would support the use of either modality in treating septic wrist arthritis. However, it is important to recognize that certain relative contraindications to arthroscopic management exist. Postoperative wrist infections that involve hardware or fractures may be more challenging or impractical to effectively address arthroscopically.
With respect to the wrist joint specifically, surgeons must be cognizant that infection may exist in other nearby anatomic spaces, which can limit the efficacy of arthroscopic debridement alone in eradicating infection. Open irrigation and debridement may also be required in young children because of the size of the joint relative to the arthroscopic instrumentation. In addition to these patient-specific factors, surgeon experience and resource availability should be considered when making the decision to proceed with either open or arthroscopic irrigation and debridement of septic wrist arthritis.
Our study has certain limitations. Although we used data from a large, national patient population, the study is limited by its retrospective nature. We also do not have the documentation to explain the rationale to proceed with either open or arthroscopic treatment in individual cases. The extent of infection, presence of infection at multiple sites, and medical acuity of the case could all have influenced the surgical treatment decision. Additionally, all database studies are limited by the amount and accuracy of the information they contain. The PearlDiver Patient Records Database uses the International Classification of Diseases, Ninth/Tenth Revision and CPT codes that are dependent on reliable input. For example, when examining trends of arthroscopic versus open debridement in this study, it is unclear whether this accounts for some of the variability in the number of cases performed by year or the number of patients in the database each year. Theoretically, any differences in input would be equally represented between treatment groups, and the large number of patients included within this study help to control for any error introduced. The Centers for Medicare & Medicaid Services identified a 1.0% to 1.6% rate of coding errors during the study period.
Limitations in information in the database precluded any analysis for LOS. Finally, analyses for complications, readmissions, and reoperations were not controlled for differences in demographic factors or comorbidities because this was beyond the scope of our study design. All the results reported are from unadjusted analyses, which could notably impact our findings.
Despite these limitations, our study provides valuable information regarding the trends in the usage of open and arthroscopic techniques for irrigation and debridement of septic wrist arthritis, with no obvious patient detriment from the use of arthroscopic debridement. Although the indications and applications of wrist arthroscopy are expanding, open debridement of septic wrist arthritis remained the preferred approach during our study period. The operative approach is likely surgeon-dependent and based on a variety of factors, including age, comorbidities, acuity, and presence of concomitant infection. Further prospective, randomized studies are warranted to evaluate the clinical differences in outcomes between open and arthroscopic management of septic wrist arthritis.
Acknowledgments
We thank Marieke Jones, Research Data Specialist at the Claude Moore Health Systems Library at the University of Virginia, for her help with the statistical analysis.
Declaration of interests: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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