Needle Arthroscopy for Bacterial Arthritis of a Native Joint: Surgical Technique for the Shoulder, Elbow, Wrist, Knee, and Ankle Under Local Anesthesia

Suspected bacterial arthritis of a native joint requires urgent management to control potential life-threatening sepsis and limit cartilage damage. Diagnosing bacterial arthritis is often challenging and relies on diagnostic tests with low accuracy. A high threshold for surgery poses a risk of undertreatment, whereas a low threshold for surgery could lead to overtreatment with unnecessary invasive and costly procedures. Surgical lavage through arthroscopy or arthrotomy is generally considered standard treatment. Nowadays, needle arthroscopy provides an alternative and potentially less-invasive approach that can safely lower the surgical threshold. Needle arthroscopy can be performed directly upon presentation at the patient’s bedside, as it is well tolerated under local anesthesia. Therefore, this Technical Note presents a stepwise guideline for performing standardized needle arthroscopic lavage in patients with (suspected) bacterial arthritis of the shoulder, elbow, wrist, knee, and ankle.

Surgical lavage, arthroscopic or open, followed by antibiotic treatment is considered standard treatment for a bacterial infection of a native joint. However, the diagnosis of bacterial arthritis is difficult and relies on diagnostic tests with poor-to-moderate accuracy (i.e., specificity and sensitivity). This results in a practice in which a high threshold for surgery poses a risk of undertreatment for true positives and a low threshold for surgery will result in an unnecessarily invasive and costly procedure for false positives.

Needle arthroscopy under local anesthesia has been proposed as a treatment modality for native joint bacterial arthritis that can be performed directly upon presentation at the patient’s bedside, in the emergency department or in the outpatient clinic. In a minimally invasive manner, it may address true-positive patients in a timely fashion yet decrease the burden of overtreatment for false-positive cases.

Compared with conventional arthroscopy, needle arthroscopy has various differences. Less equipment is needed, and only small (2-mm) portals are required, which are acceptable for the patient under local anesthesia. The scope’s direction of view is 0°, with a 120° field of view, which may be unfamiliar to many surgeons who are comfortable with the 30° viewing angle in standard arthroscopy. These differences in instrumentation and technology necessitate a modified technique to accommodate thorough, uniform, and safe therapeutic lavage for bacterial arthritis at the patient’s bedside. In addition, this technique combines adequate diagnostic joint aspiration followed by direct minimally invasive lavage.

Therefore, the purpose of this article is to provide a surgical guide for performing a standardized needle arthroscopic approach for the treatment of patients with bacterial arthritis of a native shoulder, elbow, wrist, knee, and ankle.