The application of hip arthroscopy for the management of septic arthritis in adults

The application of hip arthroscopy for the management of septic arthritis in adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The application of hip arthroscopy for the management of septic arthritis in adults Shu Chen, Zi-ye Liu, Ya-guang Han, Yi-qin Zhou, Jia-hua Shao, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4227763/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Primary septic arthritis of the hip is a rare differential diagnosis of acute hip pain in adults, but if it is not diagnosed and treated in time, it often leads to irreversible joint damages. However, the diagnostic options of primary septic arthritis of the hip are limited. The accurate aspiration is difficult to achieve, and the traditional open arthrotomy is invasive and associated with high rates of potential complications. We used hip arthroscopy for the diagnosis and intervention of primary septic arthritis of the hip in adults and evaluated their safety and efficacy. Methods Seven patients (4 female, 3 male), average age 48±17.3 years with unexplained acute pain and limited hip joint were included. Septic arthritis was confirmed by aspirated joint fluid analysis or synovial pathology. Surgical treatment consisted of immediate arthroscopic lavage using only 2 portals for debridement, high-volume irrigation, partial synovectomy, and drainage. Antibiotics were used according to drug susceptibility results or empirically. The symptoms, related primary disease, levels of inflammatory indicators, bacterial culture results, surgical complications, duration of antibiotic use, and follow-up results were all recorded and analyzed. Results The median duration of symptoms prior to the arthroscopic lavage was 11.6 (4-45) days. All patients had different degrees of leukocytosis and elevated level of erythrocyte sedimentation rate (ESR) and C-reaction protein (CRP). 2 cases got positive results of preoperative bacterial culture results, and 6 cases got positive results of postoperative bacterial culture results, among which Staphylococcus aureus was the most frequently detected pathogen (3 cases). Antibiotics were administered for 4-6 weeks. After an average of 43 days after surgery, CRP returned to physiological levels, ESR returned to normal in 54 days, and after follow-up for 6 months, the average score of Visual Analogue Scale (VAS) decreased from 6.4±1.3 points to 1.3±0.2 points (p<0.05), and the average score of modified harris hip score（mHHS） increased from 53±9.8 points to 85±8.6 points (p < 0.05). None of the patients had significant surgical complications. During the mean follow-up for 24 months (range 18–30 months), no patient showed recurrence of infection, while 1 case underwent subsequent total hip arthroplasty due to serious destruction of articular cartilage and rapidly progressive degeneration. Conclusion Hip Arthroscopic therapy is a safe and effective method for the diagnosis and intervention of primary septic arthritis of the hip without dissemination, which is reliable, tends to be less invasive and more thorough than the traditional open arthrotomy. primary infection septic arthritis hip arthroscopy Figures Figure 1 Figure 2 Figure 3 Background Primary septic arthritis of the hip is a rare differential diagnosis of acute hip pain in adults with an estimated mortality rate of 11%[ 1 , 2 ]. Symptoms mainly include pain and limited hip range of motion in hip. Due to strong muscular and ligamentous wraps around the hip joint, there is often no typical symptom such as redness, swelling, and pyrexia. there are also no specific proprietary signs. The joint cavity effusion and thickening of the synovium can be presented in MRI. It is difficult to distinguish infectious effusion with rheumatoid arthritis or traumatic effusion. Early diagnosis highly depends on doctor’s clinical experience and etiology. Delayed diagnosis and intervention may lead to dissemination of infection, prolongation of treatment, cartilage damage, joint deformation, and even lead to disability[ 3 , 4 ]. For the early diagnosis of hip infection, aspiration was frequently used, but as the articular cavity is covered by several muscles and ligaments, it is hard to pinpoint and draw fluid easily, besides, with the low positive rate of culture results, repeated aspiration is mostly required. Treatment methods include: 1. Long-term high-dose antibiotic therapy: in the absence of clear etiology and drug sensitivity results, antibiotic treatment merely base on clinical experience, it may lead to drug resistance. 2. open arthrotomy: open arthrotomy remains the gold standard for treatment of septic arthritis of the native hip[ 5 ], but may have many complications such as osteonecrosis of the femoral head, dislocation, and cosmesis problem. Besides, patients are often less receptive to open surgery, what’s more, debate persists as to which approach is the best option[ 6 ]. Minimally invasive and precision surgery are the trends of joint surgery in recent years. The indications for hip arthroscopic therapy are also expanding and have been reported for the treatment of septic arthritis in paediatric population[ 7 , 8 ], but few studies have specifically addressed arthroscopic management of septic arthritis of the hip in adults, and there remains uncertainty about the success of arthroscopic treatment. No consensus has been reached so far, probably due to the small number of patients included in the studies available. We applied hip arthroscopy to diagnose and treat 7 patients with primary septic arthritis of the hip (2 cases with specific preoperative aspiration results, the other five cases were highly suspected of infection), which were finally confirmed by the repeated aspiration or the synovial pathology results. Infection was eradicated by hip arthroscopic therapy and antibiotic treatment, all were cured and none of the infection recurred, what’s more, this surgical approach has fast recovery and few arthroscopy-related complications . Materials and Methods The design and protocol of this monocentre retrospective study were approved by the institutional review boards, who waived informed consent. 7 patients were treated for primary septic arthritis from October 2021 to October 2022 in our institution (Shanghai Changzheng hospital). There were 3 males and 4 females with average age 48 ± 17.3 years (range: 27–73 years). Mean duration of symptoms prior to the arthroscopic lavage was 11.6 (4–45). Only 2 patient had pyrexia, and the main symptoms and signs of hip were anterior groin or hip pain with limited hip range of motion and an inability to bear weight. Diagnostic criteria joint fluid aspiration is mandatory. Septic arthritis of the hip joint was confirmed by aspirated joint fluid analysis, that is by microbiological culture or demonstration of acute suppurative synovitis by synovial tissue biopsy or synovial fluid white blood cell (WBC) count of > 50,000 cells/mm 2 with a high percentage of polymorphonuclear cells[ 9 , 10 ]. Exclusion Criteria Patients with secondary septic arthritis and implant-associated infection after surgery, or patients younger than eighteen, or patients with tuberculous and fungal infection were excluded. 3.1 Patient’s basic information Table 1 Patient’s basic information case Year sex Pro-VAS Pro-mHHS Duration of symptoms（d） Related primary disease WBC (*109/L) ESR（mm/h） CRP(mg/dl) PCT（pg/ml） IL-6 （ng/ml） 1 66 F 6 45 4 No 12.3 83 36.3 9.85 3.4 2 27 F 7 56 11 No 10.6 35 15.1 9.67 2.6 3 73 M 8 40 45 prostate cancer 13.1 80 42.5 10.02 6.5 4 48 M 5 56 5 No 11.0 45 34.2 4.64 3.2 5 32 M 5 68 6 RA 9.8 86 24.4 8.54 3.1 6 36 F 6 59 4 diabetes 10.7 110 23.0 11.0 2.1 7 51 F 8 45 6 diabetes 9.9 55 28.6 9.87 2.5 3.2 Imaging examination (1) X-ray: no characteristic change was showed, there may be showing a well-preserved joint space, different degrees of joint space stenosis, degenerative changes of the hip. (2) Hip MRI: MRI studies confirmed the increased fluid accumulation and thickening of the synovia, changes in signal intensity of the proximal femur and acetabular bone marrow, and edema of soft tissues around the affected hip joint (Fig. 1 plus arrow). MRI can also exclude extra-articular abscess formation. 3.3 Surgical methods All surgeries were performed by a senior title orthopedic surgeon skilled in hip arthroscopic techniques. All patients were placed in a supine position on a fracture table with both lower limbs were in traction at the same time. During which, the perineal column protected with a thickened soft pad was used to counter traction. The affected hip was abducted about 5°, the hip flexion was 10°, and the internal rotation was 20° to place the femoral neck parallel to the ground. After fluoroscopy confirmed that the joint space is retracted up to 8–10 mm, a 70° 5.5mm arthroscope was inserted through the anterolateral portal for initial hip joint inspection, which was created 1 cm distal and 2 cm anterior to the tip of the greater trochanter. The anterior portal was placed at the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line drawn from the tip of the greater trochanter. A banana knife was used to enlarge each portal to facilitate maneuvering of the instruments. The joint fluid was aspirated for analysis and culture (if the amount of joint fluid is not enough, 20 ml of normal saline can be injected in advance and then pump back). Microscopic can show inflammatory synovial hyperplasia, hyperemia and edema in the joint cavity, different degrees of cartilage lesion. After full rinsing, part of the synovial tissue was taken and sent for pathological examination. devitalized tissue was delibrated, exfoliated and free cartilage was removed, and continuously rinse and irrigation with 11–15 L of normal saline solution mixed with 1mL of 0.1% epinephrine. Also placement of a suction drain tube was done easily through the 5.5mm arthroscopic sheath. The suctions drains were removed after surgery depending on the volume of fluid drained. Antibiotic use In the early stage, we used antibiotics empirically, commonly used penicillin or second-generation cephalosporin. Following, we adjusted antibiotics according to drug susceptibility results, and the duration of antibiotics was 4–6 weeks (adjusted according to clinical symptoms and Inflammatory indicators levels). Postoperative Rehabilitation patients can perform hip flexion and extension at early period of postoperation. Internal and external rotation exercise in bed to prevent joint capsule fibrosis and adhesions, and then gradually started to weight-bearing walk after symptoms were relieved, part of the weight-bearing can promote soft tissue healing, reduce pain, protect the damaged joint cartilage during the inflammatory period. Once the CRP level was not elevated due to partial weight-bearing, patients were allowed to perform complete weight-bearing. The perioperative and postoperative follow-up symptoms of patients were scored by visual analogue scale (VAS) and modified Harris Hip score (mHHS), and then this surgical approach was evaluated. 3.4 Culture and treatment results Table 2 Treatment evaluation data Case Culture result Antibiotic Duration of antibiotics result complication recurrence 1 staphylococcus epidermidis Penicillin 4w cure no no 2 streptococcus hemolyticus Penicillin 30d cure no no 3 staphylococcus aureus Ampicillin 5w rapidly progressive osteoarthritis and THA was performed 5 months after arthroscopy no no 4 staphylococcus aureus Vancomycin 41d cure no no 5 staphylococcus aureus Vancomycin 4w cure no no 6 NO Cephalosporins 28d cure no no 7 escherichia coli Cephalosporins 6w cure no no Results Preoperative data of patients are shown in Table 1 . Four patients suffered related primary diseases. There were three female and 4 male patients with an average age of 44 ± 13.7 years (range 26–63 years). The mean preoperative CRP level was 29.16 ± 9.25 mg/dl (range 15.1–42.5), and the mean preoperative ESR level was 70.57 ± 26.45 mm/h (range 35–110). The mean duration of preoperative symptoms was 11.57 days (range 4–45 days). Histological analysis of intraoperative biopsy specimens of synovial tissue of all patients demonstrated acute active inflammation, and synovial fluid cultures yielded positive findings in 6 of the 7 patients. One had received oral or intravenous antibiotics before arthroscopic surgery elsewhere. The causative organism varied, but the most frequently detected pathogens were Staphylococcus aureus, which is consistent with the literature [ 11 ]. Treatment evaluation data are shown in Table 2 . All patients completed post-operative treatment according to our post-operative protocol. Infection was completely eradicated in all patients, and the inflammatory indicators gradually returned to normal levels. The mean time of CRP return to normal was 43 days (range 10–65 days) and ESR normalized at 54 days (range 15–84 days). During the mean follow-up of 24 months (range 18–30 months) no patient showed recurrence of infection. There were no significant complications during treatment. One patient underwent subsequently total hip arthroplasty (THA) five months after hip arthroscopic surgery when twice consecutive normal levels of leukocyte, ESR and CRP. The postoperative recovery was good lastly. Discussion The adult incidence of hip septic arthritis ranges from 2 to 10 per 100,000 population per year[ 6 ], representing less than 0.00001 percent of all acute admissions[ 12 , 13 ]. Hip infection can induce avascular necrosis of the femoral head through viral epiphyseal vascular thrombosis and increased intra-articular pressure[ 14 ]. Complications of undiagnosed septic arthritis include chronic osteomyelitis, extra-articular abscess formation, pathological dislocation, and sepsis[ 15 , 16 ]. If diagnosis and treatment are delayed, it can lead to rapid joint destruction, and early diagnosis and early treatment of joint infection are important to avoid joint function destruction. Complications as a result of nondiagnosed septic/infectious arthritis are chronic osteomyelitis, extra-articular abscess formations, pathologic dislocation, and sepsis [ 17 ]. Hip arthroscopy has been used for removal of cement fragments after arthroplasty, removal of cartilaginous loose bodies of synovial chondromatosis, removal of torn labrum, synovectomy, and evaluation of the status of the cartilage in posttraumatic arthritis or osteoarthritis. All patients received copious irrigation followed by placement of suction drain tubes through two arthroscopic portals. Application of hip arthroscopy is an effective method with many advantages for treatment of hip diseases. Compared with traditional open arthrotomy, the injury is less invasive, the observation and debridement can be more thoroughly, less bleeding. Besides, Complications and recurrence were relatively low, which is conducive to early functional exercise of and the recovery is good[ 18 , 19 ]. However, hip arthroscopy requires several instruments, such as a fracture table for traction, specialized instruments, and steep learning curve. Combined with the successful application of sensitive antibiotics through simple arthroscopic lavage and synovial debridement for infection of knee and shoulder. However, unlike knee joint infection often has typical symptoms such as redness, swelling, pyrexia, symptoms of hip arthritis septic are often more insidious and non-specific, thus lead it difficult to diagnose. For the diagnosis of infection, etiology result is the gold standard, and etiology and drug susceptibility results are very important for our reasonable selection of antibiotics, but how to accurately obtain samples is the key point. Hip aspiration may not draw liquid successfully. Intraoperative fluid is also faced with not being able to aspirate fluid, but we can inject fluid into the hip joint, culture the lavage solution or send next-generation sequencing, which can effectively improve the positive rate of diagnosis. For some patients with unexplained hip pain, MRI are difficult to identify and differentiate, and if the possibility of hip infection is not considered, it often leads to the wrong treatment plan and direction. Preoperative puncture is difficult to enter the hip cavity due to the deep hip joint, and even ultrasound guidance is not easy to enter the joint cavity because of the narrow gap. Traditional open arthrotomy is intuitive, but it is traumatic, easy to destroy the blood supply to the femoral head. There is also a blind area and infection cannot be completely debrided, and there is a possibility of recurrence of infection. what’s more, adult patients with hip septic arthritis tend to have related primary diseases and a weakened immune system, we believe that surgical invasion should be minimized. Hip arthroscopic lavage has little impact on hip anatomy, less damage to joints, and simple surgical operation, which can observe the internal structure of the hip joint in an all-round way, without leaving dead angles, accurately locating the infection foci, and thoroughly cleaning up the necrotic tissue of the lesion. Patients can get out of bed early, avoid complications such as deep vein thrombosis of the lower extremities, joint stiffness, muscle atrophy, etc., which is beneficial for the recovery of hip joint function. The advantages of hip arthroscopic management of joint infections are that it allows extensive and thorough debridement of necrotic synovial tissue, removal of purulent substances, the possibility of extensive adequate irrigation, as well as direct examination of cartilage, low surgical complications. Güachter[ 20 ]staged septic arthritis in four stages based on arthroscopic findings. the sealing of the central compartment by the labrum makes a lavage and debridement of the cartilage area difficult in open surgery without traction. Compared with open arthrotomy, hip arthroscopic surgery is relatively complex, with a certain learning curve, high technical requirements, and the surgeon needs to be familiar with the intra-articular structure and surrounding anatomical relationships, in addition to the necessary equipment. To prevent damage to the joint surface, the operation must be gentle and delicate. Articular surface injuries are mostly caused by the surgeon's unskilled technique, arthroscopic trocar needle core, arthroscopic scratches on the articular surface. No iatrogenic vascular or articular surface injuries were found in this study. The literature reports that different scholars differ in the diagnosis and treatment of hip arthroscopy in the treatment of primary septic arthritis mainly in the following six aspects: (1) the number of optimal arthroscopic approaches; (2) Approach location; (3) patient position; (4) the use and specific types of postoperative drainage tubes; (5) the use, dose, route and timing of antibiotics; (6) The volume and type of flushing fluid. Regarding surgical approaches: Blitzer and Boud et al. [ 21 , 22 ]both reported the first case of arthroscopic treatment of hip septic arthritis using a single approach to the hip. Kaminski et al. [ 23 ]reported that facetle joint tomy with the modified Watson Jones approach, anterior capsular fenestration, arthroscopy under traction, treatment results are good, and infection is fully controlled. Schroder et al. routinely use four approaches for hip cavity cleaning, irrigation and postoperative drainage. Young-Kyun Lee and Shukla et al.[ 24 , 25 ] use 2–3 approaches. We routinely use only 2 approaches, and various parts of the hip joint can be observed during surgery, and effective and thorough debridement can be performed, and good surgical results can be achieved from the follow-up results. Regarding the need for intraoperative drainage, Lee et al. have reported that 1–2 drainage tubes or irrigation tubes are routinely placed [ 24 ], and Schroder et al. insert two suction systems in the peripheral chamber after synovectomy and irrigation. The first drainage is placed anteriorly around the femoral neck; The second is placed in the anterolateral approach to ensure adequate drainage from the lateral and posterior sides. However, sustained postoperative intra-articular irrigation is not performed[ 26 ]. Sustained postoperative intra-articular irrigation may cause secondary infection. For antibiotics, we do not advocate intra-articular antibiotics, as Nelson et al.[ 27 ] have long shown no advantages over intra-articular administration. Moreover, intra-articular administration will cause certain damage to cartilage. For joint deformation caused by septic arthritis, disappearance of joint space, or femoral head necrosis, hip osteoarthritis and infection, the timing of THA after infection control is also worth discussing, on the one hand, the acute phase of infection is a contraindication to hip artroplasty, on the other hand, for advanced osteonecrosis of the femoral head or osteoarthritis, THA is the only method to restore joint function. Our principle is that THA can be performed with normal laboratory indicators after infection (twice consecutive normal levels of leukocyte, ESR and CRP), and the postoperative follow-up results confirm that this protocol is safe and reliable. Limitations. The primary goal of our study was to evaluate infection eradication by arthroscopic lavage in adult patients for which the limited follow-up is sufficient. However, our results do not allow conclusions in regard to the long-term functional and radiographic outcome. The small number of patients in our and other available studies is based on the low incidence of acute primary septic arthritis of the hip. we did not compare the results of arthroscopic treatment with those of other surgical options, such as repeated aspiration, open arthrotomy, or resection arthroplasty. Conclusions For patients with unexplained hip pain, limited function, and MRI manifestations of hip effusion, edema, conservative treatment such as rest and mediation fails, septic arthritis must be under consideration, hip arthroscopic lavage can be used to confirm the diagnosis, what’s more, synovectomy, debridement, combined with antibiotic use, can effectively eradiated the infection, and have few complication. In short, timely diagnosis and intervention remain the most critical prognostic factors for successful outcomes. Infection is not easy to control with simple medication, open arthrotomy is invasive, lavage through hip arthroscopy, can handle the joint cavity in an all-round way, debride the inflammatory tissues, and perform joint irrigation at the same time for eradication of infection, without increasing the destruction of the hip joint, the effect is clear. Abbreviations ESR Erythrocyte sedimentation rate CRP C-reaction protein VAS Visual analogue scale mHHS modified Harris hip score THA Total hip arthroplasty Declarations Acknowledgements We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study. Author contributions SC and ZL drafted the manuscript, YH and JS made substantial contributions to acquisition and statistical analysis of data; ZD and LZ prepared table 1-2. JP and JC revised the manuscript critically for important intellectual content and conception and design. All authors given final approval of the version to be published. Funding Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to the lack of an online platform but are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This study was conducted in accordance with the declaration of Helsinki and approved by the Ethics Committee of Shanghai Changzheng Hospital, Naval Medical University. All participants gave their informed consent in writing prior to inclusion in the study. Consent for publication Informed consent was obtained from all subjects/participants/patients and/or their legal guardian(s) for the publication of identifying information/images in an online open-access publication. Competing interests The authors declare that they have no competing interest. References Bauer T, et al. 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Outcome of arthroscopic drainage and debridement with continuous suction irrigation technique in acute septic arthritis. J Clin Orthop Trauma. 2014;5(1):1–5. Schroder JH et al. Arthroscopic Treatment for Primary Septic Arthritis of the Hip in Adults. Adv Orthop, 2016. 2016: p. 8713037. Nelson JD. Antibiotic concentrations in septic joint effusions. N Engl J Med. 1971;284(7):349–53. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4227763","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290901352,"identity":"a4df4a65-d4dd-4369-b3e2-22ee0eff5eaf","order_by":0,"name":"Shu Chen","email":"","orcid":"","institution":"Zhabei Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shu","middleName":"","lastName":"Chen","suffix":""},{"id":290901353,"identity":"28d42f02-c9b2-476f-93b6-5d03fa829d5f","order_by":1,"name":"Zi-ye Liu","email":"","orcid":"","institution":"Changzheng Hospital, Second Military Medical 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University","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Cao","suffix":""},{"id":290901360,"identity":"a23555d0-adc6-4ca1-99a7-e77cdbb7f91a","order_by":8,"name":"Jinghui peng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYLACCQOGBAZm5gMHEgwk5NjY2w8Qq4Ut8cGDAhtjPp4zCURZBFTFY2z44ENa4jwJBwO8Ss3Zew+/sCi4k2dwnMFMIsHgcHqbBFD/j4ptOLVY9pxLs5AweFZscJghDaQlt0268QBjz5nbOLUY3MgxM5AwOJy44TDDMYgWmQMJzIxteLTcfwPTwtgGdhgbkMSv5QaP8QOIFmZmgwSDtASCWix7cswYQFpmHmZjfJBgYGPYBgzkg/j8Ys5+xvizxJ/DiX3nz384+OOPhLx8e/vBBz8q8DiMgYFNWgJd9ABO9RAtzB8/4FMxCkbBKBgFowAAHJxdy6CH0WoAAAAASUVORK5CYII=","orcid":"","institution":"Changzheng Hospital, Second Military Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jinghui","middleName":"","lastName":"peng","suffix":""}],"badges":[],"createdAt":"2024-04-06 14:00:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4227763/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4227763/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54994785,"identity":"cbf81f38-0899-447a-89ac-54edcd47a863","added_by":"auto","created_at":"2024-04-19 17:49:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":136827,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative MRI (CASE4: the presence of synovial thickening, signal intensity alterations of the bone marrow of both proximal femur and acetabulum, and soft tissue exhibiting strong enhancement around the left hip)\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4227763/v1/f5d959e5235ae759ddcf70c9.jpg"},{"id":54996375,"identity":"d4f0fd49-3e48-4ac0-812e-5db0de21a39b","added_by":"auto","created_at":"2024-04-19 17:57:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1049329,"visible":true,"origin":"","legend":"\u003cp\u003ecase 1:Hip arthroscopic intraoperative photo: synovial hyperplasia and hyperemia\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4227763/v1/b2a4f18ff5a3a638d4221b1f.png"},{"id":54994787,"identity":"93aed9fc-0b01-4708-9ab7-ca8c5aaaca93","added_by":"auto","created_at":"2024-04-19 17:49:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1084627,"visible":true,"origin":"","legend":"\u003cp\u003eCase 6:the joint space stenosis when the initial infection was diagnosed and the cartilage was extensively destroyed, thus the joint collapse was followed, and THA was subsequently performed\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4227763/v1/950f9f9ced9c54aab56a5e0e.png"},{"id":56840191,"identity":"37de553b-9ea5-4133-a28a-2b278d3a3a07","added_by":"auto","created_at":"2024-05-21 06:46:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3758773,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4227763/v1/c94ac57e-aa38-4983-aa09-7a6f29d54eda.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The application of hip arthroscopy for the management of septic arthritis in adults","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary septic arthritis of the hip is a rare differential diagnosis of acute hip pain in adults with an estimated mortality rate of 11%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Symptoms mainly include pain and limited hip range of motion in hip. Due to strong muscular and ligamentous wraps around the hip joint, there is often no typical symptom such as redness, swelling, and pyrexia. there are also no specific proprietary signs. The joint cavity effusion and thickening of the synovium can be presented in MRI. It is difficult to distinguish infectious effusion with rheumatoid arthritis or traumatic effusion. Early diagnosis highly depends on doctor\u0026rsquo;s clinical experience and etiology. Delayed diagnosis and intervention may lead to dissemination of infection, prolongation of treatment, cartilage damage, joint deformation, and even lead to disability[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the early diagnosis of hip infection, aspiration was frequently used, but as the articular cavity is covered by several muscles and ligaments, it is hard to pinpoint and draw fluid easily, besides, with the low positive rate of culture results, repeated aspiration is mostly required. Treatment methods include: 1. Long-term high-dose antibiotic therapy: in the absence of clear etiology and drug sensitivity results, antibiotic treatment merely base on clinical experience, it may lead to drug resistance. 2. open arthrotomy: open arthrotomy remains the gold standard for treatment of septic arthritis of the native hip[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but may have many complications such as osteonecrosis of the femoral head, dislocation, and cosmesis problem. Besides, patients are often less receptive to open surgery, what\u0026rsquo;s more, debate persists as to which approach is the best option[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMinimally invasive and precision surgery are the trends of joint surgery in recent years. The indications for hip arthroscopic therapy are also expanding and have been reported for the treatment of septic arthritis in paediatric population[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but few studies have specifically addressed arthroscopic management of septic arthritis of the hip in adults, and there remains uncertainty about the success of arthroscopic treatment. No consensus has been reached so far, probably due to the small number of patients included in the studies available. We applied hip arthroscopy to diagnose and treat 7 patients with primary septic arthritis of the hip (2 cases with specific preoperative aspiration results, the other five cases were highly suspected of infection), which were finally confirmed by the repeated aspiration or the synovial pathology results. Infection was eradicated by hip arthroscopic therapy and antibiotic treatment, all were cured and none of the infection recurred, what\u0026rsquo;s more, this surgical approach has fast recovery and few arthroscopy-related complications .\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe design and protocol of this monocentre retrospective study were approved by the institutional review boards, who waived informed consent.\u003c/p\u003e\n\u003cp\u003e7 patients were treated for primary septic arthritis from October 2021 to October 2022 in our institution (Shanghai Changzheng hospital). There were 3 males and 4 females with average age 48\u0026thinsp;\u0026plusmn;\u0026thinsp;17.3 years (range: 27\u0026ndash;73 years). Mean duration of symptoms prior to the arthroscopic lavage was 11.6 (4\u0026ndash;45). Only 2 patient had pyrexia, and the main symptoms and signs of hip were anterior groin or hip pain with limited hip range of motion and an inability to bear weight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ejoint fluid aspiration is mandatory. Septic arthritis of the hip joint was confirmed by aspirated joint fluid analysis, that is by microbiological culture or demonstration of acute suppurative synovitis by synovial tissue biopsy or synovial fluid white blood cell (WBC) count of \u0026gt;\u0026thinsp;50,000 cells/mm\u003csup\u003e2\u003c/sup\u003e with a high percentage of polymorphonuclear cells[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with secondary septic arthritis and implant-associated infection after surgery, or patients younger than eighteen, or patients with tuberculous and fungal infection were excluded.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Patient\u0026rsquo;s basic information\u003c/h2\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient\u0026rsquo;s basic information\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003ecase\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003eYear\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003esex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003ePro-VAS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003ePro-mHHS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003eDuration of symptoms（d）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eRelated primary disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eWBC\u003c/p\u003e\n\u003cp\u003e(*109/L)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003eESR（mm/h）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eCRP(mg/dl)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003ePCT（pg/ml）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003eIL-6\u003c/p\u003e\n\u003cp\u003e（ng/ml）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e12.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e36.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e9.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e3.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e10.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e15.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e9.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eprostate cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e13.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e42.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e10.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e6.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e11.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e34.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e4.64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e3.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003eRA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e9.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e24.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e8.54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e3.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003ediabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e10.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e110\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e23.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e11.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e2.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"28\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"33\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"60\"\u003e\n\u003cp\u003ediabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e9.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003e28.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e9.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"55\"\u003e\n\u003cp\u003e2.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e3.2 Imaging examination\u003c/h2\u003e\n\u003cp\u003e(1) X-ray: no characteristic change was showed, there may be showing a well-preserved joint space, different degrees of joint space stenosis, degenerative changes of the hip.\u003c/p\u003e\n\u003cp\u003e(2) Hip MRI: MRI studies confirmed the increased fluid accumulation and thickening of the synovia, changes in signal intensity of the proximal femur and acetabular bone marrow, and edema of soft tissues around the affected hip joint (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e plus arrow). MRI can also exclude extra-articular abscess formation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e3.3 Surgical methods\u003c/h2\u003e\n\u003cp\u003eAll surgeries were performed by a senior title orthopedic surgeon skilled in hip arthroscopic techniques. All patients were placed in a supine position on a fracture table with both lower limbs were in traction at the same time. During which, the perineal column protected with a thickened soft pad was used to counter traction. The affected hip was abducted about 5\u0026deg;, the hip flexion was 10\u0026deg;, and the internal rotation was 20\u0026deg; to place the femoral neck parallel to the ground. After fluoroscopy confirmed that the joint space is retracted up to 8\u0026ndash;10 mm, a 70\u0026deg; 5.5mm arthroscope was inserted through the anterolateral portal for initial hip joint inspection, which was created 1 cm distal and 2 cm anterior to the tip of the greater trochanter. The anterior portal was placed at the intersection of a sagittal line drawn distally from the anterior superior iliac spine and a transverse line drawn from the tip of the greater trochanter. A banana knife was used to enlarge each portal to facilitate maneuvering of the instruments. The joint fluid was aspirated for analysis and culture (if the amount of joint fluid is not enough, 20 ml of normal saline can be injected in advance and then pump back). Microscopic can show inflammatory synovial hyperplasia, hyperemia and edema in the joint cavity, different degrees of cartilage lesion. After full rinsing, part of the synovial tissue was taken and sent for pathological examination. devitalized tissue was delibrated, exfoliated and free cartilage was removed, and continuously rinse and irrigation with 11\u0026ndash;15 L of normal saline solution mixed with 1mL of 0.1% epinephrine. Also placement of a suction drain tube was done easily through the 5.5mm arthroscopic sheath. The suctions drains were removed after surgery depending on the volume of fluid drained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAntibiotic use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the early stage, we used antibiotics empirically, commonly used penicillin or second-generation cephalosporin. Following, we adjusted antibiotics according to drug susceptibility results, and the duration of antibiotics was 4\u0026ndash;6 weeks (adjusted according to clinical symptoms and Inflammatory indicators levels).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Rehabilitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003epatients can perform hip flexion and extension at early period of postoperation. Internal and external rotation exercise in bed to prevent joint capsule fibrosis and adhesions, and then gradually started to weight-bearing walk after symptoms were relieved, part of the weight-bearing can promote soft tissue healing, reduce pain, protect the damaged joint cartilage during the inflammatory period. Once the CRP level was not elevated due to partial weight-bearing, patients were allowed to perform complete weight-bearing.\u003c/p\u003e\n\u003cp\u003eThe perioperative and postoperative follow-up symptoms of patients were scored by visual analogue scale (VAS) and modified Harris Hip score (mHHS), and then this surgical approach was evaluated.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e3.4 Culture and treatment results\u003c/h2\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTreatment evaluation data\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCase\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCulture result\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAntibiotic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDuration of antibiotics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eresult\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ecomplication\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003erecurrence\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003estaphylococcus epidermidis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePenicillin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4w\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003estreptococcus hemolyticus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePenicillin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30d\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003estaphylococcus aureus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAmpicillin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5w\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003erapidly progressive osteoarthritis and THA was performed 5 months after arthroscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003estaphylococcus aureus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVancomycin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41d\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003estaphylococcus aureus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVancomycin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4w\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCephalosporins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28d\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eescherichia coli\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCephalosporins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6w\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eno\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePreoperative data of patients are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Four patients suffered related primary diseases. There were three female and 4 male patients with an average age of 44\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7 years (range 26\u0026ndash;63 years). The mean preoperative CRP level was 29.16\u0026thinsp;\u0026plusmn;\u0026thinsp;9.25 mg/dl (range 15.1\u0026ndash;42.5), and the mean preoperative ESR level was 70.57\u0026thinsp;\u0026plusmn;\u0026thinsp;26.45 mm/h (range 35\u0026ndash;110). The mean duration of preoperative symptoms was 11.57 days (range 4\u0026ndash;45 days). Histological analysis of intraoperative biopsy specimens of synovial tissue of all patients demonstrated acute active inflammation, and synovial fluid cultures yielded positive findings in 6 of the 7 patients. One had received oral or intravenous antibiotics before arthroscopic surgery elsewhere. The causative organism varied, but the most frequently detected pathogens were Staphylococcus aureus, which is consistent with the literature [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eTreatment evaluation data are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. All patients completed post-operative treatment according to our post-operative protocol. Infection was completely eradicated in all patients, and the inflammatory indicators gradually returned to normal levels. The mean time of CRP return to normal was 43 days (range 10\u0026ndash;65 days) and ESR normalized at 54 days (range 15\u0026ndash;84 days). During the mean follow-up of 24 months (range 18\u0026ndash;30 months) no patient showed recurrence of infection. There were no significant complications during treatment. One patient underwent subsequently total hip arthroplasty (THA) five months after hip arthroscopic surgery when twice consecutive normal levels of leukocyte, ESR and CRP. The postoperative recovery was good lastly.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe adult incidence of hip septic arthritis ranges from 2 to 10 per 100,000 population per year[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], representing less than 0.00001 percent of all acute admissions[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Hip infection can induce avascular necrosis of the femoral head through viral epiphyseal vascular thrombosis and increased intra-articular pressure[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Complications of undiagnosed septic arthritis include chronic osteomyelitis, extra-articular abscess formation, pathological dislocation, and sepsis[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. If diagnosis and treatment are delayed, it can lead to rapid joint destruction, and early diagnosis and early treatment of joint infection are important to avoid joint function destruction. Complications as a result of nondiagnosed septic/infectious arthritis are chronic osteomyelitis, extra-articular abscess formations, pathologic dislocation, and sepsis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hip arthroscopy has been used for removal of cement fragments after arthroplasty, removal of cartilaginous loose bodies of synovial chondromatosis, removal of torn labrum, synovectomy, and evaluation of the status of the cartilage in posttraumatic arthritis or osteoarthritis. All patients received copious irrigation followed by placement of suction drain tubes through two arthroscopic portals. Application of hip arthroscopy is an effective method with many advantages for treatment of hip diseases. Compared with traditional open arthrotomy, the injury is less invasive, the observation and debridement can be more thoroughly, less bleeding. Besides, Complications and recurrence were relatively low, which is conducive to early functional exercise of and the recovery is good[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, hip arthroscopy requires several instruments, such as a fracture table for traction, specialized instruments, and steep learning curve. Combined with the successful application of sensitive antibiotics through simple arthroscopic lavage and synovial debridement for infection of knee and shoulder. However, unlike knee joint infection often has typical symptoms such as redness, swelling, pyrexia, symptoms of hip arthritis septic are often more insidious and non-specific, thus lead it difficult to diagnose. For the diagnosis of infection, etiology result is the gold standard, and etiology and drug susceptibility results are very important for our reasonable selection of antibiotics, but how to accurately obtain samples is the key point. Hip aspiration may not draw liquid successfully. Intraoperative fluid is also faced with not being able to aspirate fluid, but we can inject fluid into the hip joint, culture the lavage solution or send next-generation sequencing, which can effectively improve the positive rate of diagnosis. For some patients with unexplained hip pain, MRI are difficult to identify and differentiate, and if the possibility of hip infection is not considered, it often leads to the wrong treatment plan and direction. Preoperative puncture is difficult to enter the hip cavity due to the deep hip joint, and even ultrasound guidance is not easy to enter the joint cavity because of the narrow gap.\u003c/p\u003e \u003cp\u003eTraditional open arthrotomy is intuitive, but it is traumatic, easy to destroy the blood supply to the femoral head. There is also a blind area and infection cannot be completely debrided, and there is a possibility of recurrence of infection. what\u0026rsquo;s more, adult patients with hip septic arthritis tend to have related primary diseases and a weakened immune system, we believe that surgical invasion should be minimized. Hip arthroscopic lavage has little impact on hip anatomy, less damage to joints, and simple surgical operation, which can observe the internal structure of the hip joint in an all-round way, without leaving dead angles, accurately locating the infection foci, and thoroughly cleaning up the necrotic tissue of the lesion. Patients can get out of bed early, avoid complications such as deep vein thrombosis of the lower extremities, joint stiffness, muscle atrophy, etc., which is beneficial for the recovery of hip joint function. The advantages of hip arthroscopic management of joint infections are that it allows extensive and thorough debridement of necrotic synovial tissue, removal of purulent substances, the possibility of extensive adequate irrigation, as well as direct examination of cartilage, low surgical complications. G\u0026uuml;achter[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]staged septic arthritis in four stages based on arthroscopic findings. the sealing of the central compartment by the labrum makes a lavage and debridement of the cartilage area difficult in open surgery without traction.\u003c/p\u003e \u003cp\u003eCompared with open arthrotomy, hip arthroscopic surgery is relatively complex, with a certain learning curve, high technical requirements, and the surgeon needs to be familiar with the intra-articular structure and surrounding anatomical relationships, in addition to the necessary equipment. To prevent damage to the joint surface, the operation must be gentle and delicate. Articular surface injuries are mostly caused by the surgeon's unskilled technique, arthroscopic trocar needle core, arthroscopic scratches on the articular surface. No iatrogenic vascular or articular surface injuries were found in this study.\u003c/p\u003e \u003cp\u003eThe literature reports that different scholars differ in the diagnosis and treatment of hip arthroscopy in the treatment of primary septic arthritis mainly in the following six aspects: (1) the number of optimal arthroscopic approaches; (2) Approach location; (3) patient position; (4) the use and specific types of postoperative drainage tubes; (5) the use, dose, route and timing of antibiotics; (6) The volume and type of flushing fluid.\u003c/p\u003e \u003cp\u003eRegarding surgical approaches: Blitzer and Boud et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]both reported the first case of arthroscopic treatment of hip septic arthritis using a single approach to the hip. Kaminski et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]reported that facetle joint tomy with the modified Watson Jones approach, anterior capsular fenestration, arthroscopy under traction, treatment results are good, and infection is fully controlled. Schroder et al. routinely use four approaches for hip cavity cleaning, irrigation and postoperative drainage. Young-Kyun Lee and Shukla et al.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] use 2\u0026ndash;3 approaches. We routinely use only 2 approaches, and various parts of the hip joint can be observed during surgery, and effective and thorough debridement can be performed, and good surgical results can be achieved from the follow-up results.\u003c/p\u003e \u003cp\u003eRegarding the need for intraoperative drainage, Lee et al. have reported that 1\u0026ndash;2 drainage tubes or irrigation tubes are routinely placed [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and Schroder et al. insert two suction systems in the peripheral chamber after synovectomy and irrigation. The first drainage is placed anteriorly around the femoral neck; The second is placed in the anterolateral approach to ensure adequate drainage from the lateral and posterior sides. However, sustained postoperative intra-articular irrigation is not performed[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Sustained postoperative intra-articular irrigation may cause secondary infection.\u003c/p\u003e \u003cp\u003eFor antibiotics, we do not advocate intra-articular antibiotics, as Nelson et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] have long shown no advantages over intra-articular administration. Moreover, intra-articular administration will cause certain damage to cartilage.\u003c/p\u003e \u003cp\u003eFor joint deformation caused by septic arthritis, disappearance of joint space, or femoral head necrosis, hip osteoarthritis and infection, the timing of THA after infection control is also worth discussing, on the one hand, the acute phase of infection is a contraindication to hip artroplasty, on the other hand, for advanced osteonecrosis of the femoral head or osteoarthritis, THA is the only method to restore joint function. Our principle is that THA can be performed with normal laboratory indicators after infection (twice consecutive normal levels of leukocyte, ESR and CRP), and the postoperative follow-up results confirm that this protocol is safe and reliable.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations.\u003c/b\u003e The primary goal of our study was to evaluate infection eradication by arthroscopic lavage in adult patients for which the limited follow-up is sufficient. However, our results do not allow conclusions in regard to the long-term functional and radiographic outcome. The small number of patients in our and other available studies is based on the low incidence of acute primary septic arthritis of the hip. we did not compare the results of arthroscopic treatment with those of other surgical options, such as repeated aspiration, open arthrotomy, or resection arthroplasty.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFor patients with unexplained hip pain, limited function, and MRI manifestations of hip effusion, edema, conservative treatment such as rest and mediation fails, septic arthritis must be under consideration, hip arthroscopic lavage can be used to confirm the diagnosis, what\u0026rsquo;s more, synovectomy, debridement, combined with antibiotic use, can effectively eradiated the infection, and have few complication.\u003c/p\u003e \u003cp\u003eIn short, timely diagnosis and intervention remain the most critical prognostic factors for successful outcomes. Infection is not easy to control with simple medication, open arthrotomy is invasive, lavage through hip arthroscopy, can handle the joint cavity in an all-round way, debride the inflammatory tissues, and perform joint irrigation at the same time for eradication of infection, without increasing the destruction of the hip joint, the effect is clear.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eESR \u0026nbsp; Erythrocyte sedimentation rate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCRP \u0026nbsp; C-reaction protein\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS \u0026nbsp; Visual analogue scale\u003c/p\u003e\n\u003cp\u003emHHS \u0026nbsp;modified Harris hip score\u003c/p\u003e\n\u003cp\u003eTHA \u0026nbsp;Total hip arthroplasty\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSC and ZL drafted the manuscript, YH and JS made substantial contributions to acquisition and statistical analysis of data; ZD and LZ prepared table 1-2. JP and JC revised the manuscript critically for important intellectual content and conception and design. All authors given final approval of the version to be published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to the lack of an online platform but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate This study was conducted in accordance with the declaration of Helsinki and approved by the Ethics Committee of Shanghai Changzheng Hospital, Naval Medical University. All participants gave their informed consent in writing prior to inclusion in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects/participants/patients and/or their legal guardian(s) for the publication of identifying information/images in an online open-access publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBauer T, et al. Arthroplasty following a septic arthritis history: a 53 cases series. Orthop Traumatol Surg Res. 2010;96(8):840\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKao FC, et al. High 2-year mortality and recurrent infection rates after surgical treatment for primary septic arthritis of the hip in adult patients: An observational study. Med (Baltim). 2019;98(32):e16765.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathews CJ, et al. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunter JG, et al. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLum ZC, Shieh AK, Meehan JP. Native Adult Hip with Bacterial Septic Arthritis. JBJS Rev. 2018;6(10):e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldenberg DL. Septic arthritis. Lancet. 1998;351(9097):197\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGivon U, Ganel A. Re: Treatment of early septic arthritis of the hip in children: comparison of results of open arthrotomy versus arthroscopic drainage. J Child Orthop. 2008;2(6):499.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNusem I, McAlister A. Arthroscopic lavage for the treatment of septic arthritis of the hip in children. Acta Orthop Belg. 2012;78(6):730\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBulmer JH. Septic arthritis of the hip in adults. J Bone Joint Surg Br. 1966;48(2):289\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford). 2001;40(1):24\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeipel U. Pathogenic organisms in hip joint infections. Int J Med Sci. 2009;6(5):234\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShulman G, Waugh TR. Acute bacterial arthritis in the adult. Orthop Rev. 1988;17(10):955\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorgan DS, et al. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect. 1996;117(3):423\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMargaretten ME, et al. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvrard J, Soudrie B. Primary arthritis of the hip in adults]. Int Orthop. 1993;17(6):367\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeargan SA 3rd, et al. Hematogenous septic arthritis of the adult hip. Orthopedics. 2003;26(8):771\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Angelo F, Monestier L, Zagra L. Active septic arthritis of the hip in adults: what's new in the treatment? A systematic review. EFORT Open Rev. 2021;6(3):164\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvey M, Clark R. Arthroscopic debridement of the knee for septic arthritis. Clin Orthop Relat Res, 1985(199): p. 201\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly MA. Role of arthroscopic debridement in the arthritic knee. J Arthroplasty. 2006;21(4 Suppl 1):9\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGachter A. \u003cem\u003eDer Gelenkinfekt.\u003c/em\u003e Inform Arzt, 1985. 6: pp. 35\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlitzer CM. Arthroscopic management of septic arthritis of the hip. Arthroscopy. 1993;9(4):414\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBould M, Edwards D, Villar RN. Arthroscopic diagnosis and treatment of septic arthritis of the hip joint. Arthroscopy. 1993;9(6):707\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaminski A, Muhr G, Kutscha-Lissberg F. Modified open arthroscopy in the treatment of septic arthritis of the hip. Ortop Traumatol Rehabil. 2007;9(6):599\u0026ndash;603.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee YK, et al. Arthroscopic treatment for acute septic arthritis of the hip joint in adults. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):942\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShukla A, Beniwal SK, Sinha S. Outcome of arthroscopic drainage and debridement with continuous suction irrigation technique in acute septic arthritis. J Clin Orthop Trauma. 2014;5(1):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchroder JH et al. \u003cem\u003eArthroscopic Treatment for Primary Septic Arthritis of the Hip in Adults.\u003c/em\u003e Adv Orthop, 2016. 2016: p. 8713037.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson JD. Antibiotic concentrations in septic joint effusions. N Engl J Med. 1971;284(7):349\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"primary infection septic arthritis hip arthroscopy","lastPublishedDoi":"10.21203/rs.3.rs-4227763/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4227763/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e Primary septic arthritis of the hip is a rare differential diagnosis of acute hip pain in adults, but if it is not diagnosed and treated in time, it often leads to irreversible joint damages. However, the diagnostic options of primary septic arthritis of the hip are limited. The accurate aspiration is difficult to achieve, and the traditional open arthrotomy is invasive and associated with high rates of potential complications. We used hip arthroscopy for the diagnosis and intervention of primary septic arthritis of the hip in adults and evaluated their safety and efficacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Seven patients (4 female, 3 male), average age 48±17.3 years with unexplained acute pain and limited hip joint were included. Septic arthritis was confirmed by aspirated joint fluid analysis or synovial pathology. Surgical treatment consisted of immediate arthroscopic lavage using only 2 portals for debridement, high-volume irrigation, partial synovectomy, and drainage. Antibiotics were used according to drug susceptibility results or empirically. The symptoms, related primary disease, levels of inflammatory indicators, bacterial culture results, surgical complications, duration of antibiotic use, and follow-up results were all recorded and analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e The median duration of symptoms prior to the arthroscopic lavage was 11.6 (4-45) days. All patients had different degrees of leukocytosis and elevated level of erythrocyte sedimentation rate (ESR) and C-reaction protein (CRP). 2 cases got positive results of preoperative bacterial culture results, and 6 cases got positive results of postoperative bacterial culture results, among which Staphylococcus aureus was the most frequently detected pathogen (3 cases). Antibiotics were administered for 4-6 weeks. After an average of 43 days after surgery, CRP returned to physiological levels, ESR returned to normal in 54 days, and after follow-up for 6 months, the average score of Visual Analogue Scale (VAS) decreased from 6.4±1.3 points to 1.3±0.2 points (p\u0026lt;0.05), and the average score of modified harris hip score（mHHS） increased from 53±9.8 points to 85±8.6 points (p \u0026lt; 0.05). None of the patients had significant surgical complications. During the mean follow-up for 24 months (range 18–30 months), no patient showed recurrence of infection, while 1 case underwent subsequent total hip arthroplasty due to serious destruction of articular cartilage and rapidly progressive degeneration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003e\u0026nbsp;Hip Arthroscopic therapy is a safe and effective method for the diagnosis and intervention of primary septic arthritis of the hip without dissemination, which is reliable, tends to be less invasive and more thorough than the traditional open arthrotomy.\u003c/p\u003e","manuscriptTitle":"The application of hip arthroscopy for the management of septic arthritis in adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 17:49:48","doi":"10.21203/rs.3.rs-4227763/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b78ca010-e3b0-4a5d-8625-d43eeaeb4441","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-21T06:38:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-19 17:49:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4227763","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4227763","identity":"rs-4227763","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}