The most important finding in this study is that the arthroscopic multi-channel combined approach for the treatment of knee joint cavity infection with calf infusion abscess is a safe and effective surgical method with high overall satisfaction. Knee joint infection is a joint inflammation of the knee caused by microbial infection such as bacteria. The pathogenic factors can be divided into primary and secondary. Primary infection is caused by the invasion of bacteria from other infected sites, blood or lymphatic system. Secondary infections are local puncture or trauma that lead to direct bacterial invasion. Complications of knee joint infection: joint degeneration, soft tissue injury and contracture, osteomyelitis, joint fibrous and bony ankylosis, severe consequences are sepsis and death. Therefore, early diagnosis and treatment are the decisive factors for the final outcome [10]. Knee abscess can extend to the calf and even the foot through the deep and shallow space on the back of the tibia. There are two obvious flow channels from the knee to the calf. One is formed by wrapping the posterior medial path of downward flow from the rupture of the joint capsule. The other is the posterolateral path through the popliteal tendon hiatus.
The main symptoms of knee joint infection with peri-knee abscess are: local pain, swelling, and limited mobility, with an incidence of 78%-85% [11]. Common signs are: joint tenderness, effusion, redness and swelling, and decreased passive mobility. Often in flexion due to pain and effusion. In imaging examinations, knee MRI is the most important examination method for the diagnosis of soft tissue abscesses [12]. The advantages of knee MRI application are: (1)Observe whether the abscess is connected to the joint cavity, which is of reference value for the selection of arthroscopic surgery; (2)The resolution of the soft tissue in the joint is high, the position, size and scope of the abscess can be clearly displayed, and other substances can be identified Sexual mass. Patients in this group were treated with diagnostic antibiotics first, and finally the antibiotic regimen was adjusted according to the results of drug sensitivity to ensure the exact curative effect. The most common bacterial culture result is Staphylococcus aureus, followed by Streptococcus and other Gram-positive bacteria [13, 14, 15, 16]. As shown in Table 1, 9 of the 15 patients in this study (60%) had preoperative and postoperative bacterial culture results of Staphylococcus aureus, which was basically consistent with 50% to 60% reported in the literature. It is worth noting that 1 patient (6.6%) had a bacterial culture result of Staphylococcus epidermidis. Analyzing the reason for its infection of this normal flora may be the weakened immunity of elderly patients. The diagnosis of knee joint infection with calf abscess should be comprehensively evaluated based on the patient's medical history, clinical symptoms, signs, imaging findings and laboratory indicators. In laboratory examinations, dynamic monitoring of changes in ESR and CRP can be used to judge the control of the disease and guide the course of antibiotic use. ESR and CRP at the last follow-up of this study were significantly lower than those before surgery;
Arthroscopic surgery is currently a more recognized surgical method for the treatment of knee joint infections [7,8,9]. But for patients with calf abscess, most clinicians will choose traditional open surgery, with stage I drainage of the abscess and stage II resection of the cyst wall tissue. If there are abscesses both inside and outside the knee joint, the traditional open surgery using a single approach cannot completely clean the popliteal tendon hiatus area. It is often necessary to expand the wound and change the position during the operation, which is prone to contamination. Arthroscopic technology can enter through the interstitial space and clean the area smoothly, thereby avoiding damage to important tissue structures. Nair et al [17]. showed that the cure rates of joint puncture/lavage and traditional incision were 79% and 84%, respectively. All patients in this group did not undergo lavage and drainage after surgery. The reason was that the calf muscle gap was large, and the lavage drainage fluid would penetrate into the muscle gap, which would aggravate the swelling and affect recovery. Faour et al. [7]conducted a study on 695 patients with knee joint infections through the ACSNSQIP database and showed that compared with open irrigation and debridement, patients undergoing arthroscopic surgery had lower blood transfusion rates and adverse events within 30 days after surgery. , The discharge rate is better, and the short-term effect is good. In this study, the arthroscopic multi-channel combined approach was used to treat knee joint cavity infection with calf injection abscess. It has the following advantages: (1)Small incision on the side of the calf, short healing time, small healing scar, has a certain cosmetic effect, and relieves the patient's psychology and economy burden. (2)The internal and external multiple approaches above the calf are converted into the back of the calf to inject the abscess area, which can provide clear and broad intraoperative vision and operation space, fully clean up the lesion tissue in the joint, and more effectively inject the popliteal fossa and the abscess. The regional capsule wall is thoroughly cleaned and flushed. (3)Easy to operate, no need to carefully dissect the rear structure of the calf, which can shorten the operation time. (4)There is no need to continuously change the position, open the patella, and repeatedly disinfect the drape during the operation, which greatly reduces the spread of infection and the risk of recurrence. Therefore, compared with traditional open surgery, the arthroscopic multi-channel combined approach treatment method is more in line with the concept of minimally invasive treatment, cleans up more thoroughly, reduces the occurrence of postoperative adhesions, and reduces deep vein thrombosis, joint stiffness, muscle atrophy and other complications[7,8,18,19]. Johns et al. [16] found that arthroscopic treatment can produce better postoperative range of motion and shorter hospital stay. Bohler et al. [20] also showed that the knee mobility of patients undergoing arthroscopic debridement was significantly improved. The postoperative pain of 15 patients in this group was significantly relieved. According to the Lysholm score, the knee function was excellent in 12 cases, good in 2 cases, and fair in 1 case. The excellent and good effective rate was 93.3%. This is basically consistent with the recently reported cure rate of 93-97% [7,19]. However, it is worth noting that postoperative drainage, early rehabilitation, and the use of antibiotics in the foot treatment are essential and important links for the recovery of the disease [9,14,15]; it also raises the doctor’s proficiency in arthroscopic techniques Higher requirements, such as accidental operation and easy damage to blood vessels, nerves and muscles.
The main points of the operation of the arthroscopic multi-channel combined approach during the operation are: (1)The posterolateral approach should be established slightly higher than usual by about 0.5cm in order to obtain a wide enough field of view; (2)Clean the posterior and popliteal tendon hiatus area when necessary Use curved planer heads and control the attractive force of the planer to avoid damaging the front and rear fibers of the meniscus and popliteal tendon hiatus, and avoid damaging the stability of the meniscus; (3)Pay attention to the lower surface of the meniscus and the area between the cruciate ligaments, the cruciate ligament and the femoral condyle When necessary, the area is also cleaned with a curved planer head or even with a 70° mirror. (4)The medial abscess should be cleaned down as far as possible in accordance with the arthroscopic clearing of popliteal cysts to avoid excessive cleaning inward and damage to the posterior blood vessels and nerves; (5)When establishing a high posterolateral approach, be careful not to damage the stop point of the lateral collateral ligament. Arthroscopy should Extending in the direction of the popliteal tendon is convenient for observing the area of the popliteal tendon hiatus, and clearing the hiatus between the popliteal tendon through the posterolateral approach, and if necessary, the curved planer is cleaned. At the same time, when entering the popliteal tendon hiatus area through the posterolateral approach, pay attention to the direction of the fibular head to prevent posterior damage to the common peroneal nerve; (6)The posterior calf abscess will form a large cavity after the removal. Bed rehabilitation training [9]; (7) Use 5% iodophor to soak the infected particle lesions that cannot be distinguished by the naked eye in order to completely eliminate the infected lesion tissue. Limitations: This study is a retrospective analysis and a prospective randomized controlled study of arthroscopic multi-channel approach and traditional open surgery has not been carried out; the number of selected cases in this study is small, the follow-up time is limited, and its long-term efficacy still needs Follow up further. In the future, it is necessary to conduct further studies with a larger sample size to provide more evidence.