EQUINE VETERINARY EDUCATION Equine vet. Educ. (2022) 34 (7) 389-392 doi: 10.1111/eve.13544
Critically Appraised Topic
Surgical treatment of synovial sepsis: Is endoscopy the best approach?
J. Gillingham and T. S. Mair Bell Equine Veterinary Clinic, Kent, UK *Corresponding author email:
joanna@gillingham.me
Keywords: horse; synovial; sepsis; treatment; surgical
Summary Treatment of synovial sepsis (septic arthritis, bursitis and tenosynovitis) typically involves surgical lavage of the infected synovial cavity(ies). The two most used techniques are through-and-through needle lavage and endoscopic lavage. Endoscopic lavage is considered to have several advantages, and anecdotally, there appears to be a general shift towards favouring this technique. However, there are only a limited number of published studies directly comparing the outcomes of the two treatment techniques. The available published literature suggests that the outcomes (short-term survival, return to work) are comparable. Further studies are required to expand the available veterinary literature and to assess such factors as the costs associated with the different treatment methods. A variation in diagnostic values used for diagnosing synovial sepsis is apparent in the current literature and further clarification of inclusion/diagnostic criteria would be useful for clinicians.
Introduction
Synovial sepsis is a common reason for horses to be referred and treated in equine hospitals. A variety of definitions for synovial sepsis can be found in the veterinary literature and terms such as synovial infection and synovial contamination are also used (Crosby et al., 2019; Hackett, 2015; Wright et al., 2003). In a clinical setting, the results of a thorough clinical
examination combined with diagnostic tests (such as synovial fluid analysis and diagnostic imaging) direct the clinician to a diagnosis of synovial sepsis. The causes include traumatic injury, wounds (Milner et al., 2014), foreign body penetration (e.g. organic material such as blackthorn [Ashton, 2018]), iatrogenic causes (Lapointe et al., 1992) and haematogenous spread, the latter more commonly seen in neonates (Crosby et al., 2019; Lindegaard et al., 2021). Synovial sepsis is a serious, potentially life-threatening and performance-limiting condition (Richardson & Stewart, 2019). Rapid diagnosis and aggressive treatment are important to eliminate the infection and minimise damage to the affected synovial structure. High volume lavage, with a sterile balanced electrolyte solution, is the mainstay of therapy (Richardson & Stewart, 2019), along with antibiotic therapy and pain relief. The two most used surgical lavage techniques are through-and-through needle lavage and endoscopic lavage (Koch, 1979; McIlwraith, 1983; Meijer et al., 2000; Wright et al., 2003). Arthroscopic lavage is commonly advocated as being more effective and has advantages over through-and-through needle lavage because it allows more accurate and targeted fluid delivery,
higher flow rates through arthroscopic cannulas, the ability to remove fibrin clots, accurate debridement of unstable bone or cartilage and thorough evaluation of the joint surfaces (Baxter, 2008; Richardson & Stewart, 2019). However, endoscopic examination is not always possible because of limited finances, availability of equipment and other constraints (Richardson & Stewart, 2019). In addition, a recent ex vivo experimental study comparing arthroscopic lavage and needle lavage on the recovery of coloured microspheres from the tarsocrural joint of cadaver horses, suggested that lavage with 14 gauge needles was more effective at removing the microspheres than arthroscopic lavage (Loftin et al., 2016). The aim of this critically appraised topic was to study the available literature and compare the outcome of the two surgical techniques in naturally occurring synovial sepsis in adult horses.
PICO question
In adult horses (>1 year of age) does arthroscopic/ tenoscopic/bursoscopic lavage improve the outcomes compared with needle lavage of infected synovial cavities?
Search strategy Inclusion criteria were as follows: papers relevant to the PICO question with results of outcome (short-term survival). Exclusion criteria were as follows: papers that did not
contain original data (i.e. expert opinion) and papers that were not related to the PICO question. CAB abstracts and PubMed searched using: (horse*/
Equine*), (Septic*/ sepsis), (joint* OR Synovial* Arthriti*) AND (arthroscopic* or tenoscopic* or burscopic* or endoscopic* and lavag*), (needle* and lavag*) from year 2000. Additional relevant literature has been included from a Google Scholar search and from scanning the references in included articles. Papers were included based on suitability to answer the PICO question from the title and abstract.
Results
Eight studies were found to meet the inclusion criteria, and a summary of the articles and their findings are presented in Table 1.
Discussion
The articles are all retrospective cases studies. Therefore, the strength of evidence is moderate based on the study
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