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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 12-15

Burden of cases with large joints bony ankylosis following open injuries in rural region: A hospital based cross-Sectional observation


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission08-Dec-2020
Date of Acceptance17-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jssrp.jssrp_2_20

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  Abstract 


Background: Normal large joint anatomy is important for mobility, function and overall quality of life. Trauma or diseases like various forms of arthritis may alter normal joint architecture and physiology leading to secondary arthritis. Infection within the joint leading to septic arthritis is another catastrophic disorder that may irreversibly damage the human articular cartilage. The resultant bony ankylosis in certain cases is a serious complication of septic arthritis. There has been limited data regarding the burden of people living with post-infective ankylosis of one or more major joint and its other variables. Materials and Methods: Details of all consecutive cases coming to hospital out-patient department for the related or other complaints with one or more major joint found completely ankylosed in the radiographs were noted in separate file. The clinical complaints for which they present either related with the condition or other were also noted. Key demographic details like age, sex, laterality, history of causative factor, time living with the deformity, other co-morbidities were also recorded. The relevant details of the ankylosed joint following confirmation on radiographs were clinically confirmed with presence of no apparent movement of the affected joint. Results: A total of 21 (17 males and 3 females) patients with mean age of 32.1 years were part of the study. The ankle joint was most commonly involved followed by hip, knee and elbow in 13, 6, 2 and 1 case respectively. Our study attempts to know the burden of people living with ankylosed joint as a result of open injuries in the past. Conclusion: Relevant demographic data and the type of joint involvement in adults living in rural areas with one or more major ankylosed joints shall help draft preventive and treatment strategy in this regard.

Keywords: Ankylosis, bony ankylosis, disability, infection, joint, ossification, septic arthritis, stiff joint


How to cite this article:
Dharmshaktu GS. Burden of cases with large joints bony ankylosis following open injuries in rural region: A hospital based cross-Sectional observation. J Surg Spec Rural Pract 2020;1:12-5

How to cite this URL:
Dharmshaktu GS. Burden of cases with large joints bony ankylosis following open injuries in rural region: A hospital based cross-Sectional observation. J Surg Spec Rural Pract [serial online] 2020 [cited 2021 Apr 18];1:12-5. Available from: http://www.jssrp.com/text.asp?2020/1/1/12/305919




  Introduction Top


The human joint is a marvellous natural structure enabling us to perform variety of functions in an energy efficient manner. Human hyaline cartilage is critical element in the physiology and function of large joints like hip, shoulder, knee ankle etc. The ankylosed joint is a disabling condition and septic arthritis is the major cause of this condition. Septic arthritis is commonly found in children as the infection of the bone may be communicating with the adjacent joint due to anatomical factors like lack of growth plate in very young children or in sites where the part of the metaphyseal bones forming the joint are largely intracapsular.[1] The septic arthritis of the native joint in adults is relatively uncommon condition and many of the cases may have underlying disorders like rheumatoid arthritis, osteoarthritis, drug abuse etc.[2] Large joint affliction is commonly encountered in septic joint arthritis in adults resulting in functional and ambulation problems with significant bearing on quality of life.[3] The elderly population is also at risk of community acquired septic arthritis with worsening of co-morbid conditions, disseminated infection or death as related complications.[4],[5] The neglected or inadequately managed disease may land up in complications like persistent infection, osteonecrosis, leg length discrepancies in children or adults alike.[6] Bony ankylosis of the affected joint is one uncommon but serious complication that is not described in details in medical literature. There is also paucity of literature regarding burden of cases living with one or more joint with bony ankylosis as a sequelae of post-infection septic arthritis.


  Materials and Methods Top


Details of all consecutive cases coming to hospital out-patient department for the related or other complaints with one or more major joint found completely ankylosed in the radiographs were noted in separate file. The clinical complaints for which they present either related with the condition or other were also noted. Key demographic details like age, sex, laterality, history of causative factor, time living with the deformity, other co-morbidities were also recorded. The relevant details of the ankylosed joint following confirmation on radiographs were clinically confirmed with presence of no apparent movement of the affected joint. Any signs of long term sequelae like scar or sinuses, distal neurovascular status and adjacent joint movements were noted. As the total joint ankylosis on radiograph was evident, no further advance imaging modality was performed. The exclusion criteria included patients below twenty years, those with history of any rheumatological disorder (like ankylosing spondylitis, that may also present with ankylosis of joints), congenital ankylosis, ankylosis of sites other than major extremity joints like spine, sacroiliac (SI) or temporomandibular joint. Ankylosis associated with other etiologies like burn or hemoglobinopathy were also excluded. Cases pertaining to associated heterotrophic ossification and fibrous ankylosis as witnessed in diseases like tuberculosis were also excluded and so were postsurgical joint fusion (arthrodesis) cases. The complications in other body parts associated as a complication of the ankylosed joint, if any, were also noted.


  Results Top


A total of 23 patients were included in the study after exclusion of surgical fusion and congenital cases. The males outnumbered females in a ratio of 19:4. The mean age was 32.1 years (range 20-54 years) and the mean duration of history of duration of ankylosis was 38.4 months. The ankle joint (13 cases, 56.52%) was most commonly involved followed by hip (6 cases, 26%), knee (2 cases) and elbow in one case. All the cases were unilateral. The left side was affected in most cases than right side. There clinical presentation was history of mild pain at the affected joint and adjoining region, increased on extreme use of the extremity. The evidence of complete bony ankylosis was identified on radiographs of the affected region. The ankle joint being a common site of traumatic injury or open wounds with inappropriate or delayed management was found to be prone to infected joint resulting in subsequent ankylosis. The isolated tibiotalar joint [Figure 1] ankylosis was found in 13 cases. The subtalar joint was also found to be involved in all [Figure 2] cases with ankle joint ankylosis except two cases. In one case the ankle was fixed in calcaneus position whereas one case with history of open fracture of leg bones had a cystic cavity present within ankylosed ankle [Figure 3]. The unilateral hip joint involvement in 6 cases with good fusion of the joint [Figure 4] and [Figure 5] in normal position of acetabulam in five and at abnormal position (toward iliac blade) in one case. The knee joint was found to be involved less commonly [Figure 6] with two cases showing sound and stable ankylosis. Only a singular case of elbow involvement was found in a female patient. There was previous history of infection in all cases with mean duration of 38.4 months back (range 12-54 month). Presence of associated open traumatic injury in the history was noted in all cases with associated fracture in 4 cases. The clinical features of active infection were present in only three cases at the time of consultation however there was history of long standing infection with clinical presence of healed scar or sinus on inspection. The distal neurovascular status and the motion of adjacent joints were normal in all cases except one case of ankle ankylosis with ipsilateral knee stiffness. There was no remote complications noted at the time of study like pain in contralateral extremity joints which is a known complication of surgical fusion or arthrodesis of major lower extremity joint. The part of the reason behind this might be less number of years living with the condition in those patients as most of these are long term complications. None of the patient wanted to interfere with current status, however, patients were explained regarding future surgical options including arthroplasty with prognosis.
Figure 1: The radiograph showing bony ankylosis of ankle and subtalar joint following mismanaged adjacent open wound in a villager

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Figure 2: The complete bony ankylosis of ankle and subtalar joint in a case with leg trauma leading to osteomyelitis of tibia and ankle region

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Figure 3: A case with open fracture of leg managed conservatively that later was infected leading to ankle joint fusion as late sequelae

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Figure 4: Radiograph showing a solid ankylosis of hip joint with history of associated thigh region open wound that was infected

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Figure 5: The radiograph of another case with bony ankylosis of hip with history of open fracture of femur managed conservatively to union but leading to fused hip

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Figure 6: The radiograph of bony ankylosis of knee joint following chronic proximal tibia wound leading to osteomyelitis managed by indegenous practitioner

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  Discussion Top


The infectious arthritis is usually mono-articular in 90% cases and knee and hip joints are most commonly involved.[7] Knee joint (71%) is most common affected region followed by hip and Staphylococcus aureus as most frequent organism followed by Streptococci and more than 70% cases are left with significant residual disability.[8] The older age, preexisting joint disease and infected joint with presence of synthetic materials are adverse prognostic factors in the outcome of bacterial arthritis.[9] Intra-articular jint5 injections like steroid or viscosupplementation is another unusual reason of septic arthritis in adults. In One study of ten cases Streptococcus mitis was the commonest organism noted in those subset of cases.[10] Joint ankylosis is rare complication of septic arthritis and may result from spontaneous infection or post surgical complication.[11] The necessity of early suspicion and recognition of infection is considered of paramount importance in better management of avoidance of serious complication. The considerable restriction of movement in the long term is disabling and may require joint replacement in the future to enable the patients to perform activities of daily living. In a series of six patient treated with total knee arthroplasty, 2 cases each had history of childhood pyogenic arthritis and intra-articular fracture and one each of gun shot and juvenile rheumatoid arthritis.[12] 2 cases developed infection and one of these was later managed by arthrodesis. The increasing trend of septic arthritis in native as well as prosthetic joint is worrying and may further increase on account of longevity of older subjects and increased replacement surgeries.[13] There has been also increasing number of cases pertaining to iatrogenic causes (42%) following procedures like arthrocentesis, open joint surgery and arthroscopy.[14] The reports of spontaneous ankylosis are rare with only one case reported of spontaneous fusion of knee joint in the absence of any prior history of infective, inflammatory of surgical fusion.[15] One rare instance of bilateral elbow intra-articular bony ankylosis is reported following deep burn injury around the joints.[16]

The major limitation of the study was that the history given by our patients was based on memory and most of the patients were not sure of actual events and evolution of the disease in the absence of previous data or medical records. The other limitation was not able to perform additional investigation due to financial constraints or non-willing patients regarding assessment of impact of ankylosis in gait or any other joint problem. The limitation was compounded by limited follow up of patients as most of the patients were lost to follow up once there presenting complaints were dealt with. The negative history of any related complaints in other joints given by all patients was also could not be correlated and investigated to be true or a casual negative answer. In absence of no prior data based study regarding burden of serious condition of major joint ankylosis of extremities in rural settings, the current study attempts to shed light on the plight of cases suffering from the condition that affects overall quality of life.


  Conclusion Top


The incidence of joint ankylosis has been reduced in the wake of advance treatment methods and improved availability of healthcare facility in society. A small subset of cases, though, still persist and live a life with varying grades of disability. Rural penetration of quality healthcare facilities shall be instrumental in elimination of cases with disability by early recognition, treatment and rehabilitative management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barton LL, Dunkle LM, Habi FH. Septic arthritis in childhood. A 13-year review. Am J Dis Child 1987;141:898-900.  Back to cited text no. 1
    
2.
Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001;40:24-30.  Back to cited text no. 2
    
3.
Al-Tawfiq JA, Babiker M. Incidence and bacteriological causes of septic arthritis in a general hospital in Saudi Arabia. Ann Saudi Med 2013;33:116-8.  Back to cited text no. 3
    
4.
Wu CJ, Huang CC, Weng SF, Chen PJ, Hsu CC, Wang JJ, et al. Septic arthritis significantly increased the long-term mortality in geriatric patients. BMC Geriatr 2017;17:178.  Back to cited text no. 4
    
5.
Molloy A, Laing A, O'Shea K, Bell L, O'Rourke K. The complications of septic arthritis in the elderly. Aging Clin Exp Res 2010;22:270-3.  Back to cited text no. 5
    
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Kuwatani M, Kawakami H, Yamada Y. Osteonecrosis and panniculitis as life-threatening signs. Clin Gastroenterol Hepatol. 2010;8:e52-3. doi: 10.1016/j.cgh.2009.12.026. Epu 2010 Jan 6. PMID: 20060063.  Back to cited text no. 6
    
7.
Mader JT, Shirtliff M, Calhoun JH. The host and the skeletal infection: Classification and pathogenesis of acute bacterial bone and joint sepsis. Baillieres Best Pract Res Clin Rheumatol 1999;13:1-20.  Back to cited text no. 7
    
8.
George J, Chandy VJ, Premnath J, Hariharan TD, Oommen AT, Balaji V, et al. Microbiological profile of septic arthritis in adults: Lessons learnt and treatment strategies. Indian J Med Microbiol 2019;37:29-33.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D. The outcome of bacterial arthritis: A prospective community-based study. Arthritis Rheum 1997;40:884-92.  Back to cited text no. 9
    
10.
Mohamed M, Patel S, Plavnik K, Liu E, Casey K, Hossain MA. Retrospective analysis of septic arthritis caused by intra-articular viscosupplementation and steroid injections in a single outpatient center. J Clin Med Res 2019;11:480-3.  Back to cited text no. 10
    
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Mester B, Ullerich F, Ohmann T, Glombitza M, Schoepp C. Ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction in a 13-year-old male. Orthop Traumatol Surg Res 2017;103:619-22.  Back to cited text no. 11
    
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Kovalak E, Can A, Stegemann N, Erdoğan AÖ, Erdoğan F. Total knee arthroplasty after osseous ankylosis of the knee joint. Acta Orthop Traumatol Turc 2015;49:503-7.  Back to cited text no. 12
    
13.
Nair R, Schweizer ML, Singh N. Septic arthritis and prosthetic joint infections in older adults. Infect Dis Clin North Am 2017;31:715-29.  Back to cited text no. 13
    
14.
Geirsson AJ, Statkevicius S, Víkingsson A. Septic arthritis in Iceland 1990-2002: Increasing incidence due to iatrogenic infections. Ann Rheum Dis 2008;67:638-43.  Back to cited text no. 14
    
15.
Ahmed OS, Cashman JP. A rare case of spontaneous fusion of the knee. Am J Orthop (Belle Mead NJ) 2017;46:E83-5.  Back to cited text no. 15
    
16.
Vaishya R, Singh AK, Agarwal AK, Vijay V. Bilateral spontaneous bony ankylosis of the elbow following burn: A case report and review of the literature. J Orthop Case Rep 2018;8:43-6.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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