Management of septic joints in the United States: A Nationwide comparison of surgical and non-surgical treatment

BACKGROUND: Septic arthritis is associated with substantial morbidity and mortality. While surgical irrigation and debridement are commonly recommended, non-surgical management remains frequently utilized, particularly in medically complex patients. However, large-scale national comparisons between these strategies are limited. This study aimed to compare in-hospital outcomes of surgical versus non-surgical management using a nationwide database. METHODS: A retrospective cohort study was conducted using the National Inpatient Sample (2016-2021). Adult hospitalizations with septic arthritis and known anatomic sites were identified using ICD-10 codes and stratified by treatment strategy. Primary outcomes included in-hospital mortality, length of stay, and total hospital charges. Secondary outcomes included in-hospital complications. Multivariable logistic regression was used to assess independent associations between treatment and outcomes, adjusting for demographics and comorbidities. RESULTS: A total of 46,282 hospitalizations were identified, including 27,961 (60.4%) treated surgically and 18,321 (39.6%) non-surgically. In-hospital mortality was significantly lower in the surgical group (1.4% vs. 3.1%, p < 0.001). Length of stay was similar, though more variable in the non-surgical cohort. Surgical management was associated with higher hospital charges ($71,725 vs. $63,434, p < 0.001). Non-surgical treatment demonstrated higher rates of complications, including sepsis, acute kidney injury, respiratory failure, and thromboembolic events (all p < 0.001). After adjustment, surgical management remained independently associated with reduced complications, including respiratory failure (OR 0.552), stroke (OR 0.505), cardiac arrest (OR 0.353), and sepsis (OR 0.871) (all p < 0.001). CONCLUSIONS: Surgical management of septic arthritis was associated with lower in-hospital mortality and fewer complications despite higher costs. However, these findings should be interpreted in the context of potential residual confounding and differences in baseline illness severity between treatment groups.