AETIOLOGY AND MANAGEMENT

0F SEPTIC ARTHRITIS
PRESENTED BY DR ANIKWE I.A
MODERATOR: DR ANYAEHIE
 OUTLINE
INTRODUCTION
EPIDEMIOLOLOGY
AETIOLOGY/ RISK FACTORS
PATHOLOGY
CLINICAL FEATURES
INVESTIGATION
DIFFERENTIAL DIAGNOSIS
TREATMENT
COMPLICATIONS
 OUTLINE Contd
FOLLOW UP
PROGNOSIS
CURRENT/ FUTURE TRENDS
CONCLUSION
 INTRODUCTION
Septic arthritis is an inflammation of a joint due
to infection.
It is a surgical emergency.
Not only can it rapidly destroy a joint or
irreversibly impair joint function, but it may also
be fatal, especially when it occurs in neonates.
Although septic arthritis can occur at any age,
children are particularly susceptible.
Affects major joints commonly; knee, hip,
shoulder, elbow
The risk is higher when the joint is traumatized.
The causative organisms are diverse in septic
arthritis, but Staphylococcus aureus infection is
the most common.
 Recognition of septic arthritis in the children
before excessive infection has occurred is
often difficult; thus, there is a need to
maintain a high index of suspicion.
Diagnosis can be made based on clinical
findings, laboratory tests and joint aspiration
analysis.
Management is multi disciplinary.
Failure to recognize and to appropriately treat
septic arthritis results in significant rates of
morbidity and may even lead to death
 EPIDEMIOLOGY
Approximately 20,000 cases of septic arthritis
occur in the United States each year (7.8 cases
per 100,000 person), with a similar incidence
occurring in Europe.
The incidence of arthritis due to disseminated
gonococcal infection is 2.8 cases per 100,000
person.
Septic arthritis has been reported to be more
common in males
 EPIDEMIOLOGY Contd
Common sites:
Knee 41%
Hip 23%
Ankle 14%
Elbow 12%
Wrist 4%
Others 2%
Study done in NOHE
 JOINTS AFFECTED
Joints Frequency Percent %

Hip 19 47.5

Knee 18 45

Ankle 1 2.5

Shoulder 2 5

Total 40 100%

No poly-articular septic arthritis was noted.

AETIOLOGY
 AETIOLOGY Contd..
Mycobacterium tuberculosis
Spirochete (Borrelia burgdorferi)
Fungi
Virus
 CLASSIFICATION
Acute
Chronic
Acute
i. Non gonococcal
ii. Gonococcal
 CLASSIFICATION
Arthroscopic classification of joint infections
according to Gchter.
Stage I- Opacity of fluid, redness of the synovial
membrane, possible petechial bleeding
Stage II- Severe inflammation, fibrinous
deposition, pus
Stage III- Thickening of the synovial membrane,
compartment formation
Stage IV- Aggressive pannus with infiltration of
the cartilage, undermining the cartilage
 Hunka Classification
Type I:
There is minimal collapse of the femoral head,
which is later followed by reossification.
Type II:
Deformity of the femoral head. In subtype IIa
there is no evidence of physeal damage, while in
Subtype IIb there is premature physeal closure,
resulting in deformity of the femoral neck as well.
Type III:
A pseudarthrosis of the femoral neck is observed.
 Type IV:
Destruction of the femoral
head, with retention of a
variable portion of the
femoral neck.
Type V:
Destruction of both the
femoral head and the
femoral neck
 Predisposing Factors
Rheumatoid arthritis
Chronic debilitating disorders
Intravenous drug abuse
Immunosuppressive drug therapy
Artificial joint implant
Acquired immune deficiency syndrome (AIDS).
 PATHOLOGY
A joint can become infected by:
(1)Direct invasion through a penetrating wound,
intra-articular injection or arthroscopy
(2) Direct spread from an adjacent bone abscess
(3) Blood spread from a distant site.
 PATHOLOGY Contd..
Sequence of events include;
Colonization and adhesion of the bacteria on
the synovial membrane occurs
Acute inflammatory reaction is activated
Release of inflammatory cells including
cytokines and reactive oxygen species lead to
joint damage
Joint damage also occurs from release of
lysosomal enzymes and bacterial toxins
Synovial membrane becomes acutely inflamed
and oedematous
 PATHOLOGY Contd..
Results in increase in synovial fluid, serous or
seropurulent exudates rich in leucocytes
Joint effusion impede nutrient and blood
supply to the joint cartilage and synovium
It can also leads to subluxation/dislocation.
Pus subsequently forms if not treated
promptly
Organisation of the exudates later results in
adhesions in synovial recess and peri articular
structures
 If infection goes untreated, it will spread to
the underlying bone or lead to sinus formation
May also lead to complete cartilage
destruction and bony ankylosis upon healing
PATHOLOGY Contd..
 PATHOLOGY
Gonococcal arthritis begins with localized
mucosal infection (Al-Suleiman et al)
Initial attachment to host epithelium is by pili
Phase variation.
Usually leads to less joint destruction
 DIFFERENTIAL DIAGNOSIS
Acute osteomyelitis .
Traumatic synovitis or haemarthrosis
Irritable joint
Juvenile rheumatoid arthritis
Sickle-cell disease
 CLINICAL FEATURES
Irritability, refusal to feed in infants
Loss of function of the limb
Fever
Effusion, soft tissue swelling
Painful limited range of motion
Joint held in position of maximum comfort
Acuteness of onset of the joint pain
Whether the pain is superimposed on chronic
pain
Previous history of joint disease or trauma,
whether accidental or iatrogenic
 Whether the process is monoarticular or
polyarticular and which joints are involved
The presence of extra-articular symptoms
Search for the source of infection umbilical
cord, infected iv infusion site
Patients with an infected joint typically
present with the triad of fever (40-60% of
cases), pain (75% of cases), and impaired
range of motion.
 INVESTIGATION
Joint aspiration
Definitive-aspiration and identification of
purulent effusion.
WBC greater than 40-50,000/mm3
Positive cultures 50-60% (Goldenberg, 1985)
Joint Fluid Analysis
 INVESTIGATION
FBC
WBC > 12,000/mm3
ESR
CRP
Blood cultures
Urinalysis
FBS
Genotype
Mantoux test
RVS
 IMAGING
Plain X-ray.
Not revealing in first few days of infection.
May show widened joint space, evidence of soft
tissue swelling, subluxation or dislocation.
CT Scan.
Also of limited use but in ambigous cases can be
more revealing than X-ray.
Useful in CT-guided aspirations
MRI
USS. Useful in detecting early effusions
 Bone scan:
technetium-99m show increased uptake with
increased blood flow in inflamed synovial
membranes and in metabolically active bone
Gallium and Indium scan are more sensitive and
specific in the detection of active infection.
Plain X-ray
MRI
 Kocher criteria
A tool useful in the differentiation of septic
arthritis from transient synovitis in the child with
a painful hip
Scoring
A point is given for each of the four following
criteria:
Non-weight-bearing on affected side
Erythrocyte sedimentation rate > 40
Fever > 38.5 C
White blood cell count > 12,000/mm3
 Score Likelihood of septic arthritis
1- 3%
2 - 40%
3 - 93%
4 - 99%
 TREATMENT
A surgical emergency
TX must be prompt to avert joint destruction.
Multidisciplinary approach.
Aim is to eradicate infection and rehabilitate
the patient.
Treatment principles same for all joints.
 PRINCIPLES
RESCUSITATION / SUPPORTIVE CARE

ERADICATION OF INFECTION

REHABILITATION
 RESCUSITATION/ SUPPORTIVE CARE
IV FLUIDS
ANALGESICS
ANTIPYRETICS
SPLINTAGE ( traction, casts)
 ERADICATION OF INFECTION
(antibiotics)
ANTIBIOTICS (empirical and sensitivity based)
Provide adequate cover for gram positives and
negatives.( flucloxacillin, cephalosporins)
Commenced as soon as diagnosis is made and
samples taken.
IV for 3-5 days and then orally for at least
4wks. ( Eyichukwu et al)
IV 4-7 days and then orally 3wks (Apleys)
 SURGICAL DRAINAGE
OPEN DRAINAGE AND LAVAGE
ARTHROSCOPIC DEBRIDEMENT
CLOSED ASPIRATION
 Indications for Arthrotomy
Urgent need for infected joint decompression
Joint damage by pre-existing disease
Bacterial arthritis complicated by
osteomyelitis
Failure of less invasive treatment methods
 APPROACHES FOR ARTHROTOMY
HIP DRAINAGE
Anterior approach preferred in children
In an adult, the posterior approach allows
dependent drainage. Other approaches can
also be used
 KNEE DRAINAGE
Medial or Lateral parapatellar incision
Following arthrotomy and lavage, joint capsule
may be left open or closed over suction drain
patients should spend most of their time in the
prone position for adequate drainage if capsule
was left open
SHOULDER DRAINAGE
Anterior or posterior approach
 ARTHROSCOPIC DRAINAGE
Cannula is inserted in
suprapatellar pouch for
outflow, and knee is
irrigated through
arthroscopic sheath.
Extent of procedure
depends on the stage
Small suction drain is
inserted through
arthroscopic sheath.
Sheath is removed as
drain is held in place
 CLOSED ASPIRATION
Least invasive
Useful in easily accessible joints
Done repeatedly till joint cultures are negative
 CLOSED ASPIRATION
Hip Aspiration Shoulder Aspiration
 POST OP MONITORING/
REHABILITATION
Monitoring
Clinical
Laboratory. ESR, CRP
Splints used to maintain joint in functional
position. Traction also used
Gradual mobilization when pain subsides,
passive and active ROM
Muscle strengthening exercises
Delayed weight bearing.
 COMPLICATIONS
Septicemia
AVN of the head of femur
Dislocation of the hip
Premature closure of the physis
Limb length inequality
Joint stiffness.
FOLLOW UP
 Treatment Based on Hunkas
Classification
Type III
If the femoral head is viable, a valgus
osteotomy and bone grafting. If the femoral
head is nonviable, resection of the head and
neck followed by greater trochanteric
arthroplasty can be done.
 Type IV
Maximize hip joint motion by soft tissue release
(adductors and/or psoas).
Resection of the residual femoral neck and
conversion to a greater trochanteric arthroplasty.
Type V
Treatment
(1) trochanteric Arthroplasty in those under
3years
(2) Arthrodesis Adolescents and adults.
3) Arthroplasty
Greater Trochanter Arthroplasty
 PROGNOSIS
PROGNOSTIC FACTORS.
Time from onset to irrigation and
debridement.
The joint involved
Presence of associated osteomyelitis
Age of the patient.
 PROGNOSIS
Predictors of poor outcome in suppurative
arthritis include the following:
Age older than 60 years
Infection of the hip or shoulder joints
Underlying rheumatoid arthritis
Positive findings on synovial fluid cultures
after 7 days of appropriate therapy
Delay of 7 days or longer in instituting therapy
 CONCLUSION
Septic arthritis is a surgical emergency.
Irreversible joint destruction occurs rapidly.
High index of suspicion in neonates
Treatment must be prompt and aggressive
Long term follow up is often required
 REFERENCES
Louis S,David W & Selvadurai N. Apleys System
of Orthopedics & fractures, 9thedition, Hodder
Arnold, 2010.
Canale & Beaty: Campbell's Operative
Orthopaedics, 11th ed. Mosby, An Imprint of
Elsevier 2007
David A. Spiegel, M.D.J. Norgrove Penny,
Sequelae of Septic Arthritis of The Hip, Published
by Global-HELP Organization:2007
Al-Suleuman, S.A.,E. M. Grimes, and H.S. Jonas.
1983. Disseminated gonococcal infections.
Obstet. Gynecol. 61:48-51.
 REFERENCES
Mark E.S, Jon T. M. Acute Septic Arthritis, Clin
Microbiol Review. 2002 Oct; 15(4): 527-544.
Depends on the age of the patient
NEWBORN/INFANTS:
Emphasis here is on septicaemia rather than
joint pain
Irritability
Increased pulse rate
fever
Joint warm, tender and resistant to movement
Always search for the source of infection
umbilical cord, infected iv infusion site
CHILDREN:
Acute joint pain
Tendency to keep the joint motionless
Ill looking
Increased pulse rate
Fever
Swelling, warmth and tenderness of the affected
joint
Restriction of joint movement
Search for the source of infection boil, ear
discharge
 Superficial joints often involved
Painful, swollen and inflamed
Warmth, tenderness, and restriction of
movement
Inquire or search for the evidence of the
following:
i) gonococcal infection
ii) drug abuse
iii) corticosteroid therapy
iv) HIV/AIDS
 Knee sepsis
Needle aspiration of purulent exudate is the primary method of
drainage. Daily joint aspirations are usually required until the joint
cultures are negative. The knee joint is probably the joint that is
most amenable to repeated aspirations. Most cases of
uncomplicated septic arthritis of the knee can be treated
satisfactorily by means of repeated closed needle aspirations.
A surgical approach to drainage should be considered in the
following situations:
If signs of local sepsis do not abate and synovial fluid analysis does
not return to normal within 2 days after treatment
If the purulent fluid becomes too thick to aspirate
If septic arthritis occurs in the setting of rheumatoid arthritis [27] or
another underlying joint disease
In selected patients, tidal irrigation might be beneficial