AETIOLOGY AND

MANAGEMENT 0F
SEPTIC ARTHRITIS
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
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

Gächter.
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 ead, 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

SHOULDER ASPIRATION

HIP 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 HUNKA’S
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. Apley’s 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