M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Chan et al.
Septic Arthritis

Musculoskeletal Imaging
Review
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Septic Arthritis: An Evidence-

FOCUS ON:

Based Review of Diagnosis and

Image-Guided Aspiration
Brian Y. Chan1 OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to dis-
Amanda M. Crawford cuss and interpret findings obtained with various imaging modalities, guide patient selection
Patrick H. Kobes for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both
Hailey Allen native and prosthetic joints.
Richard L. Leake CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive,
irreversible joint damage. Despite the urgency associated with this diagnosis, there remains
Christopher J. Hanrahan
a lack of consensus regarding many aspects of the management of native and periprosthetic
Megan K. Mills joint infections.
Chan BY, Crawford AM, Kobes PH, et al.
eptic arthritis is an emergency arthritis when emergency surgical interven-

S that can cause rapidly progres-

sive and irreversible damage to
the affected joint, resulting in se-
tion is deemed necessary.

Differential Diagnosis, Clinical Presentation,

Keywords: arthrocentesis, aspiration, interventional,
periprosthetic joint infection, septic arthritis
doi.org/10.2214/AJR.20.22773
Received January 1, 2020; accepted after revision
February 26, 2020.
1
All authors: Department of Radiology and Imaging
Sciences, University of Utah School of Medicine,
30 N 1900 E, Rm 1A071, Salt Lake City, UT 84132-2140.
Address correspondence to B. Y. Chan
(brian.chan@utah.edu).
AJR 2020; 215:568–581
ISSN-L 0361–803X/20/2153– 568
© American Roentgen Ray Society
rious morbidity and mortality. The incidence
of septic arthritis ranges from approximately
2 cases per 100,000 people per year [1] to 20
cases per 100,000 people per year in low-in-
come settings [2]. Its presentation varies by
patient demographics and is confounded
by preexisting comorbidities. Radiologists
should be equipped to counsel the ordering
provider regarding the role of preinterven-
tion imaging. Familiarity with clinical pre-
sentation and laboratory assessment can help
the radiologist guide patient selection for
percutaneous aspiration. When arthrocente-
sis is pursued, understanding the technical
considerations of the procedure and subse-
quent fluid analysis can minimize patient
risk and maximize diagnostic yield. Despite
the important role radiologists play, clinical
workflow varies widely by practice setting
[3]. Review of the current state of knowledge
is warranted to adopt an evidence-based ap-
proach to the diagnosis and management of
septic arthritis.
Preaspiration Assessment
Appropriate patient selection before joint
aspiration is a complex process with many
variables. Appendix 1 summarizes the con-
siderations before arthrocentesis discussed
in this review. On occasion, joint aspiration
may be deferred in the evaluation of septic
and Causative Organisms
The differential diagnosis of an acutely
painful joint is broad and includes crystal-
line and inflammatory arthritides, trauma,
neoplasm, and infection. Patients with septic
arthritis classically present with fever, chills,
and a warm, erythematous, swollen, and pain-
ful joint. However, variation in patient pre-
sentation necessitates a high index of clinical
suspicion for septic arthritis. Patients present
with high-grade fever in only 58% and serum
leukocytosis in only 50–60% of cases [4].
Many risk factors predispose patients to
septic arthritis (Table 1). Coexisting primary
rheumatologic disorders have been reported
in as many as 50% of patients with bacteri-
al arthritis [5]. Rheumatoid arthritis may in-
crease the risk of septic arthritis as much as
15-fold [6], owing to a combination of pre-
existing joint damage, baseline immune dys-
regulation, and use of immunomodulatory
therapy, such as tumor necrosis factor inhibi-
tors [7]. Both infection and acute exacerba-
tion of a chronic joint disorder may present
with joint pain and swelling.
The most common causative agent of
adult septic arthritis is Staphylococcus au-
reus, which accounts for more than 50% of
cases [4] (Fig. 1). The incidence of methi-
cillin-resistant S. aureus infection is on the
rise in the United States. Coagulase-negative

568 AJR:215, September 2020

 Septic Arthritis

TABLE 1: Risk Factors for Septic Arthritis

Preexisting Joint Diseases Skin Diseases Medical Conditions Medication-Induced Conditions Other
Rheumatoid arthritis Psoriasis Diabetes mellitus Chronic systemic corticosteroid Prior joint arthroplasty
therapy (e.g., prednisone)
Crystalline deposition arthropathies Eczema Cirrhosis Disease-modifying antirheumatic IV drug use
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(gout and calcium pyrophosphate drugs

deposition)
Osteoarthritis Skin ulcers End-stage renal disease Intraarticular corticosteroids Alcoholism
Systemic lupus erythematosus Skin infection HIV infection, AIDS, and other Other immunosuppressive Human bite (fight bite)
immunosuppressed states medications
Trauma Bacteremia Low socioeconomic status
Recent surgery Advanced age

s­taphylococci are often contaminants but can
cause clinically mild, indolent infections af-
ter orthopedic procedures. The incidence of
streptococcal and gonococcal septic arthritis
has declined over the past few decades. Gram-
negative rods typically affect elderly patients
and young IV drug users. Atypical mycobac-
terial, viral, and fungal infections also occur,
particularly in immunosuppressed patients.
Serum Laboratory Evaluation
Serum laboratory evaluation for septic
arthritis includes peripheral WBC count,
erythrocyte sedimentation rate (ESR), and
C-reactive protein (CRP) level. However,
the results of these laboratory tests are in-
adequately specific to substantially alter the
pretest probability of septic arthritis [8, 9].
Absence of leukocytosis or elevated ESR or
CRP level does not exclude a diagnosis of
septic arthritis [10]. Measurement of procal-
citonin has had diagnostic performance su-
perior to that of traditional serum laborato-
ry tests in assessing septic arthritis [11, 12];
however, procalcitonin level is insufficient
to differentiate periprosthetic joint infection
(PJI) from aseptic loosening [13]. d-Dimer is
a promising serum biomarker for early de-
tection of PJI; the test had higher sensitivity
and specificity than both ESR and CRP in
one study [14]. Unlike ESR and CRP levels,
d -Dimer level rapidly increases and returns
to baseline after elective total knee or hip ar-
throplasty, making it a potential tool in the
early detection of PJI [15]. Table 2 summa-
rizes commonly used cutoff values in stan-
dard serum laboratory evaluation.
Although synovial fluid culture is consid-
ered the reference standard for diagnosing
septic arthritis [9], blood cultures can play
a crucial role and are recommended as part
of the initial diagnostic evaluation for sep-
tic arthritis [16]. Hematogenous spread is the
most common avenue of joint infection [8],
and treatment of septic arthritis in patients
with negative synovial fluid culture results
can instead be directed at an organism cul-
tured from the bloodstream. Blood cultures
have been reported to be the only test to iden-
tify an organism in 9–14% of cases of septic
arthritis [1, 17].
Preaspiration Imaging
Preaspiration imaging can aid evalua-
tion of osseous structures and surrounding
soft tissues. Radiography is appropriate as
the first imaging study, particularly for pa-
tients who have undergone prior surgery to
evaluate existing hardware [18]. Radiograph-
ic findings are usually normal in early septic
arthritis or may reveal periarticular osteope-
nia. More advanced infections may present
with nonspecific erosions or uniform joint
space narrowing [19, 20] (Figs. 2 and 3).
MRI is complementary to aspiration [18]
and can reveal a joint effusion or deep soft-
tissue infection. Nonspecific bony erosions,
marrow edema, and articular cartilage de-
struction can be seen with septic arthri-
tis (Figs. 2B, 3D, and 3E) but also with in-
TABLE 2: Sample Cutoff Values for Commonly Used Serum and Synovial
Fluid Tests
Test
Serum
WBC count (/µL)
C-reactive protein level (mg/dL)
Erythrocyte sedimentation rate (mm/h)
Procalcitonin (ng/mL)
d-Dimer level (ng/mL)
Synovial fluid
WBC count (/µL)
Polymorphonuclear leukocytes (%)
flammatory arthropathy [21]. Notably, 16%
of septic joints in one study [21] contained a
subjectively normal amount of fluid; howev-
er, the study did not specifically address sit-
uations in which imaging evidence of joint
fluid was completely absent. IV contrast ad-
ministration can reveal synovial enhance-
ment, abscesses, and epiphyseal involvement
in children but does not increase sensitiv-
ity or specificity for septic arthritis [22].
Preaspiration ultrasound (US) can help con-
firm the presence of a joint effusion (Fig. 3B)
and assess for fluid collection in the overly-
ing soft tissues [23], although this approach
is operator and resource dependent.
A potential argument ordering providers
make against advanced preaspiration imag-
ing is concern over delaying definitive man-
agement and causing progressive, irreversible
cartilage loss. In animal models, cartilage
loss is seen as early as 24 hours after joint
infection, and permanent cartilage injury oc-
curs within 3–4 days [24]. Lauper et al. [25]
challenged the necessity of immediate surgi-
cal lavage and found similar functional out-
comes among patients who ­underwent joint
Sample Cutoff Value
Native Joint Chronic Periprosthetic Joint Infection
> 11,000
>2 >1
> 30 > 30
> 0.3
> 860
> 50,000 > 3000
> 75 > 80

AJR:215, September 2020 569


lavage less than 6, 6–12, 12–24, and more
than 24 hours after presentation. The need
for urgent intervention is balanced by the
risk of missing unexpected pathologic condi-
tions. Patients without preoperative imaging
who are later discovered to harbor extraartic-
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ular infection may need repeat operations to
rectify inadequate treatment [24, 26]. Abbre-
viated MRI protocols entailing solely fluid-
sensitive sequences are highly sensitive for
musculoskeletal abnormalities [27, 28] and
may shorten the delay to treatment while still
enabling comprehensive preoperative evalu-
ation. Ultimately, the decision to perform im-
aging before aspiration should be based on
an individualized assessment and discussion
with orthopedic colleagues.
Special Considerations
Prosthetic joints—Suspected PJI in a pa-
tient in hemodynamically stable condition
does not require immediate aspiration be-
cause of the absence of cartilage [29]. How-
ever, PJI should be considered urgent and
is a major cause of postarthroplasty failure
and ongoing pain. PJI can be acute or chron-
ic; traditionally, these were differentiated by
amount of time elapsed since surgery (for ex-
ample, acute infections occurring within 4
weeks of surgery [30]). It is now agreed that
PJI is a continuum that culminates in estab-
lishment of a chronic biofilm, and the time to
biofilm maturity depends on both the bacte-
rial species and the host [31]. Chronic PJI is
more common and often presents with pain
or functional deterioration [32]. Unlike the
situation with aseptic prosthetic loosening,
pain is unrelated to activity and is present
at rest. Overt signs, such as fever, regional
warmth, and erythema, are frequently ab-
sent. A more specific sign of PJI is evidence
of deep soft-tissue involvement, including a
sinus tract, purulence, abscess, or extensive
necrosis. Patients with multiple prosthetic
joints found to have one infected prosthe-
sis are at increased risk of a second PJI, and
clinical assessment of all prosthetic joints is
important to determine the need for addi-
tional aspirations [33].
Compared with septic arthritis in native
joints, PJIs are often characterized by less
virulent pathogens: 50–60% of hip and knee
PJIs are caused by S. aureus and coagulase-
negative staphylococci (e.g., Staphylococcus
epidermidis). In the upper extremity, coagu-
lase-negative staphylococci account for ap-
proximately 40% of shoulder and elbow PJIs.
Propionibacterium acnes is present in 24%
570 AJR:215, September 2020
Chan et al.
of shoulder PJIs [34], in which sebum-rich
hair follicles in the axilla likely promote col-
onization [35]. Organisms are typically en-
meshed in a biofilm covering the prosthesis,
which protects them from the host immune
system and antibiotics [36]. These charac-
teristics make PJI a difficult clinical diagno-
sis. Several subspecialty societies have de-
veloped diagnostic criteria and algorithms
to facilitate evaluation [37–40], and the Sec-
ond International Consensus Meeting on Or-
thopedic Infections was convened to provide
expert consensus given the heterogeneity in
practice [41]. Recommendations in these var-
ious guidelines were recently assessed to es-
tablish updated, evidence-based diagnostic
criteria and algorithms for the evaluation of
PJI [42] (Fig. 4). Elevation of either ESR or
CRP level should prompt joint aspiration; if
both ESR and CRP levels are within normal
limits, PJI is extremely unlikely [39]. Given
that PJIs are characterized by sessile rather
than free-floating bacteria, blood cultures are
not included in the definition of PJI.
Radiographs may reveal periprosthetic os-
teolysis but are frequently normal [43]. Al-
though radiographic findings are nonspecific
in the early postoperative period, radiographic
evidence of soft-tissue gas more than 14 days
after total knee arthroplasty was predictive of
early PJI in a recent study [44] and may her-
ald a broader spectrum of microorganisms
than typically encountered. Triple-phase bone
scintigraphy and WBC scintigraphy are high-
ly sensitive for infection and can be useful in
confounding cases. PJI is highly unlikely in
the absence of radiotracer uptake [40]. Hybrid
imaging techniques such as 18F-FDG PET/CT
and 99mTc-antigranulocyte SPECT/CT can be
used to improve localization of radiotracer up-
take, although their lack of specificity limits
their routine use at our institution. MRI and
CT are not routinely advocated for PJI, be-
cause aspiration and culture are needed re-
gardless of advanced imaging findings (Fig. 5).
Children—Clinical tools have been inves-
tigated for differentiating septic arthritis from
similarly presenting nonsurgical pediatric di-
agnoses, such as juvenile idiopathic arthritis,
transient synovitis, and Lyme disease [45–50].
Slipped capital femoral epiphysis and Legg-
Calve-Perthes disease are other important di-
agnostic considerations in pediatric patients
with hip pain. Trauma is an additional con-
founder; recent falls precede approximately
20% of osteoarticular infections [51].
Communication barriers may preclude a
comprehensive patient interview. Neonates
can present with irritability and listlessness,
whereas toddlers may acknowledge nonspe-
cific pain [52]. Physical examination may re-
veal guarding, limited range of motion, and
inability to bear weight. Laboratory evalua-
tion is likewise limited; leukocytosis is less
common in younger children and rare in ne-
onates [52]. Kocher et al. [46] identified four
criteria—history of fever, inability to bear
weight, WBC count greater than 12,000/μL,
and ESR greater than 40 mm/h—to differen-
tiate septic arthritis from transient synovitis.
Another study [53] applying the criteria pro-
posed by Kocher et al. did not reproduce the
originally reported high predictive value.
A threshold CRP greater than 2.0 mg/dL
has been found to have higher predictive val-
ue for septic arthritis than does leukocytosis,
elevated ESR, or refusal to bear weight [45].
Additionally, Kingella kingae, an increas-
ingly recognized cause of septic arthritis in
children younger than 4 years [54, 55], has
a milder clinical course often mistaken for
a noninfectious pathologic condition and is
notoriously difficult to detect with standard
laboratory techniques [56]. The addition of
oropharyngeal swabs and polymerase chain
reaction assays for K. kingae can help iden-
tify the causative organism in osteoarticular
infections [56].
Children with septic arthritis often have
concomitant osteomyelitis and adjacent mus-
culoskeletal infections [57–59], in part due
to anatomic differences that facilitate spread
of osteomyelitis into the adjacent joint. Ro-
bust transphyseal vessels in neonates al-
low communication of the metaphysis with
the adjacent nonossified epiphysis and joint.
After these vessels involute in early child-
hood, the metaphysis remains intraarticular
in some long bones (e.g., proximal humer-
us and radius, proximal femur, distal fibula),
and metaphyseal subperiosteal infection or
abscess can progress to deposition of puru-
lent material within the joint [60]. Schallert
et al. [61] found that 75% (41/55) of children
with metaphyseal osteomyelitis and adjacent
joint effusion ultimately were found to have
surgically confirmed septic arthritis. Those
authors concluded that children with joint
effusions associated with metaphyseal osteo-
myelitis should be presumed to have septic
arthritis [61].
Rosenfeld et al. [26] proposed an algo-
rithm including five clinical and laboratory
variables to identify patients at high risk of
adjacent infections who could benefit from
preoperative MRI, although the generaliz-

ability of these criteria to other populations
has been questioned [62]. Investigators in
several studies [63–65] and 88% of Interna-
tional Consensus Meeting delegates advocate
percutaneous or open juxtaarticular bone bi-
opsy at the time of aspiration in children to
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confirm the diagnosis of osteomyelitis and
increase sensitivity for an organism when sy-
novial fluid culture results are negative.
Immunosuppression—Immunosuppres-
sion is a relative risk factor for septic arthri-
tis and is associated with many chronic condi-
tions, including diabetes mellitus, rheumatoid
arthritis, and HIV infection [66]. Anti–tumor
necrosis factor therapy in patients with rheu-
matoid arthritis doubles the risk of septic ar-
thritis [7]. Other medications, such as cortico-
steroids and disease-modifying antirheumatic
drugs, may also induce an immunocompro-
mised state. Immunosuppressed patients can
have an atypical presentation of a blunted pain
response [67]. Immunosuppressed patients
also have theoretic differences in laboratory
values due to difficulty mounting a normal
immune response. Butler et al. [68], howev-
er, found no significant difference in labora-
tory values between immunosuppressed and
immunocompetent patients with septic arthri-
tis. Notably, procalcitonin levels are unaffect-
ed by steroids [69] and may be a helpful bio-
marker in this population.
Possible Contraindications to Percutaneous
Aspiration
Anticoagulation—There is little consen-
sus in the literature [70] or anecdotally [3] re-
garding the handling of anticoagulation be-
fore arthrocentesis. Porrino et al. [3] reported
that 39% (96/247) of surveyed radiologists
agreed that coagulopathy should be correct-
ed before arthrocentesis. However, the avail-
able literature supports the notion that clini-
cally significant bleeding complications after
both blind and image-guided arthrocentesis
in patients undergoing anticoagulation are ex-
ceedingly rare [71–74]. A 2017 retrospective
study [74] showed no bleeding complications
following 1050 consecutive procedures over 6
years on patients using direct oral anticoagu-
lants (e.g., direct thrombin inhibitors and di-
rect factor Xa inhibitors) during arthrocente-
sis. In addition, there is a real risk of inciting
thromboembolic events when interrupting an-
ticoagulation [75]. Overall, percutaneous joint
access is considered low risk [76, 77], and at
our institution we do not routinely discontinue
anticoagulation or perform preprocedural co-
agulation tests before arthrocentesis.
AJR:215, September 2020 571
Septic Arthritis
Recent antibiotic administration—Simi-
lar to the situation with blood cultures [78],
the yield of synovial fluid cultures decreases
after antibiotic administration. Barrack et al.
[79] found that 7 of 12 patients (58%) tak-
ing antibiotics who had no growth at initial
knee aspirations ultimately had a diagnosis
of septic arthritis. Hindle et al. [80] found a
combined decrease in synovial fluid culture
sensitivity from 79% to 28% in both native
and prosthetic knee aspirates after antibiotic
administration. Despite the lower diagnostic
value of microbiologic analysis after recent
antibiotic use, no guidelines have been estab-
lished regarding duration of antibiotic cessa-
tion before arthrocentesis. At our institution
we do not typically defer joint aspiration af-
ter recent antibiotic administration.
In the setting of prior arthroplasty, a lon-
ger interval between antibiotic cessation and
aspiration can increase the likelihood of cul-
ture positivity. Malekzadeh et al. [81] deter-
mined that antimicrobial therapy within 3
months was associated with increased likeli-
hood of culture-negative PJI (odds ratio, 4.7).
Both American Academy of Orthopedic Sur-
gery [39] and Infectious Disease Society of
America [38] guidelines call for withhold-
ing antibiotics for at least 2 weeks before at-
tempting joint aspiration in patients with sus-
pected PJI.
Overlying cellulitis and other concomitant
infections—A dreaded risk of arthrocente-
sis is inducing septic arthritis in a previously
aseptic joint. Rates of septic arthritis after in-
traarticular steroid injection are as low as 1 in
10,000 [82, 83]. Although intuitively the pres-
ence of overlying cellulitis increases the risk
of inducing septic arthritis, there is an absence
of literature confirming the risk of seeding a
sterile joint with a needle that has traversed a
soft-tissue infection [33]. Despite this, there is
no shortage of expert opinions endorsing [23,
70, 84] and discounting [33, 85] cellulitis as a
relative contraindication to arthrocentesis. A
best attempt should be made to select a nee-
dle entry point that avoids the overlying soft-
tissue infection, and deferring aspiration until
the overlying infection is treated is a consid-
eration. However, given the lack of high-level
evidence, cellulitis is not considered an abso-
lute contraindication [33]. Deeper soft-tissue
infections (Figs. 6 and 7), such as abscess,
bursitis, and pyomyositis, pose a greater chal-
lenge. If fluoroscopic guidance is used for ar-
throcentesis, the radiologist may be unaware
before entering the joint that an infected col-
lection has been traversed.
Seeding of a sterile joint in patients with
bacteremia is a theoretic risk. In a rabbit
model, Olney et al. [86] found that septic ar-
thritis developed in 30% of animals if blood
drawn from a rabbit with bacteremia was in-
jected directly into the joint. However, given
that most cases of septic arthritis in adults
are caused by hematogenous spread, patients
with septic arthritis presumably have con-
current bacteremia.
Aspiration Considerations
Routine approaches to image-guided joint
access are well described in the literature
[70, 87]; however, in patients with infection
or altered anatomy, the standard approach
may present undesirable risks. Planning the
optimal aspiration for an individual joint in-
cludes assessment of body habitus and visual
inspection for signs of soft-tissue infection.
Review of preaspiration imaging can reveal
normal structures susceptible to damage,
soft-tissue infection, intervening obstacles,
and osseous changes. Limitations in patient
positioning may necessitate a nonstandard
approach. Larger (e.g., 18- or 20-gauge) nee-
dles are typically used for ease of aspirating
thick purulent fluid.
Choosing an Imaging Modality for
Needle Guidance
Selecting the ideal imaging modality for
needle guidance relies on several factors, in-
cluding patient age, body habitus, suspected
pathologic condition, and the radiologist’s
expertise in anatomy and percutaneous tech-
niques. Although anticipated radiation dos-
es are low, the radiologist should adhere to
the goal of achieving as low as reasonably
achievable radiation. Other influential fac-
tors include availability of equipment and
ancillary staff, characteristics of the collec-
tion, and site of aspiration.
Fluoroscopic guidance is frequently used
for joint access and may be preferred be-
cause of operator proficiency, equipment
availability, and decreased ionizing radiation
relative to CT. Although soft-tissue and vas-
cular structures are fluoroscopically occult,
knowledge of basic anatomy can facilitate a
needle approach that easily avoids major vas-
cular structures.
US is useful for aspiration given its high
sensitivity for joint effusion [88] (Fig. 8).
Other advantages include lack of ionizing ra-
diation, visualization of vascular structures,
differentiation of joint fluid from synovitis,
identification of extraarticular fluid collec-

tions [23], and ability to accommodate many
patient positions and approaches. Mobile US
units can be used for imaging of patients
who are critically ill or in unstable condition
for whom transport to the radiology depart-
ment may be impractical or unsafe. US al-
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lows real-time needle visualization, which
simplifies aspiration of thick or loculated
collections and avoids extraarticular collec-
tions. However, US depends greatly on both
operator and technologist comfort and skill.
US also has limited capacity for evaluating
deeper structures and may be a poor choice
for imaging of obese patients.
Occasionally, sonographic and fluoro-
scopic guidance may show insufficient ana-
tomic detail for joint access. CT may be the
preferred or safer modality, particularly in
cases of irregular bony anatomy, presence of
extensive heterotopic ossification, or proxim-
ity of sensitive structures, such as mediasti-
nal vasculature.
Choosing the Approach
Patients with osseous deficiency (e.g., ex-
tensive erosive change, prior surgery) may
not have typical landmarks for joint access
(Fig. 9). Preaspiration imaging can delineate
the confines of the altered joint capsule. The
osseous void in the expected location of the
joint space can be targeted, although lack of
a tactile backstop forces the operator to es-
timate the appropriate needle depth. Famil-
iarity with anatomic alterations after surgery
can be helpful in defining new approaches.
For example, in patients with a history of
Girdlestone arthroplasty, one potential target
for access is the midpoint of a line drawn be-
tween the greater and lesser trochanters [89].
In patients who have previously undergone
arthroplasty, slight alterations to routine ap-
proaches can prevent overlapping metallic
structures from obscuring the needle tip dur-
ing fluoroscopic guidance. A frequently suc-
cessful technique for aspirating a total hip
prosthesis is to advance the needle until it
contacts the lateral aspect of the neck of the
femoral stem component and then direct the
tip laterally off the component into the more
dependent portion of the joint (Fig. 5C) [90].
Familiarity with the construction of the un-
derlying hardware can aid intraarticular nee-
dle tip positioning, such as with a reverse to-
tal shoulder prosthesis (Fig. 10).
Local Anesthesia
Several commonly used agents for local
anesthesia, including lidocaine, have been
572 AJR:215, September 2020
Chan et al.
reported to be bacteriostatic or bactericidal
[91]. A 2018 study of common pathogens im-
plicated in PJI [92] showed decreased growth
in culture on exposure to 2% lidocaine. The
presence of preservatives in commercial
preparations of lidocaine and other anes-
thetics enhances this antimicrobial effect
[93]. Caution is advised during arthrocente-
sis when instilling local anesthetics near the
joint, and preservative-free lidocaine is pre-
ferred to maximize organism yield.
Confirmation of Intraarticular Positioning
It is imperative to document intraarticular
needle tip positioning, most importantly in
the setting of a so-called dry tap to confirm
the absence of obtainable fluid. Intraarticular
positioning can be determined in real time if
US is used for guidance. In the setting of flu-
oroscopic guidance, contrast instillation after
aspiration can verify intraarticular needle po-
sitioning. Spread of iodinated contrast mate-
rial (Fig. 3C) can show intraarticular commu-
nication with fluid collections, bursae, or sinus
tracts. In prior studies, investigators have ex-
pressed concern over the bactericidal effects
of iodinated contrast material if inadvertently
mixed with aspirated fluid, but this effect has
not been found with modern low-osmolar and
isoosmolar contrast agents [94]. Air contrast
(Fig. 10B) is a cost-free alternative in patients
with allergies to iodinated contrast material
[95] but will introduce susceptibility artifacts
if MRI is subsequently performed.
Deciding Whether to Perform Lavage
There is considerable debate regarding
the role of joint lavage and reaspiration af-
ter initial failure to aspirate fluid. Kung et
al. [96] described a hip lavage technique
involving injection of 10 mL of iodinat-
ed contrast material or sterile nonbacterio-
static saline solution with average return of
2.3 mL at reaspiration. Several studies have
shown positive organism recovery by use
of percutaneous joint lavage [96–98], and a
2018 study in the orthopedic literature [97]
showed similar performance between pri-
mary joint aspiration and reaspirated sa-
line solution after dry tap in the diagnosis
of PJI. Consensus statements generally ad-
vise against saline lavage but are somewhat
ambiguous; 83% of International Consensus
Meeting delegates opposed the use of sa-
line lavage but specified that performance
by a radiologist was a possible exception
[33]. Given the degree of uncertainty, dis-
cussion with orthopedic surgeons is recom-
mended before routine performance of this
technique. Notably, aspirate obtained via sa-
line lavage will yield a dilute sample [99],
and the aspirate should be clearly labeled to
avoid inaccurate cell counts.
Analysis of Aspirated Fluid
To prevent contamination, aspirate is of-
ten sent to the microbiology laboratory in the
syringe used during the procedure. Howev-
er, several studies [100–102] have shown in-
creased pathogen yield when samples are in-
oculated in blood culture bottles rather than
as conventional cultures on standard agar me-
dia. Although the minimum amount of requi-
site fluid varies by institution, small volumes
of aspirate can be sufficient for fluid analysis.
Our microbiology laboratory requires a mini-
mal sample for culture and as little as 0.5 mL
to determine cell count and differential.
Standard synovial fluid analysis includes
culture and cell count and differential; crys-
tal analysis is also often performed in the as-
sessment of native joints in adults [103–106].
However, synovial WBC and polymorphonu-
clear leukocyte counts may remain elevated
as long as 90 days after arthroplasty [107].
Additionally, cutoff values for abnormal sy-
novial WBC count and polymorphonuclear
percentage appear to vary for different joint
sites [108, 109]. Table 2 includes potential
cutoff values for common synovial fluid tests
to assess for infection in both native and pros-
thetic joints. The presence of an adverse lo-
cal tissue reaction can lead to falsely elevated
synovial WBC counts and α-defensin levels,
and intraoperative purulence can be present
with either adverse local tissue reaction or PJI
[33]. Samples should be incubated for at least
14–21 days to isolate slow-growing organ-
isms associated with PJI [110]. Gram stain-
ing is historically performed but has low di-
agnostic performance; the false-negative rate
was 78% (111/143) in one study [111].
Additional biomarkers may be beneficial
in equivocal cases. The most promising sy-
novial biomarker at present appears to be
α-defensin [112], which is an antimicrobial
peptide released by neutrophils in response to
infection and is detectable with the Synova-
sure PJI test (Zimmer Biomet). Deirmengian
et al. [113] reported that use of the combina-
tion of synovial α-defensin and CRP detect-
ed with immunoassay led to correct diagno-
ses of asepsis or infection in 99% of cases.
Leukocyte esterase reagent strips can provide
a rapid estimate of synovial WBC count and
have been included in diagnostic algorithms

[114]. Newer molecular techniques, such as
polymerase chain reaction [115], microarray
analysis [116], and next-generation sequenc-
ing [117], are promising but require further
validation before widespread adoption.
Downloaded from www.ajronline.org by 192.141.244.104 on 01/15/22 from IP address 192.141.244.104. Copyright ARRS. For personal use only; all rights reserved
Dealing With Suspected False-
Negative Results
A negative aspiration result (either dry
tap or bland fluid) in a patient with suspect-
ed septic arthritis presents a clinical dilem-
ma. Patients with clinically suspected septic
arthritis but culture-negative synovial fluid
have outcomes similar to those of patients
with confirmed septic arthritis, supporting
the rationale for treating patients as having
presumptive septic arthritis even in the ab-
sence of confirmatory study results [118].
Several consensus statements endorse re-
peat aspiration for suspected hip PJI [33, 39].
The frequency of surgery for suspected PJI
on patients with negative aspiration and pos-
itive intraoperative culture results was 22%
(219/996) in one large institutional retrospec-
tive review [119]. Another recent review re-
vealed that repeat prosthetic hip joint aspira-
tion within 90 days of the initial aspiration
changed the diagnosis for 43% of patients
(26/60) [120].
Despite uncertainty over the reliability of
culture-negative aspiration results, there are
no guidelines for the recommended time in-
terval between or optimal number of repeat
aspirations, and whether aspiration should
be repeated should be driven by discussion
between the radiologist and orthopedic sur-
geon. Percutaneous synovial biopsy may
have a role in this population. Coiffier et al.
[121] found that 27% (3/11) of patients with
acute arthritis and inadequate synovial fluid
for analysis had positive culture results after
US-guided synovial biopsy.
Conclusion
Despite the urgency associated with a di-
agnosis of septic arthritis, there remains a
lack of high-level evidence regarding many
aspects of management of native and peri-
prosthetic joint infections. This results in
a heterogeneous approach to arthrocente-
sis across different practice settings. Under-
standing the current literature will help the
radiologist discuss challenging cases with
ordering providers and adopt an evidence-
based approach to joint aspiration. Ulti-
mately, the best approach will be institution
dependent and require interdisciplinary col-
laboration between radiology, orthopedic
AJR:215, September 2020 573
Septic Arthritis
surgery, and other providers to maximize
positive patient outcomes.
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APPENDIX 1: Considerations Before Joint Aspiration

1. Does the patient have a prosthetic joint?
2. Has the patient recently received antibiotic therapy?
3. Have blood cultures been obtained?
4. Review serum laboratory values: WBC count, erythrocyte sedimentation rate, C-reactive protein, d-Dimer.
5. Review prior imaging for underlying structural changes or intervening soft-tissue infection (e.g., abscess or bursitis).
6. Does the patient have any allergies?
7. Is the patient on anticoagulant therapy?
8. Does the patient have evidence of an overlying soft-tissue infection?
9. What imaging modality should be used for needle guidance? (Consider joint to be aspirated, assess body habitus.)

Others ≈ 12%
Polymicrobial 5%
Anaerobes 0.6%
Mycobacterium tuberculosis 1.8%
Neisseria gonorrhoeae 1.2%
Miscellaneous 4%

Gram-negative rods ≈ 16%

Pseudomonas aeruginosa 6%
Escherichia coli 3%
Proteus spp. 1%
Klebsiella spp. 1%
Others 4%
Staphylococcus ≈ 56%
MSSA 42%
MRSA 10%
CONS 3%
Streptococcus ≈ 16%
Unspecified spp. 11%
Viridans streptococci 1%
S. pneumoniae 1%
Other spp. 3%
Fig. 1—Chart shows infectious agents in 505 cases of septic arthritis reported
between 1999 and 2013. CONS = coagulase-negative Staphylococcus species;
MRSA = methicillin-resistant Staphylococcus aureus, MSSA = methicillin-
sensitive S. aureus, spp. = species. (Data from [4]).

576 AJR:215, September 2020

 Septic Arthritis

Fig. 2—29-year-old man with septic arthritis of left

knee.
A, Anteroposterior radiograph shows uniform joint
space narrowing with articular surface irregularity
(arrowheads). Marked soft-tissue swelling is evident
around knee with effacement of fat planes lateral to
distal femur and medial to proximal tibia.
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B, Axial T1-weighted fat-suppressed contrast-

enhanced MR image shows large joint effusion (star)
with thick irregular synovial enhancement (straight
arrows). Periarticular soft-tissue enhancement
and intramuscular abscesses are present in
gastrocnemius muscle (curved arrows).

A B

A B

C D E
Fig. 3—60-year-old man with septic arthritis of left hip.
A, Anteroposterior radiographs at baseline (left) and 2 months later (right) show rapidly progressive joint space narrowing and articular surface irregularity (arrowheads).
B, Oblique gray-scale ultrasound image shows complex hip joint effusion (star) and distention of joint capsule (arrowheads). Three milliliters of cloudy yellow fluid
was aspirated, and synovial fluid analysis revealed WBC count of 166,000/μL with 97% polymorphonuclear leukocytes. Synovial fluid culture result was positive for
methicillin-resistant Staphylococcus aureus. ACE = acetabulum, FH = femoral head.
C, Fluoroscopic image obtained during repeat hip joint aspiration shows intraarticular iodinated contrast material and multiple irregular filling defects (oval) suspicious
for synovitis.
D, Axial T1-weighted MR image shows confluent hypointense marrow in femoral head and neck (star) and anterior cortical erosion (arrow) consistent with osteomyelitis.
E, Axial proton density–weighted fat-suppressed MR image shows exuberant marrow edema corresponding to region of abnormal T1 marrow signal intensity (star) in D.
Synchronous reactive or degenerative marrow edema in acetabulum (dashed arrow) retains hyperintense T1 marrow signal relative to skeletal muscle in D. Joint effusion
(arrowhead) and fluid within greater trochanteric bursa (solid arrow) are also evident.

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A
Fig. 4—Proposed diagnostic tools for evaluation of suspected periprosthetic joint infection (PJI). CRP =
C-reactive protein, ESR = erythrocyte sedimentation rate, LE = leukocyte esterase, PMN = polymorphonuclear
leukocytes. (Reprinted from Journal of Arthroplasty, 34, Shohat N, Tan TL, Della Valle CJ, et al. Development
and validation of an evidence-based algorithm for diagnosing periprosthetic joint infection, Pages 2730–2736.
e1, Copyright 2019, with permission from Elsevier, https://www.sciencedirect.com/journal/the-journal-of-
arthroplasty)
A, Chart shows 2018 scoring-based criteria for PJI incorporating newer biomarkers and validated with patients
with PJI as defined by Musculoskeletal Infection Society criteria.
(Fig. 4 continues on next page)

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 Septic Arthritis
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B
Fig. 4 (continued)—Proposed diagnostic tools for evaluation of suspected periprosthetic joint infection (PJI). CRP = C-reactive protein, ESR = erythrocyte sedimentation
rate, LE = leukocyte esterase, PMN = polymorphonuclear leukocytes. (Reprinted from Journal of Arthroplasty, 34, Shohat N, Tan TL, Della Valle CJ, et al. Development and
validation of an evidence-based algorithm for diagnosing periprosthetic joint infection, Pages 2730–2736.e1, Copyright 2019, with permission from Elsevier, https://www.
sciencedirect.com/journal/the-journal-of-arthroplasty)
B, Chart shows 2019 proposed evidence-based algorithm for diagnosing PJI.

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 Chan et al.
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A B C
Fig. 5—42-year-old woman with periprosthetic joint infection (PJI) after prior right total hip arthroplasty.
A, Three-hour-delayed anterior planar 99 mTc-bone scintigram of pelvis obtained during triple-phase examination shows photopenia (circle) at hip joint corresponding to
known total hip prosthesis. There is no periprosthetic radiotracer uptake to suggest PJI or loosening.
B, Coronal STIR slice encoding for metal artifact correction MR image shows complex joint effusion with thickened low-signal-intensity joint capsule (arrowheads).
C, Fluoroscopic image obtained during hip joint aspiration shows needle tip (arrow) positioned at superolateral aspect of neck of femoral stem component. Scant
greenish-brown fluid was aspirated, and synovial fluid cultures were positive for methicillin-sensitive Staphylococcus aureus. Synovial fluid analysis from intraoperative
sample during subsequent incision and drainage revealed WBC count of 35,000/μL with 93% polymorphonuclear leukocytes.

Fig. 6—55-year-old woman with left glenohumeral

septic arthritis and history of type 2 diabetes mellitus.
A, Axial proton density–weighted fat-suppressed
MR image shows large glenohumeral joint effusion
(arrow) and fluid distention of subacromial-subdeltoid
bursa (arrowheads). Numerous low-signal-intensity
punctate foci are present within nondependent
bursa, consistent with gas.
B, Sagittal T2-weighted fat-suppressed MR image
shows gas- and fluid-filled subacromial-subdeltoid
bursa, which communicates with glenohumeral joint
via full-thickness rotator cuff tear (arrowhead) and
overlying subcutaneous tissues via defect in deltoid
muscle (arrow). Thirty milliliters of turbid fluid was
aspirated, and synovial fluid analysis revealed WBC
count of 101,000/μL with 89% polymorphonuclear
leukocytes. Synovial fluid cultures were positive for
methicillin-sensitive Staphylococcus aureus.

A B

A B C
Fig. 7—37-year-old man with clinically suspected right glenohumeral septic arthritis and history of IV drug use. Fluoroscopically guided right glenohumeral joint
aspiration performed before imaging at ordering provider’s request resulted in dry tap.
A, Coronal postaspiration T1-weighted fat-suppressed contrast-enhanced MR image shows large abscess (stars) superficial to and within deltoid muscle, consistent
with pyomyositis.
B and C, Axial proton density–weighted fat-suppressed (B) and axial T1-weighted fat-suppressed contrast-enhanced (C) MR images show minimal fluid within
glenohumeral joint (arrow, B) with trace synovial enhancement (arrow, C). Soft-tissue edema (arrowheads, B) and enhancement (arrowheads, C) are evident anterior to
glenohumeral joint along needle trajectory for aspiration. Juxtaarticular abnormal marrow signal intensity is absent. Patient later had glenohumeral septic arthritis, and
gross intraoperative purulence was noted at incision and drainage.

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 Septic Arthritis

Fig. 8—28-year-old woman with right glenohumeral

septic arthritis 1 week after anterior shoulder
dislocation and subsequent closed reduction and
history of uncontrolled type 2 diabetes mellitus.
A, External rotation Grashey radiograph of shoulder
shows ill-defined cortex at site of Hill-Sachs
impaction fracture (arrow). Apparent inferior
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subluxation of glenohumeral joint may reflect atony

or underlying effusion.
B, Transverse gray-scale ultrasound image of
posterior glenohumeral joint during aspiration shows
needle (arrowhead) positioned with tip (circle) within
complex glenohumeral joint effusion. Bulging of
posterior glenohumeral joint capsule (straight arrow)
is evident. Cortical irregularity of posterior humeral
head corresponds to known Hill-Sachs lesion (curved
arrow). Eleven milliliters of purulent white fluid was
aspirated, and synovial fluid analysis revealed WBC
count of 478,000/μL with 97% polymorphonuclear
leukocytes. Synovial fluid and blood cultures were
positive for Streptococcus agalactiae (group B
streptococcus). GLE = glenoid, HUM = humeral head.

A B

Fig. 9—Two patients undergoing aspiration to rule

out infection before arthroplasty.
A, 62-year-old man who has undergone Girdlestone
procedure. Fluoroscopic image obtained during
right hip joint aspiration shows needle tip (arrow)
positioned inferior to superior rim of acetabulum
(ACE).
B, 68-year-old woman with neuropathic shoulder.
Fluoroscopic image obtained during left
glenohumeral joint aspiration shows needle tip
(arrow) positioned along medial edge of chronically
eroded humeral head. Both aspiration attempts
yielded return of fluid.

A B

Fig. 10—Two patients with prior reverse total

shoulder arthroplasty and shoulder pain.
A, 62-year-old woman undergoing right glenohumeral
joint aspiration. Fluoroscopic still image shows
needle tip (arrow) positioned near superolateral
aspect of glenosphere component (GS).
B, 73-year-old woman undergoing right glenohumeral
joint aspiration. Fluoroscopic still image shows
needle tip (arrow) positioned at inferomedial aspect
of glenohumeral joint. Air was used for negative
contrast confirmation of intraarticular positioning
(arrowheads).
A B

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