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Septic Arthritis of the Knee in Children

A Critical Analysis Review

Ishaan Swarup, MD Abstract

» Septic arthritis of the knee is the most common type of septic
Blake C. Meza, BS
arthritis in children, and it may result in irreversible joint damage.
Daniel Weltsch, MD
» Staphylococcus aureus is the most common pathogen associated with
Asmita A. Jina, DO septic arthritis, but other causative pathogens are possible in children
John T. Lawrence, MD, PhD with certain risk factors.

Keith D. Baldwin, MD, MPH, » The diagnosis of septic arthritis of the knee is based on history and
MSPT physical examination, blood tests, and arthrocentesis.
Downloaded from http://journals.lww.com/jbjsreviews by BhDMf5ePHKbH4TTImqenVJsWiCZ2rfmUG8FQlNge7W6flg+3icwMtWiY9Cr0t4iF on 02/02/2020

» Empiric treatment with anti-staphylococcal penicillin or a first-

generation cephalosporin is usually recommended but may be tailored
Investigation performed at the
according to local resistance patterns and clinical culture data.
Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
» Open or arthroscopic surgical debridement including extensive
lavage is effective in eradicating infection, and most patients do not
require additional surgical intervention.

S
eptic arthritis of the knee is
a relatively common and im-
portant condition in pediat-
ric orthopaedics. Failure to
promptly diagnose or provide treatment
may lead to rapid destruction of the
cartilage and permanent impairment of the
knee joint. In addition, progression of the
infection to adjacent sites, such as the physis
and bone, may result in growth disturbance
and osteomyelitis, and systemic spread can
be potentially life-threatening1-4. In the
past, septic arthritis was associated with an
unfavorable prognosis and high mortality
rates. However, advancements in diagnos-
tic and treatment modalities for septic
arthritis have led to reductions in associated
morbidity and mortality5,6.
Septic arthritis of the knee is defined as
an inflammatory process of the joint that is
generated by a bacterial or fungal infection.
It primarily involves the synovium and
subsequently all of the related structures
found within the borders of the joint7. Its
presentation varies widely depending on
the causative pathogen, severity of infec-
tion, patient age, and the overall health
status of the patient. The evaluation of a
child with septic arthritis relies on history,
clinical symptoms, physical examination,
laboratory analysis, synovial fluid analysis,
and in some cases, radiographic and
advanced-imaging modalities. Addition-
ally, travel history, social history, and a
review of symptoms are critical in evaluat-
ing patients with suspected septic arthritis
of the knee. Several evidence-based pre-
dictive models and criteria have been es-
tablished to distinguish between septic
arthritis and benign conditions, such as
transient synovitis8,9. However, these
models have not been shown to be appli-
cable to the knee joint, presumably because
of differences in the inflammatory response
between septic arthritis and more benign
conditions10. In addition, the diagnosis of
septic arthritis by synovial fluid analysis
may take time and is often complicated by
false-negative culture results10,11. Not all
forms of septic arthritis of the knee require

COPYRIGHT © 2020 BY THE Disclosure: The authors indicated that no external funding was received for any aspect of this work.
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JBJS REVIEWS 2020;8(1):e0069 · http://dx.doi.org/10.2106/JBJS.RVW.19.00069 1

 | S ep t i c Ar t h r i t i s o f t h e Kn ee i n C h i l d r e n

septic arthritis, but they have been lim-

TABLE I Risk Factors for Septic Arthritis in Children
Risk Factor
Young age (,4 yr old)4,19,97
Male sex4,11,15
Bacteremia or recent IV therapy3,4,24,98
Concomitant osteomyelitis
Immunocompromised status (diabetes, malignancy, HIV*, corticosteroid
therapy, malnourished)31,99
Hemoglobinopathy (e.g., sickle cell disease)30
Low birthweight/prematurity100
Umbilical artery catheterization100-102
Low socioeconomic status4
*HIV 5 human immunodeficiency virus.
surgical management. It is important for
orthopaedic surgeons to understand the
nuances of septic arthritis of the knee in
children to successfully manage this
potentially serious condition.
There have been several recent
advancements in the diagnosis and
management of septic arthritis of the
knee in children. More specifically,
recent literature has focused on
describing etiologic pathogens,
improving diagnosis, and establish-
ing reliable treatment of this condi-
tion. In this review, we highlight
advancements in the understanding
of disease epidemiology, pathophys-
iology, diagnosis, and treatment. We
also offer a critical analysis of the lit-
erature pertaining to the diagnosis
and treatment of septic arthritis of the
knee in children.
chain reaction (PCR)-based pathogen
detection, and other improvements in
diagnostic technology, as well as due to
the emergence of treatment-resistant
bacterial strains14. Generally, septic
arthritis is more common in males and
children ,4 years of age4,15. Addition-
ally, the vast majority of septic arthritis
cases affect healthy children16; however,
several risk factors have also been iden-
tified (Table I). Moreover, the knee joint
is the most frequently infected joint in
children, and it comprises approxi-
mately 37% to 54.5% of septic arthritis
cases in children4,11,13,17-21.
Previous studies have attempted to
describe the microbiologic profile of
TABLE II Common Bacterial Pathogens Associated with Septic
Arthritis of the Knee
ited by a large number of negative cul-
tures. In recent studies, a causative
organism was identified in only 49.5%
of all cases3,11,20,22-24. However, it is
likely that rates and the identification
of causative organisms will improve
with the utilization of advanced diag-
nostic measures such as real-time
PCR (RT-PCR)25. A comprehensive
description of causative organisms of
knee septic arthritis in children is chal-
lenging because of limited literature on
this particular topic. Traditionally,
Staphylococcus aureus, both methicillin-
sensitive (MSSA) and methicillin-
resistant (MRSA), has been considered
the most commonly cultured patho-
gen across all pediatric age groups
(Table II)6. Several studies have noted an
increasing prevalence of MRSA over the
past decade26,27. Kingella kingae is
another common organism implicated
in pediatric septic arthritis, especially in
children ,4 years of age28. Kingella is a
fastidious gram-negative bacillus that is
commonly found in the oral cavity.
This organism is often difficult to cul-
ture, and clinically, it is characterized
by a less severe presentation29. The
recent increase in rates of Kingella
septic arthritis is likely attributable to
increased awareness of the pathogen
and improved detection methods using

Age Group Common Probable Bacterial Pathogen

Epidemiology
Neonates Staphylococcus aureus
Septic arthritis occurs more commonly
Group B streptococcus
in childhood than during other any
other period of life12. The prevalence of Gram-negative bacilli
pediatric septic arthritis in the United Infants and toddlers (3 mo S. aureus
to 3 yr) Kingella kingae
States was previously noted to be stable,
at approximately 1 per 100,000 chil- Group A streptococcus
dren13. However, according to a recent Streptococcus pneumoniae
study using a national database, the Hemophilus influenzae (if not vaccinated)
prevalence has increased to approxi- Children (.3 yr to 11 yr) S. aureus
mately 3.28 to 3.64 per 100,000 chil- K. kingae
dren4. This increase may be due to
Adolescents (.11 yr to S. aureus
improvements in diagnosis and related ,18 yr) Gonococcal infections (in sexually active
processes, such as sterile culture tech- patients)
niques, the incorporation of polymerase

2 JANUARY 2020 · VOLUME 8, ISSUE 1 · e0069


RT-PCR assays specific to the Kingella
toxin25,28.
In neonates, Group B Streptococ-
cus and gram-negative bacilli are also
common pathogens responsible for
septic arthritis. In infants and toddlers
aged 3 months to 3 years of age, S. aureus
and K. kingae remain prevalent, along
with Group A Streptococcus (Strepto-
coccus pyogenes) and Streptococcus pneu-
moniae. Hemophilus influenzae was once
common in this age group, but it has
become increasingly rare in the setting of
widespread vaccination programs19.
However, this pathogen should still be
considered for unvaccinated children. In
children .3 years of age and adoles-
cents, the principal causative agent
remains S. aureus. Additionally, some
pathogens are associated with specific
patient risk factors. For example, Sal-
monella is an important pathogen in
patients with sickle-cell disease and
other related hemoglobinopathies30,
and gonococcal infections are more
likely in sexually active adolescents.
Similarly, S. pneumoniae, Mycobacte-
rium tuberculosis, Bartonella henselae,
and fungal pathogens should be con-
sidered in immunocompromised
patients31,32. In addition, residence
in or travel to Lyme-endemic areas,
such as the Northeast, Midwest, and
Western United States, should raise the
suspicion for infection by Borrelia
burgdorferi, which is another important
cause of septic arthritis of the knee in
children33,34.
Pathophysiology
The most common underlying mecha-
nisms of septic arthritis in children
are hematogenous spread, direct
inoculation, and extension of a contig-
uous focus of infection12. Transient
bacteremia is common in children
because of the frequency of upper-
respiratory, skin, or gastrointestinal
infections. The lack of a basement
membrane in the synovium makes the
joint space particularly susceptible to
infection from hematogenous spread,
and trauma to the synovium through
direct impact to the knee may further
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S e p t i c Ar t h r i t i s o f t h e Kn e e i n C h i ld r en
enhance this susceptibility. Direct
inoculation of the joint is most fre-
quently associated with trauma or sur-
gery in children and can lead to
polymicrobial infections17.
Septic arthritis due to an extension
of adjacent osteomyelitis is thought to
occur most commonly before the age of
18 months, as during that time, small
transphyseal vessels cross the growth
plate from metaphysis to epiphysis,
serving as a route of entry to the joint
surface35-37. In older children, the
growth plate serves as a barrier to the
spread of metaphyseal osteomyelitis to
the epiphysis as the transphyseal vessels
atrophy. In addition, metaphyseal oste-
omyelitis can also result in septic ar-
thritis in joints with an intra-capsular
metaphysis, such as the hip, shoulder,
ankle, and elbow. Despite the absence of
an intra-capsular metaphysis, knee sep-
tic arthritis is sometimes associated with
adjacent osteomyelitis, suggesting that
additional mechanisms are responsible
for the spread of pyogenic materials from
the metaphysis to the knee joint38.
Not every occurrence of bacteria
entering the joint space leads to infec-
tion, as synovial fluid demonstrates
bactericidal activity against some of the
gram-positive pathogens often respon-
sible for septic arthritis39,40. When these
protective mechanisms are overcome by
a large inoculum of bacteria or highly
virulent organisms that cannot be
effectively removed, synovial cells
phagocytose nearly 90% of bacteria that
enter the joint space and initiate a strong,
acute inflammatory response41. Bacte-
rial endotoxins prompt host cells to
release cytokines, including interleukin
(IL)-1, IL-6, IL-8, and tumor necrosis
factor (TNF)-a42-44. Cytokines func-
tion as chemoattractants for neutrophils
and stimulate the release of collagenases,
peptidases, and metalloproteinases that
lead to cartilage matrix and synovial
damage and subsequent purulence in
the joint44,45. Neutrophils, synovial
cells, chondrocytes, and bacteria have all
been implicated in playing a destructive
role in septic arthritis by releasing these
proteolytic enzymes46-49. Ex vivo stud-
|
ies have demonstrated that cartilage
degradation, via the loss of glycosami-
noglycans, occurs within 8 hours of
initial inoculation, which underscores
the importance of prompt diagnosis and
management50.
Beyond the joint, cytokines play a
role in the systemic response to septic
arthritis as well. The pro-inflammatory
cytokines IL-1 and TNF-a are respon-
sible, in part, for producing the fever
associated with septic arthritis of the
knee51. In addition, high levels of IL-6 in
the joint and serum signal the produc-
tion of acute phase reactants such as
C-reactive protein (CRP), which serves
as an important marker for diagnosis and
in monitoring response to treatment43.
Countering the local and systemic
inflammatory response in septic arthritis
with prompt diagnosis and appropriate
management is imperative to preventing
the morbidity associated with septic
arthritis of the knee.
Diagnosis
History and Physical Examination
In children, the hallmark symptoms of
septic arthritis include fever (38° to 42°
C), joint pain, swelling, and restriction of
joint motion or pseudoparalysis40,52.
These symptoms usually occur for 2 to 5
days prior to presentation and may be
accompanied by nonspecific symptoms,
such as malaise or poor appetite. Up to
20% of children have a history of injury
to the affected extremity or a fall prior to
presentation53. Other important histori-
cal features to consider include the pro-
gression of symptoms, preceding
illnesses, birth history in neonates, expo-
sures and travel history, social history, and
immunization status, as each of these
factors helps to determine potential
causative organisms, as previously dis-
cussed40. In addition to septic arthritis,
the differential diagnosis includes fracture
or contusion, inflammatory arthritis, and
ligamentous injury.
Physical examination should
include careful inspection of the joint for
effusion and swelling as well as palpation
for tenderness and warmth. Compari-
sons with the contralateral knee are
3
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useful, and asymmetric swelling is often
an important diagnostic clue. In addi-
tion, active and passive range of motion
should be evaluated, not only for the
affected knee but also the contralateral
knee and the ipsilateral hip and ankle, as
nearly 10% of cases can involve multiple
joints54. The patient may hold the
affected knee in the flexed position to
minimize pain. Characteristically, chil-
dren with knee septic arthritis may limp
or refuse to bear weight on the affected
extremity. Meanwhile, neonates often
present with more subtle symptoms,
such as irritability or poor feeding. Skin
findings or posturing of the extremity
may provide additional clues regarding
joint involvement and associated soft-
tissue infection55.
Blood Cultures and Laboratory Tests
The laboratory evaluation for septic
arthritis can be crucial to ruling out
noninfectious etiologies of knee pain and
swelling and determining appropriate
next steps in management. The 4 most
important laboratory tests that should be
performed for children with signs and
symptoms concerning for septic arthritis
of the knee include blood cultures, white
blood-cell (WBC) count with differen-
tial, and assessment of CRP level and
erythrocyte sedimentation rate (ESR)12.
In general, blood cultures are positive in
only approximately 40% of cases, but
culture may still be critical, especially in
cases of negative synovial culture8,44,56.
Independently, an elevated WBC count
can be found in 30% to 60% of patients
with septic arthritis; however, a con-
comitant “left shift” increases the sensi-
tivity to almost 70%56,57.
The 2 most sensitive markers of
septic arthritis are ESR (.20 mm/hr) and
CRP level ($1 mg/dL), each of which
has a sensitivity of $90%, and when
elevated simultaneously, a sensitivity of
98%58,59. CRP level is the preferred
marker for determining response to
treatment, as it typically normalizes
within 1 week of appropriate treatment,
compared with ESR, which may remain
elevated for up to a month40,53,60,61.
These markers can help differentiate
septic arthritis from other causes of joint
pain and swelling, such as Lyme arthritis
and transient synovitis8,33,62,63. In addi-
tion, Lyme titers should be obtained for
patients with exposure to Lyme-endemic
areas64.
Arthrocentesis
Additional components of the diag-
nostic work-up include arthrocente-
sis, which should not be delayed
while awaiting blood culture and
inflammatory-marker results56,65-67.
The synovial fluid sample should be sent
for WBC count and differential, Gram
stain, culture, and if available, PCR
detection for K. kingae and Lyme
disease68,69. More than 50,000 WBCs
per mL with .90% polymorphonuclear
leukocytes (PMNs) is suggestive of sep-
tic arthritis70,71. Although theoretically
valuable in diagnosis, the utility of Gram
stain of synovial fluid has recently been
called into question, particularly for
gram-negative organisms11. Addition-
ally, negative synovial culture should not
rule out septic arthritis, as up to 50% to
70% of children who demonstrate clin-
ical signs of the disease have negative
culture results12,72. Synovial fluid may
be sent for crystal analysis, although
crystal-induced arthropathies are rare in
children and should only be considered
in children with metabolic disorders,
such as Lesch-Nyhan syndrome40,73.
Clinical suspicion and patient-specific
risk factors for alternative causes of septic
arthritis should guide the decision to
obtain culture using specific media, such
as blood agar (K. kingae, Pasteurella) and
Löwenstein-Jensen medium (acid-fast
M. tuberculosis)74,75.
Imaging
Radiographs should be obtained, but
they have limited utility in diagnos-
ing septic arthritis of the knee in
children. They may aid in ruling out
concurrent osteomyelitis in cases of
delayed presentation, or fracture in
the setting of trauma. Subtle signs
may include soft-tissue swelling,
which may suggest an effusion or
subcutaneous abscess. Ultrasonogra-
phy and magnetic resonance imaging
(MRI) are more useful for detecting
knee joint effusions, although such

TABLE III Diagnostic Utility of Commonly Ordered Tests for Septic Arthritis

Positive Predictive Negative Predictive

Diagnostic Test Value Sensitivity Specificity Value Value

Physical examination40,103,104 Temp. $38°C 36%-74% — — —

Blood culture56 1 41% — — —
WBC count56,57,105 11,000/mL 30%-60% 55%*
ESR59,104,106 25 mm/hr 79%-92% 22% 35% 86%
CRP59 1 mg/dL 90% 29% 34% 87%
Synovial fluid WBC count105 50,000/mL 50%-62%* 88%-92%* — —
Synovial fluid culture56,72,107 1 70%-90% 75%-95% — —
MRI 80,108
NA† 50% (67% with contrast) 98% 85% —

*Denotes values that have not been reported in research focused on septic arthritis of the knee in children. †NA 5 not applicable.

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infection, but this technique is not

TABLE IV Recommendations for the Diagnosis of Septic
commonly used for the knee 77.
Arthritis of the Knee
Advanced imaging (e.g., MRI) is
Measure Grade of Evidence* indicated when there is a high suspicion
Physical examination B
of adjacent osteomyelitis or soft-tissue
infection as well as atypical presentation
Blood culture B
in order to aid in the diagnosis and sur-
Complete blood count (CBC) with differential B
gical planning. Patients at the highest
ESR and CRP B
risk for adjacent infection are those with
Arthrocentesis B
an age of .3.6 years, a CRP level of
Radiographs of the knee B
.13.8 mg/dL, a platelet count of
Ultrasound or MRI I
,314,000/mL, and a symptom dura-
*Grade A 5 Good evidence (Level-I studies with consistent findings) for or against tion of .3 days78. However, there may
recommending intervention. Grade B 5 Fair evidence (Level-II or III studies with be regional variations in the rates of
consistent findings) for or against recommending intervention. Grade C 5 Con- concurrent periarticular infections, and
flicting or poor-quality evidence (Level-IV or V studies) not allowing a recom-
mendation for or against intervention. Grade I 5 There is insufficient evidence to regional microbiology and patient
make a recommendation. factors should guide clinical decision-
making79. MRI with gadolinium con-
imaging is typically more valuable for tion 76. For the hip, Doppler trast has been shown to improve the
joints in which effusions may be dif- sonography can be utilized to identify sensitivity of MRI in diagnosing septic
ficult to detect on physical examina- increased blood flow, suggestive of arthritis in children as well (Table III)80.

Fig. 1
Algorithm for the diagnosis and management of
septic arthritis of the knee. H&P 5 history and
physical examination, ROM 5 range of motion, GS 5
Gram stain, Cx 5 culture, PCR 5 polymerase chain
reaction, CBC 5 complete blood count, ESR 5
erythrocyte sedimentation rate, CRP 5 C-reactive
protein, and MRSA 5 methicillin-resistant Staphy-
lococcus aureus.

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When obtaining MRI, increased cost
and the potential need for sedation in
younger children must be considered, as
the latter may result in a delay in diag-
nosis or treatment.
Critical Analysis Review
To our knowledge, there are no Level-I
studies comparing diagnostic tests for
septic arthritis of the knee in children,
and the diagnosis of septic arthritis is
made using a combination of several
important factors (Table IV). In our
practice, we begin the evaluation of each
child with suspected septic arthritis of
the knee with a history and physical
examination (Fig. 1). If there is contin-
ued suspicion for septic arthritis, labo-
ratory tests including a complete blood
count (CBC) with differential, assess-
ment of inflammatory makers, Lyme
titers, and blood cultures are then ob-
tained. An arthrocentesis is also per-
formed and sent for Gram stain and
culture, WBC count, and PCR analysis
for Kingella and Lyme. PCR analysis for
gonococcal infections can also be per-
formed if there is clinical concern.
Routine radiographs are obtained.
Additional or advanced imaging is ob-
tained if there are a history of trauma, a
concern for adjacent osteomyelitis or
soft-tissue infection, or continued
symptoms despite normal laboratory
markers and synovial fluid analysis and
negative cultures.
Treatment
Antibiotics
Children with septic arthritis of the knee
are typically admitted to the hospital.
After the diagnostic work-up has been
initiated or completed, treatment is usu-
ally commenced with empiric antibiotics.
Empiric antibiotics are selected to cover
the most common pathogens, and they
should ideally be based on institutional
microbiodata and antibiotic-resistance
levels81. In general, anti-staphylococcal
penicillin, such as nafcillin or oxacillin, or
a first-generation cephalosporin, such as
cefazolin, is selected since it is effective
against MSSA, S. pyogenes, and K. kingae.
Clindamycin may be used for empiric
6 JANUARY 2020
treatment in patients who are allergic to
penicillin or cephalosporins. In neonates,
empiric treatment may include gentami-
cin in addition to oxacillin in order to
cover gram-negative organisms as well32.
It is not necessary to empirically cover
MRSA in the majority of cases, unless
there is a high community prevalence of
MRSA, recent hospitalization, or admis-
sion to the intensive care unit, or if the
patient is immunocompromised32,81. In
addition, atypical pathogens such as
M. tuberculosis and B. henselae and fungal
pathogens should also be covered in
immunocompromised patients with
septic arthritis32.
The duration and route of antibi-
otic therapy depend on several factors.
Treatment usually begins with intrave-
nous (IV) antibiotics and then transitions
to oral antibiotics on the basis of culture
data, laboratory data (down-trending
WBC count, ESR, and CRP level), and
clinical improvement32. A retrospective
study showed no difference in outcomes
when patients were treated for 7.4 versus
18.6 days of IV antibiotics, with a total
course of 4 weeks of antimicrobial ther-
apy82. Similarly, a randomized controlled
trial showed no difference in outcomes
between patients treated with a total of 10
days compared with 30 days of antibiotics
after 2 to 4 days of IV therapy83. Addi-
tional studies are needed to adequately
determine the optimal duration and route
of antibiotic therapy for septic arthritis of
the knee. In general, current literature
suggests that children with septic arthritis
of the knee can be transitioned to oral
antibiotics after a few days of IV therapy if
there has been a good initial clinical
response to therapy and there are culture
data available to guide clinical decision-
making84. To reduce variability in prac-
tice and improve the quality of care,
clinical care guidelines should be devel-
oped at each institution. Guidelines have
been shown to decrease the time to first
culture, length of stay, duration of
IV antibiotic treatment, the need for
placement of central venous catheters,
duration of fever, and readmissions
as well as decrease the time to CRP
normalization85.
Other Drugs
In addition to antibiotics, corticoste-
roids have been studied in the treatment
of septic arthritis in children. In a ran-
domized controlled study, a 4-day
course of dexamethasone in addition to
antibiotics was associated with a shorter
duration of fever, a shorter time to the
first day without fever and pain, a shorter
duration of local inflammatory signs,
lower levels of acute-phase reactants, and
a shorter duration of IV antibiotic ther-
apy86. In a recent Cochrane review,
corticosteroids were found to improve
pain and function and reduce the dura-
tion of antibiotic therapy87. However,
the evidence for corticosteroids was
deemed to be of low quality, and addi-
tional studies focusing on septic arthritis
of the knee are needed.
Surgery
In addition to antibiotics, surgery plays
an important role in the management of
septic arthritis of the knee in children.
Goals of surgical treatment are to
obtain culture and pathology samples
for analysis as well as to eradicate
infection32. Surgical management
should be performed on an urgent
basis, but it may be performed on an
emergent basis for patients who are
septic or critically ill. While surgical
management is important in the treat-
ment of septic arthritis of the knee due
to most pathogens, some authors have
suggested that Lyme arthritis and Kin-
gella infections may be treated with
antibiotics alone88,89.
Percutaneous techniques, such as
percutaneous aspiration and irrigation,
have been described in the literature
and noted to be successful in improving
clinical and functional outcomes after
septic arthritis of various joints in
children90. In another study, needle
joint aspiration was noted to be suc-
cessful in managing septic arthritis of
the knee in young patients. However, it
was not successful in patients .1 year
of age with a CRP level of .20 mg/L or
patients .3 years of age91. Regardless,
definitive management with needle
aspiration and irrigation is not
· VOLUME 8, ISSUE 1 · e0069

commonly performed in the United
States81.
Open surgical treatment compris-
ing arthrotomy and large-volume lavage
is a well-established technique for the
management of septic arthritis in chil-
dren. Extensive synovectomy or
debridement is rarely required. Arthro-
scopic debridement also has a long track
record of success over the past 30 years92.
It has also been shown to be effective in
patients who are very young (3 weeks to
6 years)93, and in a larger series, suc-
cessful eradiation of infection with
arthroscopic treatment and antibiotic
therapy was shown22. In a recent study
comparing open and arthroscopic
treatments, open treatment was associ-
ated with more repeat surgical irrigations
and an increased incidence of delayed
range of motion compared with arthro-
scopic treatment, but no differences in
long-term results were noted23. Unfor-
tunately, the patients in this study were
not randomized, and thus, these results
may be susceptible to several biases.
Additional studies are needed to com-
pare the efficacy of open and arthro-
scopic surgical techniques in the
management of septic arthritis of the
knee in children. In general, patients
with septic arthritis of the knee require
only 1 surgical procedure to eradicate
infection; however, delay in presenta-
tion or surgical management as well as
the presence of more virulent organisms
such as MRSA may increase the need
for additional procedures32,94. Other
reasons for reoperation may include
persistent or worsening symptoms,
progression of infection, or failure to
improve with initial management.
Complications
There are several potential complica-
tions associated with septic arthritis of
the knee in children. The main com-
plications are joint stiffness, degenera-
tion of the articular cartilage, and
osteonecrosis95. These complications
may ultimately require additional
surgical management, including
arthrodesis and arthroplasty, which are
inherently challenging in a pediatric
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TABLE V Recommendations for the Treatment of Septic
Arthritis of the Knee
Mode of Treatment Grade of Evidence*
Antibiotics A
Corticosteroids B
Percutaneous aspiration and irrigation C
Arthroscopic irrigation and debridement B
Open irrigation and debridement B
*Grade A 5 Good evidence (Level-I studies with consistent findings) for or against
recommending intervention. Grade B 5 Fair evidence (Level-II or III studies with
consistent findings) for or against recommending intervention. Grade C 5 Con-
flicting or poor-quality evidence (Level-IV or V studies) not allowing a recom-
mendation for or against intervention. Grade I 5 There is insufficient evidence to
make a recommendation.
population. In addition, there are some is minimal, and antibiotics are tailored to
complications that are specific to microbiologic data with the assistance of
MRSA, such as admission to the infectious disease specialists. Weight-
intensive care unit, multi-organ failure, bearing and range of motion begin
deep vein thrombosis (DVT), and after the drain is removed, and patients
septic pulmonary emboli96. It is are discharged with an outpatient anti-
important to recognize these compli- biotic regimen per infectious disease
cations, as they have the potential to specialists.
cause substantial morbidity and mor-
tality. In general, there is very little Conclusions
known about the long-term outcomes Septic arthritis of the knee is the most
of septic arthritis of the knee in chil- common type of septic arthritis in
dren. Timely management is likely children, and may result in irreversible
integral to optimal outcomes and fewer joint damage through an inflammatory
complications in the setting of this cascade. It is most commonly caused by
condition. S. aureus, but other organisms should
be suspected in younger children or
Critical Analysis Review patients with specific risk factors. The
There is sufficient literature to guide diagnosis of septic arthritis depends
treatment of children with septic on a thorough history and physical
arthritis of the knee (Table V). In our examination as well as blood work and
practice, treatment with antibiotics is arthrocentesis. Advanced imaging
commenced after joint fluid has been should be reserved for atypical cases or
obtained for WBC count, Gram stain, if there is concern for adjacent osteo-
and culture via arthrocentesis (Fig. 1). myelitis or soft-tissue infection. Anti-
Antibiotic treatment is usually started biotic management remains the
with cefazolin. Clindamycin is usually cornerstone of treatment for septic
used if there is concern for MRSA. Open arthritis of the knee, but arthroscopic or
surgical treatment consisting of evacua- open surgical treatment is critical in
tion of the purulent effusion and copious eradicating infection. Additional stud-
irrigation is then performed on an urgent ies are needed to further characterize
basis, but may performed on an emer- the specific microbiologic profile of
gent basis if the child has signs of sys- septic arthritis of the knee, standardize
temic infection or sepsis. The volume and improve diagnostic tests, compare
used for irrigation depends on the size of surgical techniques, and determine
the patient, but ranges from 3 to 9 L. long-term outcomes of septic arthritis
Postoperative drains are left until output of the knee in children.
7
 | S ep t i c Ar t h r i t i s o f t h e Kn ee i n C h i l d r e n
Ishaan Swarup, MD1,
Blake C. Meza, BS2,
Daniel Weltsch, MD2,
Asmita A. Jina, DO3,
John T. Lawrence, MD, PhD2,
Keith D. Baldwin, MD, MPH, MSPT2
1UCSF Benioff Children’s Hospital,
Oakland, California
2Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
3Weill
Cornell Medicine, New York, NY
Email address for I. Swarup:
swarupi@email.chop.edu
ORCID iD for I. Swarup:
0000-0003-3481-3408
ORCID iD for B.C. Meza:
0000-0001-6390-550X
ORCID iD for D. Weltsch:
0000-0002-0625-0401
ORCID iD for A.A. Jina:
0000-0001-8131-9424
ORCID iD for J.T. Lawrence:
0000-0002-2538-1626
ORCID iD for K.D. Baldwin:
0000-0002-2333-9061
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