SEPTIC ARTHRITIS

DR. KARTHICK
DEPT OF ORTHOPAEDICS
Infection of the joint caused by pyogenic bacteria

Septic arthritis can be

 Community acquired

 Hospital acquired

Monoarticular / Polyarticular
Route
 Hematogenous
 Direct inoculation into joint
 Spread from nearby soft tissue
 Secondary to osteomyelitis (hip, knee,
shoulder and elbow)

 Hip and Knee are commonly involved

Susceptible Group
 Neonates / Infants  Rheumatoid arthritis
 Elderly  Diabetes Mellitus
 Steroid intake  Cancer
 I.V drug abusers  Hemodialysis
 Joint prosthesis
Common Organism
 All age groups: Staphylococcus aureus

 Neonates: Staphylococcus
Streptococcus
E coli

 Infants: Staphylococcus aureus

Haemophilus Influenza
Streptococcus
Pathogenesis
Bacteraemia/Septicaemia

Seeding of joint synovium

Synovitis/inflammation

Exudate formation- Pus formation

Proteolytic enzyme production

Irreversible destruction of articular cartilage

Clinical Features- Symptoms
General features Local features

Irritability Paucity of
movements of
affected limb
Fever

Failure to feed Pseudoparalysis

Clinical Features - Signs
Febrile

Swelling / redness/ local warmth over the joint

Abnormal posturing of the limb

Intense pain on passive movements

Investigations – Blood
Total count - >12,000cells/mm3

ESR - > 40mm/hr

CRP - > 6mg/dl

Blood culture – Positive in 1/3 rd

Investigations – synovial
Fluid
Colour – Turbid

Cell count - WBC > 50,000 cells/mm3

>90% Neutrophils

Gram stain

Culture and sensitivity – 50% may be +

 No clinical test that can definitely and
absolutely diagnose septic arthritis

 Should be based on high index of

suspicion and clinical assessment

 Lab investigations may serve as an

adjunct to the clinical diagnosis
Diagnostic Criteria
Kocher et al - four simple factors

 History of fever
 Inability to bear weight on the
affected limb
 ESR > 40 mm/hr
 WBC count >12,000cells/mm3
Radiographs
Distension of joint capsule

Increased joint space

Displacement of muscle plane

surrounding joint

Leucent areas in metaphysis of

bone if its secondary
CT / MRI / Bone Scan
 CT if associated osteomyelitis
is suspected

 MRI shows soft tissue

extension

 Increased uptake on bone

scan / multiple sites

 Gallium / Indium labelled bone

scan are specific for infection
Differential Diagnosis
Cellulitis

Acute osteomyelitis

Transient synovitis
Treatment
One of the strongest determinants of good outcome is

“Early diagnosis
and
Prompt treatment”
Treatment (Medical / Surgical)
Principle

1. Adequate drainage of the joint

2. Antibiotics

3. Rest (immobilization) to the joint

Treatment – Medical
(Antibiotics)
Initially broad spectrum bactericidal
depending on age and most likely organism

Change to appropriate antibiotic based

on culture sensitivity

Route of administration – Parentral

Duration of treatment - 6 weeks

Treatment - Surgical
Drainage of the joint

Closed - Needle Aspiration & irrigation ???

Open arthrotomy

Arthroscopic debridement
Complications
Bony Ankylosis
Destruction of articular cartilage
Destruction of the growth plate
Dislocation of the joint
Damage to the blood supply & AVN
Complex problems
Total destruction of articular &
epiphyseal cartilage
Destruction of the growth plate
coxa vara
Subluxation of the joint
Dislocation of the joint
Avascular necrosis
Complex Problem: Destruction of the growth
plate with
coxa vara & instability
Long Term Consequences
Joint stiffness

Joint instability

Joint deformity

Limb length inequality

Secondary degenerative arthritis

Long Term Consequences
Joint stiffness

Joint instability

Joint deformity

Limb length inequality

Long Term Consequences
Joint stiffness

Joint instability

Joint deformity

Limb length inequality

Long Term Consequences
Joint stiffness

Joint instability

Joint deformity

Limb length inequality

Long Term Consequences
Joint stiffness

Joint instability

Joint deformity

Limb length inequality

Long Term Consequences
Joint stiffness

Joint instability

Joint deformity

Limb length inequality

Secondary Degenerative Arthritis

TUBERCULOSIS OF
HIP AND KNEE
AETIOLOGY
 Always secondary
 Mycobacterium
tuberculosis
 Haematogenous spread
AETIOLOGY
 Primary
 Lungs

 GIT

 Urinary tract

 Spine > Hip > Knee

Common Sites of Involvement
PATHOLOGY-
Hip
1. Stage of Synovitis
2. Stage of Arthritis
3. Stage of Dislocation/
Fibrous Ankylosis
 PATHOLOGY-
Knee
1. Stage of Synovitis
2. Stage of Arthritis
3. Stage of Triple Dislocation/triple
deformity****
1.Stage of Synovitis
1.Stage of Synovitis

Joint assumes the

position of maximum
capacity
1.Stage of Synovitis

Normal
1.Stage of Synovitis

Flexion
Abduction
External Rotation
2.Stage of Arthritis
2.Stage of Arthritis

Pannus formation
 Prevents nutrients
reaching the
articular cartilage
2.Stage of Arthritis

Synovial cell destruction

 Releases lysosomal enzymes
which destroy the cartilage
2.Stage of Arthritis

Articular cartilage loss

 Exposes the subchondral
bone
 Painful
2.Stage of Arthritis

Joint gets filled with

 Cellular debris

 Pus

Forms cold abscess

2.Stage of Arthritis

Cold abscess of TB hip

 Femoral triangle

 Gluteal region

 Greater trochanter
2.Stage of Arthritis
Pain + muscle spasm
Flexion
Adduction
Internal rotation
3. Stage of dislocation
3. Stage of dislocation

Pathological dislocation
 Destruction: head

 Destruction: ligaments
3. Stage of dislocation

Flexion
Adduction
Internal rotation
3. Stage of dislocation

 True
Flexion



Shortening
Adduction
Internal rotation
End Result

Fibrous Ankylosis
Knee- Stage of
Triple Deformity

Spasm of Hamstrings
 Flexion

 Posterior subluxation

 External Rotation
 Flexion
Posterior subluxation
External Rotation
Clinical Features
1. General
2. Local
CLINICAL
FEATURES
Loss of weight
Loss of appetite
Evening rise of temp
Night sweats
FEATURES
Hip
Apparent lengthening
Apparent shortening

True shortening
CLINICAL
FEATURES
Swelling
Cold abscess
Sinuses
Tender joint
FEATURES
Knee
 Swelling
 Synovial hypertrophy
 Effusion

 Cold abscess
 Quadriceps wasting
 Sinuses
FEATURES
Knee
Painful
restriction of
movements
Triple deformity
Fibrous ankylosis
 INVESTIGATION
X RAY
Periarticular osteoporosis
Joint space reduction
Lytic lesions: Acetabulum/ Femur/Tibia

Later : triple deformity

INVESTIGATIONS
1. Complete blood picture

2.ESR
Raised
3.CT / MRI
for early detection
4. Bone scan
for multifocal lesion
INVESTIGATIONS
5. Rule out primary TB
 Sputum examination
 Chest X Ray
INVESTIGATIONS
5. Rule out primary TB
 Urine
 USG abdomen
(Remember: MS TB is never primary)
INVESTIGATIONS
6. Aspiration
 C/S
 AFB Staining
INVESTIGATIONS
7. PCR
TREATMENT:
GENERAL
ATT
 INH 5 mg / kg / day
 Rifampicin 10 mg / kg / day
 Ethambutol 15 mg / kg / day
 Pyrazinamide 20 mg / kg / day
 4 drugs X 3 months
 3 drugs X 3months
 2 drugs X 6-12 months
TREATMENT

HIP
TREATMENT: LOCAL
Hip

Limb
Splinting v en t

p r e t o f
To p m e n
 Traction ve l o
de it y
 POP spica fo r m
de
TREATMENT: Early
 Synovectomy and
curettage of the lesion
 Removes bacilli
 Improves blood supply
 Provides tissue for diagnosis
TREATMENT: Early

 Drainage of cold
abscess
TREATMENT: Late
Management
of
sequelae
TREATMENT: Late
 Arthrodesis

Surgical fusion of the joint

 Excision Arthroplasty
Excision - head of femur
 Total Hip Replacement
TREATMENT

KNEE
TREATMENT: LOCAL
1.Splinting
POP cast
Thomas` splint
Bi-axial traction
TREATMENT: LOCAL

2.Surgery (early)
 Synovectomy
 Curettage
 Joint debridement
TREATMENT: LOCAL

2.Surgery (late)
 Arthrodesis
 Arthroplasty

Total Knee Replacement

THANK YOU