SEPTIC ARTHRITIS

DEFINITION
• Inflammation of synovial membrane with purulent effusion into joint
capsule due to infection
• Referred as infectious arthritis
• Considered as medical emergency
• Failure to initiate appropriate antibiotic within first 24 to 48 hours of
onset can cause subchondral bone loss and permanent joint
dysfunction
• Also can lead to septic shock
ANATOMY

Synovial membrane
 Membrane surrounding joint cavity
 Produce synovial fluid
 Contain rich capillary network for
Phagocytic and hyaluronate producing function
 AETIOLOGY
• The most common type of bacteria that causes septic arthritis is
called staphylococcus aureus. The bacteria can enter the body in
numerous ways
• A broken bone (open fracture)
• Infection spreads from other parts of body
• Infected wound
• Foreign body
• trauma
• Surgery
• Unsterile injection
• The infective organism travels through bloodstream , to the joint
• Infection can be caused by bacteria, virus or fungus
 Staphylococcus aureus Staphylocoocus epidermidis streptococci

• Most common infection • Common in prosthetic • Second most common

either in native or joint infection after staph aureus
prosthetic joint • Group B streptococcus is
• MRSA common in IVDU common in neonates
or elderly , usually • s.pyogens, s.pneumoniae
affecting more than 1 common in children
joint <5years
• Genitourinary
infections/gastrointestinal
Gram negative • IVDU, elderly, immunocompromised
bacilli • Elderly usually having underlying DM, Rheumatoid
arthritis
• Drugs for RA might predispose patients to develop septic
arthritis
• H.influenza common in 1-5 years old children
• Kingella kingae common in children younger than 2-3
• Pseudomonas aeuroginosa common in IVDu, premature
infants and patient with cvl
Neisseria gonorrheae • Possible in young, healthy sexually active
• Related to socioeconomic status
anaerobes • Common in DM and prosthetic joint
Mycobacterial sp and fungi • Less common compare to bacterial
• Immunocompromised
RISK FACTORS
1. Age : >80 years old
2. Existing joint problems
3. Medications : medications for rheumatoid arthritis
4. Skin fragility : eczema, psoriasis, IVDU, infected wound
5. Weak immune system
6. Alcoholism and IVDU
PATHOPHYSIOLOGY

HEMATOGENOUS SPREAD

DIRECT INOCULATION

INFECTION FROM ADJACENT STRUCTURES

1. Bacteria deposit in synovium producing inflammation
2. Spreads to synovial fluids and multiply
3. Products of inflammation destroyed joint components
4. Swollen, painful joint
A:Acute synovitis with B & C: The articular cartilage attacked by D: healing leads to bony
purulent joint effusion bacterial and cellular enzymes. If the infection ankylosis
not arrested, cartilage may be completely
destroyed
CLINICAL FEATURES
• Fever
• Acute joint swelling
• Pain
• Warm
• Redness
• Joint immobility
INVESTIGATION
• BLOOD INVESTIGATIONS
1. Raised WCC, ESR, CRP
2. Blood cultures (positive)
• IMAGING
1. X-ray
2. Ultrasound
3. MRI
SYNOVIAL FLUID ANALYSIS
The technique described involves insertion of the needle 1
cm above and 1 cm lateral to the superior lateral aspect of
the patella. The needle is tilted beneath the patella at a 45-
degree angle.
 Xray

Soft tissue Widening joint Narrow joint Ankylosis

swelling space space
 ULTRASOUND

• Sensitive to detect effusion, in

hip (joint difficult to examine)
• Guided in joint aspiration
 MRI
Cartilaginous
damage
MANAGEMENT
• Analgesic
• Initiate antibiotic treatment
• Joint drainage : arthrotomy, arthroscopy, needle aspiration,
continuous knee irrigation
• Splintage
• Physiotherapy : for early joint mobilisation and avoid contracture
CONTINUOUS KNEE IRRIGATION
COMPLICATIONS
• Septic shock
• Dislocations: tense effusion may cause dislocation
• Epiphyseal destruction : in neglected infants the large cartilaginous
epiphysis may be destroyed, lead to unstable pseudoarthrosis
• Growth disturbance : physeal damage may result in shortening or
deformity
• Ankylosis: if articular cartilage is eroded, healing may lead to ankylosis
SEPTIC ARTHRITIS IN CHILDREN
• Infection of joint space, an orthopedic emergency
• Commonly occur in children less than 4 years
• Usually affecting knee and hip
• routes of infection : hematogenous spread, direct inoculation,
infection from adjacent structures.
RISK FACTORS
• weakened immune system may be at greater risk. A weakened
immune system can be caused by diabetes, kidney disease, HIV
infection, or cancer.
• Bacteria can enter the body through infected wound, skin infection,
genitalia infection, open fracture, umbilical catheterization that lead
to bacteremia.
1. Bacteria deposit in synovium producing inflammation
2. Spreads to synovial fluids and multiply
3. Products of inflammation destroyed joint components
4. Swollen, painful joint
5. Sequele

Infant – destroy Children- vascular

epiphysis, which is still occlusion lead to necrosis
cartilaginous of epiphyseal bone
Pathogens
Neonates Group B streptococcus

Infants Staphylococcus aureus

Haemophilus influenza

children Staphylococcus aureus

Salmonella
s.Pyogens
s.Pneumonia
CLINICAL FEATURES
Symptoms : limping, pain, restricted
movement, generally ill
Signs:
• Irritable
• Warm
• Tenderness
• tachycardia
• Refused feeding
• Loss of spontaneous movement of extremity
INVESTIGATIONS

Wcc, ESR, CRP

Joint space widening
KOCHER CRITERIA
MANAGEMENT
• Analgesic
• Initiate antibiotic treatment
• Joint drainage : arthrotomy, arthroscopy, needle aspiration,
continuous knee irrigation
• Splintage
• Physiotherapy : for early joint mobilisation and avoid contracture
• child should be followed up with a clinical examination and repeat
inflammatory markers 1 week after discharge and then 1 week after
stopping antibiotics to ensure complete recovery.
• Ongoing follow-up with an orthopaedic surgeon for at least 2 years is
recommended to monitor for long-term sequelae of septic arthritis.
• These include cartilage damage, growth disturbance due to growth
plate damage, and avascular necrosis of the femoral head. While
these sequelae are rare, early diagnosis and intervention may
improve long-term outcomes.
DIFFERENTIAL DIAGNOSIS IN
CHILDREN
1. Transient synovitis – benign, self limiting condition that involves
synovial inflammation and effusion formation. Usually viral in origin.
Commonly affecting hip.
2. Osteomyelitis
3. Perthes disease
4. Slipped upper femoral epiphyseal
References
1.  lewis, d., 2021. approach to septic arthritis. [online] Aafp.org. Available at:
<https://www.aafp.org/afp/2011/0915/afp20110915p653.pdf> [Accessed 15 September
2011].
2. Apley & Solomon’s concise system of orthopedics and trauma
3. National antimicrobial guideline, 2019
4. https://specialty.mims.com/infectious%20arthritis/references
5. https://www.racgp.org.au/afp/2015/april/septic-arthritis-in-children/
6. Bedside Continuous Irrigation and Drainage as an Interim Local Treatment for Septic Arthritis of the Knee in the Medically Unstable
Patient: A Case Report