3. Introduction
WHAT IS SEPTIC ARTHRITIS?
• Inflammation with purulent effusion
• Considered as Orthopaedic
emergency
• Failure to initiate appropriate
antibiotic -permanent joint
dysfunction.
• It can cause septic shock, which can
be fatal.
4. Anatomy
Lines joint & cavity
and secretes synovial
fluid for lubrication
Protection of joint
cavity
Lubricates the
articulating joints,
nutrient and waste
transportation
Prevents grinding
of the bone and
allow for smooth
articulation
5. • MC in children
• 70% in children from 1 month to 5 years
• M:F at 2:1
• Single joint involvement in 94% of children
• Hip(41%)>Knee(23%)>ankle>elbow>wrist in
children
EPIDEMIOLOGY
6. The incidence of SA is increasing in the general population,
especially in older patients with CHF, hepatitis C, diabetes
mellitus, OA and ESRD
M/C involvement : Knee>Shoulder
7. AETIOPATHOGENESIS
• The infection can originate
anywhere in the body.
• Open wound, trauma, surgery, or
unsterile injection.
• Infective organism travels through
blood stream to the joint.
• The infection can be caused by
bacteria or other organisms.
9. • AGE
• <5 years
• EXISTING JOINT PROBLEMS
• Osteoarthritis, gout, rheumatoid arthritis or lupus
• MEDICATIONS
• Suppress the immune system
• SKIN FRAGILITY
• Psoriasis and eczema
HOSTHOST
10. • WEAK IMMUNE SYSTEM
• diabetes, kidney and liver problems
• ALCOHOLISM AND IVDU
Having a combination of risk factors puts you at greater
risk than having just one risk factor does
HOST
14. Experimental models of bacterial arthritis: a microbiologic and histopathologic characterization of the arthritis after the intraarticular injections of Neisseria gonorrhoeae, Staphylococcus aureus,
group A streptococci, and Escherichia coli.Goldenberg DL, Chisholm PL, Rice PA
J Rheumatol. 1983 Feb; 10(1):5-11.
15. Demonstration of interleukin-1beta and interleukin-6 in cells of synovial fluids by flow cytometry.Koch B, Lemmermeier P, Gause A, v Wilmowsky H, Heisel J,
Pfreundschuh M
Eur J Med Res. 1996 Feb 22; 1(5):244-8.
16. Ultrastructure of articular cartilage in pyogenic arthritis.Roy S, Bhawan J
Arch Pathol. 1975 Jan; 99(1):44-7.
17. CLINICAL FEATURE
• Acute pain
• Pseudoparesis
• Rapid pulse and swinging
fever
• Overlying skin looks red
• Obvious joint swelling
• Local warmth and marked
tenderness
18. IN CHILDREN
• Irritable
• Warm
• Tenderness
• Rapid pulse
• Refused feeding
Loss of spontaneous limb movement
21. WHAT NEXT?
Septic Arthritis suspected
Blood and Synovial fluid analysis
Empirical antibiotics based on GS
Joint Drainage
Adjust Antibiotics according to C/S
22. INVESTIGATIONS
1. BLOOD INVESTIGATIONS
Raised WBC
Raised ESR and CRP
Blood culture (positive)
2. IMAGING
X-ray Early stage: May look normal except
widening of joint space, ultrasound
helpful
Late stage: Narrowing and irregularity of
joint space; may have OM changes of
adjacent bones
MRI and radionuclide imaging
32. Four independent
multivariate clinical
predictors were
identified and
proved excellent
diagnostic performance
in differentiating
between septic arthritis
and transient synovitis
of the hip in children.
33. C-reactive protein level of >2.0 mg/dL (>20 mg/L) was a
strong independent risk factor and a valuable tool for
assessing and diagnosing children suspected of having
septic arthritis of the hip.
34. Weight-bearing status and CRP > 20 mg/l were independent in differentiating septic arthritis from
transient synovitis
Those with both had a 74% probability of septic arthritis
35. TREATMENT
1 st priority – aspirate the joint and
examine the fluid
General supportive care – analgesics and
IV fluid
Splintage
Arthrotomy and Lavage
Antibiotics
• Neonates and infants up to 6 months – penicillin ( flucloxacillin)
+ 3rd gen cephalosporin
• Children from 6 months to puberty – similar to above.
• Older teenager and adults – flucloxacillin and fusidic acid and
3rd generation cephalosporin Antibiotics given IV for 4-7 days,
then orally for 3 weeks.
38. • Remove infective material and debris
from the joint
• Any of the 3 drainage procedures may
be used:
• closed needle aspiration,
• arthroscopic drainage, or
• arthrotomy
41. With healing there may be ?
1. Complete resolution
2. Fibrosis of the joint
3. Bony ankylosis
4. Deformity of the joint
5. Secondary osteoarthritis
6. Growth disturbance
7. Presenting as either localized deformity or shortening of the
bone
42. In Hip
History, medical documentation, clinical examination,
radiographs, arthrography and sonography.
Head of femur- purely cartilaginous - more susceptible to
direct destructive activity of pus & inflammatory products
Increase in intracapsular pressure – tamponade – possible
AVN of head
Often diagnosed late- leading to irreversible damage to
the articular cartilage, blood supply to the epiphysis
Absorption of head and neck
Results in severe shortening and disability.
43. Hunka’s Classification
Type V Complete destruction of the head and neck to the intertrochanteric line, with dislocation of the hip
Type IVB complete destruction of proximal femoral epiphysis, with an unstable neck segment.
Type IVA complete destruction of proximal femoral epiphysis, with a stable neck segment.
Type III Pseudoarthrosis of femoral neck
Type IIB femoral head deformity with growth arrest
Type IIA femoral head deformity with a normal growth plate
Type I Minimal Femoral Head changes
44. Choi's classification
Type IA: No residual
deformity
Type IB: mild coxa
magna. It needs no
reconstruction.
Type IIA: coxa brevia
with deformed head
TypeIIB: asymmetric
premature closure of
proximal femoral
physis
Type IIIA: Slipping at
femoral neck with
severe
anteversion/retrovers
ion
Type IIIB:
pseudoarthrosis -
realignment surgery
for proximal femur or
bone grafting.
Type IVA: Destruction of
the head and neck of
femur with the presence
of remnant of medial
base of neck.
Type IVB:
Complete loss of
femoral head &
neck
45.
46. – Abduction orthosis initially, observation till skeletal maturityType I & IIA
– Epiphysiodesis of remaining physis with/without greater trochanteric physisType IIB
– Femoral Osteotomy – correct version and neck shaft angleType IIIA
– Osteotomy + bone graftingType IIIB
– Greater trochanteric arthroplastyType IV
48. Trochanteric osteotomy
A. Gant opening wedge osteotomy fixed by blade plate.
B. Whitman closing wedge osteotomy. C. Brackett ball-and socket osteotomy fixed by
Blount blade plate
49. GIRDLESTONE ARTHROPLASTY
“removal of diseased and devitalized
tissues, flattening down of dead spaces,
and leaving drainage so complete and
lasting as will allow the wound to heal
from the bottom”
In 1928, described a radical excision for draining
tuberculous hips
in 1942, proposed a related and perhaps even
more radical operation for pyogenic
infections
50. Marchetti et al
Patients with a resection arthroplasty will be left with a significant leg length
discrepancy due to abductor strength weakness and piston effect.
Salvage procedure only in the elderly patient with poor bone stock after a failed total
hip arthroplasty
52. TOM SMITH ARTHRITIS
• Septic arthritis of the hip.
• Seen in infants.
• Head of femur is completely destroyed by the pyogenic process.
53. • Transphyseal vessels are present in early infancy before the formation
of the growth plate
• This may account for the frequency of septic arthritis of the hip in the
neonate
• C/F: telescopy +ve
• X-ray- complete absence of the head and neck of femur
• Treatment: Acute surgical emergency - Open drainage
58. • supracondylar
controlled rotation
osteotomy of femur.
• A. Blue area
illustrates section of
bone to be
removed.
• B. After osteotomy,
corrected position is
maintained by blade
plate
59. Recommends 2-stage
implantation in case of
evolutive septic arthritis and a
1-stage procedure in case of
quiescent septic arthritis
achieved very good functional
results
62. TKA in ankylosed knee is technically demanding
and has considerable rate of complication.
But reasonable restoration of function can be
obtained by meticulous surgical technique and
aggressive rehabilitation
63. SHOULDER
• Septic arthritis of the glenohumeral
joint is rare
• M/C route is hematogenous
• Acute - Arthroscopic lavage and
debridement with appropriate antibiotic
therapy
• Bony and/or cartilage destruction - joint
preservation not possible
• Resection arthroplasty or arthrodesis
recommended.
• Arthroplasty??
69. Periprosthetic
Joint Infection
• New diagnostic criteria in 2018
• With sensitivity of 97.7%
• Cause of 23-25 % of revision
arthroplasty
• Risk factors – multiple
• Role of Biofilm
• Early (developing in the first 3
months after surgery),
• Delayed (occurring 3–24
months after surgery)
• Late (greater than 24 months).
Inflammation of synovial membrane with purulent effusion into the joint capsule
Considered as Orthopaedic emergency
Failure to initiate appropriate antibiotic therapy within the first 24 to 48 hours of onset - subchondral bone loss - permanent joint dysfunction.
It can cause septic shock, which can be fatal.
Synovial fluid: synovial fluid is an ultrafiltrate
contains proteins derived from the blood plasma and proteins that are produced by cells within the joint tissues
The fluid contains hyaluronan - fibroblast-like cells in the synovial membrane,
lubricin - chondrocytes
interstitial fluid filtered from the blood plasma
Knee is most commonly involved in adults
The infection can be caused by bacteria, virus or fungus., although rare : its possible.
epiphyseal plate - prevents infection from entering joint in older children
not so in infants
synovial membrane inserting distally to epiphysis – bacterial spread
The synovial membrane - no limiting basement plate - easy hematogenous entry of bacteria.
low fluid shear conditions - bacterial adherence and infection.
And their Colonization may also be aided in cases where the joint has undergone recent injury.
host-derived extracellular matrix proteins - promote bacterial attachment and progression to infection.
Once colonized - bacteria rapidly proliferate - activate various acute inflammatory responses.
Initially, host inflammatory cytokines, including interleukin 1-β (IL-1β) and interleukin 6 (IL-6), are released
These cytokines - release of acute-phase proteins (such as C-reactive protein) from the liver that bind to the bacterial cells.
promote opsonization and activation of the complement system
-host mount a protective inflammatory response- contains the invading pathogen - resolves the infection.
However, the potent activation of the immune response with the associated high levels of cytokines and reactive oxygen species leads to joint destruction.
-joint effusion - increases intra-articular pressure- impeding blood and nutrient supply to the joint.
antalgic limp •
active and passive range of motion are limited
Patient may hold the joint in a position to reduce the intra-articular pressure to minimize pain.
Painful limp with limb in flexion/ext rotation/abduction
MRI - obscure sites - sacroiliac and sterno-clavicular joint
Early
x-rays may be normal in the very early stage of the disease
-widening of the joint space
-in infants - lateral displacement of the proximal femur
this is a sign of significant pus in joint
subluxation
dislocation
Gas may be seen with E. coli infection
at Later stages – there is Narrowing and irregularity of joint space,
erosion of epiphysis or metaphysis
• findings of superimposed osteomyelitis
if left untreated, reactive juxta-articular sclerosis - severe cases, ankylosis
sensitive and more specific for early cartilaginous damage
C+ (Gd): synovial enhancement
USS • More reliable
• Widening of space between capsule and bone of > 2mm.
• Positively echogenic
• color Doppler - increased peri-synovial vascularity
• and USG can also be used to guide the joint aspiration
SYNOVIAL FLUID ASPIRATION CAN BE both diagnostic and therapeutic
potential to injure blood vessels, nerves, and tendons
To minimize the risk - the extensor surface of the joint
Fluoroscopically guided aspiration of a hip joint (A) with an arthrogram (B) to confirm the intraarticular location of the aspiration attempt
A septic joint aspirate will show
high WBC count (> 50,000/mm3 with >75% PMNs)
glucose 50 mg/dl less than serum levels
high lactic acid
Blood cultures
Often positive, even when local cultures are negative
Lumbar puncture
consider in a septic joint caused by H. influenzae
when 4/4 -99%
3/4 - 93%
2/4 - 40%
1/4 - 3% chance of septic arthritis
Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis:
history of fever,
non-weight-bearing,
erythrocyte sedimentation rate of at least forty millimeters per hour, and
serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter).
Univariate analysis showed that fever, the C-reactive protein level, and the erythrocyte sedimentation rate were strongly associated with the final diagnosis
-five predictive factors had a 98%
four factors had a 93% chance-
(weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis.
-Few controlled studies
-Most antibiotics achieve excellent bactericidal
concentrations in synovial fluid following parenteral or oral administration
-Intra-articular antimicrobial administration
is usually not necessary and may cause a chemical
synovitis.
Infectious arthritis of native joints. In: Mandell G, Bennett J, Dolin R et al, editors. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 7th edition. Philadelphia: Churchill Livingstone; 2010. p. 1443–56;
Drainage: Indication of Surgical Drainage:
1- not respond to antimicrobial therapy and daily arthrocentesis
2-. Any joint with limited accessibility,
3-Patients with underlying disease,
After initial joint drainage, response to therapy should be monitored with serial synovial fluid or ESR and CRP,
Arthroscopic image of a knee joint 3 days after arthrotomy, irrigation, and drainage of septic arthritis,
Depiction from Campbell 23rd, chapter 22
-arthrotomy is performed to remove all purulent fluid and to irrigate the joint
-removal of 1cm by 1cm joint capsule `- minimize chances of re-accumulation
-intra-articular drain placed
Depiction from Campbell 23rd, chapter 22
M/c jointy
Head of femur- purely cartilaginous - more susceptible to direct destructive activity of pus & inflammatory products
The joint effusion may lead to Increase in intracapsular pressure – tamponade – possible AVN of head
Harmon reconstruction for loss of femoral head and neck in child as result of infectious arthritis.
trochanteric osteotomy with bone grafting.
Period of growth and of weight bearing - produces substantial neck and trochanter
emphasized these radical operations - only for severe infections,
published in the preantibiotic era, when radical surgery was often required to save a patient’s life
The infection that occurs in a previous total hip arthroplasty - involve the medullary canal or external part of the femoral cortex or the pelvis.
.
Bone loss is less in primary septic hip, and the femoral canal - not been infected as seen in infected total hip arthroplasty.
surgical technique after resection arthroplasty may be as difficult as revision total hip arthroplasty because of leg length discrepancy and soft tissue scarring
debilitating arthritis or bony ankylosis with flexion deformity
primary Aim - allow linear weight bearing.
A flexion deformity - corrected indirectly - by a supracondylar osteotomy - causes a compensatory deformity in the opposite direction.
No clinical, microbiological or treatment-related criteria emerged as risk factors for septic failure.
No significant difference in functional outcome or successful eradication of infection was found between the 1- and 2-stage procedures
Studies have shown that Delayed reconstruction with a reverse shoulder prosthesis after successful eradication of infection results in limited improvement in functional outcomes that are far inferior to those observed for primary treatment of cuff tear arthropathy
new criteria demonstrated a higher sensitivity of 97.7% compared to the MSIS (79.3%)
Risk factors:• Postoperative surgical site infection, • Revision surgery, • Hematoma formation, • Rheumatoid arthritis, exogenous immunosuppressive medications, and malignancy • Longer operative time, • Obesity, diabetes mellitus, smoking. • Perioperative infection at a distant site, including the urinary or respiratory tract • Development of postoperative atrial fibrillation and myocardial infarction. • Use of aggressive anticoagulation • Blood transfusions
S. aureus and aerobic Gram-negative bacilli together contributed to 60% of the early-onset infections
Imaging: septic loosening, collection in usg,
Three-phase bone scintigraphy is one of the most widely utilized imaging techniques in the diagnosis of PJI.
Uptake at the prosthesis interfaces at the blood pool and late time points suggests PJI.
