orthopaedics seminar

1. Presented By-
Dr. Ashutosh Kumar
AP Dept. Of Orthopaedics
Rohilkhand Medical collage & hospital Bareilly UP.
Acute Pyogenic Arthristis

2. DEFINITION
 Inflammation of a synovial membrane with purulent effusion into the joint
capsule, often due to bacterial infection
 Considered as a rheumatologic emergency as joint destruction occurs rapidly and
can lead to significant morbidity and mortality.

3. INTRODUCTION
• Caused by pyogenic organism
• Present as an acute painful arthritis
• Can be subacute or chronic
• Pyogenic arthritis = Infective arthritis = Suppurative
arthritis
• Most dangerous and destructive monoarthritis
• Can destroy cartilage within days
• Mortality 7-15 % despite antibiotic use

4. AIMS
• To list the main differentials for acute monoarthritis
• To understand the pathogenesis of pyogenic arthritis
• To list the main organisms that cause pyogenic arthritis
• To recognize the symptoms and signs
• To understand the key risk factors and how this affects subsequent investigation
• To describe the anatomy and method for needle aspiration
• To describe empirical antibiotic therapy and approaches for joint aspiration

5. Risk Factors
• Age over 80yrs
• DM
• RA
• Recent joint surgery
• Hip or knee prosthesis
• Skin infection
• Skin infection + joint prosthesis
• HIV
• IV drug abuse
• Alcoholism
• IA steroid injection

6. AETIOPATHOGENESIS
1. HEMATOGENOUS – commonest, through pyoderma, throat
infection, septicemia.
2. SECONDARY TO NEARBY OSTEOMYELITIS – common in joint with intra articular metaphysis ; hip, shoulder.
3. PENETRATING WOUNDS – knee being superficial joint.
4. IATROGENIC – following intra articular steroid injection / femoral artery puncture for blood collection.
5. UMBILICAL CORD SEPSIS – infants.

7. Pathogenesis
Deposit in
synovial
membrane
Enter
synovial
fluid
Cause
purulent
joint
Bacteria
enter joint
Direct innoculation
Bite or trauma
Haematogenous spread

8. PATHOPHYSIOLOGY
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9. • Can be bacterial, fungal, mycobacterial or viral
• Bacterial divided into gonococcal and nongonococcal
• Gonococcal more common but less morbidity and mortality
• Staphylococcus
• Streptococcus
Causative Organisms

10. Common sites susceptible to infection
 Knee: 55%
 Ankle: 10%
 Wrist: 9%
 Shoulder: 7%
 Hip: 5%
 Elbow: 5%
 SC: 5%- IV drug
abuser
 SI: 2%- IV drug abuser
 Foot joints: 2%

11. Clinical features
Infants Septicaemia >joint pain
- Irritable
- Refused to feed
- Rapid pulse
- Fever
Check :
- Joints carefully
- Umbillicalcord
- Inflammed IV site
- Chest’s, spine, abdomen
Children Acute pain – single large joint Ex: knee and hip
- Reluctance to move (pseudoparesis)
- Rapid pulse, Swinging fever
- Overlying skin – red, Local warmth
- Superficial joint swell obvious
- All movement restricted

12. Adult Superficial joints
(knee, wrist, finger, ankle or toe)
- Painful
- Swollen
- Inflamed
- Movement restricted
*questioned and examination for:
- Gonococcal infection
- Drug abuse
- Rheumatoid arthritis

13. Signs
• Fever >37.5 57%
• Hot, swollen tender joint (or joints)
• Reduced ROM

14. Symptoms
• Pain in affected joint 85%
• Swelling in affected joint 78%
• Large joint (knee or hip 60%)
• Wrists and ankles also common
• Sweats 27%
• Rigors 19%
• May be subacute- especially TB and prosthetic joints
• More than 1 joint affected in 22% cases
• Underlying RA or overwhelming sepsis

15. Joint affected Attitude
1.Knee Flexion
2. Hip Flexion, abduction &
internal rotation.
3. Shoulder Adduction &
internal rotation.
4. Elbow Flexion & mid
pronation
5. Wrist Flexion
6. Ankle Planter flexion

16. DIFFERENTIAL
• Infection- bacterial, mycobacterial, fungal
• Gout
• Pseudogout
• Reactive arthritis
• Osteoarthritis
• Haemarthrosis
• Lyme disease
• SLE
• RA
• 2-9 / 100 000 person years
• 8-27% patients presenting to ED with acute arthritis
INCIDENCE

17. Imaging
• Ultrasound
– most reliable method
• revealing joint effusion
– widening of space between capsule and bone >2cm
• X-ray
– Search for signs:
• Soft tissue swelling
• Loss of tissue plane
• Widening of radiographic ‘joint space’
• Slight sublaxation
– Late features?
• Narrowing and irregularity of joint space

19. INVESTIGATIONS
• Blood
– Neutrophilic leucocytosis
– Increase ESR, elevated CRP
• Joint aspiration
– Quickest and best method
 Arthrocentesis
 Usually purulent with increased count (50,000 to150,000 cells/mm3)
 The synovial fluid glucose is often depressed and lactic acid concentration is elevated.
 Synovial fluid culture

20. DIAGNOSIS
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21.  Radionuclide bone scans:
technetium-99m , methyldiphosphonate
increase in isotope accumulation in areas of osteoblasts and increased
vascularity
 Computed tomography (CT), or magnetic resonance imaging (MRI) are far more
sensitive than plain films in early septic arthritis.
 MRI:
Synovial enhancement and the presence of a joint effusion & perisynovial soft tissue
edema.

22. Treatment
general
supportive
care
• The first priority is to aspirate the joint and examine the fluid. If aspirate
looks purulent, joint drainage should be done neglecting the lab results
splintage
AntibioticsDrainage
aftercare

23. • General Supportive care
• Analgesics for pain and IV fluids for dehydration
• Splintage
• joint should be rest, light splintage for neonates and infants.
• For hip infection, joint should be abduct ,30 degrees flexed to prevent
dislocation.

24. TREATMENT
IV antibiotics: for initial 1-2wks followed by oral antibiotics for 3-4 wks.
 Concurrent systemic corticosteroids are also supposed to shorten
duration of illness with less residual joint damage and dysfunction.

25. • Drainage
– under anaesthesia small incisions was made , drained and washed out with physiological
saline, small catheter is place and the wound is closed, suction continue for 2-3 days
– This policy are advisable for
• In very young patients
• when hip is invovle
• if the aspirated pus is thick
– in older children with symptoms less than 3 days ,
we can do closed aspiration of the joint

26. Arthrocentesis

27. TREATMENT

28. TREATMENT
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29. Physiotherapy management
 Reduce pain
 Restore and maintain physiological function
 Patient education about exercise and management of their condition.
 Immobilization
control pain as it is often too painful to bear weight.
 Mobilization can begin if the patient is responding well following 5 days of gentle treatment. PT
needs to consists of allowing the joint to be in its functional position and positioning the joint to
allow passive range of motion activities
• Aftercare

30. • Aftercare
– Mobility after no longer painful is necessary to prevent stiffness of the
joint

31. Cont….
 Electrotherapy-ice
 hydrotherapy, heat and TENS, IFT, Ultrasound to manage
pain and joint stiffness.
 NB: heat modalities are not supposed to be used in the acute
phase or before initiation of antibiotic treatment.

32. Cont…
• Surgical options-removal of infected joint material is
imperative in improving a patient

33. FOLLOW UP
• Once general condition is satisfactory and the joint is no longer painful or warm, further
damage is unlikely.
• If articular cartilage has been preserved, gentle and gradually increase active movements.
• If articular cartilage has been destroyed the aim is splinting to keep the joint immobile while
ankylosis is awaited.
• If deformity is present, subsequent osteotomy should be planned to correct it.

34. Complications
Highest incidence occurs for infants below 6 months, most of which affect the hip
– obvious risk are
• delay diagnosis and treatment >4d
• concomitant osteomyelitis of proximal femur .
• Subluxation /dislocation of the hip /instability of the knee
– prevented by appropriate posturing or splintage
• Damage to the cartilaginous or epiphysis
– Sequelae include retarded growth, complete or partial damage to
epiphysis, joint deformity, bone necrosis, acetabular dysplasia and pseudarthrosis of the hip.
• articular cartilage erosions
– may cause restricted movements or complete ankylosis of the joints.

35. ACUTE PYOGENIC ARTHRITIS IN INFANCY
• Acute pyogenic arthritis of the hip
• Cartilaginous head of femur completely destroyed
• Rapid abscess formation, which burst out and heals rapidly
• Child complaint of limp without pain
– Examination
• Unstable gait, shorter leg, hip movement increased in all direction
• Xray : absence head and neck of femur
• Closely resemble cdh, how to differ (xray above and normally develop round of
acetabulum)

36. TOM SMITH ARTHRITIS
 Septic arthritis of hip in infancy
 Results in complete destruction of cartilaginous femoral head.
 Presentation is a child in his preschool age with painless limp
 Affected limb is shorter
 X-ray shows complete absence of head and neck of
femur.

37. GONOCOCCAL ARTHRITIS
• Nisseria gonnorrhea is the commonest cause of acute
pyogenic athritis in sexually active adults and poor
population

38. • Clinical features
– disseminated gonococcal infection
• triad of polyarthritis, tenosynovitis and dermatitis
– septic arthritis of a single joint
• usually the knee, ankle, shoulder, wrist or hand
• Investigation
– ESR and WBC count will be raised.
– If get suspected, the patient should be questioned about possible contacts during the previous days or weeks and they should
be examined for other signs of genitourinary infection (e.g. a urethral discharge or cervicitis).
– Joint aspiration : high white cell count and typical Gram-negative organisms.
• Treatment
– third-generation cephalosporin iv im
– Ass with chlamydial infection : quinolone antibiotics (ciprofloxacin and ofloxacin)
– If organism is found to be sensitive to penicillin, treatment with ampicillin,
amoxicillin or clavulanic acid is also effective

39. Prognosis
The best outcome for individuals with acute pyogenic arthritis is immediate treatment.
Mortality ranges from 19-25% permanent joint disability occurs in 25-
50% of the cases.
Fifty percent of adults with acute pyogenic arthritis have significant decreased ROM or
chronic pain after the infection.
 Poor outcome predictors in prognosis of acute pyogenic arthritis include the following:
 Age older than 60, infection of the hip or shoulder joints, underlying rheumatoid arthritis,
positive findings on synovial fluid cultures after 7 days of therapy, delay of 7 days or longer in
beginning treatment