SEPTIC ARTHRITIS AS AN INFECTIOUS PROCESS, DESCRIBING THE APPLIED ANATOMY, THE ORGANISMS INVOLVED, STAGES , PRESENTATION ALL THE WAY DOEN TO THE MANAGEMENT PROTOCALS

1. SEPTIC ARTHRITIS
DR SETH JOTHAM
CUHAS

2. OUTLINE
• Anatomy
• Risk factors
• Pathophysiology
• Presentation
• Investigations
• Treatment modalities
• Complications

3. ANATOMY

4. Definition
• Septic arthritis is an inflammation of synovial membrane
with purulent effusion into the joint capsule due to infection.
• Also referred to as Infectious Arthritis
• It is Considered as an orthopedic emergency

5. …
• Acute septic arthritis can occur at any age but young children
and elderly adults are most susceptible
• Male = female
• The lower extremity weight bearing joints are predominantly
affected (61-79%)
• However any joint can be involved
• Multiple joint infections do occur

6. Risk factors
• Rheumatoid arthritis
• Osteoarthritis
• Prosthetic joint
• IV drug abuse
• Diabetes
• Previous I/A corticosteroid injection
• Cutaneous ulcers

7. Organisms
As per Patient age
• Neonate : Staph. Aureus
• <2 yrs : H.influenzae, S.aureus
• >2 yr : S.aureus
• Young adults : Neisseria gonorrhea (sexually active)
• Elderly adults : S.aureus(50%), Streptococci, gram negative
bacilli

8. As per Medical conditions
• Injecting drug use : atypical gram negative bacilli (eg.
Pseudomonas species)
• Rheumatoid arthritis : S.aureus
• SLE, sickle cell anemia : Salmonella species
• Hemophilia : S.aureus(50%), streptococci, gram negative
bacilli
• Immunosuppression : S.aureus, Mycobacterium species,
fungi

9. Modes of infection
1. Hematogenous spread from a distant site- most common
2. Direct invasion through a penetrating wound, intraarticular
injection or arthroscopy
3. Direct spread from adjacent bone
Can develop from osteomyelitis especially in infants in
whom transphyseal vessels allow proximal spread into the
joint in joints with an intra-articular metaphysis (hip, elbow,
shoulder, ankle)

10. …

11. .

12. Pathogenesis
1st : The usual trigger is a hematogenous infection which settles in the
synovial membrane
2nd : There is an acute inflammatory reaction with a serous or
seropurulent exudate and an increase in synovial fluid
3rd : As pus appears, articular cartilage is eroded and destroyed,
partly by bacterial enzymes and partly by proteolytic enzymes released
from synovial cells, inflammatory cells and pus

13. 4th : Spread to the underlying bone or burst out of the joint to form
abscesses and sinuses
Fate:
Complete resolution and a return to normal
Partial loss of articular cartilage and fibrosis of the joint
Loss of articular cartilage and bony ankyloses
Bone destruction and permanent deformity of the joint

14. .

15. Clinical presentation
In neonates
• Emphasis on septicemia rather than joint pain
• Irritable
• Refusal to feed
• Fever
• Rapid pulse
• Joint warm, tender and resistant to movement
(a/w umbilical cord inflammation, IV site inflammation)

16. In Children
• Acute pain in a single large joint (commonly the hip or the
knee)
• Reluctance to move the limb (pseudoparesis)
• Fever
• Rapid pulse
• Joint swelling and redness
• Joint tenderness
• All movements are restricted and often completely abolished
by pain and spasm
(Look for source of infection)

17. In adults
• Often involve a superficial joint (knee,wrist, finger, ankle or
toe)
• Joint painful, swollen and inflamed
• Unable to bear weight
• Warm and tender
• Evidence of gonococcal infection or drug abuse
• Patients with RA and on corticosteroids may develop silent
joint infection

18. Ddx(s)
1. Acute osteomyelitis
2. Other infections such as
psoas abscess
3. Traumatic synovitis or
hemarthrosis
4. Transient synovitis
5. Hemophilic bleed
6. Rheumatic fever
7. Juvenile rheumatoid
arthritis
8. Sickle cell disease
9. Gaucher’s disease
10. Crystal induced arthritis
(gout, pseudogout)
11. Periarticular syndrome
(bursitis, tendinitis)

19. Investigations
Blood investigations
• WBC raised
• ESR raised
• C-Reactive Protein raised
• Blood culture may be positive

20. …
Aspiration of joint fluid and analysis
• May be frankly purulent or in early cases clear
• White cell count and Gram stain
• Fluid culture and sensitivity

21. Imaging
May help confirm the suspicion but not diagnostic
Radiographs
• Usually normal- in first few days of infection
• Soft tissue swelling, displacement of fat pad or joint space
widening from localized edema
• As infection progresses, joint space narrowing from
destruction of cartilage

22.  USS
• Used to detect even small collections of fluid deep in the
large joints such as hip
• Widening of space between capsule and bone of more than
2 mm is indicative of an effusion
Echogenic fluid- likely septic
Echo-free fluid- likely synovitis
• Used to guide joint aspiration and drainage

23.  MRI and Radionuclide bone scans
• Helpful in diagnosing infections that are difficult to assess
• In obscure sites such as sacro-iliac and sternoclavicular joints

24. Septic Arthritis: Kocher Criteria
4 Criteria
• Non-weight bearing on affected side
• ESR >40 mm/hr
• Fever
• WBC >12,000
If 4 criteria met: 99% chance of septic arthritis
If 3 criteria met: 93% chance of septic arthritis
If 2 criteria met: 40% chance of septic arthritis
If 1 criterion met: 3% chance of septic arthritis

25. RX
The principles in the management of acute septic arthritis
include
(1)Adequate drainage of the joint and resection of infected
tissue,
(2)Antibiotics to diminish the systemic effects of sepsis, and
(3)Resting the joint in a stable position.
Prompt drainage and evaluation of purulent joint fluid is
crucial for preservation of articular cartilage and for resolution
of the infection.

26. Empirical Antimicrobial Therapy

27. Remember:
• If the diagnosis is made early and the involved joint is
superficial, such as the elbow or ankle, aspiration should be
performed and repeated if necessary
• Appropriate antibiotics should be administered, and the joint
should be splinted in a position of function.
• If no organism is isolated, empirical therapy should be
continued.
• Appropriate antibacterial management, and duration of
therapy can be brief (<2 weeks).

28. …
• Infections caused by staphylococci and gram-negative bacilli
respond more slowly, often requiring 4 to 6 weeks of
treatment.
• A longer period of therapy is required if:
I. The hip or shoulder is involved
II. If the patient is immunocompromised
III. If the response to treatment has been poor.

29. ……
• If the response is not favorable and repeat aspiration does
not show a decrease in the synovial leukocyte count within
24 to 48 hours, open surgical drainage is necessary.
• If purulent material is deeply situated in a joint, such as the
shoulder or hip, open surgical drainage should be done

30. …..
• Arthroscopic drainage is a good alternative to open drainage
in many instances, especially for infections involving the
knee, elbow, shoulder, or ankle

31. .
Aspiration and Drainage approaches

32. Aspiration of ankle
Needle is inserted 2.5 cm
proximal and 1.3 cm anterior
to the tip of the lateral
malleolus.

33. Ankle drainage
1. Anterolateral
2. Anteromedial
3. Posterolateral- safer and more effective
4. Posteromedial

34. POSTEROLATERAL DRAINAGE
OF THE ANKLE
• Hold the foot in dorsiflexion
• Begin the incision 5 cm proximal to the tip of the lateral
malleolus and just lateral to the Achilles tendon.
• Extend the incision distally to the calcaneus and curve it
along the superior border of that bone for 2.5 cm.
• Retract the sural nerve and small saphenous vein laterally.
• Retract the peroneal tendons laterally
• Incise the posterior capsule under direct vision

35. POSTOPERATIVE CARE
• After the capsule has been incised by any of the previous
approaches, the wound is closed loosely over drains.
• A posterior splint is applied with the foot in neutral position
and the ankle at 90 degrees.
• The splint is worn until the wound has healed; then
graduated weight bearing and active range-of-motion
exercises are begun.

36. Aspiration of knee
• Needle is inserted on the
lateral side at the level of
the superior pole of the
patella.
• It is advanced through the
lateral retinaculum and into
the joint

37. Knee drainage
1. Anteromedial- most common
2. Anterolateral
3. Posteromedial
4. Posterolateral

38. ANTERIOR DRAINAGE OF THE KNEE
• Make parallel anterior incisions 7.5 to 10 cm long on each
side of the patella and sufficiently medial or lateral to the
sides of the patellar tendon.
• Incise the capsule and synovium, carefully evacuate the
purulent material, and disrupt any loculations or adhesions.
• Use copious saline irrigation.
• Leave the synovium open, but loosely close the capsule and
skin over drains.
• Use absorbable monofilament sutures for closing the capsule

39. Arthroscopically

40. POSTOPERATIVE CARE
• An active exercise regimen beginning with straight-leg raising
and quadriceps setting is begun immediately postoperatively.
• Active range of motion is started as soon as the patient is
comfortable, generally 24 hours after anteromedial
arthrotomy or arthroscopic drainage.
• The drains, if present, are removed at 24 to 48 hours after
surgery.
• Functional splinting is maintained for 1 week except for
periods of exercise

41. Aspiration of Hip
• Insert the needle 2.5 cm
lateral and 2.5 cm distal to
the point joining inguinal
ligament and femoral artery
at a 45- degree angle to the
skin surface.
• Advance the needle 5 to 7.5
cm medially and proximally
into the joint.

42. Hip- Drainage
• Anterior – in children
• Posterior- in adults
• Medial
• Lateral

43. ANTERIOR APPROACH
• Make a vertical incision beginning about 1 cm below the
anterior superior iliac spine inferiorly.
• Expose the sartorius muscle on the medial side and the tensor
fasciae latae and vastus lateralis muscles on the lateral side.
• Use blunt dissection to separate these muscles.
• Identify the lateral border of the rectus femoris and retract this
muscle medially ; this exposes the hip joint capsule.
• Incise the capsule, evacuate the pus, and irrigate the joint with
saline.
• Leave the capsule open, but close the skin loosely over drains.

44. POSTERIOR APPROACH
• Make an oblique incision in the line of the femoral neck
extending from the greater trochanter toward the posterior
superior iliac spine
• Split the gluteus maximus muscle in line with its fibers,ligating
branches of the inferior gluteal vessels as they are
encountered.
• Identify and protect the sciatic nerve in the medial angle of the
incision.
• Divide the external rotators of the hip at their insertions on the
greater trochanter.
• Incise the capsule Irrigate the joint profusely with saline

45. .

46. POST OP CARE
• An infant usually is best treated after surgery in a double spica
cast with the affected extremity in moderate abduction.
• Adequate windows are made in the cast for wound inspection
and care.
• Older children and adults are confined to bed rest in Buck
traction until the wound has healed and the patient
• Can control the leg (i.e., can raise the limb from the bed
against gravity).
• Protective weight bearing using crutches is permitted, and
active range-of-motion exercises are started.

47. Aspiration of Shoulder
• The aspiration site is located half
the distance between the
coracoid process and the
anterolateral edge of the
acromion.
• The needle is directed
posteriorly through the joint
capsule, and the joint is
aspirated.

48. Shoulder- Drainage
• The shoulder may be drained through an anterior incision or
a posterior incision, but the anterior incision is preferable.

49. ANTERIOR DRAINAGE
• Begin an anterior longitudinal incision at the anterior border of
the acromion and extend it 5 to 7.5 cm over the center of the
humeral head.
• Split the fibers of the deltoid muscle 5 cm from the acromion,
divide the subscapularis tendon, and open the capsule under
direct vision.
• Open the synovial sheath of the long head of the biceps
tendon.
• Evacuate the pus and irrigate the joint copiously with saline.
• In children, drill the proximal humeral metaphysis to
decompress any abscess but take care not to injure the physis.
• Close the wound loosely over drains.

50. POST OP CARE
• The shoulder is supported on a splint at 45 degrees of
abduction until the wound has healed.
• Then active and active-assisted range-of-motion exercises
are started.

51. Elbow- Aspiration
• Flex the elbow and insert
the needle on its posterior
aspect just lateral to the
olecranon

52. DRAINAGE
• Medial approach
• Lateral approach
• Posterior approach

53. MEDIAL DRAINAGE
• Make an incision over the medial humeral epicondyle and
extend it 5 cm proximally and 2.5 cm distally.
• Develop the interval between the triceps posteriorly and the
brachialis anteriorly, taking care not to injure the ulnar
nerve.
• Elevate the periosteum laterally and distally until the capsule
is exposed.
• Incise the capsule and evacuate the pus.
• Irrigate the joint with saline and close the skin loosely over
drains.

54. LATERAL DRAINAGE
• Make an incision over the lateral humeral epicondyle and
extend it 5 cm proximally and 2.5 cm distally.
• Separate the triceps muscle posteriorly from the extensor
carpi radialis longus anteriorly and expose the joint capsule.
• Dissect close to the bone to avoid injuring the radial nerve.
• Incise the capsule, evacuate the pus, and irrigate the joint
with saline.
• Close the skin loosely over drains.

55. POST OP CARE
• The elbow is splinted at 90 degrees with the forearm in
neutral rotation until the wound has healed.
• Then active range-of-motion exercises are started.

56. COMPLICATIONS
Epiphyseal damage and altered bone growth
Pathological dislocation
Pathological fracture
Metastatic infection
Chronic osteomyelitis
Pelvic abscess
Septicemia

57. References
• Campbell’s operative orthopaedics 14th Ed
• Apley & Solomon’s system of orthopaedics and trauma 10th
Ed
• Essential orthopaedics 5th Ed