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Septic arthritis
- 2. OUTLINES • INTRODUCTION • PATHOGENESIS • CLINICAL FEATURES • INVESTIGATION • DIFFERENTIAL DX • TREATMENT
- 3. Septic arthritis • Orthopaedic and rheumatologic emergency as joint destruction occurs rapidly can lead to significant morbidity and mortality ( ~10%) • Case study showed • 73% pt with <7days duration of symptoms had satisfactory result • 75% pt which had symptoms > 7days had unsatisfactory outcomes • Most of the poor outcomes had positive cultures • 77%> staphy aureus
- 4. INTRODUCTION • Inflamation of a synovial membrane with purulent effusion into the joint capsule due to infection • Bacterial replication in the joint and the ensuing inflammatory process can lead to rapid local joint destruction • may be accompanied by systemic infection. • Cartilage injury can occur within 8hours caused by released of proteolytic enzyme from inflammatory cells
- 5. Epidemiology • Joint involved • Knee ~ 50% cases • Hip • Shoulder • Elbow • Ankle • Sternoclavicular joint
- 6. Organisms Staphylococcus species • ~ > 50% cases • Staphylococcus aureus • MRSA • Staphylococcus epidermis Neiserria gonorrhoea • ~ 20% cases • Manifests as a bacteremic infection • Arthiritis dermatitis syndrome in ~ 60 % cases • Localized septic arthtiris ~ 40% cases
- 7. Gram –ve bacilli • ~ 10-20 % cases • Ex : e. coli, proteus, klebsiella, enterobacter • Risk factor • Neonates • Ivdu • Elderly • Immunocompromised pt with diabetes Streptococcus • Strep pyogens gr A (most common) • Gr B strep • Predilection for infants, elderly and diabetic pt
- 8. • Propionibacterium Acnes > Associated with shoulder surgery • Salmonella or Strep Pneumonia > In pt with sickle cell disease • Bartonella Hanselea > In pt with HIV • Pseudomonas Aeruginosa > In pt with hx of ivdu • Pasteurella Multodica > In pt after dog or cat bite • Eikenella Corrodens > In pt after human bite • Fungal/Candida > found in immunocompromised host
- 9. Predisposing factors • IVDU • Medical conditions • Diabetes • RA • Cirrhosis • HIV • Immunosuppresive drug therapy • Recent joint surgery ex joint prothesis • Alcholism • Cutaneous ulcers • Age >80
- 10. Etiology • 3 ROUTES • HEMATOGENOUS (bacteremia) • DIRECT INOCULATION • Trauma • Surgery • DIRECT SPREAD FROM ADJECENT FOCAL INFECTION • Osteomyelitis • Cutaneous ulcers
- 16. Physical examination • Lower limb • Inability to bear weight > antalgic limp • Inability to tolerate PROM • Upper limb – affected part is closely guarded • Marked tenderness • Examine for synovial effusion, erythema, heat and tenderness • Spasm of muscle around the joint may be marked • Pt may hold the joint in a position to reduce the intro articular pressure to minimize the pain
- 17. Investigation • Blood • Imaging • Synovial fluid analysis
- 18. Blood • Fbc : marked elevation of TWC count • Esr > 40mm/hr • CRP > 20mg/dL • Blood culture > may be positive
- 19. Synovial fluid analysis • Aseptic technique is used during aspiration • Avoid taken from infected site of skin • The fluid then analysed by gross and microscopic examination and culture • Gross • Appearance, volume, viscosity, mucin clotting • Microscopic • Leucocyte count, staining of smear, serum glucose ratio, protein • C+S for definitive dx and treatment
- 23. Knee arthrocentesis Indications for diagnostic knee arthrocentesis include the following: • Evaluation of monoarticular arthritis • Evaluation of suspected septic arthritis • Evaluation of joint effusion • Identification of intra-articular fracture • Identification of crystal arthropathy Indications for therapeutic knee arthrocentesis include the following: • Relief of pain by aspirating effusion or blood • Injection of medications (eg, corticosteroids, antibiotics, or anesthetics) • Drainage of septic effusion
- 24. Contraindication for arthrocentesis: No absolute contraindications for knee arthrocentesis. Relative contraindications include the following: • Cellulitis overlying the joint • Skin lesion or dermatitis overlying the joint • Known bacteremia • Adjacent osteomyelitis • Uncontrolled coagulopathy
- 25. Imaging • Xray • Early stage – normal • Look for • tissue swelling • Loss of tissue planes • Widening of joint space • Slight subluxation • Gas may be seen with e.coli infection • Late stage – narrowing and irregularity of joint space • Plain film finding of superimposed osteomyelitis may develop • Periosteal reaction • Bone destruction • Sequestrum formation
- 27. Ultrasonography • More reliable in revealing a joint effusion in early cases • Widening of space between capsule and bone >2mm indicate effusion • Echo-free > transient synovitis • Positively echogenic > septic arthiritis
- 29. Differential diagnosis • Gout • Pseudogout • Reactive arthritis • OA • Haemaarthrosis • Lyme diasese • SLE • RA
- 30. Treament • General supportive care • Analgesic • Iv fluids • Splintage • Joint must be rested • In neonates and infants with infection of hip joint, held in abducted and 30 degree flexed on traction to prevent dislocation • Antibiotic • Antibiotic is started once the blood and samples are obtained without waiting the result details
- 31. Antibiotics
- 33. Surgical management • Operative irrigation and drainage of the joint • Indication • Considered as orthopaedic surgical emergency • Approach • Can be performed open or arthroscopically • Irrigation • Remove all purulent fluid and irrigate joint ( ~3L NS) • Debridement • Synovectomy can be performed as needed • Cultures • Obtain joint fluid and tissue for c+s
- 35. Classification by G¨achter Arthroscopic classification of joint infections Stage I opacity of fluid, redness of the synovial membrane, possible petechial bleeding, no radiological alterations Stage II Severe inflammation, fibrinous deposition, pus, no radiological alterations Stage III thickening of the synovial membrane, compartment formation, no radiological alterations Stage IV aggressive pannus with infiltration of the cartilage, undermining the cartilage, radiological signs of subchondral osteolysis, possible osseous erosions and cysts
- 36. Rehabilitation • Suction drains were removed after surgery depending on volume of fluid drained • Mobilization from 1st day after surgery with partial NWBC for 3/52 • Continuous passive motion • IV antibiotics followed by oral administration for duration minimum 4weeks
- 37. COMPLICATION • Bone destruction and dislocation of the joint • Cartilage destruction • May lead to either fibrosis or bony ankylosis • In adult, partial destruction of the joint will result in secondary OA • Growth disturbance • Presenting as either localised deformity or shortening of the bone
- 38. Hip septic arthritis in paediatric Epidemiology • Demographics • Incidence • peaks in the first few years of life • Age • 50% of cases occur in children younger than 2 years of age
- 39. • Location • hip joint involved in 35% of all cases of septic arthritis • Risk factors for neonatal septic arthritis • prematurity • cesarean section
- 40. Pathophysiology• Routes of inoculation • Direct inoculation from trauma or surgery • Hematogenous seeding • Extension from adjacent bone • can develop from contiguous spread of osteomyelitis • often from metaphysis • common in neonates who have transphyseal vessels that allow spread into the joint • joints with intra-articular metaphysis include • hip • shoulder • elbow • ankle • (not the knee)
- 41. Bacteriolgy
- 42. Prognosis • Good unless dx is delayed • Poor indicator • age < 6 months • associated osteomyelitis • hip joint (versus knee) • delay >4 days until presentation
- 43. Presentation • History • similar to history of osteomyelitis • history of rash and swollen lymph nodes are associated with other conditions in the differential diagnosis and are not expected findings of septic arthritis • vaccination history must be obtained • Symptoms • presents more acutely than osteomyelitis • often associated with fever and other systemic symptoms causing toxic appearance • children refuse to walk or move their hip
- 45. • Physical exam • Inspection and Palpation • localized swelling • effusion, tenderness, and warmth • hip rests in a position of flexion, abduction, and external rotation • hip capsular volume is maximized with flexion, abduction, and external rotation and is the position of comfort for hip septic arthritis • Range of motion • severe pain with passive motion • unwillingness to move joint (pseudoparalysis) • examine adjacent joints • must rule out adjacent joint involvement
- 46. Imaging • Xray • Rocommended view • AP and frog leg lateral pelvic view • Findings • may be normal, especially in early stages of disease • often see widening of the joint space, subluxation, or dislocation • in infants, prior to ossification of the femoral head, widening of joint space can be seen by lateral displacement of the proximal femur • may see bone involvement with associated osteomyelitis
- 49. Evaluation (Koc’her Classifications) • Must distinguish from transient synovitis • Probabilty of septic arthritis ranged as high as 99.6% when all four criteria below are present q • WBC > 12,000 cells/µl • Inability to bear weight • Fever > 101.3° F (38.5° C) • ESR > 40 mm/h • CRP > 2.0 (mg/dl) is an independent risk factor (not included in studies of the previous 4 criteria) • CRP > 2.0 (mg/dl) in combination with refusal to bear weight yields a 74% probability of septic arthritis • Order of sensitivity of above criteria: q • Fever > CRP > ESR > refusal to bear weight > WBC
- 51. Treatment • Non-operative • Antibiotics alone • Indications • adolescent Neisseria gonorrhoeae infection • can be treated with large doses of penicillin alone and usually does not require surgical debridement • Operative • Emergent surgical I&D • indications • standard of care for almost all septic joints • considered a surgical emergency due to chondrolytic effect of pus
- 52. Septic Arthritis Antibiotic Treatment Age Organism Antibiotics <12 months staphylococcus sp., group B streptococci, and gram-negative bacilli 1st generation cephalosporin 6 months to 5 yrs S. aureus, S. pneumoniae, group A streptococci, H. influenzae 2nd or 3rd generation cephalosporin 5-12 yrs S. aureus 1st generation cephalosporin 12-18 yrs N. gonorrhoeae, S. aureus oxacillin/cephalosporin
- 54. Surgical technique • Emergent I & D • approach • most commonly one of the following approaches is utilized • medial approach to the hip • anterolateral approach to the hip • Technique • an arthrotomy is performed to remove all purulent fluid and to irrigate the joint • synovial culture and drain placement is recommended • follow with IV antibiotics targeting pathogens based on age and medical comorbidities • convert to PO antibiotics once the clinical picture improves and definitive sensitivities are obtained • duration of antibiotic therapy is generally 3-4 weeks • terminate antibiotics once the CRP or ESR return to normal
- 55. Post op care • Splint the affected joint in a functional position for the first few days after a diagnosis of septic arthritis (SA). • Encourage early passive range of motion to stretch tendons and prevent contractures.
- 56. Reference • Arthroscopic Treatment for Primary Septic Arthritis of the Hip in Adults • http://dx.doi.org/10.1155/2016/8713037 • Clinical Management of Septic Arthritis • INFECTIONS AND ARTHRITIS (K WINTHROP, SECTION EDITOR) • https://www.med.unc.edu/tarc/events/event-files/septic%20arthritis%20management.pdf • Pediatric Septic Arthritis • http://emedicine.medscape.com/article/970365-overview • Hip Septic Arthritis - Pediatric • http://www.orthobullets.com/pediatrics/4032/hip-septic-arthritis--pediatric • Septic Arthritis Treatment & Management • http://emedicine.medscape.com/article/236299-treatment • Septic arthritis: current diagnostic and therapeutic algorithm • http://www.osuem.com/downloads/m_m/Septic_arthritis_current_diagnostic_and_therapeutic_algorithm.pdf