This document provides information about septic arthritis, including: - It is an inflammation of the synovial membrane with purulent effusion into the joint capsule, often due to bacterial infection. The most common organism is Staphylococcus aureus. - Risk factors include previous arthritis, trauma, diabetes, older age, immunosuppression, bacteremia, recent joint surgery or having a prosthetic joint. - Joints most commonly involved are the knee, hip, shoulder, elbow and ankle. - Without treatment, it can lead to erosion of cartilage, bone destruction and joint deformity. Treatment involves antibiotics, drainage if needed, and rest for the joint.

1. Septic Arthritis
Dr. GautamSinha
Resident - Orthopaedics
Dr. HardasSingh Orthopaedic Hospital & SuperspecialtyResearchCenter

2. Septic Arthritis
• Inflammation of a synovial membrane w/ a
purulent effusion into the joint capsule,
often due to bacterial infection.

3. Risk Factors
• Previous Arthritis
• Trauma
• DM
• Elderly
• Immunosupression
• Bacteremia
• Recent Joint Surgery
• Prosthetic Joint

4. MC Joints involved
Knee (50%)
Hip
Shoulder
Elbow
Ankle
Sternoclavi
cular Jt.

5. Direct Invasion
through a
penetrating wound
Hematogenous
spread from a
distant site
Direct Spread from
an adjacent Bone
abscess
Diagnostic or
Therapeutic
measures
(Arthroscopy).
Direct Spread from
an adjacent Soft
Tissue

6. • MC Organism – S. Aureus
• H. Influenzae - Imp. pathogen in 1-4yr old
• Others – Streptococcus, E. Coli, Proteus

7. Pathophysiology
Hematogenous
Spread
Synovial
Membrane
Serous/Seropurul
ent Exudate
Acute
Inflammation
↑Synovial Fluid
Erosion of
articular
cartilage
Pus in joint
Bacterial
enzymes
Proteolytic
enzymes
from
synovial
cells
Underlying
Bone
Burst out of
Joint
Abscess/
Sinus
If Untreated OM

9. `
In Infants Epiphysis may be severely damaged
(coz its Cartilaginous)
In Older Children Vascular occlusion may lead to
Epiphyseal necrosis
In Adults Usually confined to articular cartilage

10. Sequelae after Healing
I. Complete resolution & return to Normal.
II. Partial loss of articular cartilage & Fibrosis of
the Joint.
III. Complete loss of articular cartilage & bony
ankylosis.
IV. Bone destruction & permanent deformity of the
Joint.

11. Clinical Features in New Born
o Irritable
o Refusal to feed
o Rapid pulse
o Fever
o Local ↑ in Temp.
o Tenderness
o Resistance to movement
o Umbilical cord checked for source of
infection

12. Clinical Features in Children
o Acute pain in a Single large Jt.
o Reluctance to move the Jt. (Pseudoparesis)
o Rapid pulse
o Fever
o Overlying Skin red
o Swelling
o ↑in Local Temp.
o Tenderness
o Restriction of all movements
o Look for source of infection – Septic Toe, Boil, Ear
discharge

13. Clinical Features in Adults
• Pain
• Swelling
• ↑in Local Temp.
• Tenderness
• Restriction of motion
• Ask & examine for evidence of Gonococcal
infection or, Drug abuse
• Ask for h/o Rheumatoid Arthritis

14. Investigations
• Aspiration - 1st Priority
• Microscopic examination of Aspirate,
Gram staining, Culture sensitivity
• ↑WBC
• ↑ESR
• Blood Culture
• USG
• MRI

15. • X-ray - usually Normal
• Earliest findings are soft
tissue swelling around the
joint and a widened joint
space from joint effusion

16. Treatment
• Analgesics
• IV Fluids - for Dehydration
• Antibiotics - IV for 4-7days then Oral for
another 3wks
• Splintage - to rest the joint

17. Drainage
o Advised in -
• Very young infants
• Hip involvement
• If the aspirated pus is very thick

18. Aftercare
• If articular cartilage has been preserved,
gentle and gradually increasing active
movements are encouraged.
• If articular cartilage has been destroyed
the aim is to keep the joint immobile while
ankylosis is awaited.

19. • If deformity is present, subsequent
osteotomy should be planned to correct it.

20. Complications
• Highest Risk in Infants <6mos (due to delay in
Dx & concomitant OM) of the adjacent bone.
• Subluxation/Dislocation of the Hip
• Instability of the Knee
• Physeal damage
• Erosion of Articular cartilage – In old

21. Gonococcal Arthritis
• MC cause of Septic Arthritis in sexually active adults
• Infection is acquired only by direct mucosal contact with
an infected person - carrying a risk of >50% after a
single contact.
• 2-Types of Clinical d/o :
I. Disseminated Infection (Triad of polyarthritis,
tenosynovitis and dermatitis)
II. Septic Arthritis of a Single Joint

22. Gonococcal Arthritis
• Low grade fever
• ↑ESR, ↑WBC
• Joint aspiration – G-ve bacteria & ↑WBC
• Also tests performed for other STIs

23. Gonococcal Arthritis
Treatment :
• Similar to other types of Pyogenic arthritis.
• 3rd Gen. Cephalosporin IM/IV
• If concomitant Chlamydial infection -
Quionolones

24. Septic Arthritis & HIV Infection
• MC organisms – S. Aureus, Streptococci
• Others – Opportunistic Organisms
• Patient may present with an acutely painful, inflamed
joint and marked systemic features of bacteremia or
septicemia.
• Treatment follows the general principles as others.

25. Tubercular Arthritis
• Bones or joints are affected in about 5 %of patients w/
Tb.
• Predilection for the Vertebral bodies & the large Synovial
joints.
• Multiple lesions occur in about 1/3rd of patients.
• In established cases it is difficult to tell whether the
infection started in the joint and then spread to the
adjacent bone or vice versa
• Synovial membrane and subchondral bone have a
common blood supply and they may be infected
simultaneously.

26. Pathology
• Synovium thickening & edematous → Marked Effusion
• A pannus of granulation tissue may extend from the
synovial reflections across the joint.
• Articular Cartilage is slowly destroyed.
• At the edges of the joint, along the synovial reflections,
there may be active bone erosion.
• In addition, the increased vascularity causes local
osteoporosis.

27. Pathology
• If unchecked, caseation and infection extend into the
surrounding soft tissues to produce a ‘cold’ abscess.
• This may burst through the skin, forming a sinus or
tuberculous ulcer, or it may track along the tissue planes
to point at some distant site.
• Secondary infection by pyogenic organisms is common.
• If arrested at an early stage, healing may be by
resolution to apparent normality.

28. • If articular cartilage has been severely damaged,
healing is by fibrosis and incomplete ankylosis,
with progressive joint deformity.
• Within the fibrocaseous mass, mycobacteria
may remain imprisoned, retaining the potential
to flare up into active disease many years later.

30. Clinical Features
• Hx of Previous Infection or, Recent contact w/ Tb.
• MC age gp. - Child or Young Adult
• C/O - Pain & Swelling in a superficial joint swelling.
• In advanced cases - Fever, night sweats, lassitude and
loss of weight.
• Night Cries
• Muscle wasting
• Synovial Thickening
• Tender & Enlarged LNs
• Restriction of Movements in all directions

31. • Multiple foci of infection are sometimes
found, with bone and joint lesions at
different stages of development. This is
more likely in people with lowered
resistance.

32. X-Ray appearance
• Soft-tissue swelling and peri-articular
osteoporosis are characteristic.
• ‘Washed-out’ appearance of the bone.
• Articular space is narrowed.
• In children the epiphyses may be
enlarged, probably the result of long-
continued hyperaemia.
• Erosion of the subarticular bone;
characteristically this is seen on both
sides of the joint, indicating an
inflammatory process starting in the
synovium.

33. Investigations
• ↑ESR
• Relative Lymphocytosis
• Mantoux Test +ve
• Synovial Fluid :
- Cloudy
- ↑Ptn. Conc.
- ↑WBC
- Culture +ve (>50%)
- Acid fast bacilli
(10-20%)
• Biopsy :
- More reliable
- Show Tb granuloma
- Culture +ve in >80%
cases if not received
Anti Tb drugs.

34. Treatment
1. Rest
2. Chemotherapy
3. Surgery

35. Treatment - REST
• Prolonged, Uninterrupted, Rigid, Enforced.
• Done by Splinting & Traction.

36. Treatment - Chemotherapy
Intensive Phase 5-6mos - INH 300-400mg
- Rifampicin 450-600mg
- Fluoroquinolones 400-600mg
Continuation Phase 9mos - INH & PZE 1500 mg/day for 4mos
- INH & Rifampicin for another 4mos
Prophylactic Phase 3-4mos - INH & Ethambutol 1200mg/day

37. Treatment - Surgery
• Operative drainage or clearance of a tuberculous focus
is seldom necessary nowadays.
• However, a cold abscess may need immediate
aspiration or draining.
• Arthrodesis or Replacement Arthroplasty - If Joint is
destroyed.
• Give chemotherapy for 3mos before and after the
operation – due to risk of reactivation.

38. Thank you…