1. Septic arthritis results from bacterial invasion of a joint space and can occur through hematogenous spread, direct inoculation from trauma or surgery, or contiguous spread from an adjacent infection. 2. Risk factors include rheumatoid arthritis, prosthetic joints, IV drug use, diabetes, and previous joint injections. Clinical presentation varies from pain and swelling to no symptoms in neonates. 3. Treatment involves joint aspiration, antibiotics based on patient factors, and sometimes surgical drainage. Duration of treatment depends on the infecting organism but usually lasts 4-6 weeks.

1. SEPTIC ARTHRITIS
BY DR. PONNILAVAN

2. DEFINITION
Acute septic
arthritis results
from bacterial
invasion of a
joint space
Hematogenous spread
Direct inoculation
from trauma or
surgery
contiguous spread from an
adjacent site of
osteomyelitis or cellulitis

3. RISK FACTORS
RA,
OA,
hemophilia
a prosthetic joint,
low socioeconomic status,
intravenous drug abuse,
Cancer,
alcoholism,
diabetes,
uremia,
cirrhosis.
previous intra-articular
corticosteroid injection, &
cutaneous ulcers.

4. CLINICAL PRESENTATION
Common in extremes of ages, can occur at any age group. Most freq in adults.
most serious sequelae from infection occur in children, especially if a hip joint is
involved & Rx has been delayed.
Lower extremity weight-bearing joints - predominantly affected (61% to 79%);
however, any joint can be involved, & multiple joint infections do occur.
It can be difficult to diagnose in neonates bcoz the inflammatory response is
blunted.
The only finding in a neonate may be infection at another site (e.g., the umbilical
catheter), irritability, failure to thrive, asymmetry of limb position, or displeasure at
being handled.

5. CLINICAL FACTOR ORGANISM
PATIENT AGE
Neonate Staphylococcus aureus
<2 yr Haemophilus influenzae, S. aureus
>2 yr S. aureus
Young adults (healthy, sexually active) Neisseria gonorrhoeae
Elderly adults S. aureus (50%), streptococci, gram-negative bacilli
STRUCTURAL ABNORMALITIES
Aspiration or injection S. aureus
Trauma Gram-negative bacilli, anaerobes, S. aureus
PROSTHESIS
Early infection S. epidermidis
Late infection Gram-positive cocci, anaerobes
MEDICAL CONDITIONS
Injecting drug use Atypical gram-negative bacilli (e.g., Pseudomonas species)
Rheumatoid arthritis S. aureus
Systemic lupus erythematosus,
sickle cell anemia
Salmonella species
Hemophilia S. aureus (50%), streptococci, gram-negative bacilli
Immunosuppression S. aureus, Mycobacterium species, fungi

6. HEMATOGENOUS SPREAD:
 Hematogenous infection of a joint begins with a systemic bacteremia that
ultimately invades the synovial cartilaginous junction from the
intravascular space and spreads throughout the synovium and synovial
fluid.
 Soon after the synovium has been infected it becomes hyperemic and
infiltrated with polymorphonuclear leukocytes that rapidly increase over
the next several days
Pathogenesis

7.  Destruction of the articular cartilage, which results from degradation of
ground substance, is apparent 4 to 6 days after infection.
 Complete destruction of articular cartilage occurs at approximately 4
weeks. Joint dislocation or subluxation and osteomyelitis also may occur.

8. IMAGING STUDIES - XRAYS
 In the first few days of infection, radiographs usually are normal; however,
they may be helpful in that they may show soft tissue swelling,
displacement of the fat pad, or joint space widening from localized edema.
As the infection progresses, joint space narrowing from the destruction of
cartilage may become evident.
 used to monitor the response to treatment

9. IMAGING – USG –
detect even small collections of fluid deep in the joints.
Non–echo-free effusions from clotted hemorrhagic collections are characteristic
of a septic joint
used to guide initial joint aspiration and drainage and to monitor the status of
intraarticular compartments
Radionuclide bone scans often can detect localized areas of inflammation
CT, MRI, and bone scans also may be obtained to diagnose septic arthritis;
however, these tests are not always necessary.

10.  If SEPTIC ARTHITIS is suspected, aspiration with a large-bore needle should be done
before antibiotic therapy is initiated.
 fluid obtained should be sent for immediate Gram staining, culture, cell counts, and
crystal analysis.
 Measuring ESR or CRP helps in following the treatment course.
 Typically, synovial leukocyte counts greater than 50,000/
 leukocyte counts < 28,000/mm3 , especially in immunocompromised patients.
 polymorphonuclear neutrophils > 90%, indicates infection.
 Cultures can be negative in up to 75% of patients with septic arthritis.
 Rx in children should be aggressive whether or not a causative organism is identified.

11.  Empirical antibiotic treatment is based on the patient’s age and risk factors
.
 Empirical antibiotic therapy should be given until culture and sensitivity
results are available, at which time definitive treatment is initiated .
 If no organism is isolated, empirical therapy should be continued.

12. TREATMENT DURATION
Infections caused by H. influenzae type b, Neisseria, or Streptococcus generally respond
rapidly to appropriate antibacterial management, and duration of therapy <2 weeks
staphylococci and gram-negative bacilli needs 4 to 6 weeks of treatment.
A longer period of therapy is required if the hip or shoulder is involved, if the patient is
immunocompromised, or if the response to treatment has been poor.

13. Observe for decrease in pain, swelling, temperature & for improved joint mobility.
Open surgical drainage – If response is not favorable & repeat aspiration does not show a decrease in the
synovial leukocyte count within 24 to 48 hours,.
If purulent material is deeply situated in a joint, such as the shoulder or hip, open surgical drainage should be
done. Arthroscopic drainage is a good alternative to open drainage in many instances, especially for
infections involving the knee, elbow, shoulder, or ankle.
As the infection resolves, therapy to restore normal joint function is begun, including functional splinting
initially to prevent deformity, isometric muscle strengthening, and active ROM exercises.

14. TARSAL JOINTS
Primary septic arthritis of the
tarsal joints is rare. An
uncontrolled infection in the
tarsal joints requires wide
surgical drainage.
ANKLE
ASPIRATION
Swelling around the ankle often makes fluctuation difficult
to locate. To avoid injuring important structures, the
needle is inserted 2.5 cm proximal and 1.3 cm anterior to
the tip of the lateral malleolus. This is just lateral to the
peroneus tertius tendon
DRAINAGE
The ankle may be drained through any of the following
approaches: anterolateral, anteromedial, posterolateral,
and posteromedial

15. KNEE
The knee joint is the most frequently affected.
ASPIRATION
Because the knee is a superficial joint, it can be aspirated
easily. The 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

16. DRAINAGE
In acute septic arthritis, usually anteromedial arthrotomy or arthroscopic
drainage & antibiotic Rx are adequate.
In more difficult cases, the following approaches may be used.
If the posterior compartment of the knee is distended,& a popliteal
is well established, parallel anterior incisions combined with posterolateral
and posteromedial (Henderson) incisions usually are best.
If possible, posterior drainage should be avoided because infection may
spread through the fascial planes of thigh & leg.
When fluctuation indicates a pocket of pus in posterior compartment of
joint that has not been or that cannot be drained effectively through
Henderson incisions, posterior drainage is necessary.

17. The posterior compartment may be divided by a median septum into medial
and lateral compartments. These may be drained effectively by the Klein or
Kelikian approach .
A posterior midline approach should not be used to drain an infected knee
because it exposes the popliteal vessels to pus and to pressure from the drain
and creates a potentially contracting scar across the joint.

18. ARTHROSCOPIC
DRAINAGE
Preferred treatment for acute septic arthritis of the knee in
adults.
avoids the disadvantages of needle aspiration and arthrotomy.
ADVANTAGES :
-purulent material can be removed & joint can be irrigated.
- Joint cartilage can be inspected, & loculations or adhesions can
be removed with the arthroscope.
-Partial synovectomy can be performed if necessary.
-Drains can be placed into the joint through the portal sites for
drainage or for a continuous suction drainage system.
-Arthroscopy also has the advantage of allowing much earlier
range of motion & rehabilitation of knee joint compared with
arthrotomy.

19. Arthroscopic irrigation of septic knee. A, Cannula is
inserted in suprapatellar pouch for outflow, and knee is
irrigated through arthroscopic sheath.
B, Small suction drain is inserted through arthroscopic
sheath.
C, Sheath is removed as drain is held in place. SEE

20. HIP
 Acute septic arthritis of hip is a more serious disease in children than in
adults, & severe complications are much more common in children.
 Infection begins first in metaphysis or epiphysis and is carried into the
joint.
 Septic hip places the femoral head at high risk for osteonecrosis.
 After an infected hip in an infant or child has been surgically drained, the
hip should be supported in abduction to reduce the risk of pathological
dislocation.
 B/L septic arthritis is seen more often in the hip than in other joints and
occasionally is associated with spinal infection.

21. ASPIRATION & DRAINAGE OF HIP
A lateral, anterior, or medial approach can be used to aspirate the hip joint.
Drainage of the hip may be accomplished through a posterior, medial,
lateral, or anterior approach.
The anterior approach is preferred in small children for several reasons: (1)
damage to the major blood supply to the femoral head is avoided, (2) the
chance of postoperative dislocation is reduced, and (3) the landmarks for the
surgical approach are much clearer in a small child.
In an adult, the posterior approach allows dependent drainage and is a
more familiar approach for most orthopaedic surgeons.

22. COMPLICATIONS OF ACUTE SEPTIC
ARTHRITIS OF THE HIP
 PATHOLOGICAL DISLOCATION
 OSTEOMYELITIS
 PELVIC ABSCESS
 PERSISTENT INFECTION

23. PATHOLOGICAL DISLOCATION
 predominantly in children.
 When dislocation is recognized before severe contracture of the soft tissue
has occurred, reduction is accomplished easily at the time of drainage and
satisfactory function may result (Fig. 22-8).
 If the femoral head has been damaged by the infection, however, skeletal
traction should be applied through the distal femur and continued until
the femoral head is at the level of the acetabulum.
 The dislocation is reduced by abduction and gentle rotation; manipulation
before the femur is displaced distally should not be attempted because the
femoral head or neck may be fractured.
 After the dislocation has been reduced, the hip is immobilized in a spica
cast until it is stable or until fibrous or bony ankylosis develops.

24. Appearance of hip 21 years after pathological dislocation
and treatment of septic arthritis. Joint space is slightly
narrowed, and acetabulum and femoral head are slightly
incongrous

25. Pathological dislocation of hip. A,
Early sequestration of epiphysis,
as shown by apparent increase
in density. B, After 16 months,
note absorption of epiphysis and
part of neck.

26. OSTEOMYELITIS
 When the infection is confined to the joint, prompt drainage and appropriate antibiotic
therapy should prevent osteomyelitis of the proximal femur.
 If osteomyelitis results in sequestration of the femoral head in children younger than 12
years old, however, the head may be totally reabsorbed (Fig. 22-9), or it may be replaced
by new bone after its circulation is restored.
 In older children and adults, it usually remains as an infected sequestrum and requires
excision.
 Any of the approaches described for draining the hip may be used, but the anterior
approach gives better exposure of the joint.
 In a child, osteomyelitis of the ilium may complicate acute septic arthritis of the hip or
the joint infection may be secondary to infection in the bone; in each case, the hip joint
and ilium require drainage.
 In adults, osteomyelitis of the ilium is a less common complication, but impairment of
the circulation of the femoral head may lead to pathological fracture of the neck and
sequestration of the femoral head.

27. PELVIC ABSCESS
 caused by suppurative infection of the iliac lymph nodes or by spread from the joint into the
sheath of the iliopsoas, which may communicate with the joint.
 The abscess is retroperitoneal and tends to gravitate along the iliopsoas muscle beneath the
inguinal ligament, eventually pointing in the medial thigh.
 In large abscesses, the pus may track proximally along the iliopsoas and point proximal to
the posterior iliac crest.
 MRI may help locate and determine the true extent of psoas involvement.
 Often this can be drained by CT-directed aspiration.
 Freiberg and Perlman advise draining pelvic abscesses as follows. When the abscess points
to the medial thigh, a Ludloff incision is made (see Fig. 1-79). By blunt dissection between
the adductor longus and brevis muscles, the abscess is found anterior or posterior to the
pectineus muscle. When the abscess points subcutaneously anterior to the pectineus, the
incision may be made directly over it, but care must be taken to avoid injuring the femoral
vessels and nerve. Drainage above the inguinal ligament is not advised because a fecal
fistula may result, and the abscess cannot be thoroughly evacuated. If the abscess points
proximal to the iliac crest posteriorly, the incision is made parallel with the crest and just

28. PERSISTENT INFECTION
 rare but difficult to treat.
 Usually, scarring is extensive, and draining sinuses have become established.
 Often the sinuses become blocked, causing recurring abscesses.
 Unless aggressive surgery is performed, chronic sepsis and its sequelae result.
 Girdlestone described a radical operation for chronic pyogenic infection
around the hip. In this operation, the infected area around the hip is almost
completely saucerized. In addition to resecting all of the infected bone, a mass
of muscle is resected to ensure drainage. This operation may result in a nearly
useless pseudarthrosis or ankylosis. Marked shortening of the affected
extremity results. For these reasons, this operation is a last resort. Before the
operation, sinograms should be made and appropriate antibiotic therapy
should be started. Adequate amounts of blood should be available during
surgery.

30. Klein et al. described a technique for the treatment of chronic sepsis of the
hip in paraplegic patients;
it consists of three separate measures to control the infection:
(1) a Girdlestone procedure,
(2) transposition of the vastus lateralis muscle into the void left by the
removal of the femoral head and neck and acetabular wall, and
(3) external fixation to prevent unrestrained motion of the femoral shaft that
might damage the transposed muscle. The external fixator spans the hip joint
with a posterior pelvic-femoral frame.

31. SACROILIAC JOINT
 uncommon but not rare
 Patients have buttock pain and commonly also have low back, thigh, and
abdominal pain
 Diagnosis: Routine radiographs usually are normal. the most sensitive
diagnostic study is CT
 Treatment: Most of the reported patients responded well to appropriate
antibiotic treatment. Patients who develop an abscess require open
drainage.
 Complication: Osteomyelitis of the adjacent sacrum or ilium is a common
complication

32. STERNOCLAVICULAR AND
ACROMIOCLAVICULAR JOINTS
 affected only when acute septic arthritis involves other joints or in heroin
addicts, in whom the causative organism now is predominantly S. aureus.
 Because these joints are subcutaneous, aspiration and surgical drainage
can be accomplished.
 Occasionally, a portion of the clavicle needs to be excised for associated
osteomyelitis.

33. SHOULDER
 in children it occurs as a complication of osteomyelitis of the proximal
humeral metaphysis
 in adults, it usually is associated with a debilitating disease and rarely
responds well to treatment.
 The joint should be aspirated whenever an infection is suspected, and early
surgical drainage is indicated if frank pus is obtained.
 CT or MRI can be helpful in determining if an abscess is present.

34. ASPIRATION
The shoulder may be aspirated anteriorly, posteriorly, or laterally.
Because the fluctuant area usually is palpable anteriorly, and the
bony landmarks can be identified more easily , the needle is
inserted here most often. 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.

35. DRAINAGE
 anterior incision or a posterior incision, but the anterior incision is
preferable.
 In a review of adult patients treated for septic arthritis of the shoulder,
Leslie et al. found that arthrotomy yielded better results than repeat
aspirations.

36. ARTHROSCOPIC DRAINAGE of
shoulder
 is being seen in increasing frequency for the treatment of acute septic
arthritis of the shoulder.
 With arthroscopy, washout is done under direct vision, ensuring complete
removal of purulent material.
 Loculations and adhesions can be débrided, and a synovectomy can be
done. Drains can be placed through portal sites if needed.
 Early active mobilization may be initiated sooner than with an open
technique.

37. ELBOW
The elbow is best drained through a medial or lateral
approach or both.
ASPIRATION
 For elbow aspiration, the physician flexes the elbow
and inserts the needle on its posterior aspect just
lateral to the olecranon. The needle is advanced
through the skin and joint capsule, and the joint is
aspirated.

38. WRIST
 usually occurs only after penetrating trauma.
 Signs may be subtle, and the diagnosis is easily missed.
 Early incision and drainage should be performed to avoid the
complications of:
joint ankylosis, periarticular osteomyelitis, or suppurative flexor tenosynovitis.

39. ASPIRATION OF WRIST
 The most common site of aspiration is between
the first and second extensor compartments at
the radiocarpal level, immediately adjacent to the
point where the extensor pollicis longus crosses
the extensor carpi radialis longus. Other aspiration
sites are between the third and fourth extensor
compartments or between the fourth and fifth
extensor compartments

40. DRAINAGE
 can be drained by a medial, lateral, or posterior approach.
 Avoid opening the tendon sheaths.

41. OPERATIONS TO CORRECT
DEFORMITIES AFTER SEPTIC
ARTHRITISANKLE
When the ankle is fixed in equinus by soft tissue contracture, treatment by
Quengel casting or serial wedged casts or by operations such as
lengthening of the Achilles tendon with or without posterior capsulotomy
generally are effective in restoring plantigrade position of the foot.
When fixed equinus is caused by bony ankylosis, cuneiform osteotomy
through the joint is indicated.

42. KNEE
A flexion deformity can be corrected indirectly by a supracondylar
osteotomy that causes a compensatory deformity in the opposite direction.
This operation should be considered when the flexion deformity is not
severe but the joint is unsuitable for manipulation or soft tissue release. In
children, the osteotomy should be made well proximal to the physis.

43. TRANSVERSE SUPRACONDYLAR
OSTEOTOMY OF THE FEMUR
Supracondylar osteotomy for
ankylosis of knee in flexion.
Transverse osteotomy. line
indicates the femur after correction

44. Thompson telescoping-V osteotomy
Ankylosis of the knee in
flexion may be corrected
by the V-osteotomy
described by Thompson
pos

45. CUNIEFORM OSTEOTOMY
Cuneiform osteotomy based anteriorly.
Section of bone removed is indicated by
blue area

46. Modification of Osgood
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

47. HIP
Harmon
reconstruction for
loss of femoral
head and neck in
child as result of
acute infectious
arthritis. Period of
growth and of
weight bearing
produces
substantial neck
and trochanter

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. Conclusion
 The principles in the management of acute septic arthritis include (1)
adequate drainage of the joint,
 (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.

50. Source- Campbell chapter 22
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