JOINT INFECTIONS

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JOINT INFECTIONS

• K. Bougoulias

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Septic arthritis

• Haematogenous spread to synovium
• Extension of osteomyelitis involving epiphysis or
  intracapsular metaphysis
• Direct contamination following diagnostic/
  therapeutic procedures
• Saunders 1981

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Clinical features

• Fever
• Swelling/ synovial effusion
• Limitation of joint movements
• Usually monoarticular involvement (knee most
  common)

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Clinical features

• 50 have history of preexisting arthritis- 30
  history of trauma (Cooper, Cawley. Ann Rheum Dis
  1986)
• -Rheumatoid arthritis may have multiple joint
  involvement (Gardner, Am J Med 1990)
• -Sternoclavicular sacroiliac joints often
  affected in iv drug users (Philips 1984)

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Bacterial etiology

• lt2 years of age
• 2-16 years
• 16-30 years of age
• gt30 years of age

• Haemophilus inluenzae, S.aureus
• S.aureus, S. pyogenes
• Neisseria gonorrhoeae, S.aureus
• S.aureus, Streptococci

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Risk factors associated with pathogens
Neisseria gonorrhoeae Sexual activity
Strept. pneumoniae Sickle cell disease
Gram-neg bacilli UTI
Eikenella corrodens Human bite
Pasteurella multocida Cat/ dog bite
Borrelia burgdorferi Tick exposure
Sporothrix schenckii gardeners
Mycobacterium marinum Tropical fish
Candida species Trauma, steroid inj
Pseudoallescheria Trauma
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Radiographic studies

• X rays asymmetrical soft tissue shadows
  (displacement of muscles)- comparison with other
  side usefull
• Destruction of subchondral bone and articular
  cartilage
• Infraction and sequestration of epiphysis
• Arthrography helpful in unossified nucleus

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Radiographic Studies

• Bone, indium and gallium scans positive in
  Septic arthritis (routine imaging is not
  necessary unless osteomyelitis is suspected)
• CT, MRI, Sonography more sensitive in detecting
  joint effusions

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Diagnostic aspiration

• Synovial fluid analysis at the earliest possible
  moment
• Bacteriologic studies white blood and
  differential blood cell counts
• Average of 100,000 cells/mm3 (range 25,000 to
  250,000)
• Strong suspicion gt50,000 cells/mm3 with 90
  polymorphs

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Aspiration

• Gram stain give guidance to most effective
  antibiotic treat before sensitivity tests
• Blood cultures, cultures from other septic areas
• Glucose concentration in synovial fluid is less
  than blood levels

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Aspiration

• Protein may be up to 6 or 8 g/Dl-electrophoretic
  pattern resembling of plasma
• Urate or calcium pyrophosphate crystals are
  important in differencial diagnosis
• Nade S, JBJS 1983
• Ward et al, Arthritis Rheum 1960

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Differencial Diagnosis

• Bursitis
• Cellulitis
• Transient synovitis
• Aseptic inflammation
• Acute osteomyelitis
• Crystal deposition disease
• Acute rheumatoid arthritis

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Differential diagnosis

• Chronic arthritis
• Acute rheumatic fever
• Hemophilia

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Treatment

• Parenteral antibiotics immediately upon admission
• Type of antibiotics natural history of disease,
  age, Gram stain
• lt5 years old empiric therapy against
  H.influenza, S.aureus, Streptococci- Cefotaxime,
  ceftizoxime

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Treatment

• Sexually active adult, ceftriaxone, if gram stain
  is suggestive of gonococcus
• Combination of vancomycin and gentamycin against
  S.epidermidis and S.aureus
• Usual length 2-3 weeks

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Surgical Drainage

• Serial aspiration
• Open surgical drainage
• Arthroscopic lavage
• Instilling antibiotics locally is not helpful,
  may be harmful
• Bobechko, pediatric Orth 1978
• Nade S, JBJS 1983

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Immobilization

• Traditional for pain relieve, but
• Continuing passive motion improves nutrition of
  cartilage, prevents adhesions, enhances clearance
  of lysosomal enzymes,stimulate chondrocytes to
  synthesize matrix components
• Salter RB et al, Clin Orthop. 1981

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Thank you