SEPTIC ARTHRITIS

Dr. Irfan Ali Shujah

OVERVIEW
SCENARIO
CLINICAL PRESENTATION
ETIOLOGY
PATHOPHYSIOLOGY
RISK FACTORS
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
COMPLICATIONS
TREATMENT
SUMMARY
SCENARIO
60 yrs old female presented to a clinic
C/O: (R) Hip Pain for 3 days
O/E: Stiff & Painful Hip
AP Pelvis X-Ray: insignificant
Diagnosis of Hip Sprain
Patient treated conservatively for 7 weeks
with rest, NSAIDS & electrotherapy
Her condition failed to improve
Patient referred for an Orthopaedic
consultation
Results from Bone Scan suggested the
diagnosis of Hip Joint Infection
Subsequent radiographs of the (R) Hip
revealed marked destruction of the (R)
femoral head & acetabulum
Staph. Aureus isolated following aspiration of
the painful hip joint
Septic Arthritis of the hip can easily be
overlooked

Despite advances in diagnostic studies,
powerful antibiotics & early drainage,
significant joint destruction commonly occurs


Why?
Lack of clinical suspicion
Delay in definitive diagnostic needle
aspiration
Failure to adequately drain the joint

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

CLINICAL PRESENTATION
Fever
Chills
Severe Pain in the affected joint
Swelling (increased fluid within the joint)
Warmth (the joint is red & warm to touch due
to increased blood flow)
Fatigue & generalized weakness
Markedly decreased passive & active ROM

Infants Presentation:

Septicemia
Failure to feed
Irritability
Fever
Anemia
Swelling of the leg & buttock
Lack of movement
Asymmetrical skin creases
Abnormal posture

Physical examination:
- Decreased or absent ROM
- Signs of inflammation
- Joint orientation as to minimize pain
(Position of Comfort)

Hip: Abducted, flexed & externally rotated
Knee, ankle & elbow: Partially flexed
Shoulder: Abducted & internally rotated

ETIOLOGY
Staphylococcus Aureus

In children under the age of 2 years
Haemophilus influenzae

Neisseria Gonorrhoeae

E. coli

Streptococci

INFECTION SOURCES
Hematogenous spread
Local: injections, surgery, penetrating inj.
Distant: Sinusitis, brochiectasis, IVDU
Direct Inoculation
Host Factors:
Immunosuppression due to chronic disease,
Chemotherapeutic agents
Local Factors:
Trauma, Prior Arthritis
PATHOPHYSIOLOGY
Acute synovitis
Purulent joint effusion
Synovial membrane becomes edematous,
swollen & hyperemic
Produces ed amount of cloudy exudates
contains leukocytes & bacteria
Infection spreads through the joint
Articular cartilage destroyed by bacterial &
cellular enzymes.
Cartilage may be completely destroyed
Pus may burst out of the joint



RISK FACTORS
Weak Immune System
(Diabetes, CLD, CRF and HIV infection
Immunosuppressive medication)
Alcohol or other Drug abuse
Cancer
Previous joint problems
(Prev. Arthritis, previous Joint Surgery, Joint
Replacements & Joint Injuries)
Skin wounds

DIAGNOSIS
CBC
Blood Culture
Synovial Fluid Analysis (Arthrocentesis)
Radiography
Ultrasonography
Radio-isotope Bone Scan
CT scan / MRI
Synovial Fluid Analysis
Synovial Fluid Analysis
Radiography
Appearance depends upon the duration &
virulence of infection
Generally non-specific
- Soft tissue swelling,
- Widening of the joint space
(due to the effusion)
- Periarticular osteoporosis during the first 2
weeks
Later, when the articular cartilage is attacked,
the joint space is narrowed.
(Destructive Arthritis)

DIFFERENTIAL DIAGNOSIS
Osteomyelitis
Near a joint, Assume both

Acute Haemarthrosis
- Post-traumatic
- Haemophilic bleed
(History & Joint Aspiration will help)

Transient Synovitis
- Self limited post-infectious arthritis
- Predominantly in boys
- Low grade fever
- Less painful

Gout & Pseudo-gout
- Presence of Urate or Pyrophosphate
crystals in the Aspirate

Rheumatic fever
- Skin manifestations, Chest pain

COMPLICATIONS
Destruction of the epiphysis.
Dislocation
Growth disurbance
Ankylosis
Secondary osteoarthritis
Osteomyelitis/abcess/sinus

TREATMENT
Aspirate the joint & examine the fluid

Analgesics

Fluid replacement & Nutritional support

Co-existing medical conditions must be
identified and treated
Intravenous Antibiotics
- If gram-positive organisms identified
Flucloxacillin (1g I/V BD), Cefazolin (1g I/V 8H)

- If in doubt
3
rd
Gen Cephalosporin
Vancomycin (30mg/kg I/V OD)

- Children less than 3yrs (suspicion of H. Infl)
Ampicillin

- According to C/S

Indications for Surgery
Joint does not respond to serial aspirations

No improvement after A/B

Frank Pus is aspirated

Loculations noted on MRI or USG

Documented Hip and SI septic arthritis should be
debrided surgically

Joint Drainage: Closed Asp. by Needle - Arthroscopy
Open Drainage
SUMMARY
Immunosuppression with abnormal joints is a
risk factor for developing septic arthritis (SA)

Staphylococcus is the most common organism

Cannot make the diagnosis without synovial
fluid analysis

Treatment involves appropriate antibiotic
therapy and joint drainage