Septic Arthritis

144
Erik Bowman and Justin Siebler

Definition Adjacent Osteomyelitis

• An infection within a native joint space that is • Direct intra-articular spread of metaphyseal
a surgical emergency affecting people of all osteomyelitis
ages [1] • Can occur in all joints where the metaphysis is
intracapsular
–– The metaphysis of the knee is extra-­
Location in Order of Occurrence articular and, therefore, unlikely to spread
to the joint.
• Knee (~50%) –– Most commonly occurs in hip osteomyeli-
• Hip tis [1, 5].
• Shoulder
• Elbow
• Ankle Pathogens
• Sternoclavicular joint
• IV drug users [1] • Staphylococcus aureus (~60% of cases)
• Streptococcus species
• Gram-negative organisms
Mechanism of Infection • Special considerations
–– IV drug users
Hematogenous ◦◦ Most common is S. aureus, but highly
associated with Pseudomonas
• Transient bacteremia leading to seeding of –– Young, sexually active preceded by fever,
the joint through the capillary-synovial mem- chills, rash, and migratory arthritis
brane [2]. ◦◦ Neisseria gonorrhoeae
–– Children
◦◦ < 6 weeks
• Group B strep
• Group A strep
E. Bowman, MD • J. Siebler, MD (*) • Gram-negative rods
Department of Orthopaedic Surgery and ◦◦ > 6 weeks
Rehabilitation, University of Nebraska Medical
Center, Omaha, NE, USA • Most commonly S. aureus
e-mail: jsiebler@unmc.edu ◦◦ < 5 years

© Springer International Publishing AG 2017 703

A.E.M. Eltorai et al. (eds.), Orthopedic Surgery Clerkship, DOI 10.1007/978-3-319-52567-9_144
704 E. Bowman and J. Siebler

• Increasing incidence of Kingella –– Gout

• Incidence of Haemophilus influenzae –– Pseudogout
B decreasing due to HIB vaccine • Acute inflammatory arthropathy in adults and
–– Surgically related septic arthritis children [2, 5]
◦◦ Staphylococcus aureus still the most
common.
◦◦ Normal skin floras are occasional Imaging
causes (may require alternate detection
methods). Radiographs
• P. acnes (shoulder)
• S. epidermis (prosthetic joint infec- • Often normal
tions) [1, 3, 4] • Effusion/widened joint space
• Delayed presentations
–– Periosteal elevation or cortical thickening
Pathophysiology –– Loss of joint space

Cellular Mechanism of Injury

• Proteolytic enzymes (matrix metalloprotein-
ases) released from polymorphonuclear leu-
kocytes causes cartilage destruction within
8 h.
• Irreversible cartilage damage after 8 h [1, 3, 5].
MRI
• Indicated if concern for the bone involvement
• Will demonstrate effusion
• Not necessary for diagnosis and not routinely
ordered [4, 5, 9]

 resentation (Red Hot Swollen

P Laboratory Studies
Joint)
CBC
Symptoms
• Nonspecific. Only 50% of adults have a
• Fever often present (but not always) leukocytosis.
• Pain localized to joint • Blood cultures.
• Refusal to bear weight or lift with affected
extremity
ESR and CRP

Physical Examination • CRP most commonly elevated.

• Inability/refusal to actively move joint/extremity
• Erythema about the joint
• Joint effusion (difficult to appreciate in hip
and shoulder)
• Inability to tolerate joint passive ROM
• ESR may remain normal in very acute presen-
tations, typically elevated [8].
 riteria for Predicting Septic Arthritis
C
and Distinguishing Transient
Synovitis in Children

Differential Diagnosis • Three out of four have a 93% probability of

septic arthritis.
• Transient synovitis in children –– WBC > 12 K
• Crystalopathy in adults [6] –– Fever >38.5 C
144  Septic Arthritis
–– ESR > 40
–– Inability to bear weight [7]
Joint Aspiration
• Required for diagnosis.
• Especially indicated when presentation and
laboratories are equivocal but concern is high
for septic arthritis.
• Attempt should be made to avoid aspiration
through cellulitic skin; however, do not avoid
aspiration if this is not possible [1, 9, 10].
• Fluid studies.
–– Cell differential (no one value is absolutely
diagnostic)
◦◦ > 50–75% PMN is suspicious.
◦◦ > 95% very likely infectious.
–– Cell count (no one value is absolutely
diagnostic)
◦◦ <50,000 WBC, unlikely infection.
◦◦ 50,000 – ~75,000 WBC can be infec-
tious or inflammatory.
◦◦ >75,000 WBC, more than likely
infectious.
–– Gram stain
◦◦ Gram stain is often negative.
◦◦ Considered diagnostic if positive.
–– Culture and sensitivities
◦◦ Guides antibiotic treatment [3, 9, 10]
–– Crystal examination [6]
◦◦ Gout – negative birefringent
◦◦ Pseudogout – positive birefringent
Treatment (Surgical Emergency)
• Emergent surgical drainage (debridement)
and irrigation of joint open or arthroscopically
to reduce bacterial load, toxin levels, and
PMN proteases.
–– It is possible to have crystals in a joint and
also have an acute infection.
–– Intraoperative cultures are routinely sent.
–– Surgical drain often left in place.
–– May require repeat debridement and irriga-
tion [1, 2, 9].
705
• Empiric antibiotic coverage postoperatively
with transition to culture-specific antibiotic(s)
when sensitivities are complete.
–– Ideally given after joint aspiration/cultures
to increase probability of detecting
organism.
–– Typically cover S. aureus and gram-­
negative rods. However, dependent on hos-
pital/local bacterial biome.
◦◦ Nafcillin/oxacillin (MSSA) or vanco-
mycin (MRSA) + third-generation
cephalosporin
–– If suspect N. gonorrhoeae
◦◦ Large doses of PCN or third-generation
cephalosporin
–– If suspect Pseudomonas (IV drug user)
◦◦ Add antipseudomonal [2]
• Length and route of antibiotic administration
varies depending on severity/duration of
infection, bacteria isolated, and patient’s
health/immune status.
–– Typically 2–6 weeks of intravenous
antibiotics.
• Outcome is multifactorial but influenced by
time to surgery.
References
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Academy of Orthopedic Surgery: orthopedic knowl-
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of pyarthrosis. In: Chapman MW, editor. Chapman’s
orthopedic surgery. 3rd edn. Philadelphia: Lippincott
Williams & Wilkins; 2001. p. 3561–75.
3. Esterhai Jr JL, Ruggiero V. Adult septic arthritis. In:
Esterhai Jr JL, Gristina AG, Poss R, editors.
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4. Bernstein J. Musculoskeletal medicine. Park Ridge:
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7. Luhmann SJ, Jones A, Schootman M, Gordon JE,
Schoenecker PL, Luhmann JD. Differentiation
between septic arthritis and transient synovitis of the
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