SEPTIC ARTHRITIS

Is the purulent invasion of a joint by an infectious agent

1. Orthopaedic emergency, early diagnosis and appropriate treatment are essential for optimum results. 2. There are around 2-10 cases of septic arthritis per 100,000 in the general population. 3. There can be due to bacteria, fungi and viruses 4. Can affect any age group and any joint 80 % of septic arthritis involve only one joint knee (50%) hip (20%) shoulder (8%) ankle (7%), wrists (7%). The elbow, interphalangeal, sternoclavicular, and sacroiliac joints each make up 1-4% of cases.

RISK FACTOR
1) AGE Elderly Children <2 years or age 4) JOINT PATHOLOGY Rheumatoid arthritis Joint prosthesis (Prostetic Jt Infection) Trauma

2) IMMUNOSUPRESSED and other COMORBID 5) Sexually active person Diabetic Hemodialysis patient Cancer patient (on steroid) AIDS 3) IVDU

CAUSATIVE ORGANISM
Staphylococcus aureus - commenest in adults and children > 2 years old Streptococci - the second most common cause Haemophilus influenzae - predominate in children under age 2 years. Neisseria gonorrhoea - in sexually active adults Escherichia coli- in the elderly, IV drug users and the seriously ill patient M.tuberculosis,Salmonella spp. and Brucella spp. - cause septic spinal arthritis

ROUTE OF INFECTION
Micro-organism reach the synovial membrane via:

1. Hematogenous spread (bacteremia)

2. Direct infection from a penetrating wound

3. Direct spread from a contiguous focus of osteomyelitis 4. Iatrogenic

PATHOLOGY

In the early stage a) There is an acute synovitis with a purulent joint effusion. b) Soon the articular cartilage is destroy by bacterial and cellular enzymes. c) If the infection is not arrested cartilage may be completely destroyed. d) Healing then leads to bony ankylosis

With healing there may be:

(1) complete resolution and a return to normal (2) partial loss of articular cartilage and fibrosis of the joint- fibrous ankylosis (3) loss of articular cartilage and bony ankylosis (4) bone destruction and permanent deformity of the joint

CLINICAL FEATURE
TRIAD of 1. Fever 2. Acute joint pain 3. Impaired ROM Usually one joint(monoarthritis) Joint-red, swollen, and tender
In newborn infant 1. 2. 3. Irritable and refuses to feed Rapid pulse May have fever

Joint- local sign : warmth, tenderness and resistance to movement Identify the source of infection: umbilical cord, IV line or from respi tract, spine and abdomen

CLINICAL FEATURE
In children and adult 1. 2. 3. 4. Acute pain in single large joint Pseudoparesis (reluctance to move the limb) Rapid pulse Swinging fever

Joint- local sign Identify source of infection Children : septic toes, boil & ear infection Adult: gonococcal infection & IVDU

INVESTIGATION
1) Blood CRP >20mg/dL ESR >40mm/hr WBC +Blood culture 2) Specific Ix Needle aspiration of joint fluid Synovial fluid culture / Gram stain 3) Imaging u/s-- joint effusion (Widening of the space between capsule and bone of more than 2 mm) X-ray appear normal in early stage, it will then shows soft-tissue swelling, widening of joint space and slight subluxation MRI--synovial enhancement, perisynovial edema and joint effusion.

JOINT FLUID ASPIRATION

Appearance Normal Septic arthritis Tuberculous arthritis RA OA Clear yellow Purulent Turbid Cloudy Clear yellow Viscosity High Low Low Low High WBC <300 >50 000 + ++ Few

TREATMENT
1. The first priority is to aspirate the joint and examine the fluid 2. The treatment is then started without delay
Principle of treatment Supportive care
Analgesic-relieve pain IV fluid dehydration

Splintage
Splint/traction-to rest the joint (eg; in hip infection, joint should be held abducted and 30 flexed, on flexion to prevent dislocation)

Antibiotics
IV antibiotic after blood sampling and synovial aspiration older children and adult flucloxacillin+ fusidic acid In children less than 4 when H.influenza is suspected ampicilin is given

1.

Antistaphylococcal antibiotic
First line
Cloxacillin- given IV, 1-2 g 6 hourly Fucidic acid- 500mg orally 8 hourly Vancomycin

2.

Second line

Antistreptococcal antibiotics
Benzylpenicillin

Antibiotics should be given intravenously for 47 days and then orally for another 3 weeks.

Drainage
Advisable in very young infant, hip involvement ,and aspirated pus is very thick. under anaesthesia, joint is opened through small incision,drained and washed out with physiologic normal saline, small catheter is left in place then wound is closed; suction irrigation continues for another 2-3 days.

COMPLICATION
Dislocation
a tense effusion

Epiphyseal destruction Growth disturbancePhyseal damage result in shortening or deformity

Ankylosis
If articular cartilage is eroded, healing may lead to ankylosis

Poorer outcome in
Age older than 60 years Infection of the hip or shoulder joints Underlying rheumatoid arthritis Positive findings on synovial fluid cultures after 7 days of appropriate therapy Delay of 7 days or longer in instituting therapy Mortality rate N.gonorrhoeae SA -extremely low mortality rate, whereas S aureus can approach 50%.

REFERENCES
Apleys System of Orthopaedics & fracture Essential orthopaedics and trauma by Dandy emedicine.medscape.com