Major Infections seen in Orthopedic

Practice
- Osteomyelitis & Septic Arthritis

Dr Vishva Randhara Alles

Registrar In Surgery – Orthopedics Attachment
SJGH
 Part 02
Septic ARTHRITIS
Septic arthritis, also known as infectious arthritis, represents an
inflamation caused by infection of joint space by various microorganisms,
most commonly caused by bacteria.

There is inflammation in synovial membrane and purulent effusion in

joint cavity .

This is in contrast to Reactive arthritis, where it is a sterile inflammatory

process that may result from an extra-articular infectious process.

Other than bacteria , viruses, mycobacteria, and fungi have been implicated
in pathogenesis .

Itis mandatory to exclude septic arthritis in a patient with Acute Mono-

artheritis .

Septic arthritis is a rheumatologic /surgial emergency.

 Failure to recognize and to appropriately treat septic arthritis results in

significant rates of morbidity and may even lead to death.

Septic Arthritis - Background

What are the Differential Diagnosis when a
patient present with Mon:arthritis ? .

1. Acute Osteomyelitis
2. Trauma
3. Flare of Ostioarthritis
4. Hemophilic Bleeding
5. Rhematoid Fever
6. Juvenile Rhematoid arthritis
7. Reactive Arthritis
8. Sickle cell crisis
9. Gout / Psedo gout
10. Gaucher’s Disease
11. Lyme disease

Septic Arthritis
Approximately 20,000 cases of septic arthritis occur in the
United States each year (7.8 cases per 100,000 person-
years), with a similar incidence occurring in Europe.

The incidence of arthritis due to disseminated gonococcal

infection is 2.8 cases per 100,000 person-years.

The increasing use of prosthetic joints, infection

associated growing septic arthritis incidence.

Septic
arthritis is also becoming increasingly common
among people who are immunosuppressed and elderly
persons.

Septic Arthritis of Native Joints.

Infect Dis Clin North Am. 2017; 31(2):203-218 (ISSN: 1557-9824)

Septic Arthritis - Epidemiology

Normal Anatomy Of Synovial Joint

Septic Arthritis
Route Of Infection
Joints with intra-articular metaphysis include.

hip
shoulder
elbow
ankle
(NOT the knee)

Septic Arthritis - Etiology

Predisposing factors for Septic Arthritis .

Age > 80
Existing Joint Issues :Rheumatoid
DM , CKD ,CLCD
Immunosuppression : HIV / Drug Induced
Prosthetic joints
IV Drug abuse
Recent Joint Intervention :Arthroscopy Or Aspiration / Surgery
Sickle cell disease
SLE
Trauma to joint
STD – Gonorrhea
Skin conditions : infection / eczema

Septic Arthritis – Risk Factors

Previously damaged joints, especially those damaged by
rheumatoid arthritis, are the most susceptible to
infection.
The synovial membranes of these joints exhibit
neovascularization and increased adhesion factors; both
conditions increase the chance of bacteremia, resulting
in a joint infection.

Some microorganisms have properties that promote

their tropism to the synovium.
S aureus readily binds to articular sialoprotein,
fibronectin collage, elastin, hyaluronic acid, and
prosthetic material via specific tissue adhesion factors

Septic Arthritis - Pathogenesis

Septic Arthritis –Inflamation
In Infants , It destroy the Joint cavity and epiphysis which is
still cartilaginous.

Inflammation mediated joint destruction can occur early within

8 hours .

In Children , Vascular occlusion leads to avascular necrosis of

epiphyseal bone.

In Adults the effects are mainly confined on cartilage and

extensive erosion can occur due to synovial proliferation and
ingrowth

Ifthe process is not arrested the destroyed joint get healed

with ankylosing .

Septic Arthritis –Pathogenesis

In adults, the arteriolar anastomosis between the epiphysis
and the synovium permits the spread of osteomyelitis into the
joint space.

Rheumatoid arthritis and systemic lupus erythematosus hamper

the defensive functions of synovial fluid

Patients with deficiencies of the terminal components of

complement are susceptible to neisserial bacteremia and
joint infections.

Viral infections may cause

1. Direct invasion (rubella)

2. Production of antigen/antibody complexes.

Such immunologic mechanisms occur in infections with hepatitis

B, parvovirus B19 etc.
Septic Arthritis - Pathogenesis
As the destructive process continues, pannus
formation begins, and cartilage erosion
occurs at the lateral margins of the joint.
Large effusions, which can occur in infections
of the hip joint, impair the blood supply and
result in aseptic necrosis of bone.

Ifthe infection goes untreated, it will spread

to the underlying bone or burst out of the
joint to form abscesses and sinuses.

Septic Arthritis - Pathogenesis

With management and healing there may be:

(1) complete resolution and a return to normal

(2) partial loss of articular cartilage and fibrosis of the

joint

(3) loss of articular cartilage and bony ankylosis

(4) bone destruction and permanent deformity of the

joint

Septic Arthritis – Squeale

The pattern of joint involvement is an extremely
important diagnostic feature.

Ofcases of nongonococcal suppurative arthritis, 85-

90% are monoarticular.

Gonococcal musculoskeletal involvement may present in

1 of 2 ways

1. Fever, arthralgias of multiple joints, and multiple skin

lesions (dermatitis-arthritis syndrome)

2. Monoarticular arthritis without associated systemic

symptoms, tenosynovitis,

Septic Arthritis – Clinical Picture

Gonococcal Vs Non Gonococcal
Patient has antalgic gait if the affected joint is in lower
limb.

Patient is actively guard the affected upper limb .

Patienthas markedly tender joint where both Active &

Passive movements are restricted .

There may be marked muscle spasm related to the joint.

Jointis swollen, Warmth , Reddish & may be pus forming

sinus is there.

Patient has Fever Or No symptoms at all like in Silent

arthritis in immune compromised patient

Septic Arthritis – Clinical Picture

Patient may have another infectious focus / evidence
of Prosthetic device or surgical intervention.

A child may be irritable ,Refusing feeding ,Febrile and

having Joint tenderness.

Patient may keep the Joint In COMFORT position.

Example

HIP : Abducted,Flexed & Ext rotated

Knee /Ankle & Elbow : Partially flexed
Shoulder : Abducted & Internally rotated

Septic Arthritis – Clinical Picture

Blood Investigation
Inflammatory Markers / RFT / LFT /FBC
/procalcitonis /TNF level /IL- 6 Etc
Imaging
Joint Fluid Analysis
Culture ABST

Note :
Prompt empirical treatments with Antibiotics
should not get delayed due to Investigation.

Septic Arthritis – Investigation

work up
The white blood cell count, CRP and ESR are
raised.

Blood cultures should be taken in two different

places of the body ,ideally before starting
antibiotics or just before the next antibiotic dose. .
Few studies assessed the sensitivity of blood
cultures, which ranged from 23% to 36%

Bacterial arthritis: are fever, rigors, leucocytosis and blood

cultures of diagnostic value?
Schlapbach P, Ambord C, Blöchlinger AM, Gerber NJ Clin
Rheumatol. 1990 Mar; 9(1):69-72.

Septic Arthritis – Investigation

work up
Sensitivity and specificity of leukocytosis for the diagnosis of
septic arthritis. Positive corelation .
But what is the cutoff Valve ?
Li SF, Cassidy C, Chang C, Gharib S, Torres J. Diagnostic utility of laboratory tests in septic arthritis. Emerg
Med J. 2007;24:75–77.

Multiplestudies demonstrated acceptable sensitivity for

erythrocyte sedimentation rate (ESR) of >30 mm/hour.

Procalcitonin, tumor necrosis factor, and various cytokines

including interleukin (IL)-6 and IL-β, were generally specific
with very poor sensitivity.
Martinot M, Sordet C, Soubrier M, et al. Diagnostic value of serum and
synovial procalcitonin in acute arthritis: a prospective study of 42
patients. Clin Exp Rheumatol. 2005;23:303–310.

Septic Arthritis – Investigation

work up
Plain X Ray Findings

 Increased Joint Space initially and reduced joint space due

to destruction of cartilage.
 Features of Osteomyelitis.
 Juxta-articular osteoporosis due to hyperaemia / Ostiopenia.
 Periosteal reactions.
 x-rays may be normal in the very early stage of the
disease
 joint effusion may be seen
 narrowing of the joint space due cartilage destruction in the
acute phase
 destruction of the sub chondral bone on both sides of a joint
 if left untreated, reactive juxta-articular sclerosis and, in
severe cases, ankylosis will develop an seen in X Ray films

Septic Arthritis – Imaging

Septic Arthritis – Imaging
Progressive Destruction

Septic Arthritis – Imaging

Ultrasound Scan of Joint .

Useful in superficial and deep joints and in even children

Shows joint effusion.

Example : Capsular distention in the hip, noted as convexity of the
anterior recess when compared to the contralateral

Echogenic debris may be present and can be seen in the study

Colour Doppler may show increased peri-synovial vascularity

The study can be used to guide the joint aspiration and sent to
culture ABST and Analysis.

Imaging of infectious arthritis.

Radiol Clin North Am. 2001; 39(2):267-76 (ISSN: 0033-8389)
Greenspan A; Tehranzadeh J

Septic Arthritis – Imaging

Iffurther imaging is required after USS ,
MRI is the most sensitive and specific
technique, although it is of low utility for
acute diagnosis.

 Scintigraphy, CT, and FDG-PET are also

used, although to a lesser extent.

Septic Arthritis - Imaging

Septic Arthritis – Joint Fluid
Analysis
Kocher Criteria for Septic Arthritis
Morrey’s Diagnostic Criteria for Septic
Arthritis

 Developed for Hip Septic arthritis of

children
 Adult diagnosis ?

Septic Arthritis
Septic Arthritis – Management
Other Aspects of the Management

IV Fluid – Prevent Dehydration

Analgesics
Anti Inflammatory Drugs
Splintage of the joint / Limb Or Plaster in resting
position of joint
Keep the joint decompressed – Frequent arthrocentesis
Nutritional Care
Monitor adverse effect of antibiotics
Physiotherapy & Rehabilitationof Joint
Patient education
Audit & Feedback – PJI

Septic Arthritis – Management

ANTIBIOTICS

Antibiotic
treatment follows the same guidelines as presented for
acute haematogenous osteomyelitis.

The initial choice of antibiotics is based on judgement of the most

likely pathogens.

Do not delay antibiotic .Take cultures and start .

 Correct antibiotic combination in correct route in correct dose and

frequency indicated for a correct duration .

IVantibiotic Minimum 7 to 14 days and then converted to Oral for

duration decided by clinical feature of patient

Septic Arthritis – Management

Principles of Arthotomy

 Should be under proper anesthesia (GA , Regional).

 Skin Preparation.
 Sand bad under the joint if possible.
 Avascular field if possible .
 Take Synovial Fluid / Synovial Tissue / Bone tissue /
Prosthetic –
For Full report , Culture ABST , PCR ,Histology AFB etc.

 Irrigate the Joint cavity with at least 3 – 5 litters of N.Saline

 Irrigate the cavity with Gentamicin – No much evidences
 Can leave drain If suspicion of recurrent collection is there.
 Should closed in Layard > Mass closure
 Immobilization.Ex Hip spica cast in moderate abduction

Septic Arthritis
Surgical Management
Surgical Approach to Hip In septic arthritis.

Open arthrotomy remains the gold standard for

treatment of septic arthritis of the hip by far.
◦ Septic arthritis of the hip - current concepts.
◦ Rutz E, Brunner R
◦ Hip Int. 2009 Jan-Mar; 19 Suppl 6():S9-12.

Anterior and lateral approaches of the hip are most

frequently used as damage to the blood supply to
the femoral head is avoided.

Fullextent of Smith-Peterson approach & Watson-

Jones approach also can be used either:
Septic Arthritis
Surgical Management
Hip Arthrotomy – Anterior Approach .

Make a vertical incision beginning about 1 cm below the anterior

superior iliac spine inferiorly.

Protectthe lateral femoral cutaneous nerve and retract it to the

medial side.

Expose the sartorius muscle on the medial side and the tensor fasciae
latae and vastus lateralis muscles on the lateral side.

Use blunt dissection to separate these muscles. Identify the lateral

border of the rectus femoris and retract it medially,

thus exposes the hip joint capsule.

Septic Arthritis – Surgical

Management
Prosthetic Joint Infection Pathogenesis

Septic Arthritis
 TOM SMITH ARTHRITIS & SEQUALE

It is a form of acute Hip Joint arthritis in

Infants. The head of the femur is
completely destroyed.
Gonococcal Arthritis -

Seen in Gonococcal infection.More common in women and

patient who has complement component defects are more
prone to this .

Therecan be migratory artheritis with tenosynovitis or

monoarthritis.

Jointaspiration show WBC more than 50K , Blood cuture

are negative .

Septic Arthritis
Special consideration
Mycobacterial arthritis.

10% of Extrapulmonary TB and 1-3% Of active TB patient can

get TB arthritis.
Cause granulomatous infection ,Tissue destruction and caseation.
Synovia involved , Thickening of synovium with granuloma is
characteristic. The articular cartilage slowly destroyed
Spread via droplets mainly .The primary focus is Lung , Pharynx
Or Gut
Spine one of the commonest region involved .
Need chemotherapy with Isoniazide ,Pyracinmyde & Rifampicin
Prolong treatment regimes are needed
Fibrous ankylosis of joints occur

Septic Arthritis
Special consideration
Tuberculosis – Pathogenesis
Tuberculosis Arthritis
Tuberculosis Arthritis
TB Hip Joint
Fungal Arthritis

Septic Arthritis –Special

Consideration
Antibiotic
prophylaxis with an antistaphylococcal antibiotic has
been demonstrated to reduce wound infections in joint
replacement surgery.

 Identify High risk patient

Polymethylmethacrylate cement impregnated with

antibiotics may decrease perioperative infections.

Strictlyadhere to sterile procedures whenever the joint space

is invaded (eg, in aspiration or arthroscopic procedures).

Patient education

Septic Arthritis –Prevention

Complication : Early

Joint destruction
Pathological dislocation of joint
Acute ostiomyelitis
Septicemia ,SIRS ,MODS
Avascular Necrosis

Complication Of Septic Arthritis

Complication : Late

Coxa Magna
Secoundry Ostioarthritis
Ankylosing of Joint
Growth disturbances
Deformities of the joint and skeleton

Complication Of Septic Arthritis

Bone and joint infection Summery .

Bone and Joint Infections are destructive ,Limb and Life threatening.

Identification of different clinical pictures and early treatments will

minimize the morbidity .

Proper Use of Antibiotics , Timely Surgical intervention will save the

Joint / Limb and Life

Preventive measures always important when considered the morbid

cost of Bone and joint infections

TB is a silent slow progressing Bone and Joint infection where

management is challenging
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