Septic arthritis

Also known as acute suppurative arthritis. Caused by pyogenic organisms. The causal organism: 1. Staphylococcus aureus 2. Haemophilus influenzae 3. Streptococcus 4. E.coli 5. Proteus

Neonates : E.Coli, H.Influenzae Child : H.Influenzae Elderly : Gram negative enteric bacteria Prosthetic : S.Epidermidis Fit adult : Nisseria gonorrhea(75%)

Predisposing conditions
Rheumatoid arthritis Intravenous drug abuse Immunosuppressive therapy AIDS Trauma Diabetes mellitus Bacteremia Sickle cell anemia prosthesis

 Most cases of early prosthetic joint infection are caused by S aureus Delayed infections are due to coagulasenegative S aureus (CoNS) and gram-negative aerobes Late cases of prosthetic joint infection are secondary to hematogenous spread from various infectious foci

The organisms reach the joint by one of the following routes

Haematogenous- the commonest route Secondary to nearby osteomyelitis-intraarticular metaphysis Penetrating wounds Iatrogenic Umbilical cord sepsis

Etiology and pathophysiology

Healthy synovial cells possess significant phagocytic activity, and synovial fluid normally has significant bactericidal activity Damaged joints exhibit neovascularization and increased adhesion factors This increases 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 In adults, the arteriolar anastomosis between the epiphysis and the synovium permits the spread of osteomyelitis into the joint space

 Damage to articular cartilage due to the particular organism's pathologic properties, such as the chondrocyte proteases of S aureus, as well as to the host's polymorphonuclear leukocytes response Inflammatory products, resulting in the hydrolysis of essential collagen and proteoglycans

 Infection with N gonorrhoeae induces a relatively mild influx of white blood cells (WBCs) into the joint thus causing minimal joint destruction Pannus is formed 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 In late stage, erosion of bones occured

pathology
Organism reaches joint and inflammatory respond beigns in the synovium Inflammation produces serous and seropurulent exudate and synovial fluid increases

Pus appears in the joint and articular cartilage is destroyed.

In infant- entire epiphysis is damaged. IN older children-necrosis of the epiphyseal bone In adult- in late case- extensive erosion of joint

With healingComplete resolution Partial loss of articular cartilage Loss of articlaur cartilage and bony ankylosis Bone destrcution and permenant deformity

Clinical features
Depends on age of the patient. In newborn infants symptoms I. Irritable II. Refuses to feed III.Fever Signs I. Tachycardia II. Warmth III.Tender IV.Resistance to move

In children
Symptoms I. Pain II. Pseudoparesis III. Malaise IV. Fever Signs I. Warmth II. Tender III. Movements restricted

In adults
Symptoms I. Pain II. Swelling III. Fever IV. Malaise Signs I. Pain II. Swollen III. Warmth IV. Local tenderness V. Joints movements restricted

Pattern of joint involvement

In nongonococcal suppurative arthritis, 8590% are monoarticular If the disease affects more than one joint, S aureus is most commonly implicated Polyarticular arthritis is usually observed in gonococcal disease and various viral infections

Gonococcal bacterial/suppurative arthritis

Fever, arthralgias of multiple joints, and multiple skin lesions Typically, hand joints are involved most often Skin lesion:  Less than 12  Evolve over a few days from papular to pustular or vesicular to necrotic  This course may recur for several months

investigation
X-ray  Normal in early stage  Increased joint space , subluxation of joint and soft tissue shadowing  Later stage : osteoporosis, reduce joint space and bone destruction Ultrasound  Useful in detecting fluid collection.

 Full blood count- raised WBC ESR- increased Blood culture- Obtain at least 2 sets of blood cultures to rule out a bacteremic origin of the septic joint Obtain cultures from the patient's rectum, cervix, urethra, and pharynx and from any skin lesions- gonococcol infection Joint aspiration- gram staining

Normal Gross examination Volume(ml) viscocity colour clarity Examination in lab WBC count PMN leucocytes culture Mucin clot Glucose level <200 <25% Firm Equal to blood glucose often< 3.5 high Colourless Transparent

Noninflammatory

Inflammatory

septic

Often> 3.5 High Straw colour Transparent

Often>3.5 Low Yellow Translucent

>3.5 Variable Variable Opaque

200-2000 <25% Firm

2000-7500 >50% Friable

>10000 >75% + Friable >25mg% of blood glucose

Nearly equal to <25mg% of blood glucose blood glucose

treatment
Analgesic- to reduce pain Splintage-rested on a splint or splint plaster Physical therapy- to maintain the joint in its functional position and providing passive range-ofmotion exercises Antibiotic- can be substituted after full bacteriological Older children and adults- flucloxacillin, fusidic acid- IV for 2-7 days , then orally for another 3 weeks Children under 4 years- ampicillin or newer cephalosporin

Antibiotic treatment
In native joint infections, antibiotics usually need to be administered parenterally for at least 2 weeks Infection with either methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) requires at least 4 full weeks of intravenous antibiotic therapy

 Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis Ceftriaxone is the drug of choice against N gonorrhoeae Vancomycin - methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulasenegative S aureus (CONS)

 drainage 1.In very young infants 2.When the hip is involved 3.If the aspirated pus is thick If pus is aspirated, the joint should be opened up( arthrotomy) , washed and closed with suction drainage.

Surgical Intervention in Prosthetic Joint Infection

Remove the prosthesis and follow with 6 weeks of antibiotic therapy Then, place the new joint, impregnating the methylmethacrylate cement with an antiinfective agent

complications
Bone destruction Cartilage destruction Growth disturbance Avascular necrosis of epiphysis