01/07/2024, 22:14 Septic Arthritis - Adult - Trauma - Orthobullets

Updated: Nov 29 2022

Septic Arthritis - Adult

Ujash Sheth MD Derek W. Moore MD

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IMAGES


SUMMARY


 Septic Arthritis is the inflammation of the joints secondary to an infectious

etiology, most commonly affecting the knee, hip, and shoulder.

 Diagnosis is made with an aspiration of joint fluid with a WBC count >
50,000 being considered diagnostic for septic arthritis. Lower counts may still
indicate infection in the presence of positive gram stains or cultures results.

 Treatment is usually urgent surgical irrigation and debridement followed by

culture directed IV antibiotics.

EPIDEMIOLOGY


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 Anatomic location

most commonly affected joints in descending order


knee (~ 50% of cases) >


hip >


shoulder >


elbow >


ankle >


sternoclavicular joint     


found in IV drug users


pseudomonas aeruginosa was most common pathogen in
1980's


staphylococcus aureus is now the most common pathogen in
all patients, including IV drug users


advanced imaging (CT/MRI) should be obtained preoperatively
to rule out retrosternal abscess or chest wall phlegmon  

 Risk factors

age > 80 years


medical conditions


diabetes


rheumatoid arthritis


cirrhosis


HIV


history of crystal arthropathy


endocarditis or recent bacteremia


IV drug user


recent joint surgery

ETIOLOGY


 Pathophysiology

pathoanatomy


3 etiologies of bacterial seeding of joint


bacteremia


direct inoculation


from trauma or surgery

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
contiguous spread


from adjacent osteomyelitis


cellular biology


septic arthritis causes irreversible cartilage destruction in an involved
joint


cartilage injury can occur by 8 hours


caused by release of proteolytic enzymes from inflammatory cells
(PMNs)


microbiology


most common pathogens is staphylococcus aureus (accounts for
>50% of cases)


see Classification below
 Associated conditions

prosthetic implant infection 

CLASSIFICATION


 By organism

staphylococcus species    


staphylococcus aureus 


most common and accounts for >50% of cases


MRSA


staphylococcus epidermis


neisseria gonorrhea      


account for ~20% of cases


most common organism in otherwise healthy sexually active
adolescents and young adults


manifests as a bacteremic infection


arthritis-dermatitis syndrome in ~60% of cases


localized septic arthritis in ~40% cases


gram-negative bacilli


account for 10-20% of cases


pathogens include


E coli, proteus


klebsiella

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
enterobacter


risk factors


neonates


IV drug users


elderly


immunocompromised patients with diabetes


streptococcus


streptococcus pyogenes (Group A)


most common


Group B streptococcus (e.g., agalactiae)


predilection for infants, elderly and diabetic patients


propionibacterium acnes


associated with shoulder surgery


salmonella or streptococcus pneumoniae


seen in patients with sickle cell disease


bartonella henselae


seen in patients with HIV


pseudomonas aeruginosa


seen in patients with history of IV drug abuse


pasteurella multocida


seen in patients after dog or cat bite


eikenella corrodens


seen in patients after human bite


fungal/candida


found in immunocompromised host

PRESENTATION


 Symptoms

pain in affected joint


fevers (only present in 60% of cases)


may appear toxic

 Physical exam

inspection


erythema 

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
effusion


extremity tends to be in position of maximum joint volume


hip would be in FABER position (flexed, abducted, externally
rotated) 


palpation


warmth


tender


motion


inability to bear weight


inability to tolerate PROM

IMAGING


 Radiographs

recommended views


AP and lateral of the joint in question


findings


may show joint space widening or effusion 


periarticular osteopenia

 Ultrasound

indications


may help in confirming joint effusion in large joint such as hip 


can be used in guiding aspirations

 MRI

indications


detects joint effusion, and may detect adjacent bone involvement
such as osteomyelitis 

STUDIES


 Serum labs

WBC >10K cells/mL with left shift


ESR >30 mm/hr


ESR is often elevated but may be normal early in process

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
rises within 2 days of infection and can rise 3-5 days after
initiation of appropriate antibiotics, and returns to normal 3-4
weeks


CRP >1 mg/dL


most helpful


best way to judge efficacy of treatment, as CRP rises within few hours
of infection, and may normalize within 1 week of treatment

 Joint fluid aspirate  


gold standard for treatment and allows directed antibiotic treatment


should be analyzed for


cell count with differential


gram stain


culture


glucose level


crystal analysis


septic arthritis occurs concurrently with gout or pseudogout in
< 5% of cases


characteristic findings


joint fluid appears cloudy or purulent


cell count with WBC > 50,000 is considered diagnostic for septic
arthritis, however lower counts may still indicate infection   


antibiotics administered within 24 hours of arthrocentesis can
lower synovial WBC count and lead to false negative results 


gram stains only identifies infective organism 1/3 of time


glucose less than 60% of serum level


negative "string" sign


septic synovial fluid has low viscosity compared to normal
synovial fluid (high viscosity) 

 Saline load test  


utilized to determine if wound near a joint communicates with the joint


for the knee


155 mL of saline is needed to reach 95% sensitivity  


175 mL of saline is needed to reach 99% sensitivity  

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DIFFERENTIAL


 Crystal arthropathy

gout 


pseudogout 
 Cellulitis
 Bursitis

prepatellar bursitis 

TREATMENT


 Operative

IV abx, operative irrigation and drainage of the joint


indications


considered an orthopaedic surgical emergency


IV antibiotic therapy


initiate empiric therapy prior to definitive cultures based on
patient age and or risk factors


young, healthy adults


staphylococcus aureus and neisseria gonorrhea


immunocompromised patients


staphylococcus aureus and pseudomonas
aeruginosa


transition to organism-specific antibiotic therapy based once
obtain culture sensitivities


outcomes


treatment can be monitored by following serum WBC, ESR, and
CRP levels during treatment

 Nonoperative

gonococcal septic arthritis can be treated with antibiotics and aspiration


typical antibiotic therapy includes ceftriaxone or fluoroquinolones


high resistance pattern to penicillin and tetracyclines

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TECHNIQUE


 Operative irrigation and drainage of the joint


approach


can be performed open or arthroscopically (depending on joint)


irrigation


remove all purulent fluid and irrigate joint


debridement


synovectomy can be performed as needed


cultures


obtain joint fluid and tissue for culture

COMPLICATIONS


 Arthritis
 Fibrous ankylosis
 Osteomyelitis

PROGNOSIS


 Delayed diagnosis can lead to profound, extensive cartilage damage within 8

hours

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SORT BY: RECENT ON TOP INCLUDE: BULLETS COMMENTS  35 Comments

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Abdullah Alhossan

This is an unusual presentation at my practice

Commented on Topic 1058 at 12:16 AM on 6/5/2024

Earned 10 Educator Points 

Earned 0.5 CME Credits 

PMID: 38832055 J Surg Case Rep. 2024 Jun;2024(6):rjae257. Epub 2024 Jun 3.

Unusual presentation of cutaneous myiasis in the knee: case report.

 Omar S Dahduli | Sarah A Aldeghaither | Abdullah M Alhossan

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