Transcript JOINT INFECTIONS

JOINT INFECTIONS
K. Bougoulias
Septic arthritis

Haematogenous spread to synovium
 Extension of osteomyelitis involving
epiphysis or intracapsular metaphysis
 Direct contamination following diagnostic/
therapeutic procedures
Saunders 1981
Clinical features

Fever
 Swelling/ synovial effusion
 Limitation of joint movements
 Usually monoarticular involvement (knee
most common)
Clinical features

50% have history of preexisting arthritis30% history of trauma (Cooper, Cawley.
Ann Rheum Dis 1986)
-Rheumatoid arthritis may have multiple
joint involvement (Gardner, Am J Med
1990)
-Sternoclavicular & sacroiliac joints often
affected in iv drug users (Philips 1984)
Bacterial etiology

<2 years of age

2-16 years
 16-30 years of age

>30 years of age

Haemophilus
inluenzae, S.aureus
 S.aureus, S. pyogenes
 Neisseria gonorrhoeae,
S.aureus
 S.aureus, Streptococci
Risk factors associated with
pathogens
Neisseria gonorrhoeae
Strept. pneumoniae
Gram-neg bacilli
Eikenella corrodens
Pasteurella multocida
Borrelia burgdorferi
Sporothrix schenckii
Mycobacterium marinum
Candida species
Sexual activity
Sickle cell disease
UTI
Human bite
Cat/ dog bite
Tick exposure
gardeners
Tropical fish
Trauma, steroid inj
Radiographic studies

X rays: asymmetrical soft tissue shadows
(displacement of muscles)- comparison with
other side usefull
Destruction of subchondral bone and
articular cartilage
Infraction and sequestration of epiphysis
Arthrography helpful in unossified nucleus
Radiographic Studies
Bone, indium and gallium scans positive in
Septic arthritis (routine imaging is not
necessary unless osteomyelitis is suspected)
CT, MRI, Sonography: more sensitive in
detecting joint effusions
Diagnostic aspiration

Synovial fluid analysis at the earliest
possible moment
 Bacteriologic studies & white blood and
differential blood cell counts
 Average of 100,000 cells/mm3 (range
25,000 to 250,000)
 Strong suspicion: >50,000 cells/mm3 with
90% polymorphs
Aspiration

Gram stain give guidance to most effective
antibiotic treat before sensitivity tests
 Blood cultures, cultures from other septic
areas
 Glucose concentration in synovial fluid is
less than blood levels
Aspiration

Protein may be up to 6 or 8 g/Dlelectrophoretic pattern resembling of
plasma
 Urate or calcium pyrophosphate crystals are
important in differencial diagnosis
Nade S, JBJS 1983
Ward et al, Arthritis Rheum 1960
Differencial Diagnosis

Bursitis
 Cellulitis
 Transient synovitis
 Aseptic inflammation
 Acute osteomyelitis
 Crystal deposition disease
 Acute rheumatoid arthritis
Differential diagnosis

Chronic arthritis
 Acute rheumatic fever
 Hemophilia
Treatment

Parenteral antibiotics immediately upon
admission
 Type of antibiotics: natural history of
disease, age, Gram stain
 <5 years old :empiric therapy against
H.influenza, S.aureus, StreptococciCefotaxime, ceftizoxime
Treatment

Sexually active adult, ceftriaxone, if gram
stain is suggestive of gonococcus
 Combination of vancomycin and
gentamycin against S.epidermidis and
S.aureus
 Usual length 2-3 weeks
Surgical Drainage

Serial aspiration
 Open surgical drainage
 Arthroscopic lavage
 Instilling antibiotics locally is not helpful,
may be harmful
Bobechko, pediatric Orth 1978
Nade S, JBJS 1983
Immobilization
Traditional for pain relieve, but…
 Continuing passive motion: improves
nutrition of cartilage, prevents adhesions,
enhances clearance of lysosomal
enzymes,stimulate chondrocytes to
synthesize matrix components
Salter RB et al, Clin Orthop. 1981

Thank you