Promwangkhwa MD Orthopedics Pua Hospital Nan Epidemiology Septic arthritis osteomyelitis 2 1 S aureus is most common cause 40 to 90 7090 septic arthritis in lower extremities ID: 914797
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Septic Arthritis
Saran Promwangkhwa, M.D.OrthopedicsPua Hospital, Nan
Slide2Epidemiology Septic arthritis : osteomyelitis = 2 :1S. aureus is most common cause (40% to 90%) 70-90% septic arthritis in lower extremities
Hip infection – most commonly involved joint(54%) Osteomyelitis and septic arthritis may occur simultaneous
Slide3Common organismNeonate Group
B strep, gonococci, S.aureus, coliform bacteria (gram negative) Unimmunized infants younger than 2yrsH.influenzae, group A strep, K kingae, S.aureusImmunized infants and older childrenS.aureus , pneumococcus, group A strep
Slide4Common organism
Slide5Slide6Pathophysiology- Septic Arthritis
Bacterial inoculation
Inflammatory Response
Metalloproteases
Enzyme
Protease,pepidase,collaginase
IL1, IL6, TNF-
α
Collagen and Cartilage damage
Macrophage
PMN
Chondrocyte(protease)
Synovial cell (IL1)
Loss of glycosaminoglycan at 8
hrs
Softens the cartilage
+ Increase wear
Increase
intracapsular
pressure
Impair
intracapsular
vascular supply
Subluxation
Once Catalytic enzyme in joint, presence of living bacteria is not necessary for cartilage destruction to continue
Slide7Clinical feature History Pain is the most common Refuse to walk /
bear weight, limp, or refuse to use or move a limb. Age , Recent activity and Exposure provide clues to causative organism Neonate : group B Streptococcus or gram-negative rodsSickle cell disease : Salmonella infection.
Slide8Clinical feature History History of recent illnessRecent upper respiratory symptoms may suggest a noninfectious causeToxic synovitis
Poststreptococcal reactive arthritis (PSRA) Rashes or swollen lymph nodesLyme disease, cat-scratch disease, rheumatoid arthritis, and leukemiaConcurrent chickenpoxgroup A Streptococcus
Slide9Physical ExaminationFeverJoint erythema, warmth, swellingSwelling of the anterior aspect of thigh is a late signPseudoparalysis
Hip in external rotation/abduction/mild flexion TendernessLimited and painful ROMPain with passive joint motion
Slide10Slide11Slide12InvestigationCBC with differential WBC count are least sensitiveElevate in 25-73 % of osteomyelitis
ESR (Elevate in 85- 95% of septic arthritis, 90-95% of osteomyelitis )CRP (Elevate in 98% of osteomyelitis )H/C (Positive in 30-50% of pts)Plain filmUltrasoundJoint aspirationNone of these tests are specific for musculoskeletal infection
Slide13ESR VS CRPESRResponse to inflammationUnreliable in
neonate,anemia,sickle cell, who taking steroidElevate 85-95% of septic arthritis3-1-3(3day/1wk/3wk)CRPResponse to inflammation and traumaRaise in 6 hrs/peak on day 2/normal within 1 wkEarly Dx and determine resolution of inflammation เนื่องจากขึ้นเร็ว-ลงเร็วกว่า 6-2-6 (6hrs/2day/6day)
Slide14ImagingPlain radiographBone scanUltrasonographyCT Scan
MRI
Slide15Help to confirm, not diagnostic.Early infection : normal, soft tissue swelling, displacement of the fat pad, joint space widening from localized edema.Late infection : joint space narrowing from destruction, generalized joint destruction, osteomyelitis, osteoarthritis, joint fusion, or bone loss.
Plain radiograph
Slide16Plain radiograph
Slide17Plain radiographFilm pelvis AP and hip lateral view (Sensitivity 43-75%, Specificity 75- 83% )Soft tissue swelling
Widening joint space Capsular distention Subluxation of the hip Bone changes may not appear for > 7 days
Slide18Bone scanRadionucleotide technetium-99m diphosphonate bone scaning (Sens89%, Spec 94%, Accu92%)
Hot uptake Acute osteomelytis Cold uptake Area of bone ischemiaSevere osteomyelitisFalse negative in 1st 24 hr Neonate sensitivity 30 -86%
Slide19Computed TomographyHelpful to determine the extent of bone destructionDetect soft tissue abnormalities , gas in soft tissuesLocalizing the infection
(Abscess)Surgical planningGuide needle localization prior to surgical biopsy or debridementDisadvantagesLess sensitive at detecting soft-tissue changes.
Slide20Magnetic Resonance Imaging ( MRI )Sensitivity 88% - 100%, specificity
75% - 100%, PPV 85%Helpful when differentiating between osteomyelitis and primary bone malignancy - Marrow involvementMRI findings of osteomyelitis – Low T1, High T2Gadolinium – R/O neoplasm, fracture, or bone infarctDisadvantagesCostNecessity for sedation
Slide21MRIDetect infection and extent of infection Greater resolution than CT.Useful in differentiating between bone and soft tissue infections and showing joint effusion.
Slide22Ultrasonographylow cost , noninvasive, nonradiation, lack of need for sedationPPV 87.9% of septic arthritis
Septic arthritis : Presence of intraarticular effusion Capsule to bone distance > 2 mm High sensitivity and low specificity
Slide23Ultrasonography
Slide24UltrasonographyDetect small collections of fluid deep in joints.Non-echo-free effusion from clotted hemorrhagic collections : characteristic of septic joint.Guide initial joint aspiration and drainage.Noninvasive, inexpensive.
Slide25Perform as soon as possibleConfirm diagnosis septic joint
Determine specific bacteriaATB treatment should be held until all initial Culture are obtainedSend forCell count and differentiateAerobic and anaerobic CultureGram stainFungal and mycobacterial C/SAspiration
Slide26Lateral aspiration
Point 45 o Just ant r and inf r to the greater trochanterAnterior aspirationPalpate femoral a. in line with inguinal ligament2.5 cm. laterally and distallypoint 45 o
Slide27Medial aspiration
Flex and abduct the legPlace the needle inf r to the adductor longus tendonBelow the femoral aFemoral head or neck is reached
Slide28Lateral side of the superior pole of the patella
Through the lateral retinaculum
Slide29Inserted 2.5 cm. proximal and 1.3 cm. anterior to the tip of the lateral malleolus
Lateral to peroneus tertius tendon
Slide301
/2 between coracoid process and the anterolateral edge of the acromion
Slide31Flex the elbow
Posterior aspect just lateral to the olecranonPalpate radial head
Slide32Dorsal side of the wrist.
Most common - between 1 st, 2 nd compartmentsBetween 3 rd , 4 th compartments orbetween 4 th , 5 th compartments
Slide33Aspiration
Slide34Differential diagnosis : Septic arthritis Osteomyelitis
Juvenile rheumatoid arthritis (JRA)Toxic synovitisRheumatic fever (sequela of group A streptococcal infection)Jone criteria ( 2 major or 1 major and 2 minor) Enteroarthritis secondary to Salmonella or Yersinia infection Kawasaki diseaseSerum sickness
Slide35Treatment septic arthritis
Slide36Principle of treatmentAdequate surgical drainage
Empiric intravenous antimicrobial therapyJoint must be rested
Slide37Non-surgical treatmentEmpirical intravenous ATB begin immediately after H/C and C/S of bone and jointNeonate group B strep
, gonococci, S.aureus, coliform bacteriaCeftriaxone/ cefotaxime/ oxacillinUnimmunized infants and younger than 2yrs H.influenzae, group A strep, K kingae, S.aureusCetriaxone/ cefotaxime/ cefuroxime/ oxcacillinImmunized infants and older children S.aureus, pneumococcus, group A strepOxcacillin/ cefazolin
Slide38Slide39Nonsurgical treatmentIntravenous ATB should be continue for 72 hrs (
Tachdjian)All patients received initial parenteral antibiotic therapy and switched to high-dose oral therapy within 5 days. (Lowell)If clinical improve can be conversion to oral ABOAfebriledecreased localized swellingdecrease/no painIncreased ROMMonitor renal function, liver function, CBC, ESR, CRP weekly
Slide40Surgical treatmentSurgery is indicated forCulture and biopsyEvacuation and elimination of bone or joint abscess
Stopping tissue destruction. Neisseria gonorrhoeae And Tubercolous may not required Surgical drainage
Slide41Gold standard : Open surgical debridementDo not require synovectomy
Drain should be placed Surgical treatment
Slide42Slide43Slide44Slide45Slide46Wrist
joint - lateral , medial , dorsal
Slide47Postoperative CareSuction drainage should be maintained for 24 to 48 hours (or until drainage subsides)Immobilize based on risk of hip instabilitySubluxated
or dislocated : closed reduction + Hip spica/single-leg spica cast (2-3 wk)Acute septic arthritis and Hip stable (during intraoperative exam) no immobilization is necessary.
Slide48Infection resolves : physical therapy.Muscle strengthening, active ROM exercises.Residual stage (deformity or limitation of motion) : correction, restoration of the joint.
Postoperative Care
Slide49Author preference treatment Acute septic arthritis: open surgical debridement IV ATB
conversion to oral antibiotics after treatment response Total treatment duration about 3 weeks (depending on clinical and laboratory response to treatment.)
Slide50Sequelae of septic arthritis Irreversible articular damage Growth arrestDisruption of joint continuity, permanent joint destructionJoint contracture
Gait abnormalityAVN of femoral headAcetabulum dysplasticSubluxation and dislocation Limb length discrepencyComplications associated with antibiotic treatmentDiarrhea, nausea, rash, thrombocytopenia, transient changes in liver enzymes, and antibiotic-induced neutropeniaComplication
Slide51Complication
Slide52Complication
Slide53- Investigation - ESR, CRP
- Aspiration - Perform as soon as possible, Confirm diagnosis - Leukocyte > 50,000, PMN > 75 %TreatmentAdequate surgical drainageEmpiric intravenous antimicrobial therapy: If clinical improve can be conversion to oral ABOJoint must be restedSummary
Slide54References