1. SEPTIC ARTHRITIS
PRESENTOR – DR SAGAR TP

2. INTRODUCTION
• Inflammation of synovial membrane with
purulent effusion into the joint capsule, often
due to bacterial infection
• Or Pathological invasion of joint space
followed by inflammation

3. INCIDENCE :
• 2-10 PER LAKH IN GENERAL POPULATION
30-70 PER LAKH IN IMMUNOCOMPROMISED
• Gonococcal, Women 3x > Men

4. PATHOGENESIS:
Risk with intra articular injection is 0.0002 and
with a.scopy sx it is <o.ooo5

5. PATHOGENESIS:

7. -Age>80 YRS
-Diabetes
-Abnormal joint
architecture
-Prosthetic
joints or recent
joint surgery
-Skin
infection
-Sickle cell
disease
-ESRD
-HIV
-I.V injection
-I.V drug
abuser
-Heamophilia
-Malignancy

8. COMMON SITES OF INFECTION
ADULTS
1. Knee 40-50%
2. Hip 20-25%
INFANTS AND YOUNG CHILDREN
• Hip 95%

9. PATHOPHYSIOLOGY:
Bacteria enters synovial joint via blood stream

Inflammatory reaction

 synovial fluid and seropurulent exudate

Destruction of articular cartilage
Infants children adults

10. FIBROUS ANKYLOSIS, ARTICULAR EROSION BY PANNUS
(CHONDROLYSIS), DESTRUCTION OF THE LIGAMENTS
Increased intra-articular pressure and
tissue ischemia lead to destruction of
the articular cartilage.
Late sequel of Septic arthritis
is secondary osteoarthritis.
PYOGENIC INFECTIONS
Pyoarthrosis - extremely resistant to
antibiotic therapy.
Requires surgical drainage or repeat
arthrocentesis (EMERGENCY)
INFLAMMATORY PROCESS
Synovitis and inflammatory cell
Infiltrate (cytokines IL-1 and TNF-@)
Associated exudate (purulent, serous,
or fibrinous)

12. ETIOLOGY:
 Most common-S.aureus > Group A strept > S.pneumonia
 Neonates and infants (<2 months) - Group B streptococcus
 Sexually active adults - N.gonococcus
 DM and late periprosthetic - E.coli
 Sickle cell disease - Salmonella
 Immunocompromised patient - Group A streptococcus
 I.V drug users - Candida
 Prosthetic joint infection– Staphyloccus epidermidis
(CoNS)

13. ACUTE
MONOARTICULAR
-Staph aureus
-Strepto pneumonia
-B-hemolytic
streptococcus
-Crystal induced
arthritis
-Hemophilic arthritis
-Monoarticular R.A
CHRONIC
MONOARTICULAR
-M. Tuberculosis
-Non tubercular
-Borrelia brugdoferia
-Perthes disease
-Osteonecrosis
-Femoro-Acetabular
impingement
POLYARTICULAR
-N.gonorohhea
-N.meningitidis
-Non gonococcal
arthritis
-Sickle Cell Disease
-Reactive arthritis
-IBD
-Serum sickness
CAUSITIVE ORGANISMS AND DIFFERENTIALS OF
VARIOUS FORMS OF SEPTIC ARTHRITIS

14. CLINICAL FEATURES:
History
Symtoms
• Acute pain, systemic features
Physical examination
1. Vitals
2. Inspection and palpation
3. Range of motion

15. BASED ON AGE
NEW BORN
INFANTS
- Septicemia
- Refusal of feed
with regurgitation
- Cyanosis during
feeding
- Child not able to
use the lower limb
actively
- Abnormal position
of femur in flexion
adduction.
CHILDREN
- Acute joint pain
(most common-hip)
- Pseudoparesis
- Fever, rapid pulse
- Skin looks red and
swelling of the joint
- Local warm and
marked tenderness
- All movements of
joints are restricted
due to spasm
ADULTS
- Most common-
HIP<KNEE
- Joint are painful
and swollen
- Warm and marked
local tenderness of
joint
- Restricted
movements
- R.A patient may
develop silent joint
infection

17. • 4/4 criteria = 99% chance
• 3/4 criteria = 93% chance
• 2/4 criteria = 40% chance
• 1/4 criteria = 3% chance of septic arthritis

18. INVESTIGATIONS
1. Bood investigations
2. Imaging
3. Synovial fluid analysis

19. 1. WBC : Elevated count
[Gonococcal arthritis – Normal WBC]
• In adults WBC counts of >12,000/mm3,
combined with four or five other parameters,
have a high positive predictive value for SA
(93%) and sensitivity of 23-75%

20. 2. ESR (Sensitivity=66-90%) : Elevated
3. CRP (Sensitivity=upto 90%)
>10 mg/dl
>13.5mg/dL in prosthetic joints (sensitivity=91%,
specificity=86%)
• May be elevated upto 2 weeks post-surgery
• Septic arthritis can present with Normal ESR & CRP
• No cutoff level for diagnostic accuracy

21. CRP Vs ESR in Septic Arthritis

22. Blood culture
• Sensitivity : 23-36 %
• Done prior to antibiotic therapy
• (Culture may become positive after 3-4 days)
• Comparision study culture negative v/s culture
positive SA in children
Conclusion : culture negative patients have milder
symptoms, early response to treatment and better
outcome
[wei-szu et,all J Microbiol Immunol infect, 2005 jun]

23. 1.
Most reliable in
revealing joint
effusion in early
cases
2.
Widening of space
between capsule
and bone > 2mm
indicate effusion
3.
Echo free –
Transient synovitis
Positive
echogenic- Septic
arthritis
 80% sensitivity & 100% specificity

24. USG
FEATURES
Septic arthritis Osteoarthritis RA
1.Hyperechoic or
mixed aspects of
the fluid joint
2. In the hip joint,
Joint asymmetry+
Fluid/effusion+
Thickness of the
articular capsule
1.Cartilage
damage
2. Joint
inflammation
3. Osteophytes
Min. effusion
1.High synovial
vascularity
2. Persistent
synovitis
and tenosynovitis
3.Joint erosion

25. -Loss of joint space
-Subchondral erosions and sclerosis
-Osteonecrosis and complete collapse
-Narrowing of joint space
-Irregularity of subchondral bone
-Early stage- normal
-Soft tissue swelling, widening of joint space,
subluxation due to fluid in joint
8 months
3-4 weeks
Sensitivity = 28%

26. -Increased joint space
-Subluxation
-Healing changes
2 months after I & D
4 years old child

27. SEPTIC ARTHRITIS TB RA OSTEOARTHRITIS
Joint effusion PHEMISTER’S TRIAD Soft tissue swelling
-fusiform &
periarticular
Asymmetrical joint
space reduction
Juxtraarticular
osteoporosis
Periarticular
osteoporosis
Osteoporosis: initially
juxta-articular & later
generalized
Joint margin sclerosis
Decreased joint space Peripherally located
osseous erosion
Bone erosions are
larger
Osteophytes
Juxtra-articular
sclerosis
Progressive
diminution of joint
space
joint space narrowing
: symmetrical or
concentric
Joint erosion
Ankylosis Deformities Subchondral cysts

32. Osteoarthritis

33. SYNOVIAL FLUID ANALYSIS
• Sensitivity of 46% for a serum PCT of >0.5
ng/ml for bone and joint infections
• But a specificity of 90%
• An improved sensitivity of 90% was observed
when a cutoff of >0.2 to 0.3 ng/ml was used
• [Cristina Costales, A Real Pain: Diagnostic Quandaries and Septic
Arthritis, 10.1128/JCM.01358-17]

34. SYNOVIAL FLUID ANALYSIS
• Aseptic technique to be followed
• Avoid taking from infected site of the skin
• Fluid is examined by gross, microscopic and
then culture
• CULTURE IS GOLD STD

35. Normal straw
colored synovial
fluid
Degenerative
arthropathy
Crystal
arthropathy
.
SEPTIC
ARTHRITIS

37. TREATMENT:
• Medical
• Surgical
• Physiotherapy

40. • IN ADULTS
1. Non gonococcal SA : 2 Weeks iv
2. Disseminated gonococcal : 7-10 days iv
then oral therapy
3. MRSA : 4 weeks
• Symptoms improve in 24-48 hrs
[septic arthritis treatment and management
Author: John L brursch, update: sep.3, 2019]

41. -Drainage of pus and necrotic debris
-Septic arthritis of hip-arthrotomy
-Septic arthritis knee-arthroscopy
-Early Joint mobilization and weight
bearing
Surgical drainage should be done even if suspicious of Septic arthritis

42. • Arthroscopy Versus Open Arthrotomy for Treatment
of Native Hip Septic Arthritis: An Analysis of 30-Day
Complications.
• Khazi et. all, 20 Nov 2019, 36(4):1048-1052
• Conclusion : Similar short-term complication
rates and ROR but arthroscopic management
may be a safe option for the treatment of SA
of the hip with potentially limited morbidity
 ROR – RETURN TO OPERATING ROOM

43. SEPTIC ARTHRITIS OF HIP IN CHILDREN
• Acute septic arthritis of the hip is more
serious disease in children
• More common in less than 18 months of age
due to “TRANSEPIPHYSEAL VESSELS”
• Septic arthritis of infancy known as
“TOM-SMITH’S ARTHRITIS”

44. 1.
• Increased intra-capsular pressure.
2.
• Direct destructive action of pus on the articular
cartilage (Clostridium welchi and Histolyticum)
3.
• Thrombosis of the vessels on both sides of
epiphyseal plate- ischemia of the plate.
PATHOPHYSIOLOGY

45. DIFFERENTIAL DIAGNOSIS
1. Transient synovitis
2. Hemathrosis
3. Iliacus syndrome
4. Retroperitoneal abscess
5. Appendicitis
6. Osteomyelitis of the pelvis
7. Rheumatic fever

46. Transient synovitis Septic arthritis
General condition Normal Irritable or malaise
Max. Temperature Rarely >38’ c >38’c and chills
WBC <12000 >12000
ESR <40 >40
USG – JOINT SPACE >2mm, preserved
periarticular fat pad
<2mm, displaced
periarticular fat pad
USG- EFFUSION Mild to moderate Severe
Treatment Rest, traction, analgesics Arthrotomy, antibiotics
Sequelae Self limiting in 3-10 days Destuction of joint
X ray Normal Reduced joint space

47. SEQUELAE OF SEPTIC ARTHRITIS

51. TREATMENT
• Based on Choi classification
• Type 1a : Transient ischemia
1b : Coxa magna
Abduction cast or brace for 1 year
Satisfactory outcome 5/5

52. • Type 2a : Coxa breva
2b : Coxa vara/valga
Femoral osteotomy
Contralateral epiphysiodesis
Satisfactory outcome 7/10

53. • Type 3a : Plus severe retro/anteversion
3b : Pseudoarthrosis
Femoral osteotomy and bonegrafting
Satisfactory outcome 3/4

54. • Type 4a : Small remnant of neck
4b : Complete loss of head and neck
Pemberton osteotomy
GT arthroplasty
Tibial lengthening or observation
Satisfactory outcome 4/13

55. TREATMENT
A. Loss of movements - Soft tissue release
B. Painful joint degeneration :
1. Interposition/cup arthroplasty
2. Pelvic support osteotomy
3. Arthrodesis
4. Resection arthroplasty
5. THR in old patients

56. C. Abductor insufficiency
1. Trochanteric epiphysiodesis (<7 years age)
2. Trochanteric transfer (distal, lateral or both)
3. Pelvic support osteotomy (if there is
additional joint instability)
4. Arthrodesis

57. D. Procedure to stabilize hip:
1. Arthrodesis
2. Pelvic osteotomy such as acetabuloplasty, salter
or chiari is useful in children
Advantages :
Provide support when the proximal femur have
been absorbed.
limp is decreased
Mobility is preserved
Disadvantages :
Pain persists

58. 3. Schantz or Proximal femoral osteotomy
- When the remnant of the neck
remaining in the acetabulum is large enough
4. Trochanteric arthroplasty (Colonna) with
proximal femoral osteotomy
5. Harmon or L-episcopo reconstruction

59. Interposition/cup arthroplasty
• Useful in young patients with ankylosed hip

60. Resection/excision arthroplasty
• One / both articular surfaces excised
• Gap fills with fibrous tissue
• Indications :
1. Infection with multiple organisms resistant to
antibiotic therapy
2. Poor quality local soft tissues
3. Unacceptable complexity of any possible
reconstruction
4. Patients with systemic disease / poor overall health
5. Inadequate bone stock/combinations of these factors

62. • Advantagaes of resection arthroplasty
1. Implant-free interval : residual micro-
organism can’t escape to artificial materials
underneath a biofilm.
2. Application of a specific mixed antibiotic-
containing cement spacer & the possibility of
cementless re-implantation which allows a
broad range of revision implants.

63. • Disadvantagaes of resection arthroplasty
1. Leg length discrepancy up to 5-7 cm
2. Restricted mobilization
3. Contractures
4. Atrophy of the hip/thigh muscles.

64. Arthrodesis
• Severe unilateral destruction of the
femoral head in young patients with
severe loss of bone stock

65. • Advantages
1. Provides a stable & painless hip with
moderate inconvenience
2. Reduced risk of infection recurrence
3. Excellent stability of construct
4. Reduces time to fusion
5. Early rehabilitation

66. • Disadvantages
1. Excessive hip flexion may cause excessive
compensatory lumbar lordosis
(leads to back pain)
2. >10 degrees of hip abduction/adduction may
lead to varus/valgus knee instability

67. Trochanteric epiphysiodesis
• Done in <7 years of age
• For abductor insufficiency
• In case of choi 2b
• Prevents progressive varus deformity

68. Trochanteric transfer
• If varus deformity already exists at
presentation without much shortening
• Advantages :
1. Restore effective adbuctor mechanism
2. Prevent trochanteric impingement during
abduction

69. Schantz/Proximal femoral osteotomy
• When the remnant of the neck remaining in
the acetabulum is large enough
• Advantages
1. Decreases lurch
2. Increases the functional length of the limb by
abducting the distal fragment.

70. Ankylosed hip
• Ankylosed in flexion and adduction
• Treated by intertrochanteric osteotomy

71. • Hip is fixed in
neutral rotation
0 degrees of flexion
20 to 30 degrees of abduction
• Second osteotomy may be required later.
 Because the deformity may recur before the child reaches
maturity,
 In adults, 25 degrees of flexion and neutral abduction is the
best position

72. Trochanteric arthroplasty
• Substitutes the trochanteric apophysis to
femoral head into the acetabulum
• Advantages
1. Decreased limb length discrepancy
2. Improved ROM
3. Pain relief
4. Improvement in gait

73. • Disadvantages
1. Gradual subluxation of hip
2. Degeneration
3. Pain, Shortening
4. Spontanous ankylosis
• These complications can be reduced by adjuvant
procedure - proximal femoral osteotomy (done 1
month later) +/- acetabuloplasty

74. Harmon or L-episcopo reconstruction
• New femoral neck is fashioned to articulate
with the acetabulum
• For young children whose femoral head &
neck have been absorbed

75. THR
• Reinfection rate was 14% and complication
rate is around 36%.
• 2 stage THA worthy procedure
• Advantages :
1. Dramatic reduction in pain
2. Early mobilization
 because hip function was significantly improved in
patients with primary septic arthritis of the hip.

76. Left primary hip septic arthritis;
B-C: Treated with antibiotic impregnated cement spacer augmented
with hip compression screw after resection arthroplasty
D: After stabilization of infection, revision THR is performed

77. PROGNOSIS
• Best outcome is with immediate treatment
• Mortality = 19-25 %
• Permanent joint disability 25-50 %
Poor prognostic factors :
1. Infection before 22 weeks of age
2. Symptoms > 4 days

78. THANK YOU