Septic Arthritis

Septic Arthritis
Ahmed Said Ali

MD Orthopedic and Trauma Surgery.
UOH
5/21/2019 1
Introduction
• Acute septic arthritis results from bacterial invasion of a joint space,

which can occur through hematogenous spread, direct inoculation
from trauma or surgery, or contiguous spread from an adjacent site
of osteomyelitis or cellulitis.
• A surgical emergency that requires prompt recognition and treatment
5/21/2019 2
Epidemiology
• peaks in the first few years of life

 50% of cases occur in children younger than 2 years of age
 hip joint involved in 35% of all cases of septic arthritis
• risk factors for neonatal septic arthritis :

 prematurity
 cesarean section
• other risk factors for developing joint sepsis included
rheumatoid arthritis, osteoarthritis, a prosthetic joint, low
socioeconomic status, intravenous drug abuse, alcoholism,
diabetes, previous intra-articular corticosteroid injection, and
cutaneous ulcers.
5/21/2019 3
Pathophysiology
routes of inoculation
 direct inoculation from trauma or surgery
 hematogenous seeding
 extension from adjacent bone
can develop from contiguous spread of osteomyelitis

•  often from metaphysis , commonly in neonates who have
transphyseal vessels that allow spread into the joint
•  joints with intra-articular metaphysis include like hip . shoulder

elbow
5/21/2019 . ankle (not the knee) 4
mechanism of destruction
• release of proteolytic enzymes (matrix metalloproteinase) from

inflammatory and synovial cells, cartilage, and bacteria which
may cause articular surface damage within 8 hours
• increased joint pressure may cause femoral head osteonecrosis

if not relieved promptly
5/21/2019 5
Bacteriology
• Age is an important factor in determining the causative agent in

bacterial infection.
• S. aureus is the leading cause in all ages followed by group A
Streptococcus and Enterobacter.
• In older adults with nongonococcal disease, S. aureus infection

causes about half of the cases of septic arthritis, and streptococci and
gram-negative bacilli are responsible for the other half.
5/21/2019 6
Neisseria gonorrhea
• causes approximately 75% of septic arthritis cases in healthy,

sexually active young adults,
• This infection has a slightly different presentation than other types of
infectious arthritis. Often the infection is polyarticular and may be
associated with a papular rash.
• Joint cultures often are negative, but cultures from the pharynx or
urethra may be positive.
• Polymerase chain reaction may help identify N. gonorrhea in
culture-negative synovial fluid.
• Gonococcal arthritis generally has a favorable outcome if treated with
appropriate antibiotics, and drainage usually is unnecessary.
• and usually does not require surgical debridement
5/21/2019 7
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Clinical Presentation
• presents more acutely than osteomyelitis
• often associated with fever and other systemic symptoms

causing toxic appearance
• children refuse to walk or move that joints

• obtain vaccination history must be obtained
5/21/2019 9
Physical exam
 inspection and palpation

 localized swelling
 effusion, tenderness, and warmth
 hip rests in a position of flexion, abduction, and external rotation
because hip capsular volume is maximized with flexion, abduction, and
external rotation and is the position of comfort for hip septic arthritis
 range of motion
 severe pain with passive motion
 unwillingness to move joint (pseudoparalysis)
 examine adjacent joints
 must rule out adjacent joint involvement
5/21/2019 10
• I:2 The clinical photograph reveals a right septic hip resting in a
position of flexion, abduction, and external rotation to maximize
joint volume
5/21/2019 11
Kocker Criteria
Probability of septic arthritis ranged as high as 99.6% when
all four criteria below are present :
 WBC > 12,000 cells/μl
 inability to bear weight
 fever > 101.3° F (38.5° C)
 ESR > 40 mm/h
• CRP > 2.0 (mg/dl) is an independent risk factor (not included in
studies of the previous 4 criteria) .
• CRP > 2.0 (mg/dl) in combination with refusal to bear weight yields a
74% probability of septic arthritis
• Order of sensitivity of above criteria:

 Fever > CRP > ESR > refusal to bear wieght > WBC
5/21/2019 12
Joint aspiration
• indicated whenever a high suspicion for infection

• required to confirm diagnosis
• joint fluid studies should include :
 cell count with differential
 Gram stain, culture, and sensitivities
 glucose and protein levels
a septic joint aspirate will show :

 high WBC count (> 50,000/mm3 with >75% PMNs)
 glucose 50 mg/dl less than serum levels
 high lactic acid level with infections due to gram positive cocci or gram
negative rods
5/21/2019 13
Imaging
recommended views :
 AP and frog-leg lateral pelvic x-rays
findings :
 may be normal, especially in early stages of disease
 often see widening of the joint space, subluxation, or dislocation
 in infants, prior to ossification of the femoral head, widening of joint
space can be seen by lateral displacement of the proximal femur
 may see bone involvement with associated osteomyelitis
Ultrasound :
• may be helpful to identify effusion
• can be used to guide aspiration
5/21/2019 14
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TREATMENT
 The principles in the management of acute septic arthritis include:

(1) adequate drainage of the joint,
(2) antibiotics to diminish the systemic effects of sepsis, and
(3) resting the joint in a stable position.
5/21/2019 17
• If a joint is suspected of being infected, aspiration with a large-bore
needle should be done before antibiotic therapy is initiated.
• Cultures can be negative in up to 75% of patients with

septic arthritis.
• The use of empirical antibiotics may obscure results.
• Regardless, treatment in children should be aggressive whether or

not a causative organism is identified.
• Empirical antibiotic treatment is based on the patient’s age and risk

factors (Table 22-2).
5/21/2019 18
• Empirical antibiotic therapy should be given until culture and
sensitivity results are available, at which time definitive treatment is
initiated
• If no organism is isolated, empirical therapy should be continued. In
general, the decision regarding duration of therapy is left up to the
physician and depends on the type of infecting organism, the
condition of the patient, and the response to therapy.
• As the infection resolves, therapy to restore normal joint function is

begun, including functional splinting initially to prevent deformity,
isometric muscle strengthening, and active range-of-motion
exercises.
5/21/2019 19
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5/21/2019 21
Complications
• Femoral head destruction
•  Deformity
•  Joint contracture
•  Hip dislocation
•  Growth disturbance
•  Gait abnormalities
•  Osteonecrosis
5/21/2019 22
5/21/2019 23

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Septic Arthritis

Ahmed Said Ali

• Acute septic arthritis results from bacterial invasion of a joint space,

• A surgical emergency that requires prompt recognition and treatment

• peaks in the first few years of life

• risk factors for neonatal septic arthritis :

can develop from contiguous spread of osteomyelitis

•  joints with intra-articular metaphysis include like hip . shoulder

• release of proteolytic enzymes (matrix metalloproteinase) from

• increased joint pressure may cause femoral head osteonecrosis

• Age is an important factor in determining the causative agent in

• In older adults with nongonococcal disease, S. aureus infection

• causes approximately 75% of septic arthritis cases in healthy,

• presents more acutely than osteomyelitis

• often associated with fever and other systemic symptoms

• children refuse to walk or move that joints

 inspection and palpation

• Order of sensitivity of above criteria:

• indicated whenever a high suspicion for infection

a septic joint aspirate will show :

 The principles in the management of acute septic arthritis include:

• Cultures can be negative in up to 75% of patients with

• The use of empirical antibiotics may obscure results.

• Regardless, treatment in children should be aggressive whether or

• Empirical antibiotic treatment is based on the patient’s age and risk

• As the infection resolves, therapy to restore normal joint function is

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