Septic arthritis and sequelae

diagnosis and management of acute septic arthritis and its sequelae

1. Septic Arthritis and its Sequelae Presenter: Dr Namith Moderator: Prof. B. Chowdhury Co-moderator: Dr. Ashish

2. Infective Arthritis

3. Introduction WHAT IS SEPTIC ARTHRITIS? Inflammation with purulent effusion Considered as Orthopaedic emergency Failure to initiate appropriate antibiotic -permanent joint dysfunction. It can cause septic shock , which can be fatal.

4. Anatomy Lines joint & cavity and secretes synovial fluid for lubrication Protection of joint cavity Lubricates the articulating joints, nutrient and waste transportation Prevents grinding of the bone and allow for smooth articulation

5. MC in children 70% in children from 1 month to 5 years M:F at 2:1 Single joint involvement in 94% of children Hip(41%)>Knee(23%)>ankle>elbow>wrist in children EPIDEMIOLOGY

6. The incidence of SA is increasing in the general population, especially in older patients with CHF, hepatitis C, diabetes mellitus, OA and ESRD M/C involvement : Knee>Shoulder

7. AETIOPATHOGENESIS The infection can originate anywhere in the body. Open wound, trauma, surgery, or unsterile injection. Infective organism travels through blood stream to the joint. The infection can be caused by bacteria or other organisms.

8. AGENT

9. AGE <5 years EXISTING JOINT PROBLEMS Osteoarthritis, gout, rheumatoid arthritis or lupus MEDICATIONS Suppress the immune system SKIN FRAGILITY Psoriasis and eczema HOST HOST

10. WEAK IMMUNE SYSTEM diabetes, kidney and liver problems ALCOHOLISM AND IVDU Having a combination of risk factors puts you at greater risk than having just one risk factor does HOST

11. PATHOPHYSIOLOGY

12. Experimental models of bacterial arthritis: a microbiologic and histopathologic characterization of the arthritis after the intraarticular injections of Neisseria gonorrhoeae, Staphylococcus aureus, group A streptococci, and Escherichia coli. Goldenberg DL, Chisholm PL, Rice PA J Rheumatol . 1983 Feb; 10(1):5-11.

13. Demonstration of interleukin-1beta and interleukin-6 in cells of synovial fluids by flow cytometry. Koch B, Lemmermeier P, Gause A, v Wilmowsky H, Heisel J, Pfreundschuh M Eur J Med Res. 1996 Feb 22; 1(5):244-8.

14. Ultrastructure of articular cartilage in pyogenic arthritis. Roy S, Bhawan J Arch Pathol . 1975 Jan; 99(1):44-7.

15. CLINICAL FEATURE Acute pain Pseudoparesis Rapid pulse and swinging fever Overlying skin looks red Obvious joint swelling Local warmth and marked tenderness 

16. IN CHILDREN Irritable Warm Tenderness Rapid pulse Refused feeding Loss of spontaneous limb movement

17. DDx 9. Transient synovitis of Hip

18. WHAT NEXT?

19. INVESTIGATIONS

20. Later stage

21. MRI T1 : low signal within subchondral bone T2 :  perisynovial edema and joint effusion

22. SYNOVIAL FLUID ASPIRATION

23. SYNOVIAL FLUID ASPIRATION

24. n

25. Four independent multivariate clinical predictors were identified and proved   excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.

26. C-reactive protein level of >2.0 mg/dL (>20 mg/L) was a strong independent risk factor and a valuable tool for assessing and diagnosing children suspected of having septic arthritis of the hip.

27. Weight-bearing status and CRP > 20 mg/l were independent in differentiating septic arthritis from transient synovitis Those with both had a 74% probability of septic arthritis

28. TREATMENT

29. Cho et al

30. Remove infective material and debris from the joint Any of the 3 drainage procedures may be used: closed needle aspiration, arthroscopic drainage, or arthrotomy

31. Arthroscopic Debridement

32. Arthrotomy

33. With healing there may be ? 1. Complete resolution 2. Fibrosis of the joint 3. Bony ankylosis 4. Deformity of the joint 5. Secondary osteoarthritis 6. Growth disturbance 7. Presenting as either localized deformity or shortening of the bone

34. In Hip

35. Hunka’s Classification

36. Choi's classification

37. Harmon reconstruction

38. Trochanteric osteotomy A. Gant opening wedge osteotomy fixed by blade plate. B. Whitman closing wedge osteotomy. C. Brackett ball-and socket osteotomy fixed by Blount blade plate

39. GIRDLESTONE ARTHROPLASTY “removal of diseased and devitalized tissues, flattening down of dead spaces, and leaving drainage so complete and lasting as will allow the wound to heal from the bottom” In 1928, described a radical excision for draining tuberculous hips in 1942, proposed a related and perhaps even more radical operation for pyogenic infections

40. Marchetti et al Patients with a resection arthroplasty will be left with a significant leg length discrepancy due to abductor strength weakness and piston effect. Salvage procedure only in the elderly patient with poor bone stock after a failed total hip arthroplasty

41. -Two-stage total hip arthroplasties (THA) performed after primary septic arthritis of hip were studied of which 79% had excellent outcome

42. TOM SMITH ARTHRITIS Septic arthritis of the hip. Seen in infants. Head of femur is completely destroyed by the pyogenic process.

43. Transphyseal vessels are present in early infancy before the formation of the growth plate This may account for the frequency of septic arthritis of the hip in the neonate C/F: telescopy + ve X-ray- complete absence of the head and neck of femur Treatment: Acute surgical emergency - Open drainage

44. KNEE

45. TRANSVERSE SUPRACONDYLAR OSTEOTOMY OF THE FEMUR Supracondylar osteotomy for ankylosis of knee in flexion.

46. Thompson telescoping-V osteotomy Ankylosis of the knee in flexion may be corrected by the V-osteotomy described by Thompson.

47. CUNIEFORM OSTEOTOMY Cuneiform osteotomy based anteriorly. Section of bone removed is indicated by blue area

48. supracondylar controlled rotation osteotomy of femur. A. Blue area illustrates section of bone to be removed. B. After osteotomy, corrected position is maintained by blade plate

49. Recommends 2-stage implantation in case of evolutive septic arthritis and a 1-stage procedure in case of quiescent septic arthritis achieved very good functional results

50. Advocated this technique only in patients with a current septic knee with already disabling arthritis.

51. 1 st Stage TKA

52. TKA in ankylosed knee is technically demanding and has considerable rate of complication. But reasonable restoration of function can be obtained by meticulous surgical technique and aggressive rehabilitation

53. SHOULDER Septic arthritis of the glenohumeral joint is rare M/C route is hematogenous Acute - Arthroscopic lavage and debridement with appropriate antibiotic therapy Bony and/or cartilage destruction - joint preservation not possible Resection arthroplasty or arthrodesis recommended. Arthroplasty??

54. Thank you

55. EXTRA

56. Periprosthetic Joint Infection New diagnostic criteria in 2018 With sensitivity of 97.7% Cause of 23-25 % of revision arthroplasty Risk factors – multiple Role of Biofilm Early (developing in the first 3 months after surgery), Delayed (occurring 3–24 months after surgery) Late (greater than 24 months).

57. Cho et al