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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

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JOINT INFECTIONS

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  1. JOINT INFECTIONS K. Bougoulias

  2. Septic arthritis • Haematogenous spread to synovium • Extension of osteomyelitis involving epiphysis or intracapsular metaphysis • Direct contamination following diagnostic/ therapeutic procedures Saunders 1981

  3. Clinical features • Fever • Swelling/ synovial effusion • Limitation of joint movements • Usually monoarticular involvement (knee most common)

  4. Clinical features • 50% have history of preexisting arthritis- 30% 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)

  5. <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 Bacterial etiology

  6. Risk factors associated with pathogens

  7. 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

  8. 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

  9. 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

  10. 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

  11. Aspiration • Protein may be up to 6 or 8 g/Dl-electrophoretic pattern resembling of plasma • Urate or calcium pyrophosphate crystals are important in differencial diagnosis Nade S, JBJS 1983 Ward et al, Arthritis Rheum 1960

  12. Differencial Diagnosis • Bursitis • Cellulitis • Transient synovitis • Aseptic inflammation • Acute osteomyelitis • Crystal deposition disease • Acute rheumatoid arthritis

  13. Differential diagnosis • Chronic arthritis • Acute rheumatic fever • Hemophilia

  14. 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, Streptococci- Cefotaxime, ceftizoxime

  15. 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

  16. 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

  17. 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

  18. Thank you

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