Septic Arthritis

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- See: orthopaedic infection menu

- Discussion:

- General Orders and Treatment
    - synovial fluid exam;
    - gram stain:
            - gram negative bacilli:
            - gram negative cocci: (NG)
            - gram positive bacilli:
            - gram positive bacilli 
            - ref: Gram staining in the diagnosis of acute septic arthritis.
    - differential diagnosis
            - lyme disease
            - osteomyelitis
    - radioisotope scanning
            - Gallium scintigraphy for diagnosis of septic arthritis and osteomyelitis in children.

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- Treatment Based on Age:
    - less than 3 months
            - upto 60-100% of neonates w/ septic arthritis have adjacent osteomyelitis.
            - septic arthritis is both more common and more often associated w/ metaphyseal osteomyelitis in neonates than in older children;
            - may occurs from transphyseal blood vessels (see epiphyseal vessels), which disappear by age
                   six months, and from synovial reflections over metaphyseal bone, which decrease with age;
                   - in the older children, only the metaphysis of the shoulder, hip, radial head and ankle remains intracapsular;
    - from 6 mo to 2 yrs
            - there should first be a search for evidence of other infections because a large percentage (50%) of children w/ hematogenous osteomyelitis and septic
                   arthritis have evidence of an associated infection;
            - concomitant meningitis may occur in upto 20% of patients w/ septic arthritis due to H. influenzae;
                   - cerebrospinal examination should be considered and antibiotics that can cross the blood-brain barrier should be chosen;
     - greater than 2 yrs
          - references:
                - Acute septic arthritis in infancy and childhood. 10 years' experience.
                - Management of septic arthritis in children.
                - Septic arthritis in children. Morrey BF, Bianco AJ, Rhodes KH: Orthop Clin North Am 1975;6:923.
                - Septic arthritis in infants and children: A review of 117 cases. Pediatrics 1978; 92: 131. Nelson JD, Koontz WC:
    - adults:
          - staph aereus
          - streptococcus
                - adults with septic arthritis due to streptococcus should be worked up for multiple myeloma;
          - neiseria gonococcus
                - most common organism causing septic arthritis in young adults;
                - look for skin lesions;
                - unlike most forms of septic arthritis, GC does not necessarily require surgical washout, and
                       and usually responds to IV antibiotics alone.
          references:
                - Septic arthritis in the elderly.

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- Treatment Based on Location: (see open joint injuries)
    - septic knee:
    - septic hip:
          - pediatric septic hip:
          - adult hip:
              - references:
                    - Sepsis of the hip in paraplegic patients.
                    - Hematogenous septic arthritis of the adult hip.
    - SI Joint:
              - references:
                    - Pyogenic arthritis of the sacro-iliac joint. Long-term follow-up.
                    - Disorders of the sacro-iliac joint in children.
                    - Pyogenic sacroiliitis in children.
                    - Aspiration of infected sarco-iliac joints.
                    - Pyogenic sacroiliac joint infection.
                    - Pyogenic arthritis of the SI joint in pediatric patients.  UB Schaad et al.  Pediatrics. Vol 66. 1980. p 375-379.
                    - The Early Diagnosis of Sacroiliac Joint Infections in Children. 
                    - Septic Sacroiliitis in Children.

    - septic shoulder:
              - in the study by CFA Bos et al 1999, 8 children (10 shoulders) were followed after shoulder sepsis;
                    - shoulders were treated with IV Atb, aspiration, and in two cases by arthrotomy;
                    - at follow up, 5 out of 10 shoulders had a full range of motion;
                    - one patient had shortening of 10 cm;
                    - functional loss was minimal in this series of patients;
              - references:
                    - Percutaneous catheter drainage of septic shoulder joint.
                    - Pyogenic arthritis of the shoulder in adults.
                    - Septic arthritis of the shoulder in adults.
                    - Late sequelae of neonatal septic arthritis of the shoulder. CFA Bos et al.  JBJS Vol 80-B. No 4. July 1998. p 645.
                    - Septic arthritis of the shoulder in children in Malawi. A randomised, prospective study of aspiration versus arthrotomy and washout. 
                    - Septic arthritis of the glenohumeral joint. A report of 11 cases and review of the literature.
    - septic wrist:
              - references:
                    - Septic arthritis of the wrist. 
    - septic SC joint:
              - Sternoclavicular joint infection in hemodialysis patients. Nephron 1990;56:212-213. 
              - Sternoclavicular osteomyelitis and pyoarthrosis as a complication of subclavian vein catheterization: Orthopedics 1984;7:1017-1021.

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- Antibiotic Treatment Based on Organism:
    - IV antibiotic menu
    - Criteria for PO ATB's:
    - references:
          - Antibiotic concentrations in septic joint effusions. Nelson JD: N Engl J Med 1971;284:349.
          - Etiology and medical management of acute suppurative bone and joint infections in pediatric patients. J Pediatr Orthop 1982; 2:313. Jackson MA, Nelson JD:
          - Benefits and risks of sequential parenteral--oral cephalosporin therapy for suppurative bone and joint infections.
          - The effect of antibiotics on the destruction of cartilage in experimental infectious arthritis.

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- Surgical Drainage and Lavage:
    - references:
            - Lavage of septic joints in rabbits: effects of chondrolysis.
            - Pyogenic arthritis: emphasis on the need for surgical drainage of the infected joint.
            - Results of treatment of septic knee arthritis: a retrospective series of 40 cases.

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