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Septic Arthritis

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Emma Reilly

on 28 March 2014

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Transcript of Septic Arthritis

Septic Arthritis:
How do people get it?
What is it?
A rapidly destructive joint infection caused by the introduction of a pathogen (almost always bacterial) into the joint either directly or by haematogenous spread.
Informing Physiotherapy Management
(Matthews & Coakley 2008)
Hematogenous
dissemination
54%
Joint
surgery
28%
INDIRECT
DIRECT
Corticosteroid
Injection
3%
3%
Diagnostic
Punctures
Open
trauma
(Shirtliff & Mader 2002)
Pathology
Bacteria in bloodstream diffuse into and deposit on synovial membrane.
ACUTE INFLAMMATORY RESPONSE
No basement membrane --> bacteria diffuse directly into joint capsule - enter synovial fluid.
10%
2%
Local
infection
outside joint
PREVALENCE
8-27 % of patients with an acutely painful, swollen joint have septic arthritis.
Margaretten et al 2007
78%
Monoarticular
22%
Polyarticular
Knee - 67%
WHICH JOINTS ARE AFFECTED?
Hip
5%
Shoulder
11%
Ankle
(Matthews & Coakley 2008)
1%
SC Joint
Elbow
(Khan,2012)
17% in IV drug users
RISK FACTORS
- Age > 80 years (LR - 3.5)
- Diabetes (LR - 2.7)
- Rheumatoid Arthritis (LR 2.5)
- Recent joint surgery (LR 6.9)
- Hip or knee prosthesis (LR 3.1)
- Skin infection, cutaneous ulcers (LR 2.8)
- IV drug use, alcoholism (LR 1.8)
- HIV (LR 1.7)

(Margaretten et al 2007)
CLINICAL SYMPTOMS
Short, < 2 week history of the following:

Pain in affected joint (85% sensitivity)
Hx of local joint swelling (78% sensitivity)
Fever (57% sensitivity)
Sweats (27% sensitivity)

Other clinical symptoms include heat, redness and loss of joint ROM.


(Margaretten et al, 2007)
WHY DO WE NEED TO KNOW ABOUT IT?
Most rapidly destructive joint disease --> early diagnosis and management is essential and directly related to joint outcomes.
Poor prognosis - 25-50% of patients will have irreversible loss of function.
Mortality rates for in-hospital septic arthritis around 11%
Early physiotherapy is important to preserve joint function.
(Weston & Coakley 2006, Margaretten et al 2007)
DIAGNOSIS
Diagnosis is based on a combination of clinical symptoms, analysis of synovial fluid culture and other lab investigtions.

1. CLINICAL SYMPTOMS
2. SYNOVIAL FLUID TESTING
Synovial WBC count - norm <25,000/microL (Likelihood of infection increases as WBC count increases.)
Gram stain and culture
Glucose level <40ml/d or < half serum count.
3. OTHER INVESTIGATIONS
Elevated ertrocyte sedimentation rate, C-reactive protein or peripheral leukocyte levels.

Sensitivity of diagnosic tests is low - Synovial fluid gram stain & culture gives a positive result in only 50% of cases.
TREATMENT - MEDICAL
1. Antibotic therapy
No clinical advantage shown for choice of antibiotic or route of administration.

2. Joint drainage and removal of purulent material.
Needle aspiration
Arthroscopic drainage
Open drainage (difficult and deep joints.
(Shirtliff & Mader, 2002)
MANAGEMENT - PHYSIOTHERAPY
Recommendations for physiotherapy:

Acute phase:
Rest & maintain optimal joint position

Immobilisation of joint not required, WB should be avoided until signs of inflammation have disappeared.
Maintain joint in functional position (high contracture risk)
Hip: neutral IR/ER, slight abduction
Knee: full extension
Elbow: Flexion 90 deg
+/- splinting if necessary to maintain position.
Isometric exercises to help prevent muscle atrophy.
PROM exercises as tolerated to maintain joint ROM.
(Smith et al 2006, Shirtliff & Mader, 2002 & Darton & Townsend, 2010.)
MANAGEMENT - PHYSIOTHERAPY
Post-Acute Phase:
Regain function and improve muscle strength.

Begin AROM exercises as inflammation diminishes - work within tolerable limits of pain.
Weight bearing is permitted once all signs of inflammation have disappeared.
(Smith et al 2006, Shirtliff & Mader, 2002 & Darton & Townsend, 2010.)
Early and aggressive physiotherapy is important for optimal functional recovery.
QUESTIONS?
Coakley, G, Mathews, C, Field, M, Jones, A, Kingsley, G, Walker, D, Phillips, M, Bradish, C, McLachlan, A, Mohammed, R & Weston, V 2006, ‘BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults,’ Rheumatology, vol. 45, pp. 1039-1041.

Darton, T & Townsend, R 2010 'Bone ad joint infections,' Surgery, vol. 28, no. 2, pp. 95-100.

Jeon, B, Choi, C, Seo, J, Seo, K, Seo, Ko, S & Park, J 2006 ‘Arthroscopic management of septic arthritis of the shoulder joint,’ The Journal of Bone and Joint Surgery, vol. 88, no. 8, pp. 1082-1086.

Kahn, F, Abu-Khattab, M, Baagar, K, Mohamed, S, Elgendy, I, Anand, D, Malallah, H & Sanjay, D 2013 'Characteristics of patients with definite septic arthritis ad Hamad General Hospital, Qatar: A hospital based study from 2006 to 2011,' Clinical Rheumotology, vol 32. pp 69-973.

Margaretten, M, Kohlwes, J, Moore, D & Bent, S 2007, ‘Does this adult patient have septic arthritis?’ JAMA, vol. 297, no. 13, pp. 1478-88.

Mathews, C & Coakley, G 2008, ‘Septic arthritis: current diagnostic and therapeutic algorithm,’ Current Opinion in Rheumatology, vol. 20, pp. 457-462.

Ross, J & Shamsuddin, H 2004, ‘Sternoclavicular Septic Arthritis: review of 180 cases,’ Medicine, vol. 83, no. 3, pp. 139-148.

Ross J & Hu, L 2003, ‘Septic Arthritis of the Pubic Symphysis: Review of 100 Cases,’ Medicine, vol. 82, no. 5, pp. 340-345.

REFERENCES
Schulz, A, Götze, S, Schmidt, H, Jürgens, C & Faschingbauer, M 2007, ‘Septic arthritis of the knee after anterior cruciate ligament surgery: A stage-adapted treatment regimen,’ The American Journal of Sports Medicine, vol. 35, no. 7, pp 1064-1069.

Smith, J Chalupa, P & Shabaz Hasan, M 2006, ‘Infectious arthritis: clinical features, laboratory findings and treatment,’ Clin Microbiol Infect, vol. 12, no. 4, pp 309-14.

Stutz, G, Kuster, M, Kleinstück, F & Gätcher, A 2000, ‘Arthroscopic management of septic arthritis: stages of infection and results,’ Knee Surgery, Sports Traumatology, Arthroscopy, vol. 8, pp. 270-274.

Weston, V & Coakley, G 2006 'Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis,' Journa of antimicrobial chemotherapy, vol. 58, pp. 492-493.

Williams, R, Laurencin, C, Warren, R, Speciale, A, Brause, B, O’Brien, S 1997, ‘Aeptic arthritis after arthroscopic anterior cruciate ligament reconstruction: diagnosis and management,’ The American Journal of Sports Medicine, vol. 25, no. 2, pp. 261-267.

REFERENCES
COMBINED risk factors substantially increase risk -
Skin infection + joint prosthesis risk 15 fold.
- IV drug use
- Indwelling catheters
- Animal bites
- Cuts and wounds
For example:
Proliferation of lining cells in synovial membrane.
Cytokines and proteases released by inflammatory cells
CARTILAGE BREAKDOWN
Synovial effusions cause necrosis and can lead to further cartilage degradation and bone loss.
(Matthews & Coakley 2008)
(Ross & Shamsuddin, 2004)
RED FLAGS
- Research shows generally poor accuracy of documentation of red flags by health professionals.

DISCUSS IN RELEVANCE TO SEPTIC ARTHRITIS
Leerar et al, 2007
7%
7%
Other - 2%
Full transcript