Septic arthritis

Septic arthritis is a destructive arthropathy caused by an intra-articular infection that usually is related to severe symptoms such as pain and decreased range of motion. This condition requires prompt treatment aiming to avoid permanent damage to joint, which may result in chronic deformity or mechanical arthritis.

The diagnosis of joint sepsis is often considered straightforward. Patients often present with a painful joint, fever, and purulent synovial fluid.

Risk factors for septic arthritis include bacteremia, advanced age, an immunocompromised state, rheumatoid arthritis, intra-articular injections, and prosthetic joints.

In the absence of trauma or recent instrumentation of the joint, septic arthritis is usually secondary to haematogenous seeding. S aureus is the most commonly isolated agent (31.3% of casesref).

Large joints with abundant blood supply to the metaphyses are most prone to bacterial infection, with the most commonly affected joints theoretically being the shoulder, hip, and knee.

In intravenous drug abusers, the sternoclavicular and sacroiliac joints are more frequently affected.

Imaging generally plays an adjunct role to arthrocentesis in the diagnosis of joint sepsis. If synovial fluid cannot be retrieved, however, radiologic studies become of the utmost importance.

  • x-rays may be normal in the very early stage of the disease
  • joint effusion may be seen
  • juxta-articular osteoporosis due to hyperemia 
  • narrowing of the joint space due cartilage destruction in the acute phase
  • destruction of the subchondral bone on both sides of a joint
  • if left untreated, reactive juxta-articular sclerosis and, in severe cases, ankylosis will develop 
  • useful in superficial joints and in children
  • shows joint effusion
    • echogenic debris may be present
  • color Doppler may show increased peri-synovial vascularity 
  • can be used to guide the joint aspiration
  • CT features of septic arthritis are similar to those spotted on radiographs 
  • a fat-fluid level can be a specific sign in the absence of trauma

The treatment principals for septic arthritis is drainage and appropriate antibiotics.

If the patient is heamodynamically stable then attempts should be made to obtain a sample of joint fluid for microscopy and culture prior to starting treatment with antibiotics. This will allow focused treatment of the infection4.

With smaller joints needle drainage or aspiration to decompress the joint followed by antibiotics may be adequate. For larger joints or persistent infection surgical debridement and washout will be required4.   

If unrecognised and left untreated, septic arthritis can result in irreversible joint damage within 48 hours of the onset of infection due to the proteolytic enzymes of the white blood cells that flood the infected synovial space. Osteonecrosis is also an important sequela of septic arthritis due to effusion and increase in intra-articular pressure compromises blood circulation. 

Conversely, approximately 90% of patients with septic arthritis will recover with appropriate antibiotic treatment. Therefore, timely diagnosis and treatment are critical.

Arthritides
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Article information

rID: 12846
Synonyms or Alternate Spellings:
  • Infectious arthritis

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Cases and figures

  • Case 1: involving neonatal knee
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  • Case 2: involving the hip
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  • Case 3: involving sacroiliac joint with psoas abscess
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  • Skull base osteom...
    Case 4: involving TMJ with skull base osteomyelitis
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  • Case 5: involving right hip
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  • Case 6: involving symphysis pubis
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  • Case 7
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  • Case 8: septic arthritis of the right hip joint
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  • Case 9: shoulder
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  • Case 10
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  • Case 11: sternoclavicular joint septic arthritis
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