Medical Versus Surgical Approach to Initial Treatment in Septic Arthritis: A Single Spanish Center's 8-Year Experience

Native Joint Septic Arthritis

Native joint septic arthritis (NJSA) is a severe and rapidly progressing joint infection, predominantly bacterial but also potentially fungal or viral, characterized by synovial membrane inflammation and joint damage, necessitating urgent and multidisciplinary management to prevent permanent joint damage and systemic sepsis. Common in large joints like knees, hips, shoulders, and elbows, NJSA's incidence is elevated in individuals with conditions like rheumatoid arthritis, diabetes, immunosuppression, joint replacement history, or intravenous drug use. This review provides a comprehensive overview of NJSA, encompassing its diagnosis, treatment, antibiotic therapy duration, and surgical interventions, as well as the comparison between arthroscopic and open debridement approaches. Additionally, it explores the unique challenges of managing NJSA in patients who have undergone graft anterior cruciate ligament (ACL) reconstruction. The epidemiology, risk factors, pathogenesis, microbiology, clinical manifestations, diagnosis, differential diagnosis, antibiotic treatment, surgical intervention, prevention, and prophylaxis of NJSA are discussed, highlighting the need for prompt diagnosis, aggressive treatment, and ongoing research to enhance patient outcomes.

Management of the Septic Wrist: A Systematic Review of Etiology and Therapeutic Strategies

Septic arthritis of the wrist can have severe deleterious effects on cartilage and bone if not promptly addressed. Expedient diagnosis and early medical intervention are important. The most effective strategy involves immediate arthrocentesis of the infected joint, enabling precise antibiotic selection based on joint fluid analysis. Diagnostic imaging is important in excluding fractures and identifying abscesses. This review explores the etiologic factors underlying septic wrist joint, identifying risk factors, and delineating optimal diagnosis and treatment approaches. The overarching goal is to impart valuable insights and guidance in the management of septic wrist joint, ensuring the highest quality patient care and optimal clinical outcomes.

Arthroscopic Treatment Is a Safe and Effective Alternative to Open Treatment for Acute Septic Arthritis of the Native Knee: A Systematic Review

PURPOSE

To compare complication rates, reoperation rates, and subjective outcomes after arthroscopic and open irrigation and debridement for treatment of native knee septic arthritis.

METHODS

Following The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the Embase, Cochrane, and PubMed databases was performed. Comparative studies reporting clinical outcomes after arthroscopic versus open treatment for septic arthritis of the native knee in human adults were included. Excluded were case series with <10 patients, inclusion of patients <18 years old, studies on non-native joints, abstract-only publications, and studies without stratification of the involved joint. Two reviewers in duplicate independently performed search and data extraction. The quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies instrument. The mean score among the included studies was 18.2 (range 16-23).

RESULTS

Eleven studies were included, comprising 2,343 knees treated arthroscopically, and 1,595 treated with arthrotomy. Studies reported no differences in erythrocyte sedimentation rate, C-reactive protein, peripheral white blood cells, or symptom chronicity between groups. Nine studies (81.8%) attempted to control for potentially confounding variables in their analyses, and 4 studies (36.4%) reported significant differences in patient characteristics. Reoperation rates ranged from 0% to 50% for arthroscopy and 6% to 71% for arthrotomy. Complication rates ranged from 0% to 39.4% arthroscopically and 0% to 49% for arthrotomy. Superior patient-reported outcomes were achieved after arthroscopy in 2 studies that analyzed subjective outcomes.

CONCLUSIONS

Arthroscopic management of native knee septic arthritis is a safe and effective alternative to open treatment and is associated with comparable complication rates, reoperation rates, hospitalization lengths, readmission rates, and superior patient-reported outcomes compared with open irrigation and debridement.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, III, and IV studies.

Bilateral Knee Lyme Arthritis in Children: A Report of 3 Cases

CASES

Three patients presented with bilateral knee pain, effusion, decreased range of motion, and difficulty ambulating. Synovial analysis demonstrated leukocytosis in bilateral knees with positive serum enzyme-linked immunosorbent assay. All cases were managed with antibiotics and anti-inflammatories. One patient developed chronic Lyme arthritis and underwent arthroscopic synovectomy.

CONCLUSION

Bilateral knee arthritis is a possible presentation of Lyme disease in children. Accurate diagnosis and treatment with antibiotics and anti-inflammatories can lead to satisfactory outcomes. Arthroscopic synovectomy may be indicated if conservative treatment fails.

A case of septic arthritis of the hip in Central Plains, China, during the Western Han Dynasty (3rd century BCE-1st century CE)

OBJECTIVE

Septic arthritis is not commonly reported in paleopathology. This study aims to provide a differential diagnosis of septic arthritis by looking at a case from ancient China. We also aim to add to the current literature on septic arthritis in paleopathology.

MATERIALS

One adult male skeleton recovered from the Dapuzi Cemetery, Shaanxi, dating to the Western Han Dynasty (3rd century BCE-1st century CE).

METHODS

Macroscopic observations were conducted.

RESULTS

The lytic appearance and massive new bone formation on the left acetabulum of M142 are compatible with septic arthritis. The hip pathology greatly influenced his stature. The two femur shafts present different degrees of robusticity. He also showed severe osteoarthritis.

CONCLUSIONS

The individual suffered from septic arthritis of the hip, of unknown cause, for a long period, which greatly influenced his daily life. Complications included osteoarthritis, shortened stature, and difficulties in walking.

SIGNIFICANCE

This study offers a new case of septic arthritis and provides insight into the people who guarded the royal tombs in the West Han Dynasty.

LIMITATIONS

The skeleton is not well-preserved, limiting observations of bony changes to other areas of the body.

Efficacy of Lavage by Tube under Local Anesthesia versus Arthroscopic Treatment of Acute Septic Arthritis of Native Knee

Although arthroscopic treatment is a minimally invasive surgery that effectively treats septic arthritis of the knee joint, it requires general or regional anesthesia. This study aimed to compare the clinical results of lavage after tube insertion versus arthroscopic treatment. Patients treated with arthroscopic treatment were included in group I (n = 76), while those treated with lavage by tube were included in group II (n = 34). We investigated the following in all patients: demographics, underlying disorders, initial serum white blood cell (WBC) count, C-reactive protein (CRP) level, synovial fluid WBC and polymorphonuclear cell counts, causative organism, initial Kellgren-Lawrence grade, lavage number, interventional delay, hospitalization days, CRP normalization time, and Western Ontario McMaster Universities Osteoarthritis index scores for clinical outcomes at 3 months postoperative. The mean interventional delay was significantly greater in group I (23.6 ± 15.6 h vs. 8.7 ± 9.3 h, p < 0.001). The lavage by tube featured a significantly shorter interventional delay time than arthroscopy, while the CRP decrease rate did not differ between groups. Moreover, lavage by tube showed no significant differences in outcomes, including laboratory results and functional outcomes at 3 months postoperative.

Management and outcome of native joint septic arthritis: a nationwide survey in French rheumatology departments, 2016-2017

OBJECTIVES

To describe current management and outcome of native joint septic arthritis (NJSA) in French rheumatology departments.

METHODS

For this retrospective, nationwide multicentric study, 127 French rheumatology departments were contacted to report up to 12 cases of NJSA that occurred between 1 January 2016 and 31 December 2017. Characteristics, diagnosis procedures, therapeutic management and outcome were recorded.

RESULTS

Overall, 362 patients were included (mean age 64.0±18.6 years, median Charlson comorbidity index 3.5 (0-14)). Knee was the most frequent site (n=160 (38.9%)), and Staphylococcus sp (n=185 (51.4%)), the most frequent pathogen. All patients received antibiotics for a mean duration of 46.8 (±22.0) days, including intravenous route for a mean of 17.2 (±15.4) days. Management was heterogeneous. Surgical procedure was performed in 171 (48.3%), joint immobilisation in 128 (43.8%). During follow-up, 91 (28.3%) patients have had serious complications and 28 (9.2%) of them died. Factors associated with 1-year mortality were age (OR 1.08, 95% CI 1.04 to 1.13; p<0.001), Charlson's index (OR 1.30, 95% CI 1.06 to 1.58; p=0.012), presence of bacteraemia (OR 4.02, 95% CI 1.35 to 11.99; p=0.008), antibiotic use in the previous 3 months (OR 3.32, 95% CI 1.11 to 9.87; p=0.029) and Staphylococcus aureus NJSA compared with Streptococcus sp. NJSA (OR 7.24, 95% CI 1.26 to 41.68, p=0.027). The complete recovery with no adverse joint outcome at 1 year was observed in n=125/278 patients (55.0%).

CONCLUSION

Prognosis of NJSA remained severe with a high rate of morbimortality. Its management was very heterogeneous. This study highlights the importance of the new French recommendations, published after the completion of the study, in order to facilitate NJSA management.

Management of septic arthritis of the hip joint in adults. A systematic review of the literature

BACKGROUND

The septic arthritis of the hip is a complex condition characterized by a variety of clinical presentations, a challenging diagnosis and different surgical treatment options, including arthroscopy, resection arthroplasty and one and two-stage total hip replacement. Each technique reports variable results in terms of infection eradication rate. The aim of this systematic review is to compare the most relevant studies available in current literature and to assess if a better treatment outcome can be predicted based on the microbiology, history, and type of infection (active vs quiescent) of each case.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA guidelines, including the studies dealing with the treatment of hip septic arthritis in adult patients. Electronic databases, namely the MEDLINE, Scopus, and Web of Science, were reviewed using a combination of following keywords "septic arthritis" AND "hip joint" OR "hip" AND "adult".

RESULTS

The total number of patients included in this review was 1236 (45% of which females), for 1238 hips. The most common pathogen isolated was Staphylococcus aureus in its Methicillin-sensitive variant ranging from 2 to 37% of cases. Negative cultures were the second most common finding. It was also differentiated the type of infection of the hip, 809 and 417 patients with active and quiescent hip infection, respectively, were analyzed. Eradication rates for two-stage revision arthroplasty ranged between 85 and 100%, for one-stage approach between 94 and 100%, while for arthroscopic debridement/lavage between 89 and 100%.

CONCLUSION

Staphylococcus aureus is the most common microorganism isolated followed by culture negative infections. Arthroscopic, one and two stage procedures can be effective in the treatment of hip septic arthritis when the indication is consistent with the type of infection retrieved.

LEVEL OF EVIDENCE

IV, therapeutic study.

Management of Native Joint Septic Arthritis, Serial Aspiration vs. Arthroscopic Washout During the COVID-19 Pandemic

Septic arthritis remains an orthopaedic emergency that requires prompt diagnosis and management. During the 2020 COVID-19 pandemic, British Orthopaedic Association (BOAST) guidelines dictated that medical treatment (closed-needle aspiration + antibiotic therapy) should be offered to patients as first-line management, and operative treatment (arthroscopic joint washout +/- synovectomy) be reserved for patients exhibiting signs of sepsis. Literature has previously shown that for native joint septic arthritis, operative treatment is not superior to medical treatment. During the COVID-19 'lock-down' period (March 2020 to June 2020), we prospectively followed the presentation, diagnosis, management and outcome of a total of six patients who presented with confirmed native joint septic arthritis. All six patients underwent initial medical management of their septic arthritis following their diagnostic aspiration, which involved serial closed-needle aspirations and antibiotic therapy as advised by our microbiology team. Four patients went on to have an arthroscopic washout at an average of eight days following admission (mean 2.5), prior to a consultant-led decision to proceed to arthroscopic washout. The decision for operative management was the patient's clinical deterioration based on physiological (fever, tachycardia) and biochemical (C-reactive protein (CRP), white blood cell (WBC)) parameters. All of the four patients that proceeded to operative treatment failed to provide culture yield at the time of arthroscopic washout. The mean time to discharge was 15.6 days, whilst the mean time to discharge following operative intervention was 12 days. One patient passed away during admission and one patient required a second arthroscopic washout. Medical management of septic arthritis may play a role in symptom control in the palliative setting or in patients where a general anaesthetic is undesirable. We found operative management to be therapeutic clinically, haemodynamically and biochemically as well as facilitative of a faster recovery and shorter inpatient stay.

2020 French recommendations on the management of septic arthritis in an adult native joint

Septic arthritis (SA) in an adult native joint is a rare condition but a diagnostic emergency due to the morbidity and mortality and the functional risk related to structural damage. Current management varies and the recommendations available are dated. The French Rheumatology Society (SFR) Bone and Joint Infection Working Group, together with the French Language Infectious Diseases Society (SPILF) and the French Orthopaedic and Trauma Surgery Society (SOFCOT) have worked according to the HAS methodology to devise clinical practice recommendations to diagnose and treat SA in an adult native joint. One new focus is on the importance of microbiological documentation (blood cultures and joint aspiration) before starting antibiotic treatment, looking for differential diagnoses (microcrystal detection), the relevance of a joint ultrasound to guide aspiration, and the indication to perform a reference X-ray. A cardiac ultrasound is indicated only in cases of SA involving Staphylococcus aureus, oral streptococci, Streptococcus gallolyticus or Enterococcus faecalis, or when infective endocarditis is clinically suspected. Regarding treatment, we stress the importance of medical and surgical collaboration. Antibiotic therapies (drugs and durations) are presented in the form of didactic tables according to the main bacteria in question (staphylococci, streptococci and gram-negative rods). Probabilistic antibiotic therapy should only be used for patients with serious symptoms. Lastly, non-drug treatments such as joint drainage and early physical therapy are the subject of specific recommendations.

Medical versus surgical treatment in native hip and knee septic arthritis

OBJECTIVE

Antibiotic treatment and arthroscopic or open drainage is the gold standard for septic arthritis. Full recovery takes time after surgery and hospital stay is longer than for arthrocentesis at the bedside. We aimed to evaluate the effectiveness of arthrocentesis (medical approach) versus a surgical approach.

METHOD

We retrospectively included 97 cases of native joint arthritis (hip and knee) between 2010 and 2017. The primary outcome was treatment failure of medical and surgical approaches (defined as surgical intervention within 7 days following diagnosis). Risk factors of failure were identified by univariable and multivariable logistic regression.

RESULTS

We included 72 cases of knee arthritis, of which 43 and 29 were treated medically and surgically, respectively; 25 cases of hip arthritis, of which 8 and 17 were treated medically and surgically, respectively. Failure was observed in 39.2% of cases in the medical group and in 30.4% in the surgical group (P=0.2) (37.5% vs. 52.9% and 39.5% vs. 17.2% for hip and knee, respectively). The univariate analysis identified age and male sex as risk factors for failure (P=0.048 and P=0.02, respectively), but only age was independently associated with failure (P=0.04). Hospital length of stay was 12 days shorter in the medical group (21 vs. 33 days, P=0.02), sequelae were less frequent and less important in the medical group (31.7% vs. 60%).

CONCLUSION

The medical treatment seems to be as effective as the surgical treatment for native joint septic arthritis with a shorter hospital stay and better functional outcome. Further prospective studies are warranted.

A Case Report of Pneumococcal Septic Arthritis Following a Respiratory and Gastrointestinal Prodrome with Accompanying Literature Review

We report an uncommon case of septic arthritis of the ankle from a Streptococcus pneumoniae infection and provide an update of the literature reported since 2002. A 58-year-old female presented to the hospital with right ankle pain and an inability to bear weight. She reported a history of productive cough, vomiting, diarrhea, and subjective fevers 4 days earlier. Streptococcus pneumonia was identified in her ankle aspirate, and she was treated urgently with operative incision and debridement, followed by postoperative intravenous antibiotics. At her 7-week follow-up, she demonstrated complete resolution of symptoms and near-complete recovery of range of motion. This case demonstrates the importance of early identification, as the majority of patients recover fully with prompt treatment. The literature review included 44 cases of pneumococcal septic arthritis and found that the knee was the most commonly affected joint, followed by the shoulder and ankle. Blood cultures were positive for S. pneumoniae in 27 of 38 adults (71%) and 4 of 6 children (67%). Comorbid conditions were present in 32 of 38 adults (84%) and 4 of 7 children (57%), the most frequent of which were alcoholism and osteoarthritis in adults and malignancy or immunosuppression in children. Additionally, roughly half of included adults had an extra-articular focus of pneumococcal disease, most frequently pneumonia. Operative treatment was undertaken in 32 of 38 adults (84%) and all 7 children. Of adults with data available, 24 of 33 (73%) recovered with complete joint function, compared with 5 of 7 children (71%).

Septic arthritis due to streptococci and enterococci in native joints: a 13 year retrospective study

OBJECTIVES

Streptococcal species are the second most common cause of native joint septic arthritis (SA). However, there are few systematic data about streptococcal SA.

METHODS

The medical records of adults with SA caused by streptococci, pneumococci, and enterococci at our tertiary care centre between 2003 and 2015 were reviewed.

RESULTS

71 patients (34% female) with 83 affected joints were included. Median age was 62 years. A single joint was involved in 62 patients (87%). One or more comorbidities were present in 58 patients (82%). 16 patients (23%) had a concomitant soft-tissue infection overlying the affected joint. The hematogenous route was the dominating pathogenesis (42/71, 59%). 9 (13%) patients were diagnosed with endocarditis. The knee was the most commonly affected joint (27/83, 33%) followed by shoulder (13/83, 16%). ß-haemolytic streptococci were most commonly identified (37/71, 52%) followed by polymicrobial infections (12/71, 17%). Surgical interventions included arthroscopic irrigation and debridement in 31 (44%), arthrotomy in 23 (32%), and amputation in five patients (7%). Median duration of antimicrobial therapy was 42 days. Antibiotic treatment without any surgical intervention was performed in 5 (7%) patients. Outcome was good in 55 (89%) patients; mortality was 13% with four of nine deaths attributed to joint infection. Age and pathogen group independently predicted poor outcome in recursive partitioning analysis.

CONCLUSIONS

Streptococcal SA was mostly due to ß-haemolytic streptococci in older and polymorbid patients. Old age, anginosus group streptococci, enterococci, and polymicrobial infections predicted poor outcome, while antibiotic treatment duration can likely be shortened.

Neutrophils: Beneficial and Harmful Cells in Septic Arthritis

Septic arthritis is an inflammatory joint disease that is induced by pathogens such as Staphylococcus aureus. Infection of the joint triggers an acute inflammatory response directed by inflammatory mediators including microbial danger signals and cytokines and is accompanied by an influx of leukocytes. The recruitment of these inflammatory cells depends on gradients of chemoattractants including formylated peptides from the infectious agent or dying cells, host-derived leukotrienes, complement proteins and chemokines. Neutrophils are of major importance and play a dual role in the pathogenesis of septic arthritis. On the one hand, these leukocytes are indispensable in the first-line defense to kill invading pathogens in the early stage of disease. However, on the other hand, neutrophils act as mediators of tissue destruction. Since the elimination of inflammatory neutrophils from the site of inflammation is a prerequisite for resolution of the acute inflammatory response, the prolonged stay of these leukocytes at the inflammatory site can lead to irreversible damage to the infected joint, which is known as an important complication in septic arthritis patients. Thus, timely reduction of the recruitment of inflammatory neutrophils to infected joints may be an efficient therapy to reduce tissue damage in septic arthritis.