Nhiễm trùng liên quan đến chỉnh hình từ khoa học cơ bản đến quản lý lâm sàng

POST-TRAUMATIC SEPTIC ARTHRITIS
TS BS Vũ Xuân Thành

GV BM CTCH- PHCN ĐHYD TP. HCM

CME liên chuyên ngành Bộ Môn CTCH-PHCN
“NHIỄM TRÙNG LIÊN QUAN ĐẾN CHỈNH HÌNH :
TỪ KHOA HỌC CƠ BẢN ĐẾN QUẢN LÝ LÂM SÀNG”

TP. HCM 16/9/2023


DEFINITION

What is septic arthritis?
▪ Septic arthritis is an imflammation of synovial membrane with purulent
effusion into the joint capsule due to infection
▪ Also referred as infectious arthritis
▪ Septic arthritis is akey consideration in adults presenting with acute monoarticular
arthritis


DEFINITION

What is septic arthritis?
▪ Considered as medical emergency
▪ Failure to initiate appropriate antibiotic therapy within the first 24 to 48 hours of
onset can cause subchondral bone loss and permanemt joint dysfunction
▪ It can cause septic shock, which can be fatal

ANATOMY

SYNOVIAL JOINT
Prevents grinding of the bone
and allow for smooth articulation

Protection of joint cavity

Lines joint & cavity and secretes
synovial fluid for lubrication
Synovial membrane

Articular cartilage
Fibrous joint capsule
Joint cavity filled with
synovial fluid
Ligaments


ANATOMY

Colour code

Ball and socket
Hinge
Pivot
Gliding
Condyloid
Saddle

EPIDEMIOLOGY
The prevalence of bacterial arthritis as the diagnosis among adults presenting with
one or more acutely painful joints has been estimated to range from 8% - 27%
All age groups, infants and older adults are most likely to
develop septic arthritis
50% < age 3
M=F

Infant

Hip

Children

Knee

Adults

Large Joints

ICDU

Sacroiliac joint

The knee is the most commonly affected but any joint may be involved


CAUSES
The infection can originate anywhere in the body

May also begin as the result of an open wound,
trauma, surgery, or unsterile injection
Septic arthritis occurs when the infective
organism travels through blood stream to the
joints
The infection can be caused by bacteria, virus or fungus


Routes of bacterial
infection (A)
(1) by hematogenous spread
(2) from an adjacent infected tissue
(3) through infected bones
(4) as a consequence of trauma
(5) during diagnostic procedures


Risk factors for
septic arthritis
development (B)
- Such as presence of other

rheumatic or immunosuppressive
diseases
- Prosthetic surgery

- And higher age


Post-traumatic

septic arthritis

Predominantly
in young
healthy males

The knee is the
most commonly
affected but any
joint may be
involved

Four distinct
origins differ in
pathogenesis and
microbiology

- Bites
- Thorn punctures
- And trauma sustained in
terrestrial
- Or aquatic environments




AETIOLOGY
Age

Organisms

1

Neonates

Streptococcus sp
Gram-negative organisms

2

Infants

3

Children

Staphylococcus aureus
Haemophilis influenza
Staphylococcus aureus
Salmonella

4

Adolescent

Staphylococcus aureus
Neisseria gonorrhea

5

Adults

Staphylococcus aureus
Streptococcus
Gram-negative organisms

6

IV Drug Abusers

Suspect Pseudomonas and atypical organisms


AETIOLOGY
1. AGE
Age > 80 years old
2. EXISTING JOINT PROBLEMS
Chronic diseases and conditions that affect the joints — such as osteoarthritis, gout, rheumatoid arthritis or
lupus — can increase the risk of septic arthritis, as can an artificial joint, previous joint surgery and joint injury.
3. MEDICATIONS
Taking medications for rheumatoid arthritis. People with rheumatoid arthritis have a further
increase in risk because of medications they take that can suppress the immune system, making
infections more likely to occur. Diagnosing septic arthritis in people with rheumatoid arthritis is
difficult because many of the signs and symptoms are similar.
4. SKIN FRAGILITY
Skin that breaks easily and heals poorly can give bacteria access to your body. Skin conditions such
as psoriasis and eczema increase your risk of septic arthritis, as do infected skin wounds. People
who regularly inject drugs also have a higher risk of infection at the site of injection.

AETIOLOGY
5. WEAK IMMUNE SYSTEM
People with a weak immune system are at greater risk of septic arthritis. This includes people with
diabetes, kidney and liver problems, and those taking drugs that suppress their immune systems.

6. ALCOLOISM AND IVDU

Having a combination of risk factors puts you at greater risk
than having just one risk factor does


AETIOLOGY
Table 1. Risk Factors for Septic Arthritis
Contiguous spread

Hematogenous spread (continued)

Skin infection, cutaneous ulcers8,9

Immunosuppressive medication9,11 Intravenous drug

Direct inoculation

abuse"

Previous intraarticular injection8.10 Prosthetic joint:

Osteoarthritis9

early and delayed8 (Table 6)

Other cause of sepsis9

Recent joint surgery8,10

Prosthetic joint: late8 (Table 6) Rheumatoid arthritis8,9

Hematogenous spread

Sexual activity (specifically for gonococcal arthritis)12

Diabetes mellitus8,10

Other factors

Human immunodeficiency virus infection11

Age older than 80 years8


PATHOPHYSIOLOGY


PATHOPHYSIOLOGY
HEMATOGENOUS SPREAD
Most common form of spread, usually
affects people with underlying medical problems
DIRECT INNOCULATION
May result from penetrating trauma,
introduction of organisms during

diagnostic and surgical procedures.
E.g. intra-articular injection
DIRECT SPREAD FROM ADJACENT BONE
More common in children. Osteomyelitis usually begins in the metaphyseal region, from which it breaks through
the periosteum into the joint


PATHOPHYSIOLOGY


PATHOPHYSIOLOGY


CLINICAL FEATURES


DIFFERENTIAL
DIAGNOSIS
Acute osteomyelitis

Rheumatic fever

Trauma

Juvennile
rheumatoid arthritis

Gaucher’s disease

Hemophilic bleed

Sickle-cell disease

Gout and pseudogout


SEPTIC ARTHRITIS SUSPECTED

BLOOD AND SYNOVIAL FLUID SAMPLE
EMPIRIC PARENTERAL ANTIBIOTICS BASED ON GRAM STAIN
JOINT DRAINAGE

ADJUST ANTIBIOTICS BASED ON CULTURE AND SENSITIVITY RESULT


INVESTIGATION

2. IMAGING

1. BLOOD INVESTIGATIONS
• Raised WCC
• Raised ESR and CRP
• Blood culture (positive)

• X-ray
• Early stage: May look normal except
widening of joint space, ultrasound helpful

3. SYNOVIAL
FLUID

ANALYSIS

• Late stage: Narrowing and irregularity of
joint space; may have OM changes of
adjacent bones
• MRI and radionuclide imaging are helpful in
diagnosing arthritis in obscure sites such as
the sacroiliac and steno-clavicular joint