Bacterial septic arthritis in adults

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis

BACKGROUND

In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches.

METHODS

The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression.

RESULTS

A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling.

DISCUSSION

Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D.

LEVEL OF EVIDENCE

III.

Lower Risk of Revision Surgery After Arthroscopic Versus Open Irrigation and Débridement for Shoulder Septic Arthritis

BACKGROUND

In the treatment of native shoulder septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival (RFS), complications, and resource utilization between these approaches.

METHODS

The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D) were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression.

RESULTS

A total of 4,113 patients with native shoulder septic arthritis undergoing I&D were identified, 2,775 arthroscopic (67.5%) and 1,338 open (32.5%). The median follow-up was 170 days (interquartile range 79 to 265). A total of 341 patients (8.3%) underwent revision I&D at a median of 9 days. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $4,154 ( P < 0.001) and length of stay of 0.78 days ( P = 0.030). Arthroscopic I&D was associated with reduced blood transfusions (odds ratio 0.69, P = 0.001) and wound complications (odds ratio 0.30, P < 0.001). RFS was 96.4%, 94.9%, 93.3%, and 92.6% for arthroscopic I&D and 94.1%, 92.6%, 90.4%, and 89.0% for open I&D at 10, 30, 90 and 180 days, respectively ( P = 0.00043). On multivariate Cox modeling, arthroscopic I&D was associated with improved survival (hazard ratio 0.67, P = 0.00035). On stratified analysis, arthroscopic I&D was associated with improved RFS in patients aged 65 years or older ( P < 0.001), but RFS was similar in those younger than 65 years ( P = 0.17).

CONCLUSION

Risk of revision I&D was markedly lower after arthroscopic I&D compared with open, although the protective benefit was limited to patients aged 65 years or older. Arthroscopy was also associated with decreased costs, length of stay, and complications. Although surgeons must consider specific patient factors, our results suggest that arthroscopic I&D is superior to open I&D.

LEVEL OF EVIDENCE

III.

Less Than 1-Year Quiescent Period After Septic Arthritis of the Hip is Associated With High Risk of Periprosthetic Joint Infection Following Total Hip Arthroplasty

BACKGROUND

Approximately 20,000 patients are diagnosed with septic arthritis annually, with 15% specifically affecting the hip joint. These cases exacerbate arthritic changes, often warranting a total hip arthroplasty (THA). Given their prior history of infection, these patients are predisposed to subsequent periprosthetic joint infections (PJIs). Multiple studies suggest delaying THA after a native septic hip, but no study utilizing a large cohort examined the specific timing to mitigate post-THA PJI risk within a short (<1 year) quiescent period after septic arthritis. We sought to compare patients who were diagnosed with septic hip arthritis at time intervals (0-6, or 6-12 months) prior to an ipsilateral primary THA to a cohort of THA patients who never had a septic hip history. Specifically, we assessed: from 90 days to 2 years (1) revisions due to PJI and (2) associated risk factors for PJI at 2-years.

METHODS

A national, all-payer database was queried to identify all patients who underwent a primary THA between 2010 and 2021 and patients who had prior ipsilateral septic hip arthritis were characterized using International Classification of Disease and Current Practice Terminology codes (n = 1,052). A randomized sample of patients who never had a history of septic arthritis prior to undergoing THA was used as a nonseptic group comparison (n = 5,000). The incidences of PJI at 90 days through two years were then identified and compared using bivariate chi-square analyses. Risk factors for post-THA PJIs were then analyzed using multivariate regression models.

RESULTS

The septic arthritis cohorts were more likely to require revisions due to PJIs, as compared to the non-septic group at 90 days, 1 year, and 2 years (all P < .0001). Patients who were diagnosed with septic arthritis between 0 and 6 months prior to THA were at greater PJI risk at both one-year (odds ratio (OR) of 43.1 versus 29.6, P < .0001) and two years (OR of 38.3 versus 22.1, P < .0001) compared to patients who had diagnoses between 6 and 12 months. Diabetes mellitus, obesity, and tobacco use were associated risk factors for PJIs at 2 years in the septic hip cohort in comparison to the cohort without a septic hip history.

CONCLUSION

Less than a 1-year quiescent period after septic arthritis is associated with a 38 times increased risk and a 22 times risk for post-THA PJI, at 0 and 6 months and 6 and 12 months, respectively. Though patients who undergo THA greater than 6 months after their septic arthritis treatment have a decreased risk compared to those between 0 and 6 months the risks are still high. Orthopaedic surgeons should be aware of the increased risks of PJIs when considering performing a THA in patients with a history of septic arthritis.

ROS-responsive resveratrol-loaded cyclodextrin nanomicelles reduce inflammatory osteolysis

Bone loss in inflammatory disorders such as osteomyelitis, septic arthritis, and periodontitis is caused by excessive osteoclastic activity. Meanwhile, reactive oxygen species (ROS) have been identified as contributors to osteoclast differentiation, and the application of ROS scavengers has emerged as a promising strategy to protect against bone loss. Recently, resveratrol (RSV), a polyphenolic phytoalexin, has been demonstrated to inhibit osteoclastogenesis by scavenging ROS; however, the application of RSV as an antioxidant is limited by its low water solubility, structural instability, and short elimination half-life. In this study, we developed a PEGylated cyclodextrin (CD)-based nanoplatform (PCP) for local delivery of RSV as nanomicelles (RSV-NMs). In addition, polymer functionalization with phenylboronic acid ester in RSV-NMs successfully achieved ROS-responsive release of RSV. The RSV-NMs in a well-dispersed state possessed good biocompatibility as well as improved solubility and stability compared with RSV compound. In vitro, RSV-NMs significantly inhibited the formation of tartrate-resistant acid phosphatase (TRAP)-positive multinuclear cells and suppressed F-actin (filamentous actin) ring formation. Additionally, the mRNA expressions of osteoclastic marker genes, including matrix metalloprotein-9 (MMP-9), nuclear factor of activated T cells 1 (NFATc1), TRAP, and cathepsin K, were consequently downregulated in the presence of RSV-NMs. In vivo, RSV-NMs provided protection against LPS-induced bone destruction, as evidenced by a decreased number of osteoclasts, increased bone density, and reduced area of bone resorption. Taken together, these results indicate that our ROS-responsive RSV-NMs can be employed as a potential therapeutic agent for the treatment of inflammatory osteolysis.

Bibliometric analysis of 100 most influential papers related to septic arthritis of native joints

Aim

Bibliometric studies have gained popularity since they are able to define the characteristics of articles on specific subjects. The aim of this study was to analyze the characteristics of 100 most-cited papers related to septic arthritis of the native joints.

Methods

Web of Science database was analyzed and 100 most-cited articles about septic arthritis were determined. The characteristics of the articles including publication year, country, journal, study type, and sponsorship were recorded and investigated for any possible relationship with citation numbers. The visualization of the most commonly used keywords was made by software.

Results

The highest citation number and density were 309 and 21.6, respectively. The highest contribution was from the USA with 44 articles. The most common study type was case series with 26 articles. Annals of the Rheumatic Diseases journal had the highest number of articles with 8 papers. Fifteen studies were funded. The average citation density of review articles was significantly higher than in clinical and basic science studies (p < 0.001). Citation density was positively correlated with publication year and institution number, while it was negatively correlated with the level of evidence.

Conclusion

This study summarizes the general characteristics and research trends of the 100 most influential septic arthritis papers. Citation density and level of evidence performance were better in more recent articles. Additionally, citation density was higher in papers that included contributions from multiple institutions and papers with a high level of evidence. However, a high level of evidence is lacking indicating the need for better study design in future research.

Ten-Year Single Center Retrospective Analysis of Adult Native Ankle Joint Septic Arthritis

Septic arthritis (SA) of the native ankle joint can result in serious morbidity and mortality but is a poorly quantified issue with little literature available on its clinical features, treatment and outcomes. This was a 10-y review (N ≥ 30) of adults with SA of the native ankle joint presenting to a single center from December 2009 to January 2019. Patients with prior ankle surgery, prosthetic infection, inoculation from trauma, not initially treated at our institution or lost to follow-up were excluded. Thirty-six patients met inclusion criteria. This is the largest cohort of adult native ankle joint SA in the literature. Mean age was 63.5 y (range 28-93 y). Patients most often presented with pain (91.7%), swelling (61.1%), and fever (22%). Staphylococcus aureus was the most common causative pathogen (63.9%). Readmission rate was 60%. The 1-y mortality rate was 14.3% with Charlson Comorbidity Index and age identified as independent predictors of mortality. No statistically significant predictors were found for returns to theatre. When assessing ankle pain in elderly patients, and those with poor physiology, high clinical index of suspicion should be maintained for this potentially life-threatening condition. We recommend development of evidence-based clinical guidelines for adult native ankle joint SA and establishment of a prospective multi-center database to enable further research in this field.

Therapeutic Effects of Boric Acid in a Septic Arthritis Model Induced by Escherichia coli in Rats

The study aimed to evaluate the therapeutic effect of boric acid (BA) in experimentally induced septic arthritis. A total of 30 rats, 6 rats in each group (5 groups), were used in the study. No treatment was applied to the rats in the control group. Only BA was administered intraperitoneally (IP) to the rats in the bor group. Escherichia coli was administered at a single dose of 25 μL, 1 × 10¹⁰ cfu/rat from the right foot pad of the rats, via intra-articular route, to the mice in the arthritis, arthritis-bor, and arthritis-antb groups. Then, BA at a dose of 50 mg/kg and cefazolin at a dose of 25 mg/kg were administered to the rats in the arthritis-bor and arthritis-antb groups, respectively, for 7 days via the IP route. At the end of the study, all animals were euthanized following the ethical rules. Blood and tissue samples were taken from the rats for biochemical and histopathological analyses. The levels of GSH, MDA, Endoglin, Endocan, and TNF-β markers were measured in the blood samples taken. A significant decrease was observed in MDA and Endoglin levels in the boric acid-administered group compared with the arthritis group, while a significant increase was observed at the GSH level. Histopathologically, it was determined that the reactive surrounding tissue response in the bor group was significantly reduced. As a result, a significant decrease in inflammation was found biochemically and histopathologically in the groups treated with BA.

Effect of Joint Infection After Arthroscopic Single-Bundle ACL Reconstruction With Autologous Hamstring Tendon: A Retrospective Matched MRI Study

Background:

Joint infection after anterior cruciate ligament (ACL) reconstruction is a rare but serious complication.

Purpose:

To assess the effect of joint infection on the graft, cartilage, and bone tunnel using magnetic resonance imaging (MRI) after arthroscopic single-bundle ACL reconstruction with autologous hamstring tendons.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective matched cohort study included 26 patients who underwent arthroscopic single-bundle ACL reconstruction with hamstring tendon graft at the authors’ institute between January 2002 and December 2017 and developed postoperative joint infection. These patients were matched 1:3 to patients who did not sustain joint infection after ACL reconstruction (control group). MRI scans were collected at the time of follow-up. The following parameters were evaluated: graft signal-to-noise quotient (SNQ); graft signal intensity at the bone-graft interface and within the knee joint; bone tunnel enlargement at the tunnel aperture, midsection, and exit of the tibial and femoral tunnels; and cartilage integrity.

Results:

The average follow-up time was 47.8 months in the infection group and 48.5 months in the control group. Compared with the control group, the infection group had a significantly higher SNQ (20.01 ± 12.08 vs 7.61 ± 6.70; P = .014) as well as a higher signal intensity at the bone-graft interface (P = .037) and higher Howell grade (P = .031). The mean enlargement at the femoral tunnel aperture was 31.20% ± 26.76% in the infection group and 19.22% ± 20.10% in the control group (P = .037). The articular cartilage of the patellofemoral and lateral femorotibial joints showed more degenerative change in the infection group.

Conclusion:

Study findings indicated that graft ligamentization and incorporation graft maturity were inferior in patients who experienced a joint infection after ACL reconstruction compared with patients who did not.

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.

Multiple organ failure and death caused by Staphylococcus aureus hip infection: A case report

Suppurative arthritis has an acute onset and mostly affects old people and children. Recently, the incidence of adult suppurative hip arthritis, as well as its serious consequences, has increased. The deep hip joint and surrounding hypertrophic muscle tissue limit physical examination. Furthermore, they may cause variable and atypical symptoms of suppurative hip arthritis, possibly inducing delayed diagnosis and treatment. This atypical presentation is uncommon, causing delayed diagnosis and treatment, thus worsening the outcomes. We herein report the case of a 58-year-old man with Staphylococcus aureus (S. aureus) septicemia and multiple organ failure due to left pyogenic arthritis of the hip. The patient's early symptoms were extremely atypical given that he only presented hip pain. Moreover, there was no obvious history of trauma or inflammatory manifestations, such as fever or local swelling, and laboratory examination results and imaging findings were atypical. However, the disease progressed rapidly, developing into systemic sepsis within a short period of time followed by multiple organ failure and death. Early diagnosis and effective treatment of S. aureus hip arthritis are essential to avoid poor outcomes.

Simultaneous occurrence of knee septic arthritis and coronavirus disease 2019 (COVID-19): A case report

Background

Coronavirus disease 2019 (COVID-19) pandemic is increasingly recognized as a serious, worldwide public health concern. Most of the patients with COVID-19 are asymptomatic or show mild symptoms. It is important to identify the unusual manifestations and their long-term complication.

Case presentation

A case of COVID-19 in 45 years old man with septic arthritis due to Staphylococcus aureus is presented. COVID-19 was diagnosed using real-time polymerase chain reaction without obvious clinical manifestation. The patient had no history of trauma or inflammatory arthritis and had progressive left knee pain and limitation of movement. Knee X-ray was normal. Aspiration of the knee joint fluid showed a cloudy and purulent appearance. The patient was admitted to hospital and immediately treated with vancomycin 1gr/12 hr. A polymerized chain reaction (PCR) test for COVID-19 was performed, which was positive 24 h after hospitalization. Staphylococcus aureus was reported in synovial fluid culture which was sensitive to vancomycin and ciprofloxacin, thus vancomycin was continued. On the 4th day of hospitalization the patient had cough, therefore underwent CT scan lungs and ground-glass opacities (GGO) characteristic of COVID-19 were noticed. Favipiravir and interferon were started. Patient's knee aspiration was performed for 5 consecutive days. On the 6th day of hospitalization, joint fluid markedly decreased and the patient's oxygen saturation was 96%. One week after hospitalization, the patient was discharged and a month later knee examination was completely normal.

Conclusions

Septic arthritis should be considered in the manifestations or co-morbidity of COVID-19 patients with joint pain, swelling or redness.

Polyarticular Sepsis Secondary to Staphylococcus aureus Bacteremia Post-acute Hemodialysis: A Case Report

Polyarticular septic arthritis (PASA) is less common than monoarticular septic arthritis (MASA). There is a low incidence of PASA in immunocompetent patients. This case report describes the development of PASA after hemodialysis through the permcath after a single session.

Synovial Fluid and Serum Neutrophil-to-Lymphocyte Ratio: Novel Biomarkers for the Diagnosis and Prognosis of Native Septic Arthritis in Adults

BACKGROUND

Septic arthritis (SA) is a musculoskeletal emergency for which prompt diagnosis and treatment are critical. However, traditional diagnostic criteria of a synovial fluid (SF) white blood-cell count (WBC) of >50,000 cells/mm 3 or >90% polymorphonuclear leukocytes (%PMN) are not particularly sensitive or specific for the diagnosis of SA. Furthermore, prognostic markers are lacking. The purposes of this study were to assess the discriminative ability of the SF neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of SA and of the serum NLR in the prognosis of SA.

METHODS

A multi-institution, retrospective study of 598 patients with native shoulder, hip, or knee SA in 2000 to 2018 was conducted. SF-NLR was calculated from the arthrocentesis cell count with differential. Receiver operating characteristic curves were analyzed, and the optimal threshold of SF-NLR for SA diagnosis was determined using the Youden index. Results were compared with traditional SF diagnostic criteria. Similar analyses assessed the association of serum NLR with 90-day treatment failure and mortality for the subset of patients with confirmed hip or knee SA and with serum complete blood-cell counts with differentials (n = 235). Results were compared with traditional serum prognostic markers (WBC, C-reactive protein [CRP], and erythrocyte sedimentation rate [ESR]).

RESULTS

The SF-NLR (area under the receiver operating characteristic curve [AUC], 0.85 [95% confidence interval (CI), 0.82 to 0.88]) was significantly more accurate for an SA diagnosis than SF-WBC (AUC, 0.80 [95% CI, 0.76 to 0.83]; p = 0.002) and SF-%PMN (AUC, 0.81 [95% CI, 0.77 to 0.84]; p = 0.01). The optimal threshold of SF-NLR was 25 (78% sensitivity and 81% specificity), compared with >50,000 cells/mm 3 for SF-WBC (56% sensitivity and 80% specificity) and >90% for SF-%PMN (65% sensitivity and 78% specificity). Elevated serum NLR was independently associated with 90-day treatment failure (odds ratio [OR], 7.04 [95% CI, 3.78 to 13.14]; p < 0.001) and mortality (OR, 7.33 [95% CI, 2.00 to 26.92]; p = 0.003); elevated serum WBC and CRP were also associated with treatment failure, and WBC, CRP, and ESR were not associated with mortality.

CONCLUSIONS

This study provides compelling data on the superior diagnostic and prognostic ability of serum NLR and SF-NLR for SA compared with current clinical standards. Given that this biomarker requires no additional cost or time to return than current laboratory tests already being performed, pending validation, it can readily be used to aid clinicians in the diagnosis and prognostication of SA.

LEVEL OF EVIDENCE

Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Septic arthritis in an in vivo murine model induced by Staphylococcus aureus : a comparison between actions of the haemolysin toxin and the effects of the host immune response

Aims

Staphylococcus aureus is a major cause of septic arthritis, and in vitro studies suggest α haemolysin (Hla) is responsible for chondrocyte death. We used an in vivo murine joint model to compare inoculation with wild type S. aureus 8325-4 with a Hla-deficient strain DU1090 on chondrocyte viability, tissue histology, and joint biomechanics. The aim was to compare the actions of S. aureus Hla alone with those of the animal’s immune response to infection.

Methods

Adult male C57Bl/6 mice (n = 75) were randomized into three groups to receive 1.0 to 1.4 × 10⁷ colony-forming units (CFUs)/ml of 8325-4, DU1090, or saline into the right stifle joint. Chondrocyte death was assessed by confocal microscopy. Histological changes to inoculated joints were graded for inflammatory responses along with gait, weight changes, and limb swelling.

Results

Chondrocyte death was greater with 8325-4 (96.2% (SD 5.5%); p < 0.001) than DU1090 (28.9% (SD 16.0%); p = 0.009) and both were higher than controls (3.8% (SD 1.2%)). Histology revealed cartilage/bone damage with 8325-4 or DU1090 compared to controls (p = 0.010). Both infected groups lost weight (p = 0.006 for both) and experienced limb swelling (p = 0.043 and p = 0.018, respectively). Joints inoculated with bacteria showed significant alterations in gait cycle with a decreased stance phase, increased swing phase, and a corresponding decrease in swing speed.

Conclusion

Murine joints inoculated with Hla-producing 8325-4 experienced significantly more chondrocyte death than those with DU1090, which lack the toxin. This was despite similar immune responses, indicating that Hla was the major cause of chondrocyte death. Hla-deficient DU1090 also elevated chondrocyte death compared to controls, suggesting a smaller additional deleterious role of the immune system on cartilage.

Cite this article: Bone Joint Res 2022;11(9):669–678.

Mortality of septic knee arthritis in Korea: risk factors analysis of a large national database

This study aimed to analyze the risk factors for mortality of septic knee arthritis in Korea through a large nationwide data research. The National Health Insurance Service-Health Screening database was used to analyze 89,120 hospitalizations for septic knee arthritis between 2005 and 2018. In-hospital, thirty-day, and ninety-day mortality, and their association with patient’s demographic factors, various comorbidities (i.e., cerebrovascular disease, congestive heart failure, and myocardial infarction) and Charlson Comorbidity Index (CCI) were assessed. Secondary outcomes of complications (osteomyelitis, knee arthroplasty, recurrence) were analyzed. The number of hospitalization with septic knee arthritis increased from 1847 cases in 2005 to 8749 cases in 2018. There was no significant difference in mortality after diagnosis of septic knee arthritis between years. The risk of mortality in patients who hospitalized with septic knee arthritis increased in comorbidities like Congestive heart failure, dementia, myocardial infarction, chronic kidney disease. Hazard ratio (HR) decreased in patients who have comorbidities such as rheumatoid arthritis, liver disease, rheumatologic disease. HR for mortality in septic knee arthritis increased in patients with CCI more than 1. The risk factors for mortality in all periods were male sex, old age, high CCI, comorbidities such as congestive heart failure, dementia, myocardial infarction, chronic kidney disease. Efforts to reduce mortality should be concentrate more on patients with these risk factors.

ACUTE DESTRUCTIVE HIP SEPTIC ARTHRITIS IN A YOUNG ADULT PATIENT: CASE REPORT (v2)

The Authors describe a case of rapid right hip destructive septic arthritis in a 50-year-old male patient with no previous noteworthy medical history. Patient arrived to our attention following a one week history of right hip pain. Laboratory markers and imaging at presentation were negative. However, on a follow-up examination significant joint effusion was noted and joint tap was performed. Despite wide spectrum antibiotic therapy institution, significant joint damage was observed. This required surgical femoral head excision with antibiotic loaded spacer, followed by hip arthroplasty surgery 12 weeks afterwards. Complete healing of the infection and recovery of pain-free joint motion was noted at 1 year follow-up.

Bidirectional Relationship Between Osteoarthritis and Periodontitis: A Population-Based Cohort Study Over a 15-year Follow-Up

Objective

To identify the relationship between osteoarthritis and periodontitis.

Methods

144,788 periodontitis patients and 144,788 propensity score-matched controls without history of periodontitis were enrolled in this cohort study. A Cox proportional hazard model was used to estimate the risk of osteoarthritis. Survival analysis was utilized to assess the time-dependent effect of periodontitis on osteoarthritis. Age and gender were stratified to identify subgroups at risk. A symmetrical case-control analysis was designed to determine the relationship between present periodontitis and history of osteoarthritis.

Results

Patients with periodontitis had higher risk of osteoarthritis (hazard ratio, HR =1.15, 95% CI =1.12-1.17, p < 0.001) and severe osteoarthritis that led to total knee replacement or total hip replacement (TKR/THR) (HR =1.12, 95% CI =1.03-1.21, p < 0.01) than controls, which was time-dependent (log-rank test p < 0.01). The effect of periodontitis on osteoarthritis was significant in both genders and age subgroups over 30 years-old (all p < 0.001). Among them, females (HR=1.27, 95% CI = 1.13-1.42, p < 0.001) and patients aged over 51 (HR= 1.21, 95% CI =1.10-1.33, p < 0.001) with periodontitis were predisposed to severe osteoarthritis. In addition, periodontitis patients were more likely to have a history of osteoarthritis (odds ratio = 1.11, 95% CI = 1.06 - 1.17, p < 0.001).

Conclusions

These findings suggest an association between periodontitis and a higher risk of osteoarthritis, including severe osteoarthritis that led to TKR/THR. Likewise, periodontitis is more likely to develop following osteoarthritis. A bidirectional relationship between osteoarthritis and periodontitis was observed.

Role of serum and synovial procalcitonin in differentiating septic from non-septic arthritis- a prospective study

INTRODUCTION

Septic arthritis is a serious orthopaedic emergency that must be diagnosed and managed early to prevent devastating complications. The current gold standard for diagnosing septic arthritis is synovial fluid culture, but results are delayed by 48-72 h, and the sensitivity of the test is very low. Differentiating Septic from non-septic arthritis is vital to prevent unnecessary use of antibiotics and prevent complications. Serum Procalcitonin (PCT) is a useful marker in differentiating septic from non-septic arthritis but there are very few studies that have studied the role of synovial PCT for the same.

AIM

To determine the role of serum and synovial PCT in differentiating acute Septic from non-septic arthritis.

MATERIALS AND METHODS

Prospective clinical study in which 60 patients presenting with acute inflammatory arthritis (<2 weeks duration) were enrolled from May 2018 to May 2020. Serum and synovial fluid samples were drawn at presentation and routine blood investigations, synovial fluid culture sensitivity, and Procalcitonin levels were measured. Patients were divided into 3 groups, with group-1 having confirmed pyogenic, group-2 having presumed pyogenic, and group-3 having non -pyogenic patients, respectively. All data was tabulated and statistically analysed using appropriate tests.

RESULTS

Mean serum PCT values in groups 1, 2 and 3 were 1.06 ± 1.11, 0.85 ± 0.74, and 0.11 ± 0.24, respectively. Patients in the Pyogenic group (group1 and group 2) had significantly higher mean serum PCT as compared to group3 (p < 0.0001). Group 1 had higher serum PCT as compared to group 2, but the difference was not significant (p = 0.58). Mean synovial PCT in group 1, 2 and 3 were 2.42 ± 1.98, 1.89 ± 1.18, and 0.22 ± 0.40, respectively. Patients in the Pyogenic group (Group1 and Group2) had significantly higher mean synovial PCT as compared to Group 3 (p < 0.0001). Group 1 had higher mean synovial PCT as compared to group 2, but the difference was not significant (p = 0.54). The area under the ROC curve of the serum levels of PCT was 0.0.895, and the area under the ROC curve of the synovial fluid levels of PCT was 0.914, which was higher than the serum PCT level.

CONCLUSION

Serum and synovial Procalcitonin may be used as a diagnostic marker in differentiating septic from inflammatory arthritis and can help in reducing unnecessary use of antibiotics and early diagnosis and management of septic arthritis, thereby preventing complications.

Treating 'Septic' With Enhanced Antibiotics and 'Arthritis' by Mitigation of Excessive Inflammation

Bacterial infection within the synovial joint, commonly known as septic arthritis, remains a clinical challenge as it presents two concurrent therapeutic goals of reducing bacterial burden and preservation of articular cartilage from destructive host inflammation. We hypothesized that mitigation of MRSA-induced inflammatory signaling could diminish destruction of articular cartilage in the setting of septic arthritis when used in conjunction with antibiotics. Herein, we provide evidence which supports a new therapeutic notion that concurrent antimicrobial therapy to address the 'septic' component of the disease with inflammation mitigation to manage the destructive 'arthritis' component. We established a murine model to mimic septic knee arthritis, as well as a variety of other inflammatory joint conditions. This murine septic arthritis model, in conjunction with in vitro and ex-vivo models, was utilized to characterize the inflammatory profile seen in active septic arthritis, as well as post-antibiotic treatment, via transcriptomic and histologic studies. Finally, we provided the clinical rationale for a novel therapeutic strategy combining enhanced antibiotic treatment with rifampin and adjuvant immunomodulation to inhibit post-infectious, excess chondrolysis and osteolysis. We identified that septic arthritis secondary to MRSA infection in our murine model led to increased articular cartilage damage compared to various types of inflammatory arthritis. The activation of the pERK1/2 signaling pathway, which is implicated with the mounting of an immune response and generation of inflammation, was increased in intracellular MRSA-infected synovial tissue and persisted despite antibiotic treatment. Trametinib, an inhibitor of ERK signaling through suppression of MEK1/2, alleviated the inflammation produced by the addition of intra-articular, heat-killed MRSA. Further, when combined with vancomycin and rifampin, mitigation of inflammation by pERK1/2 targeting improved outcomes for MRSA septic arthritis by conferring chondroprotection to articular cartilage and diminishing inflammatory osteolysis within bone. Our results support a new therapeutic notion that cell/biofilm-penetrating antibiotics alongside adjuvant mitigation of excessive intra-articular inflammation accomplish distinct therapeutic goals: reduction of bacterial burden and preservation of articular cartilage integrity.

Concomitant septic arthritis of the hip joint and femoral head avascular necrosis in patients with recent COVID-19 infection: a cautionary report

Purpose

At present, concomitant avascular necrosis (AVN) of femoral head and septic arthritis (SA) as a sequel of COVID-19 infection has yet not been documented. By large-scale use of life-saving corticosteroids (CS) in COVID-19 cases, our aim is to warn of the occurrence of hip joint infection in these patients.

Methods

We report a series of five cases in which patients developed septic arthritis concomitant with AVN after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 1695.2 mg. The time period of onset of hip symptoms in our cases from the beginning of the COVID-19 infection was 56 days in the first case, 43 days in the second case, 30 days in the third case, 29 days in the fourth case and 50 days in the last case, with an average time of 41.6 days. All patients underwent surgery depending on the extent of articular cartilage damage by direct anterior approach.

Results

Clinical and laboratory symptoms improved significantly in all patients. The mean visual analogue pain score of the patients decreased from 9.4 (9–10) before surgery to 2.8 (1–4) after 1 week of operation.

Conclusion

In any patient with the history of COVID-19 infection specially those who have been treated with corticosteroid as one of the medications prescribed during the disease, any joint symptom specially in the hips should draw our attention to the joint infection, and with timely diagnosis and surgery, their hip joint can be saved.

Increased Risk of 90-Day Surgical-Site Infection and Hospital Readmission but Not Reoperation After Open Arthrotomy When Compared With Arthroscopy for Septic Ankle Arthritis

PURPOSE

To compare the rates of reoperation and 90-day perioperative complications between open arthrotomy and arthroscopy for the treatment of septic ankle arthritis using a national all-payer claims database.

METHODS

Patients with a diagnosis of septic ankle arthritis who underwent irrigation and debridement through arthroscopy or arthrotomy were identified in a national data set from 2015-2020 through an all-payer claims database. Demographic and comorbidity characteristics including age, sex, infectious etiologies, and Elixhauser comorbidities were obtained. The rate of reoperation, defined as a proxy for failure of initial intervention, was the primary outcome. Secondary outcomes including readmissions, surgical-site infections, amputations, wound complications, and 90-day medical complications were compared between the 2 cohorts.

RESULTS

In total, 168 patients undergoing arthroscopy and 794 patients undergoing arthrotomy for septic ankle arthritis were identified. There were no significant differences in reoperation rates between patients who underwent open arthrotomy and those who underwent arthroscopy (P = .997). However, the rates of surgical-site infection (P = .014) and hospital readmission (P < .001) were significantly higher in the open arthrotomy cohort compared with the arthroscopy cohort.

CONCLUSIONS

Although there was no significant difference in reoperation rates between arthroscopic and open irrigation and debridement for the treatment of septic ankle arthritis, this study showed significantly higher odds of surgical-site infection and hospital readmission in patients who underwent open arthrotomy when compared with arthroscopy. Case-specific patient and technical considerations should guide the surgical decision-making process to limit secondary complications because this study exemplifies similar reoperation rates between the 2 surgical modalities.

LEVEL OF EVIDENCE

Level III, nonrandomized cohort analysis.

Rare septic arthritis of the wrist and carpus primary osteoarticular manifestation of Mycobacterium tuberculosis: A case report

Mycobacterium tuberculosis is one of the oldest and most studied infections, yet it remains one of the most common causes of infection-related death worldwide. The majority concern pulmonary tuberculosis. Therefore, extrapulmonary cases are rare and are often neglected in the differential diagnosis, especially in chronic musculoskeletal complaints. Nevertheless, osteoarticular manifestation of tuberculosis can cause disabling destruction of bone, cartilage, and surrounding soft tissues which may be exacerbated by a delay in diagnosis. This case report documents a case of primary osteoarticular tuberculosis causing septic arthritis of the wrist and carpus. In our case, the patient had no pulmonary burden of tuberculosis, which further delayed diagnosis and lead to irreversible damage to the wrist as well as carpus. This case illustrates the need to consider this diagnosis in at risk populations in order to prevent a delay in diagnosis and treatment.

Comparison of Arthroscopy versus Open Arthrotomy for Treatment of Septic Arthritis of the Native Knee: Analysis of 90-Day Postoperative Complications

Septic arthritis is an orthopaedic emergency, often necessitating surgical debridement, and the knee joint is most frequently affected. Arthroscopic and open irrigation and debridement (I&D) are the two commonest surgical treatments for septic arthritis of the native knee. Several studies have compared outcomes of open and arthroscopic management without coming to a clear conclusion which yields superior outcomes. The purpose of this study was to compare the results of these two surgical techniques to treat septic arthritis of the native knee using a large nationwide database. Patients who underwent arthroscopic or open I&D as treatment for knee septic arthritis from 2010 to 2019 were identified using a national insurance database. The primary outcome was the 90-day reoperation rate. Secondary outcomes included surgical site infection, readmission, and other postoperative complications. A total of 1,139 patients were identified, 618 of whom (54%) underwent open treatment and 521 (46%) underwent arthroscopic treatment. The two groups did not differ significantly by age, gender, or most comorbidities. There was no significant difference in 90-day reoperation rate between the groups (15.0.% open and 18.0% arthroscopic, p = 0.174). Patients who underwent open treatment had increased odds of readmission to the hospital (odds ratio [OR] = 1.46 [1.14-1.86]; p = 0.003), postoperative anemia (OR = 1.71 [1.08-2.75]; p = 0.025), and blood transfusion (OR = 1.76 [1.04-3.06]; p = 0.040) compared with those who underwent arthroscopic surgery. Using administrative claims data, we found that arthroscopic and open I&D have similar rates of reoperation and most 90-day postoperative outcomes. Lower rates of readmission, postoperative anemia, and blood transfusion were found with arthroscopic I&D, suggesting that arthroscopy may be preferable to open treatment in the management of septic arthritis of the native knee in cases in which other case- and surgeon-specific factors do not otherwise dictate the best treatment modality.

Risk of nonpulmonary infections requiring hospitalization in spondyloarthritis

Objectives

To compare the risk of five nonpulmonary infections leading to hospitalization between spondyloarthritis (SpA) and nonspecific back pain (NSBP), and to identify the risk factors.

Methods

A total of 3018 patients with SpA and 2527 patients with NSBP were identified. Data from December 1995 to June 2019 was retrieved from a centralized electronic medical record system. The date of onset of five types of nonpulmonary infections including: urinary tract infection (UTI), skin infection, gastroenteritis (GE), septic arthritis, and pancreato‐hepatobiliary tract infection were identified. Demographic data, comorbidities, and medications used were also retrieved. Comparative risk of each type of infection between SpA and NSBP was determined using propensity score adjustment method. Cox regression model was used to identified risk factors.

Results

Patients with SpA were younger in age, predominantly male, with fewer comorbid diabetes mellitus (DM), renal impairment, and depression. Compared with NSBP, patients with SpA had higher risk of UTI (hazard ratio [HR] 1.91; p < .001), skin infection (HR 1.79; p < .001), and septic arthritis (HR 4.57; p = .04). Risk of GE (HR 1.42; p = 1.00), and pancreato‐hepatobiliary tract infection (HR 1.67; p = .06) were not increased. Infliximab was an independent risk factor for UTI (HR 2.21; p = .04). Duration of steroid therapy >6 months (HR 2.22; p < .001), smoker (HR 1.81; p < .001), and psoriasis (HR 2.47; p < .001) were risk factors for skin infection.

Conclusion

SpA was associated with increased risk of UTI, skin infection, and septic arthritis. Infliximab, prolonged steroid therapy, smoking, and psoriasis were associated risk factors.

Arthroplasty after septic arthritis of the native hip and knee: retrospective analysis of 49 joints

Abstract. Background: Arthroplasty after septic arthritis (SA) treatment raises diagnostic and therapeutic questions. The main objective was to evaluate infection-free survival of patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) post-SA. Other objectives were to describe the population's characteristics, surgical strategies, results of preoperative examinations and cultures of intraoperative samples taken at implantation, and postoperative antibiotic therapy. Methods: This is a retrospective, observational, monocenter study, from January 2005 to May 2019, including all patients undergoing TKA or THA with prior or ongoing SA in the same joint. Infection–free survival was analyzed and reported. Results: Forty-seven patients, 29 men, 49 joints operated on (30 knees, 19 hips), were included. Median SA-to-arthroplasty interval was 32 [1–216] weeks. It was <2 years for 43 joints and <6 months for 19 joints. Six patients underwent arthroplasty while still on SA treatment. One-stage arthroplasty was done for 43 joints and two-stage arthroplasty for 6 joints. Eight (16 %) cultures of intraoperative specimens were positive. Median durations of postoperative antibiotic therapy were 10 d for sterile cultures and 82 d for those that were positive. At 2 years, infection-free survival rate was 95.9 % (±0.02). After a median follow-up of 47 [18–142] months, no SA relapse was observed, but five patients developed new periprosthetic joint infections (PJIs) with a different microorganism. Conclusion: Arthroplasty may be a post-SA option, even within a short period of time. One-stage arthroplasty can be done if synovectomy is thorough, intraoperative samples are taken and antibiotics are administered until those culture results become available. We observed no SA relapse, but new PJIs occurred.

Clinical Efficacy of the Antibiotic-Loaded Collagen Sponge During Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee

Background:

To completely eliminate an infection, the antibiotic concentration must exceed the minimum inhibitory concentration for the causative pathogens. The antibiotic-loaded collagen sponge (ALCS) has been used to manage an infection through a high local concentration of antibiotics.

Purpose:

To evaluate the clinical efficacy of ALCS in the arthroscopic treatment of patients with acute septic arthritis of the native knee.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors retrospectively reviewed the data for 132 consecutive patients with acute septic arthritis of the knee who underwent arthroscopic debridement between 2013 and 2019. Patients with a history of surgery in the affected joint, concomitant osteomyelitis, or accompanying medical infection were excluded. The study patients were divided into 2 groups based on the use of ALCS during surgery. C-reactive protein (CRP) levels were temporally measured to normalization and the duration of intravenous antibiotic administration was recorded, and the mean length of hospital stay was compared between the groups. Independent t test and chi-square test were performed to assess differences between the groups, and univariate analysis was used to analyze factors affecting recurrence of septic arthritis.

Results:

Of the 132 patients, 88 were ultimately included in this study; 51 patients were managed without ALCS and 37 were treated with ALCS. There were statistically significant differences between groups in the mean period for CRP-level normalization (15.2 ± 8.2 days [ALCS] vs 26.2 ± 14.7 days [without ALCS]; P = .004), mean duration of intravenous antibiotic use (18.4 ± 7.3 days [ALCS] vs 26.6 ± 16.1 days [without ALCS]; P = .046), and mean length of hospital stay (21.1 ± 11.6 days [ALCS] vs 30.3 ± 18.3 days [without ALCS]; P = .045). The preoperative CRP level was the only significant risk factor for recurrence or treatment failure after single arthroscopic debridement.

Conclusion:

The results of this study indicated that ALCS was able to reduce the duration of CRP-level normalization, intravenous antibiotic use, and hospitalization in patients who underwent arthroscopic irrigation and debridement for acute septic arthritis of the native knee.

Two-Stage Total Hip Arthroplasty for Primary Advanced Septic Arthritis of the Hip in Adults

Background

Comparing the outcomes of debridement and total hip arthroplasty (THA) with antibiotic-loaded spacer implantation and subsequent THA for the treatment of patients affected by primary advanced septic arthritis (SA) of the hip in adults.

Methods

All of the 20 patients (20 hips) underwent two-stage surgery. Nine patients were submitted to surgical debridement first and then THA (group 1), while 11 patients were treated with antibiotic-loaded spacer and subsequent THA (group 2). Patients were evaluated based on the recurrence of infection, Harris hip score, visual analogue scale (VAS) pain score, and leg length discrepancy.

Results

No cases of infection, deep vein thrombosis, death, and loosening of the hip prosthesis were observed during follow-up. The mean follow-up time was 29.09 ± 10.80 months in group 1 and 28.22 ± 14.80 months in group 2. Before the THA surgery, the mean leg length discrepancy was 2.80 ± 2.03 cm in group 1 and 0.50 ± 0.23 cm in group 2 (P < 0.05). In the latest follow-up, the Harris hip scores of patients were 90.33 ± 4.85 in group 1 and 94.36 ± 2.34 in group 2 (P < 0.05), respectively. There was no statistically significant difference in the VAS pain score of the hip between the two groups (P > 0.05).

Conclusions

Debridement and antibiotic-loaded spacer and subsequent THA were effective in eradicating the infection for advanced SA. However, antibiotic-loaded spacer and subsequent THA was superior for effectively maintaining the length of the lower limb and function of the hip.

Short- and Mid-Term Survival of Geriatric Patients with Septic Arthritis of the Knee and the Impact of Risk Factors on Survival

Septic arthritis is common in older adults and can be related to joint surgery or hematogenous distribution. To date, the risk factors affecting survival are unknown. This study aimed to evaluate the effects of existing implants, positive synovial microbiological culture results, and the American Society of Anesthesiology Physical Status (ASA) classification on the short- and mid-term survival of older patients with primary septic gonarthritis. This retrospective study included 133 older adults >60 years who underwent surgery for primary septic gonarthritis. Data were collected from medical records and public obituaries. Kaplan–Meier survival curves were used to estimate the probability of survival, as well as log-rank tests to measure and compare survival rates over one- and five-year periods. The mean age was 74.9 years (SD ± 9.2), and the 5-year follow-up rate was 74.3% (the mean follow-up was 3000.5 days; SD ± 1771.6). Mean survival was significantly different in patients with implants and without implants (p = 0.015), and between ASA II, ASA III, and ASA IV (p < 0.001). There was no significant difference in the survival of patients with or without a positive synovial microbiological culture (p = 0.08). Older adults with septic monoarthritis and pre-existing medical implants showed impaired survival. The ASA classification prior to surgery for primary septic monoarthritis can be helpful in identifying patients with poorer mid-term outcomes.

Similar Efficacy of Arthroscopy and Arthrotomy in Infection Eradication in the Treatment of Septic Knee: A Systematic Review and Meta-Analysis

Aim: To compare the arthroscopy vs. arthrotomy for the treatment of native knee septic arthritis.

Methods: Electronic databases of PubMed, Embase and Cochrane Library were searched for eligible studies. Retrospective comparative studies comparing arthroscopy or arthrotomy for patients with septic arthritis of the native knee were eligible for this review. The primary outcome was recurrence of infection after first procedure. The secondary outcomes included hospital length of stay, operative time, range of motion of the involved knee after surgery, overall complications and mortality rate,

Results: Thirteen trials were included in this study. There were a total of 2,162 septic arthritis knees treated with arthroscopic debridement and irrigation, and 1,889 septic arthritis knees treated with open debridement and irrigation. Arthroscopy and arthrotomy management of the knee septic arthritis showed comparable rate of reinfection (OR = 0.85; 95% CI, 0.57–1.27; P = 0.44). No significant difference was observed in hospital length of stay, operative time and mortality rate between arthroscopy and arthrotomy management group, while arthroscopy treatment was associated with significantly higher knee range of motion and lower complication rate when compared with arthrotomy treatment.

Conclusion: Arthroscopy and arthrotomy showed similar efficacy in infection eradication in the treatment of native septic knee. However, arthroscopy treatment was associated with better postoperative functional recovery and lower complication rate.

Management of a Hot Swollen Joint in the Acute Setting

BACKGROUND

The presentation of a hot swollen joint is common in the emergency department, general practice, rheumatology and orthopedic clinics. There is a wide set of differential diagnoses for a hot swollen joint, thus making it difficult to diagnose and manage, especially for junior doctors. Initially, it is pertinent to exclude/diagnose medical and surgical emergencies.

OBJECTIVE

This paper aims to summarize the key indications within the history, examination and investigations in order to quickly and effectively diagnose a hot swollen joint based on the original 2006 management guidelines and the papers discussing other possible indications and management strategies published since.

RESULTS

Currently, the management of crystal and non-infectious arthropathies are well recognized with little disparity. However, the treatment of infectious arthritis is not concrete and there are discrepancies in management between doctors.

CONCLUSION

We have summarized the key indications and provided a diagnostic flow chart to aid with the management.

Devastating Pneumococcal Arthritis of the Shoulder After Two Corticosteroid Injections

A 36-year-old man was treated with two intraarticular corticoid injections for intense pain and severely decreased range of motion of his left shoulder. After the second injection, he came back with fulminant arthritis. Microbiological examination revealed streptococcus pneumoniae. Open debridement, long-term antibiotics, and total shoulder replacement were necessary to restore acceptable shoulder function. The fulminant course with rapid destruction of the joint illustrates the risks of intraarticular corticoid injections. This case also shows that the diagnosis should be accurately made and risk factors excluded before considering injection as a treatment.

Microbiological pathogen analysis in native versus periprosthetic joint infections: a retrospective study

BACKGROUND

The presence or absence of an implant has a major impact on the type of joint infection therapy. Thus, the aim of this study was the examination of potential differences in the spectrum of pathogens in patients with periprosthetic joint infections (PJI) as compared to patients with native joint infections (NJI).

METHODS

In this retrospective study, we evaluated culture-positive synovial fluid samples of 192 consecutive patients obtained from January 2018 to January 2020 in a tertiary care university hospital. For metrically distributed parameters, Mann-Whitney U was used for comparison between groups. In case of nominal data, crosstabs and Chi-squared tests were implemented.

RESULTS

Overall, 132 patients suffered from periprosthetic joint infections and 60 patients had infections of native joints. The most commonly isolated bacteria were coagulase-negative Staphylococci (CNS, 28%), followed by Staphylococcus aureus (S. aureus, 26.7%), and other bacteria, such as Streptococci (26.3%). We observed a significant dependence between the types of bacteria and the presence of a joint replacement (p < 0.05). Accordingly, detections of CNS occurred 2.5-fold more frequently in prosthetic as compared to native joint infections (33.9% vs. 13.4% p < 0.05). In contrast, S. aureus was observed 3.2-fold more often in NJIs as compared to PJIs (52.2% vs. 16.4%, p < 0.05).

CONCLUSION

The pathogen spectra of periprosthetic and native joint infections differ considerably. However, CNS and S. aureus are the predominant microorganisms in both, PJIs and NJIs, which may guide antimicrobial therapy until microbiologic specification of the causative pathogen.

Factors affecting the occurrence of osseous lesions in septic shoulder arthritis and the recurrence rate after arthroscopic surgery

HYPOTHESIS

The purpose of this study was to determine the incidence of osseous lesions and the recurrence rate after arthroscopic surgery in shoulder septic arthritis patients and evaluate the influencing factors.

MATERIALS AND METHODS

We retrospectively reviewed 44 patients who underwent arthroscopic surgery for septic arthritis of the shoulder between January 2012 and September 2019. The average age of the patients was 65.57 ± 14.2 years, and 56.8% were female patients. The minimum follow-up period was 12 months (average, 32.8 ± 14.2 months; range, 12-72 months). We assessed variables including sex, age, underlying diseases, duration from symptom onset to magnetic resonance imaging (MRI), duration from symptom onset to surgery, radiologic results (radiography and MRI), history of injection therapy, and postoperative infection. The incidence of osseous lesions and the recurrence rate were calculated according to independent variables. In addition, multivariate logistic regression was performed to identify the risk factors for osseous lesions and recurrent infection after adjustment for other variables.

RESULTS

Twenty-one patients had an osseous lesion on MRI, and 12 patients had evidence of bone erosion on radiographs. In univariate analyses, significant (P < .05) risk factors for the presence of osseous lesions were female sex, lower C-reactive protein level, and longer duration from symptom onset to MRI. The overall infection recurrence rate was 22.7% (10 of 44 patients). Culture results and the duration from symptom onset to surgery were significant risk factors for recurrent infection (P < .05). As the duration from symptom onset to MRI increased by 1 day, the probability of osseous lesions increased 1.31-fold (95% confidence interval, 1.08- to 1.59-fold; P = .007), and this probability was significantly higher after correction for other risk factors.

CONCLUSIONS

To reduce the severity of septic shoulder infection, timely diagnosis and treatment are essential. Even if osseous lesions are present, good results can be obtained if meticulous débridement is performed through arthroscopic surgery. However, functional and radiologic long-term follow-up studies are needed in patients with osseous lesions.

Hospital care and medical costs of septic arthritis in Spain: a retrospective multicenter analysis

OBJECTIVES

This study aimed to review the characteristics of patients admitted with septic arthritis in Spanish hospitals and to measure the associated direct medical costs.

METHODS

Hospital admission records of patients with septic arthritis as a primary diagnosis registered between 2010 and 2019 were evaluated in a retrospective study. Admission cost in the database is based on the diagnosis-related group-based hospital payment systems, determined by the Spanish Ministry of Health.

RESULTS

Files from 16,438 patients were evaluated; median age was 56 years and 62.8% of patients were males. Staphylococcus was the most frequently registered pathogen, and 2.7% of admissions registered an antibiotic-resistant infection. Median hospitalization time was 14 days for adult patients and 8 days for children, with an in-hospital mortality rate of 3.7% for adult patients, and no deaths registered in children. The median length of intensive care unit (ICU) stay was 3 days. The mean admission cost was €6,382 per patient, with no significant differences between age groups. Admission costs increased significantly with the length of hospital stay. The total medical cost reached 12.7 million euros per year, considering all patients in the database.

CONCLUSIONS

This study provides new data on the medical costs of septic arthritis in Spain, providing a basis for the revision of resource allocation decisions in order to reduce the burden of this condition at the healthcare system level. Further research will be required to quantify the total burden associated with this condition.

[Management of joint empyema]

Joint empyema, also known as septic arthritis, is a severe disease associated with considerable morbidity and mortality. Failing to initiate immediate treatment can result in irreversible joint destruction within a short time. The knee joint is most frequently involved, followed by the shoulder and hip joints. Small joints are rarely affected. Typical risk factors include immunosuppression, renal insufficiency, diabetes mellitus and previous joint interventions. An early targeted diagnostic work-up and initiation of therapeutic steps is crucial to avoid irreversible joint destruction. Joint aspiration for diagnostic purposes is essential and should be performed immediately when a septic arthritis is suspected. An important differential diagnosis is metabolic arthritis (gout and chondrocalcinosis), which typically presents in a similar way. A differentiation from septic arthritis is important as metabolic arthritis requires a completely different treatment. After confirming the diagnosis, treatment consisting of a surgical procedure combined with antibiotics is initiated. In most cases an arthroscopic intervention is sufficient. In severe cases the arthroscopy needs to be repeated. An arthrotomy must be carried out only rarely. A pre-emptive antibiotic treatment is initially administered and is later adjusted according to the resistogram. This article gives an overview on the pathophysiology, diagnostics and general management of joint empyema.

Bone and Joint Infections: The Role of Imaging in Tailoring Diagnosis to Improve Patients' Care

Imaging is needed for the diagnosis of bone and joint infections, determining the severity and extent of disease, planning biopsy, and monitoring the response to treatment. Some radiological features are pathognomonic of bone and joint infections for each modality used. However, imaging diagnosis of these infections is challenging because of several overlaps with non-infectious etiologies. Interventional radiology is generally needed to verify the diagnosis and to identify the microorganism involved in the infectious process through imaging-guided biopsy. This narrative review aims to summarize the radiological features of the commonest orthopedic infections, the indications and the limits of different modalities in the diagnostic strategy as well as to outline recent findings that may facilitate diagnosis.

What are the best diagnostic tests for diagnosing bacterial arthritis of a native joint? : a systematic review of 27 studies

AIMS

This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint?

METHODS

We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study.

RESULTS

Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%).

CONCLUSION

Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article: Bone Joint J 2021;103-B(12):1745-1753.

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.

The profile of the causative organisms which lead to septic arthritis of native joints over the last two decades in a single tertiary medical center in the east coast of the United States

BACKGROUND

Septic arthritis (SA) is associated with significant morbidity and mortality. Delayed or inadequate treatment may result in joint destruction, osteomyelitis and sepsis. Like other types of infection, the causative agents of SA may have changed over time. Early targeted intervention is important in cases of SA and can be achieved only by understanding the current trends in the microbiology of SA.

OBJECTIVES

To determine the trends in the microbiology of SA over the last two decades.

METHODS

We conducted a retrospective study including all patients 18 and older with culture positive, surgically treated, native joint septic arthritis (NJSA), admitted to a single tertiary medical centre in Boston between the years of 1997 and 2015. We excluded cases of osteomyelitis and septic bursitis. We focused our analysis on the microbiology data which included synovial fluid gram stain and culture, blood cultures and synovial biopsy cultures.

RESULTS

Among 260 cases, the most common bacteria isolated were Methicillin Sensitive Staphylococcus aureus (MSSA, 36%), Methicillin Resistant Staphylococcus aureus (MRSA, 17.6%), Coagulase Negative Staphylococci (CoNS, 13%) and Group B Streptococcus (GBS, 7.3%). Trends in the rates of these bacteria demonstrated no significant variation. The knee was the most common joint affected, followed by the shoulder and hip. Shoulder SA was most commonly caused by MRSA while MSSA was the leading causative organism in other joints. GBS was a causative bacterium in shoulder SA significantly more often than in knee or hip infections.

CONCLUSIONS

Although no significant trends were noted in the microbiology of SA over nearly 2 decades, we observed meaningful findings regarding shoulder SA as MRSA was the most common bacterial because of SA in this joint. Prompt joint aspiration, microbiologic testing of synovial fluid and empiric antibiotic therapy that covers MRSA may improve outcomes in SA.

Optimal Synovial Fluid Leukocyte Count Cutoff for Diagnosing Native Joint Septic Arthritis After Antibiotics: A Receiver Operating Characteristic Analysis of Accuracy

INTRODUCTION

Urgent treatment of septic arthritis is key in preventing devastating morbidity or mortality. Accurate diagnosis is critical, and the standard diagnostic cutoff of 50,000 synovial leukocytes may be altered by previous administration of antibiotics. Our objective was to identify and compare a cutoff synovial leukocyte count with a high sensitivity and specificity for diagnosis of septic arthritis in patients who received antibiotics and those who had not. A receiver operating characteristic (ROC) curve was used to provide a discriminate cutoff value for diagnosing septic arthritis.

METHODS

A retrospective chart review of 383 patients was done over a 13-year period including those who had arthrocentesis of any joint. Two groups were created, those who had not been given antibiotics within 2 weeks (control) and those who received intravenous or oral antibiotics within 2 weeks before arthrocentesis. Relevant data included synovial leukocyte count and differential cell count. Additional metrics included temperature, erythrocyte sedimentation rate, and C-reactive protein. A ROC curve determined the optimal synovial white blood cell cutoff for diagnosing septic arthritis in native joints for each group.

RESULTS

The ROC curve determined that patients who received antibiotics had an optimal cutoff of >16,000 cells (sensitivity = 82%, specificity = 76%), and a neutrophil percentage cutoff of >90% (sensitivity = 73%, specificity = 74%). The control group had an optimal synovial leukocyte cutoff of >33,000 cells (sensitivity = 96%, specificity = 95%). The optimal neutrophil percentage cutoff in the control group was >83% neutrophils (sensitivity = 89%, specificity = 79%).

CONCLUSION

When a patient is given antibiotics before arthrocentesis, a diagnostic value of >16,000 synovial leukocytes should be used to guide treatment of septic arthritis. A diagnostic value of >33,000 synovial leukocytes yields the highest accuracy for diagnosis of septic arthritis in patients who have not been given antibiotics before arthrocentesis.

LEVEL OF EVIDENCE

III.

Staged Joint Arthrodesis in the Treatment of Severe Septic Ankle Arthritis Sequelae: A Case Report

Septic ankle arthritis is a devastating clinical entity with high risks of morbidity and mortality. Prompt treatment is necessary because delayed or inadequate treatment can lead to irreversible damage that may occur on the articular surface, resulting in cartilage erosion, infective synovitis, osteomyelitis, joint deformity, and pain and joint dysfunction. An aggressive surgical approach is required when a joint infection causes severe limb-threatening arthritis. A 58-year-old woman visited our clinic with increasing pain in the right ankle, which had been present for the previous 2 months. She complained of discomfort in daily life due to deformity of the ankle; limping; and severe pain in the ankle even after walking a little. The patient reported a history of right-ankle injury while exiting a bus in her early 20s. Plain radiographs of the right ankle joint revealed that the medial malleolus was nearly absent in the right ankle joint on the anteroposterior view, and severe varus deformity was observed with osteoarthritic changes because of joint space destruction. Magnetic resonance imaging revealed diffuse synovial thickening of the destroyed tibiotalar joint with joint effusion. Hybrid 99mTc white blood cell single-photon emission computed tomography/computed tomography showed increased uptake along the soft tissue around the ankle joint; uptake was generally low in the talocrural and subtalar joints. A two-stage operation was performed to remove the infected lesions and correct the deformity, thus enabling limb salvage. The patient was nearly asymptomatic at the 6-month follow-up, with no discomfort in her daily life and nearly normal ability to carry out full functional activities. She had no complications or recurrent symptoms at the 1-year follow-up. We have described a rare case of a staged limb salvage procedure in a patient with chronic septic arthritis sequelae. For patients with severe joint deformity because of septic ankle sequelae, staged arthrodesis is a reliable method to remove infected lesions, solve soft tissue problems, correct deformities, and maintain leg length.

Non-typhoidal, Non-paratyphoidal Salmonella Species Causing Sacroiliitis and Pyomyositis in a Healthy 19-Year-Old Athlete

Salmonella is a gram-negative bacterium, subdivided into typhoidal and non-typhoidal Salmonella. It is usually caused by eating raw or undercooked meat, poultry, eggs, or egg products. The clinical manifestations of Salmonella infection can be divided into five syndromes: enterocolitis (food poisoning), enteric (typhoid) fever, bacteremia/septicemia, focal infection, and a chronic carrier state, which is usually asymptomatic. The most common clinical presentation is diarrhea. Salmonella osteomyelitis occurs most frequently in patients with sickle-cell disease; other risk factors include other hemoglobinopathies, immunocompromised status, and chronic Salmonella carrier state. The incidence of Salmonella osteomyelitis/septic arthritis in otherwise healthy individuals is rare. The duration of symptoms can range from a few months to several years, and multifocal involvement occurs in 15% of reported cases of Salmonella osteomyelitis. The symptoms of Salmonella osteomyelitis are pain and variable swelling of the affected limb; high temperatures are rarely noted. Our patient is a 19-year-old boy with no known past medical history who presented with severe right-sided sacroiliitis with extensive surrounding osteomyelitis on both sides of the sacroiliac joint with non-typhoidal, non-paratyphoidal Salmonella bacteremia.

Risk Factors of Coexisting Septic Spondylitis and Arthritis: A Case-Control Study in a Tertiary Referral Hospital

Introduction: In patients under immunosuppression or severe sepsis, it is sometimes manifested as coexisting septic arthritis and spondylitis. The aim of this study is to evaluate and investigate the risk factors of infectious spondylitis associated with septic arthritis. Methods: The study retrospectively reviewed the patients diagnosed with infectious spondylitis between January 2010 and September 2018 for risk factors of coexisting major joint septic arthritis. Results: A total of 10 patients with infectious spondylitis and coexisting septic arthritis comprised the study group. Fifty matched patients with solely infectious spondylitis were selected as the control group. Major risk factors include preoperative C-reactive protein (p = 0.001), hypoalbuminemia (p = 0.011), history of total joint replacement (p < 0.001), duration of preoperative antibiotics treatment (p = 0.038) and psoas muscle abscess (p < 0.001). Conclusion: Infectious spondylitis and septic arthritis are thought of as medical emergencies due to their high mortality and morbidity. Our study evaluated 5 risk factors as significant major findings: hypoalbuminemia (<3.4 g/dL), higher preoperative CRP (>130 mg/L), psoas muscle abscess, longer preoperative antibiotics treatment (>8 days) and history of total joint replacement. Clinicians should pay attention to the patients with those five factors to detect the coexisting infections as early as possible.

Septic Arthritis Masquerading as a Flare of Rheumatoid Arthritis: A Not So Straightforward Diagnosis

A typical presentation of septic arthritis (SA) includes pain, swelling, and erythema in the affected joint. Often, patients complain of inability to bear weight on the affected limb. However, some patients may present with subtle symptoms of pain and no fever or obvious swelling of the affected limb thus making the initial suspicion of SA low. Especially, patients with rheumatoid arthritis (RA) may present with polyarticular joint pain and initial synovial fluid analysis from an infected joint not consistent with overt septic arthritis. In such situations, the diagnosis of septic arthritis could be missed on delayed. In this case report, we present a 79-year-old female with a history of RA who presents with polyarticular pain, most notably in her right knee. SA was not initially suspected because of her history of RA and her current presentation with polyarticular pain. The initial synovial analysis did not suggest SA as well. However, cultures of synovial fluid from her right knee confirmed SA. Thus, we have highlighted that physicians should have a high suspicion for SA when addressing joint pain in RA patients.