Evaluation for septic arthritis of the native adult knee is aided by multivariable assessment.

INTRODUCTION: Evaluation of suspected septic arthritis of the native adult knee is a common diagnostic dilemma. Pre-aspirate criteria predictive of septic arthritis do not exist for the adult knee and investigations of aspiration results (cell count, differential, gram stain and crystal analysis) have been limited to univariate analyses. Given numerous clinical variables inform the risk of septic arthritis, multivariable analysis that incorporates all clinically available information is critical to allowing accurate decision-making. METHODS: We retrospectively identified 455 cases of potential septic arthritis of a native adult knee at a tertiary health system from 2012 to 2017, of which 281 underwent aspiration. We recorded demographics, comorbidities, history, exam, laboratory, and radiographic data. Among aspirated cases, we performed univariate analyses of all variables for association with septic arthritis followed by multivariable logistic regression analysis. RESULTS: Septic arthritis was confirmed in 61 of 281 patients who underwent aspiration. Independent associations of risk for septic arthritis included synovial fluid WBC ≥ 30,000 (Odds Ratio 90.8, 95% Confidence Interval 26.6-310.1, p < 0.001), bacteria reported on synovial fluid gram stain (OR 21.5, 95% CI 3.9-119.2, p < 0.001), duration of pain >2 days (OR 6.9, 95% CI. 2.3-20.9, p < 0.001), history of septic arthritis at any joint (OR 5.0, 95% CI 1.1-23.4, p = 0.039), clinical effusion (OR 4.8, 95% CI 1.2-20.0, p = 0.030). Independent associations protective against septic arthritis included presence of synovial fluid crystals (OR 0.1, 95% CI 0.1-0.4, p < 0.001). The multivariable model was highly accurate in discriminating between septic and aseptic cases (AUC = 0.942). A web-based tool was created to aid clinical decision-making. CONCLUSION: When evaluating for septic arthritis of a native adult knee, several independent associations were identified for variables related and unrelated to joint aspiration. The associated multivariable model discriminated very well between patients with and without septic arthritis, outperforming previous univariate assessments. A web-based tool was created that estimates the probability of septic arthritis based on this model. This may aid decision-making in complex clinical scenarios.

[Acute haematogenous osteomyelitis in children : Diagnostic algorithm and treatment strategies]. / Akute hämatogene Osteomyelitis im Wachstumsalter : Diagnostischer Algorithmus und Behandlungsstrategien.

Acute haematogenous osteomyelitis (AHO) in children is a severe condition. A delay in diagnosis and insufficient treatment may result in deformities, chronicity and sepsis. Therefore a structured diagnostic workup has to be followed in order to diagnose or rule out osteomyelitis. To identify the causative agent for targeted antibiotic treatment, a bone biopsy or puncture should be performed. However, approximately 25% of cases are culture-negative even after biopsy. The knowledge of the typical age-dependent bacterial spectrum is essential for empirical antibiotic therapy. The principal causative organism is Staphylococcus aureus. Surgery is not routinely required in paediatric acute osteomyelitis but surgical intervention is indicated if an abscess is detected. Secondary septic arthritis is a serious complication which has to be treated immediately by surgical intervention. Nevertheless, complete regeneration can be expected in up to 80% of children with AHO.

[Periprosthetic joint infections: a practical overview for family physicians]. / Infections de prothèse articulaire: aspects pratiques à l'attention du médecin de premier recours.

Periprosthetic joint infection is a rare but serious complication. Its management requires the collaboration between general practitioner, orthopaedic surgeon and infectious disease specialist. A delay in the diagnosis can result in complications, requiring complex surgical procedures. Identification of the causative pathogen and its susceptibility pattern is crucial, because it guides both the choice of antimicrobial treatment and the surgical strategy. Antimicrobial treatment without proper micro- biological sampling must be avoided. Swabs from open wounds are not helpful, because microorganisms belonging to the skin flora will grow. The target audience of this review article on periprosthetic joint infections is the general practitioner.

The Prognostic Value of a Novel Magnetic Resonance Imaging-Based Classification for Septic Arthritis of the Shoulder.

BACKGROUND: The purposes of the present study were (1) to create a magnetic resonance imaging (MRI)-based classification system for septic shoulder arthritis and to show the results of arthroscopic debridement based on the classification in eradicating the infection, and (2) to determine the distribution of the Gächter stages, which are determined on the basis of arthroscopic findings only, in each grade of the novel classification system. METHODS: The present study included 31 patients who underwent arthroscopic debridement for the treatment of acute septic arthritis of the shoulder between January 2001 and December 2015. The mean duration of follow-up was 2.3 years. The included patients were assessed with use of a novel classification system based on preoperative radiographic and MRI findings. MRI findings were classified as Grade I (only synovitis or joint effusion), Grade II (marrow edema in the bare area of the humeral head), Grade III (cartilaginous erosion), Grade IV (osseous erosion), and Grade V (osseous erosion on MRI also observed on radiographs). No changes on radiographs were observed in Grades I to IV. The intraclass correlation coefficients (ICCs) for interobserver and intraobserver reliability were calculated. RESULTS: The overall reinfection rate was 54.8% (17 of 31). Among patients with Grade-I, II, III, IV, and V involvement, the reinfection rates were 0 of 4, 1 of 6, 2 of 4, 9 of 12, and 5 of 5, respectively. A diverse distribution of Gächter stages were found in each grade of the novel classification system, with the exception of Grade V. The ICCs for interobserver and intraobserver reliability were 0.81 and 0.80 for the novel classification system. The ICCs for interobserver and intraobserver reliability were 0.75 and 0.78 for Gächter stages. CONCLUSIONS: This novel classification system for the grading of acute shoulder infections on the basis of radiographs and MRI allows preoperative grading of septic arthritis to be performed objectively. Patients who were classified as Grade III or higher in the novel classification system had higher reinfection rates than those who were classified as Grade I or II and required more aggressive treatment to eradicate the infection.

Stage-dependant management of septic arthritis of the shoulder in adults.

Diagnostic and therapeutic standards relating to septic conditions of the shoulder are rarely documented in the literature. For this study, patients suffering from septic shoulder arthritis were prospectively enrolled. Staging was based on the criteria of Gächter (Stutz et al., Knee Surg Sports Traumatol Arthrosc 8:270-274, 2000), and assessment of functional outcome was based on a self-assessed Constant score (Boehm et al., Unfallchirurg 107:397-402, 2004). Patients were separated into three groups according to the CEBI-classification reported by Pfeiffenberger and Meiss (Arch Orthop Trauma Surg 115:325-331, 1996). Forty-three patients were enrolled. Group I contained 21% of patients, while 23% were assigned to group II, and 56% to group III. Staphylococcus aureus was found in 71%. Eight patients were treated arthroscopically, and 35 received open surgery. None of the implants could be preserved. The mean self-assessed Constant score after 26 +/- 7 months was 74 +/- 9 points in group I, 63 +/- 14 points in group II, and 53 +/- 14 points in group III. Diagnostic work-up consisted of laboratory analysis including CRP and joint aspiration. Arthroscopic procedures can be effective when implemented early. With regard to implants and chronic symptoms, primary removal should be critically reconsidered.

Reactive arthritis: an update.

Arthritides tend to move in the classification flow sheet in a characteristic way: inflammatory--reactive--postinfectious--infective. A distinction between reactive and postinfective arthritis is rarely made in clinical practice and does not have therapeutic implications. In Finland, they are routinely lumped together and termed reactive arthritis (ReA). Native or modified HLA-B27 molecules may be directly involved in the pathogenesis of ReA, perhaps as targets for cytotoxic cells. Individuals with inadvertently strong non-specific inflammatory responses may be particularly disease-prone. The occurrence of different ensuing triggering infections in individual patients further confirms the idea that activation of the immune response and the immunogenetic make-up rather than the type and location of causative microbes as such are relevant. It is also possible that antigen processing of several microbe species of different types ends up with identical cross-reactive epitopes to be presented. It has been and certainly will to an increasing extent be reported that microbial antigens can be demonstrated in the diseased joints. It is assumed that they are involved in the local immune-inflammatory response manifesting clinically as arthritis. It has been shown that the cellular arm of the immune response is activated and for example that most of the local CD4 lymphocytes of chronic arthritides belong to the CDw29 helper-inducer memory cell subset, perhaps responding briskly to antigens originating from the triggering micro-organisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial arthritis in the adult.

A brief review of bacterial arthritis as seen at the Mayo Clinic in the years 1958 through 1973 has been presented with a selected literature review. Once considered a disease of children and adolescents, this disease now is seen more often in adults, especially in those who are elderly, are chronically ill, or are receiving medications that lower the host resistance in invading bacteria. The diagnosis must be made early, with rapid isolation and identification of the organism. Proper antibacterial drugs should be selected on the basis of in vitro susceptibility tests. The joint should be either aspirated or decompressed by closed suction-irrigation. In instances in which diagnosis is late and joint destruction occurs, joint débridement will be necessary.

Primary meningococcal arthritis: case report and review of the literature.

Meningococcal arthritis is a recognized manifestation of Neisseria meningitidis infection, the presentation of which may be confusing. Although arthritis occurs in the setting of meningococcal meningitis, it may also be seen as a primary event without neurological involvement and with or without cutaneous manifestations. We describe a patient with primary meningococcal arthritis and review the literature relating to the clinical types and pathogenic mechanisms. Comparisons of patient series from 1980 to the present with those reported before 1980 are described.

Treatment of the sequelae of septic osteoarthritis of the hip during pediatric age.

A total of 69 cases (73 hips) of the sequelae of septic osteoarthritis of the hip are studied. The sequelae are classified based on whether or not the femoral epiphysis is present, and on stability of the joint according to Hunka (1982). Three of the hips were treated non-surgically. All of the others were submitted to from a minimum of 2 to maximum of 5 operations with the purpose of re-establishing joint relationships. The results were: good: 50 hips (72.5%); fair 12 (17.4%); poor: 11 (16%). The most significant sequelae were hip instability, joint function limitation, and shortening of the limb.

Extra capsular extrusion of femoral capital epiphysis - an unusual presentation of sequelae of septic arthritis of hip.

Presentations of sequelae of septic hip in infants have been classified by various researchers, depending on the presence or absence of femoral capital epiphysis in acetabulum. This case report describes an unusual presentation of sequelae of septic arthritis of hip in which femoral capital epiphysis had extruded outside the capsule of hip joint in a 1 year and 6-months-old boy.

Artritis séptica de cadera en la infancia: clasificación práctica de sus secuelas / Septic arthritis of the hip in childhood: practical classification of sequelae

Introducción: En determinadas circunstancias, la artritis séptica de cadera puede generar secuelas de diversa magnitud. El objetivo de este estudio fue diseñar y aplicar una clasificación radiográfica, concisa e inclusiva, de las secuelas. Confiabilidad: avalada por el índice de Kappa intraobservador e interobservador. Materiales y métodos: Estudio de observación, retrospectivo de 32 pacientes (37 caderas) con secuelas de sepsis articular, admitidos y tratados en nuestro hospital, en un período de 14 años. Se incluyeron niños menores de 15 años, con un seguimiento mínimo de 2 años. El análisis estadístico se realizó con el programa SPSS 15.0. Variables: edad, sexo y cadera afectada. Las caderas secuelares, según sus lesiones específicas, fueron incluidas en la siguiente clasificación por grados: 1 o sin cambios; 2 o incongruentes; 3 o excéntricas y 4 o luxadas. Resultados: Edad promedio 3 años y 9 meses. Predominio femenino (68 por ciento) Todos los casos bilaterales fueron niñas (p <0,02). Doce caderas grado 1, cuatro grado 2, once grado 3 y diez grado 4. Secuelas predominantes: coxa vara y ascenso del trocánter mayor. De los pacientes secuelares (25 caderas), 16 tuvieron afectaciones múltiples. El índice de Kappa fue de 0,93 para el intraobservador y de 0,66 para el interobservador, expresando alta confiabilidad. Conclusiones: La clasificación Ludovica, avalada estadísticamente, cumple con los requisitos que nos propusiéramos: que sea breve y concisa, inclusiva de las diferentes secuelas; requiere únicamente radiografías, es fácil de retener y transmitir y, finalmente, permite inferir lineamientos terapéuticos. Es más sencilla que otras publicadas hasta la fecha. Nivel de evidencia: IV estudio de observación, Retrospectivo de serie de casos

[Sequelae of septic hip arthritis in infancy].

Septic arthritis of the hip represents a serious pathological condition which results in severe sequelae and high invalidity. The most serious sequelae are seen in neonatal and infantile period, when normal growth and development are brutally disturbed, followed by proximal femoral destruction and acetabular dysplasia, which in return result in anatomical limb shortening and functional deficiency. In order to achieve an adequate approach to the treatment of septic hip arthritis sequelae, different classification systems have been developed. Two of them are the most cited in literature: classification according to Hunka, and that according to Choi and associates. In this article, the authors compared both classification systems, presented their similarities and differences, and expanded them in view of treatment options applicable to each category. Although both classifications are based on radiographic findings, it has been shown that they clearly tell between treatment options relevant to particular type of sequelae of the septic hip arthritis, thus representing a useful tool in making decision about adequate treatment.

The host and the skeletal infection: classification and pathogenesis of acute bacterial bone and joint sepsis.

Bone and joints are normally sterile areas. Bacteria may reach these sites by either haematogenous spread or spread from an exogenous or endogenous contiguous focus of infection. Bone infection, or osteomyelitis, is characterized by a progressive infectious process resulting in inflammatory destruction of bone, bone necrosis and new bone formation. Joint infections, or infectious arthritis, arise either from the haematogenous spread of organisms through the highly vascularized synovial membrane or from direct extension of a contiguous bone or soft tissue infection. The most commonly involved joints are the knee and the hip, although any joint can become infected. Infectious arthritis is monoarticular in 90% of cases. Some of the questions to be answered in this chapter include: how bacteria reach and cause damage in the bones and joints; what the current classification systems of bone and joint infections are; what some risk factors and host factors associated with bone and joint infection are; what some current characteristics of musculoskeletal infections are and whether the damage to joints can be diminished by treatment.

[Septic arthritis in newborns and infants. Treatment of hip arthritis]. / Ropne zapalenia stawów u noworodków i niemowlat Leczenie zapalen stawu biodrowego.

Results of treatment of 83 septic hip joints in 75 newborns and infants have been presented. Mean age at the onset of symptoms was 41 days (from 1 to 330 days), mean follow-up was 72 months (from 12 to 252). In 26 cases systemic antibiotics were administered. Single joint puncture was done in 7 cases, in 23 patients multiple puncture and intraarticular antibiotic therapy were employed, arthrotomy and drainage of the joint was performed in 27 joints. Radiographic results achieved, according to Hunk classification were as follows: Type I-26 joints, Type IIA-6 joints, Type IIB-18 joints, Type III-5 joints, Type IVA-7 joints, type IVB-8 joints, Type V13 joints. The authors conclude, that in majority of cases the treatment of choice should include arthrotomy from antero-lateral approach, suction drainage for 24-48 hours, systemic intravenous antibiotic therapy, abduction position of extremity in Frejka pillow and early physiotherapy.

Early arthritides: nosography, nosology, and diagnostic criteria.

Follow-up studies of patients with early arthritides are sparse and they are usually restricted to certain diagnostic groups. Therefore 141 unselected patients suffering from arthritis since no more than 12 months were entered into a prospective study. The largest group (n = 57, 40%) consisted of patients with definite rheumatoid arthritis. Forty individuals (28%) were judged to have undifferentiated arthritis since they could not be classified according to established diagnostic criteria initially. After 9 +/- 3 months mean follow-up only 21 of 45 patients (47%) fulfilling criteria for definite rheumatoid arthritis at the onset of the study remained in this category, 9 (20%) still suffered from arthritis but they met less than 5 ARA criteria, and 15 (33%) went into remission. Among 50 patients with undifferentiated arthritis or spondylarthropathy an even smaller proportion of 16 individuals (32%) still had arthritis, which could not be classified, whereas 34 (68%) showed no signs of persisting peripheral arthritis. Thus, criteria diagnoses are inadequate for the selection of the patients at the onset of the disease since they are frequently false positive and they omit other arthritides important for differentiation. Further disadvantages of criteria diagnoses are evident: they imply a large spectrum of manifestations of the disease, they overlap with other entities, they do not provide sufficient information regarding the prognosis and adequate treatment. To improve the prognostic value of a nosological classification a concept of descriptive diagnoses is discussed.

[Reactive arthritis. A review]. / Artritis reactivas. Revision.

The arthritides that meet the definition or reactive arthritis include the so-called seronegative spondyloarthropathies. Patients are usually aged less than thirty-two. Preceding infection is generally intestinal or venereal, although the involved agent may remain unknown. Enteric forms occur in small epidemics, whereas venereal forms correlate with a recent new sexual partner. The clinical picture varies in severity, with manifestations overlapping between disorders, and often the first complaint is extra-articular. Highly suggestive of reactive arthritis is "sausage" deformity of fingers and toes, pain and stiffness about multiple joints accompanied by radiating lower back discomfort, and enthesitis, particularly at the Achilles tendon. One out of six or seven patients becomes disabled; therapy aimed at preventing disability is vital since medication has little effect on spinal involvement. Antibiotic therapy may be effective in cases in which specific etiologic agents are well defined.

Infection and arthritis.

The categorization in four classes of association between infection and arthritis (namely infective, post-infective, reactive and idiopathic) seems nowadays to be inadequate to cover the extensive field of interactions between infectious agents and host response resulting in arthritis. This paper is a synthetic review of the subject with particular reference to pathogenetic mechanisms in children. An effort has been accomplished, on the basis of the most recent literature, to define the respective roles of the microbial aggression and the host response in a number of conditions: septic arthritis, viral arthritides, Lyme arthritis, rheumatic fever, Reiter's syndrome, ankylosing spondylitis and rheumatoid arthritis.

Prognosis in septic arthritis of the hip in children.

Thirty-eight children (39 hips) with septic arthritis have been reviewed in an effort to determine the factors most important to prognosis of the hip joint. The younger patients, 3 or more years later, had poorer results by roentgenographic classification. This was particularly true of patients under one year of age. Longer duration of disease from clinical onset to initiation of therapy also resulted in a poorer result. The outcome could not be clearly correlated with the causative organism or with open as opposed to closed treatment although the policy of management was strongly biased to open drainage. Sixty per cent of the infections were caused by Staphylococcus aureaus and the majority of the other cases by Streptococcus pyogenes and Hemophilus influenzae. The nonstaphylococcal organisms may be less destructive to the femoral head in infants.