Age and C-reactive protein as modifiers of Kocher criteria in pediatric septic knee monoarthritis.

INTRODUCTION: Although Kocher criteria can distinguish a septic hip from an aseptic cause, they may not apply to a septic knee. We aimed to identify predictors to discriminate septic and aseptic causes of acute knee monoarthritis in children who underwent arthrocentesis. METHODS: We conducted a retrospective cohort study among children who underwent arthrocentesis for suspected septic arthritis of the knee. Collected data included demographic, clinical and laboratory characteristics. We performed univariate and multivariable analyses to identify predictors of the septic knee. We further investigated accuracy of different predictive models. RESULTS: A total of 60 patients who underwent arthrocentesis for suspected knee septic arthritis were included in this study. Septic arthritis of the knee was confirmed in 32 (53%) patients. Age ≤ 5 years (OR 4.237, [95% CI 1.270-14.127], p = 0.019), WBC > 12,000 cells/mm3 (OR 5.059, [95% CI 1.424-17.970], p = 0.012), and CRP > 2 mg/dL (OR 3.180, [0.895-11.298], p = 0.074) were the most important predictors of a septic knee. Three-tier model comprising these three factors (AUC 0.766) and 4-tier model with addition of fever >38.5°C (AUC 0.776) performed better than Kocher criteria (AUC 0.677), modified Kocher criteria (AUC 0.699) and Full Model (adding age ≤ 5 years and CRP >2 mg/dL to Kocher criteria) (AUC 0.746). Full Model successfully ruled out septic arthritis if all 6 criteria were negative. CONCLUSION: Based on these findings, we propose an algorithm to identify low, intermediate and high-risk patients for knee septic arthritis. Our proposed two-step algorithm incorporating major (age, WBC, CRP) and minor (fever, ESR, non-weight bearing) criteria can serve as a simple decision-support tool to justify arthrocentesis in children with suspected knee septic arthritis.

Investigation of synovial fluid lubricants and inflammatory cytokines in the horse: a comparison of recombinant equine interleukin 1 beta-induced synovitis and joint lavage models.

BACKGROUND: Lameness is a debilitating condition in equine athletes that leads to more performance limitation and loss of use than any other medical condition. There are a limited number of non-terminal experimental models that can be used to study early inflammatory and synovial fluid biophysical changes that occur in the equine joint. Here, we compare the well-established carpal IL-1ß-induced synovitis model to a tarsal intra-articular lavage model, focusing on serial changes in synovial fluid inflammatory cytokines/chemokines and the synovial fluid lubricating molecules lubricin/proteoglycan 4 and hyaluronic acid. The objectives of this study were to evaluate clinical signs; synovial membrane and synovial fluid inflammation; and synovial fluid lubricants and biophysical properties in response to carpal IL-1ß synovitis and tarsal intra-articular lavage. RESULTS: Hyaluronic acid (HA) concentrations, especially high molecular weight HA, and synovial fluid viscosity decreased after both synovitis and lavage interventions. Synovial fluid lubricin concentrations increased 17-20-fold for both synovitis and lavage models, with similar changes in both affected and contralateral joints, suggesting that repeated arthrocentesis alone resulted in elevated synovial fluid lubricin concentrations. Synovitis resulted in a more severe inflammatory response based on clinical signs (temperature, heart rate, respiratory rate, lameness and joint effusion) and clinicopathological and biochemical parameters (white blood cell count, total protein, prostaglandin E2, sulfated glycosaminoglycans, tumor necrosis factor-α and CC chemokine ligands - 2, - 3, - 5 and - 11) as compared to lavage. CONCLUSIONS: Synovial fluid lubricin increased in response to IL-1ß synovitis and joint lavage but also as a result of repeated arthrocentesis. Frequent repeated arthrocentesis is associated with inflammatory changes, including increased sulfated glycosaminoglycan concentrations and decreased hyaluronic acid concentrations. Synovitis results in more significant inflammatory changes than joint lavage. Our data suggests that synovial fluid lubricin, TNF-α, CCL2, CCL3, CCL5, CCL11 and sGAG may be useful biomarkers for synovitis and post-lavage joint inflammation. Caution should be exercised when performing repeated arthrocentesis clinically or in experimental studies due to the inflammatory response and loss of HA and synovial fluid viscosity.

Low frequency of septic arthritis after arthrocentesis and intra-articular glucocorticoid injection.

Objective: The aim of this study was to evaluate the risk of septic arthritis (SA) in patients who received an intra-articular (IA) glucocorticoid (GC) injection and to describe the characteristics of these patients. Methods: All patients undergoing IA procedures at the orthopaedic and rheumatological departments on the Danish island of Funen from January 2006 to December 2013 were identified in the central database and included by register extraction. Patients who developed a clinically inflamed joint and positive synovial fluid culture within 14 days after IA GC injection were considered as having SA. Retrospectively, data on age, gender, affected joint location, bacterial agent, pre-existing inflammatory disorder, and death within 30 days were extracted from the patient files. According to local recommendations, a non-touch sterile technique was used for IA procedures. Patients were informed about the risk of SA and advised to seek medical attention on suspicion of infection or lack of improvement. Results: In total, 22 370 IA procedures were performed. Among these, 14 118 GC injections and 8252 arthrocenteses were undertaken. Only 11 patients were diagnosed with SA (0.08%, 95% confidence interval 0.03-0.12). Risk factors for SA were male gender, age, and pre-existing joint disease. Conclusion: We found a low frequency of SA subsequent to IA GC injections. Older patients with pre-existing joint disease are at higher risk of developing SA.

Can Diagnostic and Therapeutic Arthrocentesis Be Successfully Performed in the Flexed Knee?

BACKGROUND/OBJECTIVE: The objective of this study was to determine whether the extended or flexed knee positioning was superior for arthrocentesis and whether the flexed knee positioning could be improved by mechanical compression. METHODS: Fifty-five clinically effusive knees underwent arthrocentesis in a quality improvement intervention: 20 consecutive knees in the extended knee position using the superolateral approach, followed by 35 consecutive knees in the flexed knee position with and without an external compression brace placed on the suprapatellar bursa. Arthrocentesis success and fluid yield in milliliters were measured. RESULTS: Fluid yield for the extended knee was greater (191% greater) than the flexed knee (extended knee, 16.9 ± 15.7 mL; flexed knee, 5.8 ± 6.3 mL; P < 0.007). Successful diagnostic arthrocentesis (≥2 mL) was 95% (19/20) in the extended knee and 77% (27/35) in the flexed knee (P = 0.08). After mechanical compression was applied to the suprapatellar bursa and patellofemoral joint of the flexed knee, fluid yields were essentially identical (extended knee, 16.9 ± 15.7 mL; flexed knee, 16.7 ± 11.3 mL; P = 0.73), as were successful diagnostic arthrocentesis (≥2 mL) (extended knee 95% vs. flexed knee 100%, P = 0.12). CONCLUSIONS: The extended knee superolateral approach is superior to the flexed knee for conventional arthrocentesis; however, the extended knee positioning and flexed knee positioning have identical arthrocentesis success when mechanical compression is applied to the superior knee. This new flexed knee technique for arthrocentesis is a useful alternative for patients who are in wheelchairs, have flexion contractures, cannot be supine, or cannot otherwise extend their knee.

Inadvertent Introduction of Tissue Coring Into Joints During Arthrocentesis: An Experimental Study.

BACKGROUND The aim of this study was to investigate whether needles introduce skin plugs into joints during arthrocentesis. MATERIAL AND METHODS In the first part of this study, the arthrocentesis site was scrubbed with a fluorescein sodium swab, and 90 needles were inserted through the joint tissue and collected for examination under a fluorescence microscope. In the second part of this study, the joints were injected using 720 needles of different gauges. Two different randomly assigned needle insertion techniques were used: needle insertion straight through the joint capsule (subgroup 1) or insertion of the needle into the subcutaneous tissue followed by flushing of the needle with 0.5 mL of 0.9% normal saline prior to advancing the needle through the joint capsule (subgroup 2). RESULTS Of the 90 needle tips examined in the first part of this study, 21 had high-grade fluorescein contamination. In the second part of this study, the incidence of tissue, epidermis, and dermis contamination in subgroup 1 was 57.2%, 43.1%, and 25.0%, respectively. There was no significant difference in the incidence among different gauge needles, except for a difference in epidermis contamination between the 21-gauge and 23-gauge needles. Compared to subgroup 1, subgroup 2 had a significantly lower OR for tissue contamination. CONCLUSIONS It is common to introduce tissue coring with epidermis and dermis into the joint during arthrocentesis, which poses a potential risk for septic arthritis. However, tissue contamination of the joint may be reduced by flushing saline through the needle into the subcutaneous tissues prior to entering the joint capsule.

Algorithm to Diagnose Delayed and Late PJI: Role of Joint Aspiration.

Total Joint Arthroplasty (TJA) continues to gain acceptance as the standard of care for the treatment of severe degenerative joint disease, and is considered one of the most successful surgical interventions in the history of medicine. A devastating complication after TJA is infection. Periprosthetic joint infection (PJI), represents one of the major causes of failure and remains a significant challenge facing orthopaedics today. PJI usually requires additional surgery including revision of the implants, fusion or amputations causing tremendous patient suffering but also a heavy health economics burden. PJI is at the origin of around 20-25 % of total knee arthroplasty (Bozic et al. 2010; de Gorter et al. 2015; Sundberg et al. 2015) and 12-15 % of total hip arthroplasty (Bozic et al. 2009; Garellick et al. 2014; de Gorter et al. 2015) failures.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short Term for Improving Function and Quality of Life After Arthrocentesis? Part 2.

PURPOSE: Although arthrocentesis has been used for the management of patients with temporomandibular joint pain, the benefit of hyaluronic acid (HA) or corticosteroid (CS) remains uncertain. The purpose of this study was to assess the efficacy of HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis for changes in quality of life (QoL), jaw function (Jaw Function Limitation Scale [JFLS] score), and maximum incisal opening (MIO). MATERIALS AND METHODS: This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then instillation of HA, CS, or LR. All patients were evaluated clinically at 1 and 3 months. The outcome variables were QoL, JFLS score, and MIO. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant. RESULTS: One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for analysis of data at 1 month. An additional 51 were lost to follow-up at 3 months, leaving 51 patients for data analysis at this time point. There was no difference among groups for QoL Mental Health Composite score at 1 month (P = .70) or 3 months (P = .69). There was no difference among groups for JFLS score at 1 month (P = .71) or 3 months (P = .98). There was no difference among groups for MIO at 1 month (P = .47) or 3 months (P = .31). All groups showed within-group improvements in JFLS score and MIO at 1 and 3 months. CONCLUSION: Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in improving jaw function and MIO at 1 and 3 months. QoL is not improved with arthrocentesis alone or in combination with CS or HA.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short-Term Reduction of Temporomandibular Joint Pain After Arthrocentesis? Part 1.

PURPOSE: Arthrocentesis has been used for the management of patients with temporomandibular joint (TMJ) pain, with good success. The additional use of hyaluronic acid (HA) or corticosteroid (CS) remains controversial. The purpose of this study was to compare HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis. MATERIALS AND METHODS: This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then the instillation of HA, CS, or LR. Patients were evaluated clinically at 1 and 3 months. The primary outcome variable was pain at 1 month (by visual analog scale). Secondary outcome variables were pain at 3 months and analgesic consumption. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant. RESULTS: One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for the final analysis. The mean age of patients in the HA, CS, and LR groups was 39.6, 44.3, and 51.8 years, respectively (P = .02). There was no difference among groups in time to follow-up at 1 month (P = .11). The mean decrease in pain in the CS group was 19% for right-side procedures (P = .12) and 36% for left-side procedures (P = .02). The mean decrease in pain in the HA group was 31% for right-side procedures (P = .01) and 34% for left-side procedures (P = .01). The mean decrease in pain in the LR group was 43% for right-side procedures (P < .01) and 37% for left-side procedures (P < .01). There was no difference in pain decrease among groups (P = .55). There was no difference in the use of narcotic (P = .52) or nonsteroidal anti-inflammatory drugs (P = .71) among groups. CONCLUSION: Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in decreasing TMJ pain.

Signs and symptoms after temporomandibular joint washing and cannula placement assessed by cone beam computerized tomography.

OBJECTIVE: Analyses of temporomandibular joint synovial fluid using the hydroxocobalamin push-pull technique are increasingly used. However, objective complications and subjective experiences from this procedure have not been described. Firstly, this study aimed to describe discomfort and potential side-effects of this method with special emphasis on symptoms related to the arthrocentesis to be used for future patient information and Ethical Committee applications. Secondly, this study aimed to evaluate the use of cone beam computed tomography (CBCT) as control of intra-capsular cannula placement. METHODS: Twenty healthy, young adult volunteers were included. Extensive objective and subjective questionnaires were completed before and 14 days after the synovial fluid sampling. With the cannula inside the joints a CBCT was done to investigate if this procedure can be used to verify intra-capsular cannula position. RESULTS: The subjective findings: Most subjects did experience mild pain or discomfort post-operatively. In 12 of 20 subjects symptoms had resolved after 2 days and no subjects had symptoms for more than a week. The longer lasting symptoms were mainly transient joint sounds on mandibular movement. Objective findings: 14 days after the sampling mandibular protrusion had improved 1 mm, but all other objective measures were equal compared to baseline. CBCT showed a large variation in cannula position and no conclusions could be drawn from this. CONCLUSION: The hydroxocobalamin push-pull synovial fluid sampling may cause minor, transient symptoms. CBCT does not seem to provide any clinical benefits concerning the correct cannula position in relation to the upper joint compartment and disc.

Complications and post-operative sequelae of temporomandibular joint arthrocentesis.

OBJECTIVE:  To evaluate intraoperative complications and postsurgical sequelae associated with arthrocentesis of the TMJ, including injection of Sodium Hyaluronate. METHODS: This retrospective study evaluated 433 arthrocentesis procedures performed in 315 patients between January 2009 and August 2016. The authors reviewed the complications identified during the procedure and the follow-up period. RESULTS: Temporary swelling of the periarticular tissues (95.1%) or the external auditory canal (23.5%), ipsilateral temporary open bite (68.8%), frontalis and orbicularis oculis paresis (65.1%), preauricular hematoma (0.4%), and a case of vertigo (0.2%) were the complications detected. CONCLUSIONS: TMJ arthrocentesis remains a procedure with a minimum number of important complications. If present, complications are generally temporary, caused by the anesthetic effect or by the soft tissue edema created by the fluid extravasation created by the irrigation procedure, and can be managed on an outpatient basis.

The use of intra-articular analgesics to improve outcomes after temporomandibular joint arthrocentesis: a review.

PURPOSE: The aim of this review was to assess the efficacy of intra-articular analgesics in improving outcomes after temporomandibular joint (TMJ) arthrocentesis. MATERIAL AND METHODS: An electronic search of PubMed, Scopus, and Google scholar databases was performed for papers in English published up to December 2017 reporting the use of intra-articular analgesics after TMJ arthrocentesis. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), comparative studies, retrospective studies, and case series were included while case reports, technical reports, animal studies, cadaveric studies, and review papers were excluded. RESULTS: Of the six studies included in the review, three were RCTs, two were randomized comparative studies, and one was a retrospective study. Both opioids and non-steroidal anti-inflammatory drugs have been used after TMJ arthrocentesis. Morphine, tramadol, fentanyl, buprenorphine, tenoxicam, and COX-2 inhibitors are the drugs used till date. Placebo-controlled studies reported improved outcomes after TMJ arthrocentesis with morphine and fentanyl but no such results with buprenorphine and tenoxicam. Tramadol was found to be better than COX-2 inhibitor. The quality of literature was not high. CONCLUSIONS: There is inconclusive evidence in literature on the benefits of using intra-articular analgesics after TMJ arthrocentesis. Well-designed high-quality RCTs with standard protocol studying the effects of intra-articular opioids and NSAIDS after TMJ arthrocentesis would provide stronger evidence on its use.

Vertiginous crisis following temporomandibular joint athrocentesis: a case report.

Temporomandibular joint arthrocentesis and arthroscopy have recently exceeded open surgeries for disorders that failed to respond to conservative treatment. The efficacy of arthrocentesis in reestablishing normal mouth opening and reducing pain and dysfunctions is now commonly accepted, but in contrast to arthroscopy, there are no large series studies on arthrocentesis complications. We report the major complication occurred in our experience: a case of a patient that complained of a violent vertigo, without hearing disorders, following the procedure.

[How to do: joint puncture]. / Die Gelenkpunktion.

Arthrocentesis is a targeted way to an exact diagnosis and efficient therapy. The procedure is poor in complication.

Diagnostic Arthrocentesis for Suspicion of Gout Is Safe and Well Tolerated.

OBJECTIVE: To determine the frequency of adverse events of diagnostic arthrocentesis in patients with possible gout. METHODS: Consecutive patients underwent arthrocentesis and were evaluated at 6 weeks to determine adverse events. The 95% CI were obtained by bootstrapping. RESULTS: Arthrocentesis was performed in 910 patients, and 887 (97.5%) were evaluated for adverse events. Any adverse event was observed in 12 participants (1.4%, 95% CI 0.6-2.1). There was 1 case (0.1%, 95% CI 0-0.34) of septic arthritis. CONCLUSIONS: Diagnostic arthrocentesis is associated with a low frequency of adverse events. Septic arthritis rarely occurs.

Is it safe to perform joint infiltrations or aspirations in patients anticoagulated with acenocoumarol?

The purpose of this study is to determine the rate of bleeding complications in patient's anticoagulated with acenocoumarol according to the international normalized ratio (INR) coagulation index. A cross-sectional study was performed with 901 charts of patients who underwent arthrocentesis or joint infiltration between 2009 and 2013; the charts were grouped on the basis of having an INR higher or lower than 2.0 (268 and 633, respectively). Comparisons were performed in terms of rates of early or late bleeding complications. A 0.37% rate of early bleeding complications (< 24hours) was observed in the group of patients with INR<2 and 0.99% in the group of patients with INR≥2 (P=.47). Only one case of late complication was presented by bleeding between 24 hours and 30 days, in the group of patients with INR≥2. We conclude that oral anticoagulation with acenocoumarol at terapeutical doses does not increase the risk of bleeding joint punctures.

Joint Aspiration for Acute Hemarthrosis in Children Receiving Factor VIII Prophylaxis for Severe Hemophilia: 11-year Safety Data.

OBJECTIVE: The aims of this study were (1) to document the prevalence of acute hemarthrosis in a cohort of 46 boys with severe hemophilia A receiving full primary prophylaxis in Western Australia (WA), and (2) to investigate the safety of the WA protocol over 11 years for management of hemarthrosis. METHODS: Case review. The WA protocol involves a pediatric rheumatologist washing out all acute hemarthrosis of large joints promptly and then instilling intraarticular (IA) corticosteroids. RESULTS: This study showed that joint bleeds occurred in 22 boys of 46 (47.8%). In over 11 years, 84 washouts were performed on 32 joints in 22 boys. No adverse events occurred. Fifteen of 22 boys had normal joints with a Hemophilic Joint Health Score = 0. Fifteen boys who had had all hemarthrosis washed out had clinically normal joints (100%). Seven boys had sustained joint damage prior to full instigation of the protocol, each having had documented hemarthrosis without aspiration. Parents needed to understand that joint bleeds constituted an emergency. CONCLUSION: Of our cohort, 47.8% of patients with severe hemophilia receiving prophylaxis developed joint bleeding. The WA protocol is safe. There is evidence suggesting joint outcomes of hemophilic patients having hemarthrosis despite factor VIII prophylaxis may be much improved if there is access to a center using a procedure similar to the WA protocol.

In vitro assessment of bacterial translocation during needle insertion through inoculated culture media as a model of arthrocentesis through cellulitic tissue.

OBJECTIVE: To determine by use of an in vitro model the potential for translocating sufficient numbers of bacteria into a joint during arthrocentesis through cellulitic tissue to cause sepsis. SAMPLE: Culture media containing 4 concentrations of Staphylococcus aureus and needles of 3 sizes. PROCEDURES: Needles (22, 20, and 19 gauge) were inserted through Mueller-Hinton agar that contained known concentrations of S aureus (10(3),10(4),10(5), and 10(6) CFUs/mL). After a needle exited through the medium, any agar plug within the needle bore was ejected into a sterile syringe and the contaminated portion of the needle was harvested. Sterile saline (0.9% NaCl) solution was used to emulsify the agar plug and wash the contaminated portion of the needle. The resulting solution was cultured to determine the number of bacterial CFUs that could be deposited into a joint during arthrocentesis through contaminated tissue. RESULTS: Needle gauge and bacterial concentration were both associated with the number of bacterial CFUs deposited after insertion through contaminated agar. Although all needle sizes were capable of bacterial translocation sufficient to cause septic arthritis, ORs for 20- and 22-gauge needles translocating > 33 CFUs of S aureus were significantly higher than the OR for a 19-gauge needle. The ORs for 20- or 22-gauge needles translocating > 33 CFUs of S aureus (the minimum population of S aureus known to cause joint sepsis) were 0.22. CONCLUSIONS AND CLINICAL RELEVANCE: Results for this in vitro model indicated that caution should be used when performing arthrocentesis through cellulitic tissue.