De novo vesico-acetabular fistula presenting with septic arthritis: Case report and literature review.

Vesico-acetabular fistula formation is a rare condition typically associated with total hip arthroplasty. Clinical features can include pain of the hip and flank, haematuria, and dysuria. We report the case of a 67-year-old female with a past medical history of bilateral pelvic fractures and calcium hydroxyapatite deposition disease of the hip joint, who developed vesico-acetabular fistula in the absence of surgery. This was then complicated by septic arthritis. We highlight the ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) findings of the case and review the previous case reports describing the vesico-acetabular fistula.

MRI in shoulder arthropathies: A short review.

Arthropathies are a frequent cause of shoulder pain and comprise of a wide range of clinical entities that may pose a diagnostic challenge. Though history and clinical examination remain vital, imaging plays a pivotal role in accurate diagnosis. Magnetic resonance imaging (MRI) remains an invaluable tool for imaging evaluation of shoulder involvement by various arthropathies. With attention to characteristic imaging features, radiologist may be able to differentiate between various disease processes affecting the shoulder joint. In this article, we have provided a brief review of common and uncommon MRI manifestations of various arthropathies affecting the shoulder joint.

Orthopedic Articular and Periarticular Joint Infections.

Acute nontraumatic joint pain has an extensive differential. Emergency physicians must be adept at identifying limb and potentially life-threatening infection. Chief among these is septic arthritis. In addition to knowing how these joint infections typically present, clinicians need to be aware of host and pathogen factors that can lead to more insidious presentations and how these factors impact the interpretation of diagnostic tests.

Associations with unplanned repeat irrigation and debridement of native septic arthritis.

PURPOSE: To identify associations with unplanned repeat irrigation and debridement (I&D) after arthrotomy for native septic arthritis. METHODS: A retrospective review identified patients with native septic arthritis treated with open arthrotomies. The primary outcome was unplanned repeat I&D within 90 days. Associations evaluated for included comorbidities, ability to bear weight, fever, immunosuppressed status, purulence, C-reactive protein, erythrocyte sedimentation rate, white blood cell count (synovial fluid and serum levels), and synovial fluid polymorphonuclear cell percentage (PMN%). RESULTS: There were 59 arthrotomies in 53 patients involving the knee (n = 32), shoulder (n = 10), elbow (n = 8), ankle (n = 6), and hip (n = 3). The median patient age was 52, and a 71.2% were male. An unplanned repeat I&D was required in 40.7% (n = 24). The median time to the second I&D was 4 days (interquartile range 3 to 9). On univariate analysis, unplanned repeat I&Ds were associated with fever (p = 0.03), purulence (p = 0.01), bacteria growth on cultures (p = 0.02), and the use of deep drains (p = 0.05). On multivariate analysis, the only variables that remained associated with unplanned repeat I&Ds were fever (odds ratio (OR) 5.5, 95% confidence interval (CI) 1.3, 23.6, p = 0.02) and purulence (OR 5.3, CI 1.1, 24.4, p = 0.03). CONCLUSIONS: An unplanned repeat I&D was required in 40.7% of patients and was associated with fever and purulence. These findings highlight the difficulty of controlling these infections and support the need for future research into better methods of management. LEVEL OF EVIDENCE: Diagnostic, Level III.

Clinical characteristics of neonatal and infant osteomyelitis and septic arthritis: a multicenter retrospective study.

OBJECTIVE: Signs and symptoms of osteomyelitis or septic arthritis in neonates and infants are often nonspecific and early-stage bone infections in infants may often go unnoticed. The objective of this study was to analyze the clinical characteristics of newborns and infants with osteomyelitis and septic arthritis to improve understanding of the disorder and to assist clinicians with diagnosis. METHODS: A retrospective multicenter study was conducted on neonates (0-28 days old, n = 94) and infants (1-12 months old, n = 415) with osteoarticular infections. Data consisting of clinical characteristics, complications, laboratory outcomes, and the pathogenic microorganisms causing osteomyelitis were tabulated. The statistics were further broken down into two regions and the significant differences between neonates and infants were evaluated and compared to the literature. RESULTS: Compared to infants, neonates had significantly lower incidences of fever (p < 0.0001), higher incidences of localized swelling (p = 0.0021), higher rate of infection at the humerus (p = 0.0016), higher percentage of Escherichia coli (p < 0.0001) and Klebsiella pneumoniae (p = 0.0039) infections, lower percentage of Staphylococcus aureus infections (p < 0.0001) and were more likely to develop septic arthritis (p < 0.0001). CONCLUSION: Distinct differences were found between neonatal and infants with osteoarticular infections. Future studies should focus on improving diagnosis and subsequent treatment regimens for younger age groups.

Pharmacokinetics of amikacin after intravenous, intra-articular, and combined intravenous and intra-articular administration in healthy neonatal foals.

BACKGROUND: Pharmacokinetics of amikacin administered IV to neonatal foals are described, but little data are available regarding the plasma concentrations contributed by concurrent intra-articular (IA) administration. HYPOTHESIS/OBJECTIVES: Compare the pharmacokinetics of amikacin when the total dose is administered IV compared to being divided between IV and IA routes of administration in neonatal foals and predict the plasma concentrations from various combined IV and IA dosing regimens. ANIMALS: Eight healthy neonatal foals. METHODS: Foals received 3 amikacin treatment protocols: (1) IV-only (25 mg/kg q24h IV), (2) concurrent IV and IA (16.7 mg/kg q24h IV and 8.3 mg/kg q24h into 1 tarsocrural joint), and (3) IA-only (8.3 mg/kg q24h into 1 tarsocrural joint). Protocols were administered for 3 days beginning at 7, 14, and 21 days of age. Plasma concentrations ≥53 µg/mL at 30 minutes were considered therapeutic for isolates with intermediate susceptibility. RESULTS: Foal age was a significant variable. The IV-only protocol met or exceeded the 30-minute plasma concentrations considered therapeutic (mean µg/mL [95% confidence interval, CI]) in 7- to 9-day-old (54.0 [52.2-56.9]), 14- to 16-day-old (58.1 [55.2-61.0]), and 21- to 23-day-old (66.6 [63.7-69.6]) foals. Concurrent IV and IA protocol did not reach the 30-minute concentration considered therapeutic in 7- to 9-day-old foals (46.5 [43.6-49.4]) but did in 14- to 16-day-old (62.9 [60.0-65.8]) and 21-to 23-day-old (62.6 [59.7-65.6]) foals. CONCLUSIONS AND CLINICAL IMPORTANCE: Concurrent IV and IA administration of amikacin produces 30-minute plasma concentrations considered therapeutic in foals 14 to 23 days old, but concentrations observed in younger foals might be below those considered therapeutic for isolates with intermediate susceptibility to amikacin.

Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT / Resumen ejecutivo: Guía de diagnóstico y tratamiento de la artritis séptica en adultos y niños de GEIO (SEIMC), SEIP y SECOT

Infection of a native joint, commonly referred to as septic arthritis, is a medical emergency because of the risk of joint destruction and subsequent sequelae. Its diagnosis requires a high level of suspicion. These guidelines for the diagnosis and treatment of septic arthritis in children and adults are intended for use by any physician caring for patients with suspected or confirmed septic arthritis. They have been developed by a multidisciplinary panel with representatives from the Bone and Joint Infections Study Group (GEIO) belonging to the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Paediatric Infections (SEIP) and the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT), and two rheumatologists. The recommendations are based on evidence derived from a systematic literature review and, failing that, on the opinion of the experts who prepared these guidelines. A detailed description of the background, methods, summary of evidence, the rationale supporting each recommendation, and gaps in knowledge can be found online in the complete document.(AU)

La infección de una articulación nativa, generalmente denominada artritis séptica, constituye una urgencia médica por el riesgo de destrucción articular y las consecuentes secuelas. Su diagnóstico requiere un alto nivel de sospecha. Esta guía de diagnóstico y tratamiento de la artritis séptica en niños y adultos está destinada a cualquier médico que atienda pacientes con sospecha de artritis séptica o artritis séptica confirmada. La guía ha sido elaborada por un panel multidisciplinar en el que están representados el Grupo de Estudio de Infecciones Osteoarticulares (GEIO) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), la Sociedad Española de Infectología Pediátrica (SEIP) y la Sociedad Española de Cirugía Ortopédica y Traumatología (SECOT); además han participado dos reumatólogos. Las recomendaciones se basan en la evidencia proporcionada por una revisión sistemática de la literatura y, en su defecto, en la opinión de los expertos que han elaborado la presente guía. En el texto completo online se hace una descripción detallada de los antecedentes, métodos, resumen de la evidencia, fundamentos que apoyan cada recomendación y las lagunas de conocimiento existentes.(AU)

Tuberculous Septic Arthritis of the Hip Following the Incision and Drainage of a Groin Abscess: A Case Report.

Tuberculosis of the hip is a relatively rare type of septic arthritis that is seldom seen in the developed world today. While pyogenic septic arthritis may present with clear features that help in early diagnosis and treatment, many of these features are absent or overlap significantly with tuberculous arthritis, making the diagnosis a clinical challenge. Here, we present a case of tuberculous septic arthritis seen in our clinic following the surgical incision and drainage of a groin abscess with minimal hip symptoms. We discuss the therapeutic approach for the patient and briefly review other reported cases of tuberculous septic arthritis in the literature.

Septic Arthritis of the Spinal Facet Joint: Review of 117 Cases.

Background: Septic arthritis of the spinal facet joints is increasingly recognized in the era of magnetic resonance imaging, but its epidemiology, clinical features, management, and prognosis are ill-defined. Methods: We review 101 previously published cases and report 16 cases occurring at our institutions between 2006 and 2018. Results: Most patients presented with fever (60%) and back or neck pain (86%). Radiation into the hip, buttock, or limb was present in 34%. The lumbosacral vertebral segments were involved in 78% of cases. Most cases (64%) were due to Staphylococcus aureus. Bacteremia was present in 66% and paraspinal muscle abscesses in 54%. While epidural abscesses were present in 56%, neurologic complications were seen in only 9%, likely because most abscesses arose below the conus medullaris. Neurologic complications were more common with cervical or thoracic involvement than lumbosacral (32% vs 2%, P < .0001). Extraspinal infection, such as endocarditis, was identified in only 22% of cases. An overall 98% of patients survived, with only 5% having neurologic sequelae. Conclusions: Septic arthritis of the facet joint is a distinct clinical syndrome typically involving the lumbar spine and is frequently associated with bacteremia, posterior epidural abscesses, and paraspinal pyomyositis. Neurologic outcomes are usually good with medical management alone.

Role of Magnetic Resonance Imaging in Concomitant Periarticular Infections in Septic Arthritis of Large Joints in Children: A Systematic Review.

Background: Septic arthritis associated with adjacent infections, presents a diagnostic challenge as the clinical presentation is similar to that of isolated septic arthritis, additional diagnostic tools are needed to detect these infections. The purpose of this study was to examine the effectiveness of magnetic resonance imaging (MRI) for diagnosis of concomitant infection in children with septic arthritis of large joints and its effect on patient outcome and treatment. Materials and Methods: Electronic literature research of PubMed, Cochrane and Scopus, was conducted in January 2022 using a combination of MeSH, search terms and keywords. The data extracted included the study details, demographic data, the proportion of patients having a concomitant periarticular infection, clinical presentation, blood parameters and culture findings and outcomes. Results: This review included seven studies with 499 patients. The mean age was 7.08 ± 2.38 years in the study. There was a male predominance, with 174 being males (62.36%). The most common joint involved was the hip joint (44.47%). 42.48% had concomitant periarticular infections detected by MRI. Osteomyelitis was the most common infection seen in 209 patients (41.84%). The mean duration of antibiotics given and hospital stay was significantly more in periarticular infections (P > 0.05). 32.5% of the patients with septic arthritis underwent a second surgical procedure whereas 61.11% of patients with periarticular infections underwent second procedure in this review (P > 0.05). Conclusions: The use of MRI to diagnose these complicated infections appears to be beneficial. Multi-centric randomised control trials are needed to investigate the efficacy of MRI and its impact on patient care and outcome.

Rheumatoid arthritis and risk of osteoarticular infection and death following Staphylococcus aureus bacteraemia: A nationwide cohort study.

OBJECTIVES: Osteoarticular infection (OAI) is a feared complication of Staphylococcus aureus bacteraemia (SAB) and is associated with poor outcomes. We aimed to explore risk of OAI and death following SAB in patients with and without rheumatoid arthritis (RA) and to identify risk factors for OAI in patients with RA. METHODS: Danish nationwide cohort study of all patients with microbiologically verified first-time SAB between 2006-2018. We identified RA, SAB, comorbidities, and RA-related characteristics (e.g. orthopaedic implants, antirheumatic treatment) in national registries including the rheumatology registry DANBIO. We estimated cumulative incidence of OAI and death and adjusted hazard ratios (HRs, multivariate Cox regression). RESULTS: We identified 18 274 patients with SAB (n = 367 with RA). The 90-day cumulative incidence of OAI was 23.1%(95%CI 18.8; 27.6) for patients with RA and 12.5%(12.1; 13.0) for patients without RA (non-RA) (HR 1.93(1.54; 2.41)). For RA patients with orthopaedic implants cumulative incidence was 29.4%(22.9; 36.2) (HR 1.75(1.08; 2.85), and for current users of tumor necrosis factor inhibitors (TNFi) it was 41.9%(27.0; 56.1) (HR 2.27(1.29; 3.98) compared with non-users). All-cause 90-day mortality following SAB was similar in RA (35.4%(30.6; 40.3)) and non-RA (33.9%(33.2; 34.5), HR 1.04(0.87; 1.24)). CONCLUSION: Following SAB, almost one in four patients with RA contracted OAI corresponding to a doubled risk compared with non-RA. In RA, orthopaedic implants and current TNFi use were associated with approximately doubled OAI risk. One in three died within 90 days in both RA and non-RA. These findings encourage vigilance in RA patients with SAB to avoid treatment delay of OAI.

Incidence of Secondary Osteoarthritis after Primary Shoulder and Knee Empyema and Its Risk Factors.

Empyema of the joint is an orthopedic emergency that is associated with a prolonged healing process despite adequate surgical and medical therapy. The risk of developing postinfectious osteoarthritis (OA) after successfully treated joint empyema is unknown. Both incidence and risk factors are important for prognostication and would therefore be clinically relevant for the selection of an adequate infectious therapy as well as for the individual follow-up of patients. The aim of this retrospective clinical study was to describe the risk of secondary OA after empyema based on knee and shoulder joint infections after successful primary infection treatment and its risk factors. Thirty-two patients were examined clinically and radiographically after completion of treatment for primary empyema of the knee or shoulder joint. Patients with previous surgery or injections in the affected joint were excluded from the study. The cumulative incidence of new-onset radiographic OA was 28.6%, representing a 5.5-fold increased risk of developing OA compared to the normal population. A figure of 25% of patients underwent total knee arthroplasty after knee empyema. Identified risk factors for primary empyema were obesity, hyperuricemia, and rheumatoid arthritis. Only about 60% of the patients tested positive for bacteria. Staphylococcus aureus, the most common pathogen causing joint empyema, was present in approximately 40% of cases. Secondary osteoarthritis, as a possible secondary disease after joint empyema, could be demonstrated and several risk factors for the primary empyema were identified.

Clinical and radiological septic joint analysis of spontaneous sternoclavicular joint infections: achieving the best outcomes-a systems engineering approach.

OBJECTIVES: Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining. METHODS: An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes. RESULTS: A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis. CONCLUSIONS: This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

The Kocher-Caird Criteria for Pediatric Septic Arthritis of the Hip: Time for a Change in the Kingella Era?

Pediatric septic arthritis of the hip (SAH) in children is a severe pathology, requiring prompt diagnosis and treatment to avoid destructive sequelae of the joint. Its diagnosis can be challenging, however, due to its spectrum of manifestations and differential diagnosis. Last century, multiple research teams studied the curves of systemic inflammation markers to aid the differential diagnosis. Kocher showed that a history of fever >38.5 °C, non-weight bearing, an erythrocyte sedimentation rate >40 mm/h, and serum white blood cells >12,000/mm3 were highly suggestive of SAH, with a predicted probability of 99.6% when all these predictors manifested in pediatric patients. Caird validated these criteria, also adding a C-reactive protein >20 mg/L, reaching a 98% probability of SAH when these five criteria were present. The Kocher and the Caird criteria were then applied in multiple settings, but were never clearly validated. Moreover, they were studied and validated in the years when Kingella kingae was just emerging, and this was probably responsible for false-negative cases in multiple centers. For this reason, the Kocher and the Caird criteria are still at the center of a debate on the diagnostic tools for pediatric SAH. We provide a historical overview of the development of clinical and laboratory test algorithms for pediatric SAH. Further, new perspectives for future research on the prediction rules of pediatric SAH are here proposed.

A prospective multicentre evaluation of BioFire® Joint Infection Panel for the rapid microbiological documentation of acute arthritis.

OBJECTIVES: To assess the performance of the rapid syndromic BioFire® Joint Infection Panel (BF-JIP) to detect bacterial and fungal pathogens, as well as antibiotic resistance genes, directly in synovial fluid specimens collected from patients with acute arthritis. METHODS: The study was conducted in six French bacteriological laboratories. To assess the performances of BF-JIP, results were compared with those of synovial fluid 14-day culture and, in case of discrepancy, with those of complementary molecular methods and intraoperative samples. A total of 308 synovial fluid specimens were tested after collection from 308 adults and children presenting with clinical and biological suspicion of acute arthritis; patients presenting with acute periprosthetic joint infection were included according to the European Bone and Joint Infection Society 2021 criteria. RESULTS: Only one specimen failed (no result). On the basis of the consolidated data, the BF-JIP was concordant with the 14-day culture in 280 (91.2%) of the 307 specimens finally included in the study. The positive percentage agreement was 84.9% (95% CI, 78.8-89.8%) and the negative percentage agreement was 100% (95% CI, 97.2-100%). The positive predictive value was extremely high (100%; 95% CI, 97.6-100%), whereas the negative predictive value was lower (82.6%; 95% CI, 75.7-88.2%), partially explained by the missing target species in the panel. DISCUSSION: The BF-JIP showed high performances to detect pathogens involved in acute arthritis.

Pediatric Patients with Osteomyelitis and/or Septic Joint Undergoing Surgical Debridement Have Equivalent Short-Term Outcomes with or without Preoperative MRI.

The purpose of this study was to determine if short-term outcomes differed for pediatric patients with suspected musculoskeletal infection with or without a preoperative MRI. This was a multicenter, retrospective review of patients aged 0-16 years who presented with atraumatic extremity pain, underwent irrigation and debridement (I&D), and received at least one preoperative or postoperative MRI over a 10-year period. Primary outcomes were time to OR, total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Secondary outcomes entailed the rate at which concurrent osteomyelitis was identified in patients with septic arthritis and the extent of the resulting surgical debridement. Of the 104 patients, 72.1% had a preoperative MRI. Patients with a preoperative MRI were significantly less likely to have surgery on the day of admission. No difference was found between groups regarding total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Of the 57 patients diagnosed with septic arthritis, those with a preoperative MRI were significantly more likely to have concurrent osteomyelitis identified and to undergo bony debridement in addition to arthrotomy of the joint. In conclusion, patient outcomes are not adversely affected by obtaining a preoperative MRI despite the delay in time to OR. Although preoperative MRI can be beneficial in ruling out other pathologies and identifying the extent of concurrent osteomyelitis, the decision to obtain a preoperative MRI and timing of surgery should be left to the discretion of the treating surgeon.

Two-stage total joint replacement for hip or knee septic arthritis: post-traumatic etiology and difficult-to-treat infections predict poor outcomes.

PURPOSE: Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients' quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure. METHODS: A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p < 0.05. RESULTS: One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA. CONCLUSIONS: Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.