Acute septic arthritis of the knee may be a challenging diagnosis in the emergency department and must always be excluded in any patient with knee pain and local or systemic signs of infection. Arthrocentesis of the suspected knee is mandatory, since the analysis of the synovial fluid gives useful information like the white blood cell count (WBC)/mm3 or the polymorphonuclear cell percentage (PMP). These parameters will help the clinician to make the decision to drain the joint in the operation room, without having to wait for the culture or Gram stain, which may take several days to be available. The classical cutoff of 50,000 WBC/mm3 with more than 90% of PMP may fail to include all the septic arthritis of the knee, since significant variation have been described in recent years. The aim of this study was to evaluate the accuracy of WBC/mm3 and PMP in the synovial fluid in the diagnosis of acute septic arthritis of the knee. We reviewed the clinical data of patients diagnosed with acute septic arthritis of the knee admitted in our center between January 2010 and December 2014, specifically the WBC/mm3 and the PMP of the synovial joint fluid. The criteria for diagnosis of an acute septic arthritis of the knee was report of purulent material when arhtrotomy or arthroscopy was performed or a positive culture of the joint fluid. The statistical evaluation of the results was performed using Student's t-test. 48 patients matched the inclusion criteria. The mean WBC/mm3 was 44.333 (14.610–182.640) and the mean PMP was 91,89% (86,4%–98,1%). 28 patients (58,33%) had a WBC/mm3 below 50.000 and 44 patients (91,67%) had a PMP above 90%, both with no statistical significance. Knee arthrocentesis is mandatory in every patient suspected to have an acute knee pyoarthrosis, since the joint fluid analysis may show several abnormal findings. Our results show that a considerable number of patients may show a relatively low WBC/mm3 in the joint fluid in the presence of a knee pyoarthrosis. The PMP may be a better criteria, but again failed to achieve statistical significance, probably because of the low number of patients. The synovial fluid analysis alone is probably misleading in the diagnosis of an acute septic arthritis of the knee if the clinician is guided by the classical guidelines. The physical examination, medical history, laboratory and imagiologic tests are all key elements in this challenging diagnosis

Acute septic arthritis of the knee can lead to joint damage or sepsis, if early diagnosis and treatment fail to occur, which includes drainage of the joint, adequate antibiotic coverage and resting of the knee. Classically, drainage of the knee was performed either with multiple aspirations or open arhtrotomy. The arthroscopic approach has becoming widely accepted, as it allows adequate drainage of the pus and debridement with partial or total sinovectomy of the joint. The aim of this study was to evaluate the differences between arthroscopy and open arthrotomy in the clinical outcomes and rate of recurrence in patients with septic arthritis of the knee joint. We reviewed patients with acute septic arthritis of the knee admitted in our center between January 2010 and December 2014. The criteria for diagnosis was report of purulent material when arhtrotomy or arthroscopy was performed or a positive culture of the joint fluid. Patients with recent surgery or documented osteomyelitis of the femur or tíbia were excluded. We used the Oxford Knee Score (OKS) to classify the clinical outcomes in the end of follow-up, and registered the rate of recurrence in each group. The statistical evaluation of the results was performed using Student's t-test. 65 patients were treated during this period, 37 by an open arthrotomy through a lateral supra-patellar aproach, and 28 by arthroscopy through 2 standard anterior portals. All the patients were imobilized with a cast or orthosis in the immediate post-operation period for a mean period of 13 days in the arthrotomy group (8–15) and 9 days in the arthroscopy group (6–12) and received endovenous antibiotics for at least 10 days, followed by oral antibiotics for a mean total of 36 days in the the arthrotomy group (30–48) and 32 days in the arthroscopy group (22–36). The mean follow-up was 22 months in the arthrotomy group (8–28 months) and 18 months in the arthroscopy group (14–24). The mean OKS was 31 in the the arthrotomy group (21–39) and 35 in the arthroscopy group (25–44). There was 1 recurrence in the arthrotomy group and 1 recurrence in the arthroscopic group, both managed by knee arthrotomy. Drainage is a key step in treatment of knee pyoarthrosis, either through an open or an arthroscopic approach. Both seem to be equally effective, with no significant statistical difference in terms of recurrence. The functional results tend to favour the arthroscopic approach, but with no statistical significance

Despite the in-depth research into the treatment of acute septic arthritis of the knee, the morbidity and mortality are still significant. The purpose of our study was to evaluate the efficacy of a treatment protocol including arthroscopic irrigation and debridement in resolving septic arthritis of the knee. During a 6-year period, 18 patients presenting with septic arthritis of the knee were included in this study. In 10 cases, septic arthritis occurred after knee arthroscopy, in 2 after open trauma, in 2 more after joint aspiration or injection; there were 2 hematogenous infections and 2 following contiguous spread from an adjacent site. The patients were treated with an arthroscopic debridement protocol consisting of (1) arthroscopic debridement and synovectomy, (2) suction drainage for 24 hours, (3) repeat arthroscopy for persisting clinical and laboratory findings and (4) antibiotics IV for four weeks and per.os. for two months (ciprofloxacin – rifampicin). The onset of the symptoms presented 18.2 days in average after the cause. The patients complained of swelling (18/18), fever ~39° C (16/18), stiffness (13/18), pain (12/18), erythema (6/18) and weakness (6/18). Arthroscopic drainage (average 1.5 procedures) was performed at an average of 8.4 days from the initiation of the symptoms. Laboratory data revealed elevated ESR (erythrocyte sedimentation rate) (average 68.9), CRP (average: 10.9) and WBC (average: 8894.3). The mean follow-up period was 3.5 years. Cultures from knee joint aspirations were negative in 9 cases. Five knees were infected with Staphylococcus aureus, 2 with Staphylococcus epidermidis, 1 with Escherichia Coli and 1 with multiple organisms. One month after the last arthroscopic debridement, the ESR and CRP levels were normalised in all cases. Lysholm scores averaged 91. Most of the patients (15/18) returned to their pre-infection level of functioning. Overall success in clinical eradication of infection was 100%. Our conclusions are:. early aggressive arthroscopic debridement as part of a treatment protocol can be an effective treatment option,. time is a crucial factor, and. the earlier the arthroscopic debridement is performed, the better results are obtained

Introduction. Septic arthritis of the native knee often results in irreversible joint damage leading to the need for a total knee arthroplasty (TKA). This study examines the mid-term risk of periprosthetic joint infection (PJI), aseptic revision, any revision, and any reoperation in primary TKAs after septic arthritis of the native knee compared to a control cohort of primary TKAs performed for osteoarthritis (OA). Methods. We retrospectively identified 215 primary TKAs performed between 1971 and 2016 at a single institution following septic arthritis of the native knee. Eighty-two percent (177 cases) were treated in a single setting, whereas a two-stage exchange arthroplasty protocol was utilized in 18% (39 cases) for ongoing or suspected active native knee septic arthritis. Each case was matched 1:1 based on age, sex, body mass index (BMI), and surgical year to a primary TKA for OA. Mean age and BMI were 63 years and 30 kg/m2, respectively. Mean follow-up was 9 years. Results. Survivorship free from any infection (inclusive of PJI and wound infections) at 10 years was 87% in the septic arthritis cohort and 98% for the OA cohort (HR=6.5, p<0.01). Survivorship free of PJI at 10 years was 90% in the septic arthritis and 99% in the OA group (HR=6; p<0.01). There was no difference in the rate of infection when TKA occurred within 5 years of a septic arthritis diagnosis compared to a diagnosis that occurred >5 years from the TKA. The survivorship free of aseptic revision at 10 years was 83% for the septic arthritis cohort and 93% for the OA cohort (HR=2.5, p<0.01). When combining the above survivorships free of aseptic and septic revisions, the survivorship free of any revision at 10 years was 78% in the septic arthritis cohort and 91% in the OA cohort (HR=3, p<0.01). The 10-year survivorship free of any reoperation was 61% in septic arthritis group and 84% in the OA group (HR=3; p<0.01). Preoperative and 2-year postoperative Knee Society scores were similar between groups (p=0.16 and p=0.19, respectively). Conclusion. There was a 6-fold increased risk of PJI in patients undergoing TKA with prior history of septic arthritis when compared to controls who had a TKA for OA, with a cumulative incidence of 9% at 10 years. Moreover, the 10-year survivorships free of aseptic revision, any revision, and any reoperation were significantly worse in the septic arthritis cohort. Summary. A history of septic arthritis prior to primary TKA allows for satisfactory clinical outcomes, but patients had increased risk of PJI, aseptic revision, any revision, and any reoperation compared to a control cohort

Septic arthritis is a therapeutic emergency with a high mortality rate (about 11%)(1). Inadequate treatment can cause permanent joint damage. Management of the septic arthritis includes prompt antibiotic treatment as well as joint-decompression and removal of purulent material(2). It is still discussed controversially and there is little evidence which surgical concept is preferable: arthroscopy with lavage and debridement or open arthrotomy with synovectomy(3,4). The aim of the study was to compare efficacy of arthroscopy and arthrotomy in patients with septic gonarthritis.

We evaluated 70 consecutive patients who underwent arthroscopy or arthrotomy at our clinic, because of a bacterial monarthritis of the knee between 2002 and 2010. Our primary outcome was the early recurrence of infection (> 3 months after surgery), which made a second surgery necessary. We compared patients who suffered reinfection and those who did not, in regard to the surgery type as well as potential confounders like comorbidity (measured by Charlson comorbidity index), age, body mass index (BMI), Gächter's -, Kellgren and Lawrence - and Outerbridge classification, duration of symptoms and inflammatory parameters. Furthermore we evaluated differences of the confounders between the surgery groups.

From the 70 patients 41 were treated arthroscopic and 29 with arthrotomy. In total eight patients (11.4%) had to undergo a second surgery because of early reinfection. The rate was significantly higher in patients treated with arthrotomy (n=6; 20.7%) compared to those treated with arthroscopy (n=2; 4.9%) (p=0.041). Whereas we found no significant influence of potential confounders between the reinfection group and the group where primary eradication was achieved. Patients who underwent arthrotomy were significantly older, had more comorbidities (both p<0.001) and higher grades of osteoarthritis according to Kellgren and Lawrence classification (p=0.023). In order to adjust the study population towards confounders we performed a subgroup analysis on patients of the second and third age percentile. When we repeated our analysis we still found a significant higher reinfection rate in the arthrotomy group (p=0.036). At the same time there were no differences in prevalence of confounders, neither between the two surgery groups, nor between the reinfection and the primary eradication group.

Patients with bacterial monarthritis of the knee who were treated with arthroscopy had a significantly lower reinfection rate than those treated with arthrotomy. As arthroscopy is the less invasive and more sufficient method it should be considered the routine treatment according to our data.

Aims. The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. Methods. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. Results. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Conclusion. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus. Cite this article: Bone Jt Open 2024;5(9):785–792

It is widely accepted by orthopaedic surgeons that antibiotics should be withheld until aspiration has been performed to increase the odds of identifying an organism in septic arthritis. Patients often present to other specialties that may not be as familiar with these principles.

Twenty-five of forty-nine patients with septic arthritis of the native or prosthetic knee had received antibiotics prior to review by the orthopaedic service. Patients were significantly less likely to demonstrate an organism on initial microscopy (entire cohort p=0.001, native knees p=0.006, prosthetic knees p=0.033) or on subsequent culture (entire cohort p=0.001, native knees p=0.017, prosthetic knees p=0.012) of their aspirate if they had received antibiotics. The sensitivity of microscopy dropped from 0.58 to 0.12 when patients had received antibiotics (native knees 0.46 to 0, prosthetic knees 0.72 to 0.27). The sensitivity of the culture dropped from 0.79 to 0.28 when the patient had received antibiotics (native knees 0.69 to 0.21, prosthetic knees 0.91 to 0.36).

Patients treated with empirical antibiotics are less likely to demonstrate an organism on microscopy and culture of their initial aspirate. There is a significantly high false negative rate associated with knee aspiration, particularly with prior administration of antibiotics.

Introduction: Hot swollen knee joints are a common presentation in clinical practice. It has wide differential diagnoses, the most serious being septic arthritis. Delayed or inadequate treatment leads to joint damage. Arthroscopic lavage should be planned appropriately after proper clinical assessment and investigation. Other differential diagnoses like crystal arthritis, reactive arthritis, monoarticular inflammatory arthritis should be considered. Patients and Methods: This retrospective audit involved 44 patients who had arthroscopic knee lavage for suspected septic arthritis from January 2005 to May 2007. Analysis included the aspects of adequate backup supportive evidence for the procedure, the time from diagnosis to operation and postoperative antibiotic regime. Results: There were 29 males and 15 females with age group ranging from 11 to 91 yrs. Fever was present in 15 patients(34%), preoperative joint aspiration done in 22(50%), peri-operatively pus found in 11(25%). 13 patients(29.5%) had procedure done within 6hrs, causal organism identified in 25%. Follow-up ranged upto 12 months without persistence or reactivation. Discussion: Arthroscopic lavage is a useful adjunct in treatment of septic arthritis of knees but proper patient selection with systematic approach considering other possible differential diagnoses is important for avoiding unnecessary operations

This text has been removed at the authors' request.

Aim. Septic arthritis is a painful infection of articular joints that is typically treated by irrigation & debridement along with antibiotic therapy. There is debate amongst the medical community whether antibiotic administration should be delayed until fluid cultures have been taken to improve culture yield. However, delaying antibiotics can also have negative consequences, including joint destruction and sepsis. Therefore, the purposes of this study were to determine: 1) whether delayed antibiotic treatment affects culture yield and prognosis and 2) if the culture yield of patients treated for septic arthritis differs for hip, knee, and shoulder based on timing of antibiotic administration. Method. A retrospective analysis was conducted on 111 patients with septic arthritis of the hip, knee, or shoulder admitted from 3/2016 to 11/2018. In patients with multiple septic joints, each joint was analyzed individually (n=122). Diagnosis was determined by the treatment of irrigation & debridement and/or a positive culture. Patients without all intervention times recorded or with periprosthetic joint infection were excluded. Demographics, laboratory tests, culture results, and intervention times were obtained through chart review. Patients were grouped based on antibiotic therapy timing: >24 hours prior to arthrocentesis (Group 1), between 24 hours and 1 hour prior (Group 2), and 1 hour prior to post-arthrocentesis (Group 3). Analysis was conducted using chi-squared tests. Results. The mean age of each group were similar: Group 1 (n=38) 55.7 years, Group 2 (n=20) 57.2 years, and Group 3 (n=64) 54.8 years. No difference was observed in culture sensitivity between groups (p=0.825) with 71.1% (27/38) positive cultures in Group 1, 75% (15/20) in Group 2, and 76.6% (49/64) in Group 3. Similarly, frequency of related readmissions within 90 days (p=0.863) did not significantly vary: 26.3% (10/38) in Group 1, 20% (4/20) in Group 2, and 25% (16/64) in Group 3. Additionally, there were no significant differences in culture sensitivity in the knee (p=0.618; Groups: 87.5%, 75%, 70.6%), shoulder (p=0.517; Groups: 77.8%, 66.7%, 90%), and hip (p=0.362; Groups: 61.9%, 80%, 80%). Conclusions. Culture sensitivities and rates of readmission were similar for all patients regardless of antibiotic administration timing. These results suggest that antibiotic administration should not be delayed in septic arthritis to improve culture yield. However, the data does not suggest that early antibiotic administration will result in better clinical outcomes by lowering readmission rates. Further research is needed to better determine the clinical benefits that early administration of antibiotics may have on patient outcomes

Septic arthritis of the knee is an uncommon complication of arthroscopic anterior cruciate ligament reconstruction, with a reported incidence ranging from 0.14% to 1.7% in recent publications. In this study, we assess the clinical presentation, management and early outcome of patients with septic arthritis of the knee following anterior cruciate ligament reconstruction. Literature on this uncommon complication is sparse. The North Shore and Auckland City Hospital Orthopaedic databases were searched and 13 patients were identified as having been treated for septic arthritis of the knee following anterior cruciate ligament reconstruction in the period from July 2002 to August 2006. Their clinical records were reviewed to compile information regarding their presentation and management. Five of these patients were also recalled for clinical follow-up at an average time of 16 months. We reviewed knee range of motion, stability, functional testing in vertical and horizontal jumps and radiographic changes. Clinical outcomes were further assessed using the Tenger, Lysholm and International Knee Documentation Committee Scores. The patients reviewed had a mean age of 26 years and presented to hospital at an average of 16 days after their autologous ACL reconstruction surgery. All had initial elevation of inflammatory markers with a mean CRP of 189mg/L (68 – 295) and mean ESR of 71mm in one hr (10 – 112.) Mean peripheral WCC on presentation was 12.3 (9.5 – 22.4.) Initial knee aspirates were performed on all patients and yielded a mean specimen WCC of 60,900 x 106/L. Of the 13 patients, six had S. epidermidis, three had S. aureus, two Propioniobacterium acnes and one Serratia marcescens. No organism was cultured from one patient’s aspirate. The study patients underwent an average of two surgical interventions, the first being arthroscopic washout in each case. Six patients subsequently underwent open knee joint washouts, four of these having their cruciate grafts removed. Of the five patients recalled for clinical review, three rated their IKDC knee performance as being significantly worse than their uninjured side. Mean IKDC scores were 63.5 for the affected knee and 97.3 for the contralateral knee. Mean Lysholm knee score was 71.8 at follow-up. Tenger scores prior to ACL reconstruction averaged 4.4, compared to 5.6 on review. Radiographs demonstrated evidence of arthritis that was not apparent pre-operatively in four of the five review patients. These individuals lacked an average 2.8 degrees of extension and 13.4 degrees flexion in comparison to their contralateral knee. Two patients demonstrated clinical instability on examination. The mean single-legged hopping distance was 62.9% horizontally and 96.4% vertically, when comparing the affected knee to the contralateral side. Staphylococcus epidermidis was the most common pathogen identified in this study. Most patients presenting with this complication will require two or more operative procedures and a prolonged course of intravenous antibiotics. The symptomatic and functional outcomes of septic arthritis associated with recent ACL reconstruction are highly variable, but were found to be worse in those patients requiring graft removal to eradicate their infections. Despite their young age, most of those patients undergoing clinical review had radiographic evidence of early osteoarthritis

Introduction: The red, hot swollen knee is commonly seen in the A& E department and can present a diagnostic dilemma for the casualty officer. While superficial cellulites and bursitis are the most common diagnoses, anxiety is induced by the spectre of septic arthritis. The potential sequalae from aspirating a knee through infected superficial tissues further emphasise the importance of making an accurate clinical diagnosis. The lymph drainage of the superficial tissues of the lower limb is via lymphatics that accompany the long saphenous vein and drain to the lower group of the superficial inguinal nodes. Drainage from the knee joint is to a popliteal node situated between the knee joint capsule and the popliteal artery. Efferents from this node ascend in close relation to the femoral vessels and drains to the deep inguinal nodes. We hypothesise that the differences in lymphatic drainage mean that palpable inguinal nodes are more likely with superficial infections than with septic arthritis. We reviewed the clinical findings in a group of patients with superficial or deep infections to test this theory. Patients and Methods: From January 1995 until June 2000, twenty-seven patients were admitted with septic arthritis of the knee and fifty-one with superficial cellulites or bursitis about the knee. The former were diagnosed on the basis of clinical findings and a knee aspirate, the latter on clinical findings and response to treatment. The presence or absence of palpable inguinal lymph nodes was determined and compared for each diagnostic group. Results: Joint aspirates from the group with septic arthritis grew organisms in twenty patients (staph aureus in 19, strep pneumoniae in one). The remaining seven patients had no growth but purulent fluid on aspirate with leukocyte counts in excess of 50,000/mm. 3. Six patients had rheumatoid arthritis and two were HIV positive IVDA’s but the rest had no pre-disposing factors. The average age was 52 (range 16–83). All were treated with arthroscopic washout (average 2.2/patient) and antibiotic chemotherapy. In the superficial infection group 28 (56%) had pre-patellar bursitis and 23 (54%) cellulites. All were treated with antibiotics while eight of the bursitis group required incision and drainage. In the patients with superficial infection 32 (63%) had palpable inguinal lymphadenopathy while no patient with septic arthritis of the knee had palpably enlarged inguinal lymph nodes. This result is highly statistically significant (p< 0.01). Discussion: It is well recognised that neoplastic or inflammatory conditions of the superficial tissues of the lower limb may be associated with inguinal lymphadenopathy. A similar association for septic arthritis of the knee has not to our knowledge been described. Our study would suggest that palpably enlarged lymph nodes are unusual in this condition. While it is worth emphasizing that the presence of lymph nodes does not rule out absolutely the possibility of septic arthritis, their presence or absence may be useful in differentiating superficial from deep infections about the knee

Purpose of Study. Bicondylar tibial plateau fractures are serious injuries to a major weight bearing joint. These injuries are often associated with severe soft tissue injuries that complicate the surgical management. This retrospective study evaluates the management of these high-energy injuries with the use of limited open reduction and fine wire circular external fixation. Methods. Between July 2008 and June 2012, 54 consecutive patients (19 females and 35 males) with high-energy tibial plateau fractures were treated at our tertiary level government hospital. All patients were treated with limited open reduction, and cannulated screw fixation combined with fine wire circular external fixators as the definitive management. The records of these patients were reviewed. Results. Forty-six patients met the inclusion and exclusion criteria. Thirty-six patients had Schatzker type-VI and ten patients had Schatzker type-V fractures. All fractures united without loss of operative reduction. No wound complications, osteomyelitis or septic arthritis occurred. Average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin tract infection was the most common complication encountered. Conclusion. Fine wire circular external fixation combined with limited open reduction and cannulated screw fixation consistently produced good functional results without serious complications. NO DISCLOSURES

Acute osteomyelitis and septic arthritis are uncommon diseases in childhood that affect previously healthy children. A high index of suspicion, early diagnosis, initiation of appropriate antibiotic treatment and surgical intervention are essential for a good outcome. The aim of our study was to evaluate our approach, clinical signs and the outcome of the diseases. We retrospectively analyzed clinical, laboratory and microbiologic data in children hospitalized for acute haematogenous osteomyelitis or septic arthritis at the Department of Orthopaedic surgery in a 10-year period (from 2003 to 2013). Follow-up of outpatients was continued for at least 1 year or until the full recovery. Acute haematogenous osteomyelitis or septic arthritis were confirmed in 22 patients, 14/22 (64%) had osteomyelitis and 8/22 (36%) arthritis, 16/22 (73%) were boys. The mean patient age was 9,3 years (SD:3,5), the median of the hospitalization was 32 days (IQR:13 – 60 days). In children with osteomyelitis 10/14 (72%) had affected lower limb and in 4/14 (28%) the spine was affected. Six (80%) children had septic arthritis of the knee, hip joint was affected in one child and sacroiliac joint in one as well. We obtained blood cultures in 19/22 (86%) patients, bone biopsy was performed in 14/22 (64%). All infections were monomycrobial, Staphylococcus aureus was the most common pathogen, as expected. In one patient the cause of the osteomyelitis was Panton-Valentine leucocidin (PVL) producing S. aureus. The characterics are presented in Table 1. All affected children recovered completely. We observed 22 cases of pediatric bone and joint infections in a 10-year period. The most common pathogen was Staphylococcus aureus, as expected, althogh in more than half of cases no pathogens were found. One child suffered from osteomielitis caused by S. aureus strain producing PVL. We observed higher proportion of spine invovelment than previously reported in the literature

Aim. Analysis of the effect of administration of antibiotics before collection of microbiology samples in patients with septic arthritis of the native and prosthetic knee. Method and Results. A retrospective analysis of patients admitted to the unit with a diagnosis of septic arthritis of the knee. There were 27 infections in 26 native knees and 27 infections in 26 prosthetic knees. Sixty-three percent of the native knees had received antibiotics prior to collection of microbiology samples. Fifty-three percent of these grew an organism from at least one of their aspirate, washout fluid or swab. Of the 37% that did not have antibiotics 100% grew an organism. There was no difference in the type or length of treatment required between the groups. Forty-one percent of the prosthetic knees had received antibiotics prior to collection of microbiology samples. Forty-five percent of these had an organism identified. Of the 59% that did not have antibiotics 81% had an organism identified. Overall 67% had an organism isolated, fifty-six percent of these retained their implant. Thirty-three percent of those with no organism identified retained their implant. Conclusion. Administration of antibiotics before samples have been collected for microbiology has a significant effect on the likelihood of isolating a responsible organism in both native and prosthetic knees. This does not have an effect on the outcome in the native knee but does have a significant effect in the prosthetic knee

Between 1997 and 2003, five patients with acquired knee flexion contractures were treated by gradual soft tissue distraction using the Ilizarov external fixator. Two patients presented following burns, two following septic arthritis of the knee and one after poliomyelitis. The mean age was 8.2 years (5 to 12). All patients had a fixed flexion contracture of the knee of 90°. The mean duration of fixator application was 4 months. No soft tissue releases or bony surgical procedures were performed. When the external fixator was removed, the mean residual knee flexion deformity was 2°. Follow-up after removal of the fixator averaged 5 months. The mean loss of correction was 15° (0° to 30°). Two patients developed mild pin-tract sepsis, which was successfully treated with oral antibiotics. Compared to preoperative status, energy-efficient mobility was markedly improved in all patients

Aim: An epidemiological analysis of spontaneous community acquired septic arthritis cases in an elderly population at a university teaching hospital. Method: We studied confirmed cases of spontaneous septic arthritis in the over 65 population. Patients with prosthetic joint infections were excluded from the study. We analysed data relating to initial presenting complaint and clinical examination, haematological and microbio-logical tests along with ultimate patient outcome. Results: There were 7 confirmed cases of spontaneous septic arthritis in over 65 population in the last 6 months (2 hips, 5 knees). The mean age was 72.14 (range 65–82) with a mean length of stay of 49 days. Those with septic arthritis of the knee presented with swelling, pain and immobility. Hip cases presented with pain and immobility. All patients were systemically well at time of presentation, with no other foci of infection detected after septic screening. All patients had aspirate and arthroscopic/arthrotomy confirmed infection. Staphylococcus Aureus was isolated from 6 joint aspirations and Pseaudomonas Auruginosa from one patient. Complications of treatment included acute renal failure, cardio/respiratory failure, disseminated infection and death (1 case). Conclusion: Septic arthritis must be considered as a differential diagnosis in all patients with joint pain, swelling and immobility. This diagnosis is not confined to the paediatric population. A backround of degenerative disease and the occult presentation in the elderly may delay diagnosis. Sepsis must be considered in the elderly with joint pathology, with treatment initiated in a prompt and aggressive manner to prevent the sequelae that ensues

We reviewed 821 children with 869 sites of septic arthritis treated from 1983 to 2002. Neonates and patients with septicaemia and penetrating injuries were excluded. There were two age groups: 46% of the children were two years or younger (mean 1.1 years) and 54% were between 3 and 12 years (mean 6.8 years). The male to female ratio was 1.7:1. The diagnosis was made clinically and with the help of special investigations. The white cell count was elevated in 67% and the ESR in 96%. Blood culture was positive in 28%. Radiographs demonstrated widening of joint spaces in 19% and isotope bone scan was positive in 11% of sites, mainly in the hip. No diagnostic joint aspiration was done. In 42 sites (4.6%) the diagnosis was regarded as incorrect because there was no growth or white cells. The most common site of septic arthritis was the knee (37%), followed by the hip (30%), ankle (14%), elbow (10%), shoulder (5%), wrist (3%) and subtalar joint (1%). Treatment was with open arthrotomy and antibiotics (cloxacillin and/or ampicillin). Bacteriologically the most common finding was no growth (50% in each age group). In the younger group the most common finding was Haemophilus influenzae (24.5%). Staphylococcus aureus was found in 37% of the older group. From 2000 the incidence of H. influenzae declined, probably owing to the introduction of vaccine in 1998. Results at 30 sites (3.5%) were poor. There was avascular necrosis in 18 hips, chondrolysis in five hips and three ankles, and stiffness in two knees, an ankle and a subtalar joint. Further analysis showed that poor results were more likely to occur in older patients with S. aureus and where there was a delay in treatment. Where good results were achieved, the mean delay was 3.5 days. It was 9.3 days where results were poor

Purpose of the study: Brodie abscess is a purulent collection in the centre of a bone separated in its typical form from soft tissue by an impermeable barrier of compact bone tissue. This “trapped” collection causes a clinical syndrome of pain and infection. Lat diagnosis is frequent after the symptoms have evolved over months or years. The purpose of our work was to illustrate the misleading features of this bone infection using a series of 11 periarticular localisations of Brodie abscess. Material and methods: Our study included ten patients, mean age 18 years, who were treated over a period of six years. One patient had a double localisation. The main foci were the distal femur (n=4) and the upper tibia (n=4). There was one case involving the lower tibia, on in the olecranon and one in an iliac bone. The clinical course was greater than one year in three patients, and greater than one month in four others. The clinical presentation was a septic arthritis of the knee joint in three patients and of the hip in one, with rupture of the abscess into the soft tissues in three cases and a central intra-osseous collection in four. Biological features of infection were present in all patients. Imaging (x-ray, CT) showed a bone defect in the metaphyseal or metaphyseal epiphyseal region in all cases with condensed contours and a fistulous tract to a joint or soft tissue. Surgical treatment was proposed in all cases to treat the causal lesion by saucerisation and drainage of the intra-osseous abscess. The defect was filled with an autologous graft in one case and by cement in another. The germ identified in 70% of the cases was a Staphylococcus aureus. Adapted antibiotics were delivered for eight weeks on average. Results: One patient had a secondary fistula which developed early after excision of a central abscess of the proximal tibia; dry drainage was achieved after cover with a medial gastrocnemian flap. At mean 27 months follow-up, all lesions have cured without recurrence; blood tests returned to normal. Radiographically, the defect exhibited bone remodelling visible in the absence of surgical filling. Regarding function, there was one stiff knee due to adherence on the extensor system. Discussion: The Brodie abscess is a form of chronic osteomyelitis. It is a rare condition generally observed in young subjects since the majority of reported cases have occurred during the second decade of life. Clinically, the Brodie abscess can be “cold” with little or no overt expression, or more readily “hot” with a syndrome of acute infection and fistulisation to soft tissue. Fistulisation to a joint can mislead the diagnosis to septic arthritis as occurred in one of our patients who underwent two revisions for septic recurrent arthritis of the knee. Most Brodie abscesses are located in the metaphysic. A double metaphyseal and epiphyseal localisation through the growth plate is rare, resulting from an old septic process with inevitable joint collection as in one of our patients aged ten years. Discovery of a second concomitant localisation can be explained by an insufficient or inadequate treatment of the initial focus as we also observed in one case. The classical radiographic image of a Brodie abscess is observed in only two-thirds of the cases. Computed tomography is highly contributive demonstrating possible infra-radiographic fistulisation to a joint or soft tissue as occurred in most of our patients. The Brodie abscess can also simulate bone tuberculosis, hydatic cyst, or bone tumour. Surgically, we adopted to therapeutic strategies: excision of the infected bone associated or not with a cancellous graft and per primam closure for cold abscesses. We have considered that cold abscesses are generally cause by germs with weak virulence; this attitude enables avoiding superinfection. The second option is excision with dressing with or without secondary cancellous graft after budding used for hot abscesses, especially when complicated by a soft tissue complication. Search for germs in blood cultures and in the excision produce was only positive in half of our cases. Staphylococcus was identified in 90%. A histology examination of the excision specimen should be systematically requested to confirm the diagnosis. Finally, the outcome of a well-treated Brodie abscess is favourable. Conclusion: Brodie abscess is a rare condition observed in young subjects generally due to Staphylococcus aureus. Cold and hot abscesses can be differentiated by their clinical and therapeutic features. Often misleading, clinical symptoms can be detailed with modern imaging, particularly important when the radiographic aspect is atypical. A biopsy is indispensable to confirm the diagnosis

Septic arthritis is a medical emergency that can lead to significant morbidity and mortality arising from irreversible joint destruction and overwhelming sepsis. The purpose of this prospective study is to present epidemiological, clinical and laboratory findings in adult patients with septic arthritis. Adult patients treated for septic arthritis at the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia, from January 2012 to December 2014, qualified for the present report. The following data were analyzed: age, sex, underlying diseases, previous joint procedure, microbiological diagnostic examinations, causative agents, complications and therapy. During the study period of three years 94 episodes of septic arthritis were diagnosed. There were 49 (52.1%) females and 45 (47.9%) males, aged 64.5 (18 to 97) years. At the first visit elevated concentration of C-reactive protein was found in 93 (98.9%) patients. The most common affected joint was knee (48.9%), followed by shoulder (20.2%), wrist (12.8%), ankle (7.4%) and others. In 8 (8.5%) patients more than one joint was affected. Risk factors were found in 63 (67%) of study patients. The underlying joint disease (e.g. osteoarthritis, rheumatoid arthritis, gout) was found in 50.8% patients, following by malignancy and immunosuppressive therapy in 28.6%, diabetes mellitus in 14.9%, recent trauma in 12.8%, and prior joint procedure in 9.6% patients. In 65/94 (69.1%) patients the causative pathogen was demonstrated by blood culture in 35.6%, by synovial fluid culture in 48.8%, and by both methods in 13.8% patients. In patients with proven aetiology Staphylococcus aureus was the most frequent (44.6%) isolated pathogen (only one methicillin resistant), followed by gram-negative bacteria in 30.8%, and Streptococcus spp. in 23.1% patients. In 4/65 (6.2%) patients more than one pathogen was isolated. The patients were treated with antibiotics according to isolated pathogen. In 17 (70.8%) out of 24 patients with complications synovectomia was performed, and adjacent osteomyelitis was found in 9 (37.5%) patients. Our results show that the foremost risk factor in adult patients with septic arthritis is pre-existing joint disease, knee is the principal target of infection, and the most common isolated pathogen is S. aureus. It was established that prompt recognition, early appropriate antimicrobial and surgical treatment in these patients are critical to ensuring a good prognosis