Little information is available about several important aspects of the treatment of melioidosis osteomyelitis and septic arthritis. We undertook a retrospective review of 50 patients with these conditions in an attempt to determine the effect of location of the disease, type of surgical intervention and duration of antibiotic treatment on outcome, particularly complications and relapse. We found that there was a 27.5% risk of osteomyelitis of the adjacent bone in patients with septic arthritis in the lower limb. Patients with septic arthritis and osteomyelitis of an adjacent bone were in hospital significantly longer (p = 0.001), needed more operations (p = 0.031) and had a significantly higher rate of complications and re-presentation (p = 0.048). More than half the patients (61%), most particularly those with multifocal bone and joint involvement, and those with septic arthritis and osteomyelitis of an adjacent bone who were treated operatively, needed more visits to theatre. Cite this article: Bone Joint J 2015;97-B:277–82

Aims. This study aimed to assess the performance of an automated multiplex polymerase chain reaction (mPCR) technique for rapid diagnosis of native joint septic arthritis. Patients and Methods. Consecutive patients with suspected septic arthritis undergoing aseptic diagnostic joint aspiration were included. The aspirate was used for analysis by mPCR and conventional microbiological analysis. A joint was classed as septic according to modified Newman criteria. Based on receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) values of the mPCR and the synovial fluid culture were compared using the z-test. A total of 72 out of 76 consecutive patients (33 women, 39 men; mean age 64 years (22 to 92)) with suspected septic arthritis were included in this study. Results. Of 72 patients, 42 (58%) were deemed to have septic joints. The sensitivity of mPCR and synovial fluid culture was 38% and 29%, respectively. No significant differences were found between the AUCs of both techniques (p = 0.138). A strong concordance of 89% (Cohen’s kappa: 0.65) was shown. The mPCR failed to detect Staphylococcus aureus (n = 1) and Streptococcus pneumoniae (n = 1; no primer included in the mPCR), whereas the synovial fluid culture missed six microorganisms (positive mPCR: S. aureus (n = 2), Cutibacterium acnes (n = 3), coagulase-negative staphylococci (n = 2)). Conclusion. The automated mPCR showed at least a similar performance to the synovial fluid culture (the current benchmark) in diagnosing septic arthritis, having the great advantage of a shorter turnaround time (within five hours). Cite this article: Bone Joint J 2019;101-B:288–296

Aim. Synovial fluid D-lactate may be useful for diagnosing septic arthritis (SA) as this biomarker is almost exclusively produced by bacteria. We evaluated the performance of synovial fluid D-lactate and determined its optimal cut-off value for diagnosing SA. Method. Consecutive patients with suspicion of septic arthritis were prospectively included. They underwent joint aspiration and synovial fluid was collected for culture, leukocyte count and D-lactate concentration (by spectrophotometry). Youden's J statistic was used for determining optimal D-lactate cut-off value on the receiver operating characteristic (ROC) curve by maximizing sensitivity and specificity. Results. A total of 155 patients were included. Using institutional criteria, 21 patients (14%) were diagnosed with SA and 134 (86%) patients with aseptic arthropathy, out of which 43 (27%) had osteoarthrosis, 80 (52%) had rheumatic arthropathy and 11 (7%) reactive arthritis. The optimal cut-off of synovial fluid D-lactate to differentiate SA from aseptic cases was 0,035 mmol/l. Synovial fluid D-lactate had a sensitivity 90% (95% CI: 70–99%) and specificity 87% (95% CI: 80–92%) compared to leukocyte count with sensitivity 81% (95% CI: 60–95%) and specificity 83% (95% CI: 76–90%). Culture was positive in only 17 (80%) out of 21 patients with SA. Conclusions. The synovial fluid D-lactate showed high sensitivity and specificity for diagnosis of SA which was higher than the current gold standard of diagnosis (culture and leukocyte count). The high sensitivity makes this biomarker useful as a point-of-care screening test for SA

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes. This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test. The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis. The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable

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

Aim. Prompt recognition and identification of the causative microorganism in acute septic arthritis of native and prosthetic joints is vital to increase the chances of successful treatment. The aim of this study was to independently assess the diagnostic accuracy of the multiplex BIOFIRE® Joint Infection (JI) Panel (investigational use only) in synovial fluid for rapid diagnosis. Method. Synovial fluid samples were prospectively collected at the University Medical Center Groningen from patients who had a clinical suspicion of a native septic arthritis, early acute (post-operative, within 3 months after arthroplasty) periprosthetic joint infection (PJI) or late acute (hematogenous) PJI. JI Panel results were compared to culture-based methods as reference standard. Results. A total of 45 samples were analyzed. The BIOFIRE JI Panel showed a high specificity (100%, 95% CI 73 – 100) and positive predictive value (100%, 95% CI 79 – 100) in all patient categories. Sensitivity and negative predictive value were 83% (95% CI 36 – 99) and 88% (95% CI 47 – 99) respectively for patients with a clinical suspicion of native septic arthritis (n=12), 77% (95% CI: 46 – 94) and 63% (95% CI: 26 – 90) for patients with a clinical suspicion of a late acute PJI (n=14), and 27% (95% CI 7 – 61) and 27% (95% CI: 7 – 61) for patients with a clinical suspicion of an early acute PJI (n=19). Conclusions. The results of this pilot study indicate a clear clinical benefit of the BIOFIRE JI Panel in patients with a suspected native septic arthritis and late acute (hematogenous) PJI, but a low clinical benefit in patients with an early acute (post-operative) PJI due to the absence of low-grade microorganisms in the panel

Aim. The diagnosis of septic arthritis mostly relies on clinical examination, several blood parameters including white blood cell count, C-reactive protein, sedimentation, and the analysis of the joint aspiration. However, the diagnosis can be difficult when the symptoms are vague and the information obtained from laboratory might be insufficient for definitive diagnosis. This study aimed to evaluate several ratios obtained from routine blood tests for a possible use in the diagnosis of septic arthritis. Method. The adult patients who were operated in our clinic due to septic arthritis between 2014–2020 were identified and retrospectively evaluated. The patients with any blood disorders or missing file information were excluded. A total of 36 patients were found to be eligible for inclusion. The control group included 40 patients without any sign of infection who underwent total knee arthroplasty due to knee osteoarthritis. Preoperative blood tests of each patients were examined. In addition to CRP and sedimentation values, neutrophil-lymphocyte, monocyte-lymphocyte, platelet-lymphocyte, and platelet count-mean platelet volume were calculated and receiving operating characteristics (ROC) curve analysis was made to determine the sensitivity, specificity and area under curve (AUC) values of these parameters. Results. The distribution of affected joint in septic arthritis group was as follow; 22 knees, 6 hips, 4 shoulders, 2 elbows, 1 wrist and 1 ankle. The cultures of joint aspiration yielded positive result in 19 patients while the cultures were negative in 17 patients. All of the analyzed parameters were significantly different between the groups (p<0.001). ROC curve analysis results are given in detail, in Table 1 and Figure 1. The AUC value was 97.3 when only CRP and sedimentation values were used but increased to 98.6 when neutrophile/ lymphocyte ratio was added and increased to 100 when all analyzed parameters were included. Conclusions. The analyzed parameters were found to increase the overall sensitivity and specificity when used together with acute phase reactants. However, when evaluated separately, CRP and sedimentation were still found as the most valuable parameters in the diagnosis of septic arthritis. In the diagnosis of septic arthritis, 35 mm/hr cut-off value for sedimentation and 10 mg/L cut-off value for CRP were found more sensitive and specific compared to standard laboratory cut-off values of 20 mm/hr and 5 mg/L. For any tables or figures, please contact the authors directly

Background. Septic arthritis diagnostic is an emergency which implies a treatment with antibiotics and hospitalization. The diagnosis is based on the cytobacteriological examination of the synovial fluid (SF), but direct bacteriological examination is insensitive, and the result of the culture is obtained only after several days. Therefore, there is still a need for a rapid, simple and reliable method for the positive diagnosis of septic arthritis. Such method must allow avoiding both unrecognized septic arthritis leading to major functional consequences, and overdiagnosis that will induce unnecessary expensive hospitalization and unjustified treatment. Mid-infrared (MIR) spectroscopy, that gives a metabolic profiling of biological fluids, has been proposed for early and fast diagnosis. Objectives. To confirm the MIR spectroscopy to discriminate SF samples from patients with septic arthritis from other causes of joint effusion. Methods. Synovial fluids from 402 patients referred for suspected arthropathies were prospectively collected in six hospitals and stored at °80°C. The infrared absorption spectrum was acquired for each of the frozen samples using a chalcogenide fiber biosensor. The most informative spectral variables were selected and then used to develop an algorithm. Then, the algorithm has been validated on independent synovial fluids collected straight after arthrocentesis from 86 patients. Results. The calibration (n=402) and validation (n=86) cohorts consists of synovial fluid samples from patients exhibiting various etiologies. These samples (n=488), by using SF bacteriological analysis and culture and 16S PCR analysis were classified as septic arthritis (n=43) or non-septic arthritis (n=443). On the calibration cohort, the performances of the algorithm show a sensitivity of 90%, a specificity of 90%, a NPV of 99% and a PPV of 41%, the area under the ROC curve (AUROC) was 0.95. On the validation cohort, the performances of the algorithm show a sensitivity of 92%, a specificity of 81%, a NPV of 98% and a PPV of 46%, the area under the ROC curve (AUROC) was 0.90. Conclusions. This study confirms the diagnostic performances of MIR spectroscopy for the discrimination between septic and non-septic synovial fluids. The high negative predictive value and the very short time (within ten minutes) required to obtain the result makes it possible to quickly rule out an infection diagnosis

C-reactive protein (CRP) level is used at our tertiary paediatric hospital in the diagnosis, management, and discharge evaluation of paediatric septic arthritis patients. The purpose of this study was to evaluate the efficacy of a discharge criterion of CRP less than 2 mg/dL for patients with septic arthritis in preventing reoperation and readmission. We also aimed to identify other risk factors of treatment failure. Patients diagnosed with septic arthritis between January 1, 2007 and December 31, 2017 were reviewed retrospectively. The diagnosis of septic arthritis was made based on clinical presentation, laboratory results and the finding of purulent material on joint aspiration or the isolation of a bacterial pathogen from joint fluid or tissue. Bivariate tests of associations between patient or infection factors and readmission and reoperation were performed. Quantitative variables were analyzed using Mann-Whitney tests and categorical variables were analyzed using Chi-square tests. One hundred eighty-three children were included in the study. Seven (3.8%) were readmitted after hospital discharge for further management, including additional advanced imaging, and IV antibiotics. Six (85.7%) of the readmitted patients underwent reoperation. Mean CRP values on presentation were similar between the two groups: 8.26 mg/dL (± 7.87) in the single-admission group and 7.94 mg/dL (± 11.26) in the readmission group (p = 0.430). Mean CRP on discharge for single-admission patients was 1.71 mg/dL (± 1.07), while it was 1.96 mg/dL (± 1.19) for the readmission group (p = 0.664), with a range of < 0 .8 to 6.5 mg/dL and a median of 1.5 mg/dL for the two groups combined. A total of 48 children (25.9%) had CRP values greater than the recommended 2 mg/dL at discharge, though only three of these patients (6.2%) were later readmitted. The only common variable in the readmitted children was either a negative culture result at time of discharge or atypical causative bacteria. CRP values are useful in monitoring treatment efficacy but not as reliable as a discharge criterion to prevent readmission or reoperation in children with septic arthritis. We recommend determining discharge readiness on the basis of clinical improvement and downtrending CRP values. There was a higher risk of readmission in children with an atypical causative bacteria and when culture results were negative at discharge. Close monitoring of these patients after discharge is suggested to identify signs of persistent infection

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

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

Aim. Septic arthritis of the hip is a rare entity among the adult population, but with a potential severe repercussion. The most accepted treatment is the hip debridement, even though a notorious proportion of the cases need further hip replacement owing to the cartilage destruction. The aim of this study is to analyse all our cases of septic arthritis of the hip treated with a 2-stage strategy using an antibiotic-loaded cement spacer. Method. We present a retrospective review of all our cases of septic arthritis of the hip diagnosed between 2004 and 2016 that were treated with an antibiotic-loaded cement spacer. We analysed age, gender, comorbidities, aetiology, duration of symptoms, C-reactive protein values, erythrocyte sedimentation rate, initial treatment, cultures, definitive treatment and evolution. Results. A total of 14 cases were included with a mean age of 47 years: 8 men and 6 women. The aetiology of the arthritis was: haematogenous in 8 cases, after osteosynthesis in 5 cases and after arthroscopy in 1 case. An initial debridement was performed in 6 cases whereas the spacer was directly implanted in 8 cases. The cultures were positive for: Staphylococcus aureus (4 cases), Candida albicans (2 cases), Staphylococcus epidermidis (1 case), Pseudomonas aeruginosa (1 case), Enterococcus faecium (1 case), Serratia marcescens (1 case), Streptococcus dysgalactiae (1 case), Salmonella spp (1 case) and negative in 2 cases. The evolution was: total hip arthroplasty in 10 cases, spacer preserved in 2 cases, pending of hip replacement in 1 case and exitus in 1 case. All cases presented negative cultures at the moment of implantation of the definitive prosthesis. Conclusions. A 2-stage strategy using an antibiotic-loaded cement spacer prior to the definitive hip prosthesis is a good treatment for the septic arthritis of the hip in cases with important cartilage destruction

Background. Gram stain microscopy is a routinely requested investigation in the evaluation of septic arthritis in both paediatric and adult patients. Recent evidence suggests that gram stain microscopy has poor diagnostic accuracy in adults with a sensitivity of only 45%, however the diagnostic accuracy remains unknown in children. We sought to establish the diagnostic utility of gram stain microscopy in the diagnosis of septic arthritis in children. Methods. We conducted a retrospective review of all patients of 16 years and under that underwent aspiration and washout of suspected septic joints in theatre from March 2005 to February 2011. Theatre data were cross referenced with microbiology results and analysed by simple descriptive methods in Excel. Results. We identified 23 paediatric patients undergoing washout or aspiration of a suspected septic joint during the time period studied. 17 (74%) of the patients were female and the average age was 2 years (Range 1 month–16 years). The most commonly affected joints were Knees (12/23, 52%) and Hips (7/23, 30%), with the remainder of infections occurring sporadically. There were 9 cases of culture confirmed septic arthritis (39% of all washouts), and these occurred in 5 knees (56%), 3 Hips (33%) and 1 ankle (11%). Organisms were Staphylococcus Aureus (2/8), Coagulase Negative Staphylococcus (2/9), Streptococcus pneumoniae (2/9), Group B Streptococcus (2/9) and Group A Streptococcus (1/9). Gram stain microscopy identified organisms in 3 aspirates both of which were confirmed on extended culture (Sensitivity 33%, Specificity 100%). Conclusion. Gram stain microscopy identified only 33% of culture positive cases of septic arthritis within this study. Our results suggest that gram stain microscopy lacks the diagnostic accuracy to be used in the exclusion of septic arthritis in the paediatric population

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

Objectives. The efficacy of Gram-stain microscopy for diagnosis of septic arthritis is fundamentally limited by an inherent false-negative rate of 25–50%. The aim of this study was to calculate the sensitivity of Gram-stain microscopy of synovial fluid collected in heparinised containers and to investigate if this collection method improves diagnostic value. Methods. 12-year retrospective study of patients undergoing synovial fluid analysis between 1998 and 2010. Gram-stain result was correlated with culture result and clinical diagnosis. The formula sensitivity = number of true positives/(number of true positives + number of false negatives) was used for analysis. Results. 602 cases of culture proven septic arthritis analysed with Gram-stain microscopy were identified over this time period. All samples were collected in heparinised containers. The most common joint affected was the knee in 390 cases. 568 cases were correctly identified by Gram-stain microscopy as positive and 34 were falsely identified as negative giving a false-negative rate of 5.6%, and a sensitivity value of 94%. Conclusion. This is the largest study investigating the efficacy of Gram-stain microscopy in the literature. We report a sensitivity of 94% for Gram-stain microscopy, far higher than previously reported (50–75%). No direct comparison was made to non-heparinised synovial fluid samples however we hypothesise that anticoagulation of our samples is directly responsible for this increased sensitivity. Based on these findings Gram-stain microscopy of anticoagulated synovial fluid samples is still a valuable investigation for suspected septic arthritis

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

Septic arthritis is a rare form of infection in the healthy adult population, especially adults who have never been submitted to any articular procedure. Our objective is to describe a rare case of an infectious arthritis of a hip caused by bone abscess in a previously healthy patient with few risk factors. This is the case of a 40 year-old female, who had a history of heavy smoking and low socioeconomic status. She was examined complaining with pain in the left hip and the x-ray showed a lytic image in the intracapsular femoral neck, but it was overlooked and the diagnosis of bone abscess was missed. She was to the hospital 3 weeks later with intense pain and a suppurative and swollen right thigh. Blood analyses were compatible with infection (elevated white-blood cells and C-reactive protein). Pelvic CT scan showed a lytic image in the intracapsular femoral neck with pus inside the hip. It also showed a huge abscess and infiltration of the tissues surrounding. She was then submitted to multiple surgeries in order to drain the abscess and articular cleaning. A S. aureus MSSA was isolated and an adequate antibiotic was instituted. Although this measures, there was only partial clinical and analytical success. We eventually ended-up by resecting the femoral head, which had no viability, as shown in an MRI, and was behaving as a sequestrum, justifying the impossibility in controlling the infection. The femoral head was replaced by a temporary cement-spacer impregnated with vancomycin, and the patient maintained adequate antibiotic therapy until normalization of the infection parameters. She now has no signs of infection, and is waiting to be submitted to a total hip replacement. This is a rare case of a septic arthritis with an uncommon onset in a healthy woman who had never been submitted to a hip procedure and had no local risk factors for the development of such pathology. In the research we did, we found no other case similar to this, in which the arthritis started as an intracapsular bone abscess with hematogenous origin. Reporting this case, we would also like to emphasize that, although its rarity, it is extremely important to always exclude septic arthritis in cases of joint pain, in order to prevent catastrophic consequences

This clinical case refers to a male patient, 45 years old, with a past medical history of Hepatitis C, admitted at the Emergency Department on July 2014, after a fall from 7 meters high at his workplace – dump – which resulted in an open fracture of the distal end of the right forearm bones – Gustillo & Anderson IIIA. With this work, the authors aim to describe the evolution of the patient's clinical status, from the initial fracture to the septic arthritis of the right wrist, as also the surgical interventions and other treatments he has undergone. There were used all patient's records from Hospital's archives, including Emergency Department registry, Clinical Diaries, Operative Reports, and results of diagnostic exams. It was also revised all patient's clinical process, with support of photographs obtained during the successive revaluations. The clinical case we present on this work began on July 2014, when the patient suffered an open fracture – Gustillo & Anderson IIIA – on the distal end of the right forearm bones. The lesion was subjected to washing, closed reduction and internal fixation with Kirschner wires, and also a cycle of antibiotic. At the fourth day after surgery, because of an unfavorable evolution of the wound, the patient was submitted to a bulky abscess drainage and a joint osteotaxis. About 1 month and a half after the traumatic event, it was performed a revision of the osteotaxis, following a failed attempt of osteosynthesis. By unfavorable evolution of the clinical status, with the development of septic arthritis in the right wrist, it was decided to undertake a Masquelet technique. Analyzing the evolution of the patient's clinical status, the authors conclude that, besides the appropriate therapeutic options taken at each stage, the development of septic arthritis at the right wrist was inevitable. This framework, in association to the fact that this is a 45 years old patient, with the dominant hand affected, raises issues of questionable therapeutic order

No consensus exists regarding the optimal graft choice between allogenic and autologous graft. Incidence of septic arthritis following ACL reconstruction is rare but may dependent on the graft type. Our meta-analysis assesses the difference in incidence of septic arthritis after ACL reconstruction across three groups of grafts: hamstring autografts, bone patellar tendon bone (BPTB) autografts and allografts of any type. A literature search was performed without language restriction on PubMed and EMBASE databases. We identified 245 infected ACL grafts across 15 included studies that provided a breakdown of infection incidence by graft type. A meta-analysis was performed using a random-effects model to estimate the overall infection rates and those for different graft types. Summary risk ratios and 95% confidence intervals (CIs) were calculated and reported for each outcome. Publication bias with respect to infection rates was estimated using a funnel plot. Our meta-analysis shows an overall ACL graft infection rate of 0.6% (CI 0.3% – 1.3%). The incidence was highest in autologous hamstring grafts at 1.1% at (CI 0.8% – 1.6%). That of allografts and autologous BPTB grafts was similar at 0.5% (CI 0.2%–1.0%) and 0.4% (CI 0.2% – 0.7%), respectively. Full breakdown of the meta-analysis results by study and graft type is reported in Figure 1. Septic arthritis after ACL reconstruction remains a rare (<1%) but a serious complication. Allograft rates of infection were not higher than those the autografts, contrary to the theoretical concerns. Therefore a higher infection risk should not be cited as a reason for not using it. The reason for the apparently higher infection rate with hamstring autografts is unclear and requires further research. The results of our meta-analysis may aid informed discussions between surgeons and patients about the risk of infection after ACL reconstructive surgery and graft choice

Background:. Early diagnosis of septic arthritis and osteomyelitis in children is essential to prevent long term sequelae. The diagnosis for these orthopaedic emergencies can be difficult and challenging especially in infants. Standard blood tests used for diagnosis have a low specificity. Procalcitonin (PCT) is significantly elevated in bacterial infections and remains low in viral infections and inflammatory conditions. Good positive predictive values for PCT have been obtained in various studies used in paediatric infections, but limited studies have examined the role in orthopaedic infections. Aims:. To introduce PCT testing in the work up of Septic Arthritis (SA) and Acute Osteomyelitis (OM) and to see if the test is useful in the diagnosis. Also to determine whether 0.2 ng/ml is a suitable cutoff level as indicated by previous studies. Method:. All children under 14 years presenting with signs and symptoms of SA/OM from 1 June 2009 to 31 June 2010 were subjected to standard blood tests with addition of PCT and compared to a control group. The definitive diagnosis was made by microbiologic examination obtained in theatre. A PCT cut-off level of 0.2 ng/mL was used. Results:. A total number of 33 patients were included in the study. Eight patients were diagnosed as OM, 4 as SA and 21 had another diagnosis. Staphylococcus aureus was the most common organism isolated in this series with no resistant organisms seen. In the SA/OM Group 11 of the 12 patients had an increased PCT level and 4 in the other diagnosis group had raised PCT. The calculated sensitivity of PCT was 92% with a confidence interval of 62–100% and the specificity was 81% with a confidence interval of 58–95%. In this study the sensitivity of CRP was 100% while the specificity 26%. The positive predictive value for PCT in this study was 73% and the negative predictive value was 94%. The accuracy for PCT in Septic Arthritis and Osteomyelitis in this study was 85%. Conclusions:. The calculated sensitivity and specificity in this study has shown that PCT testing can aid in the diagnosis of SA/OM in children using 0.2 ng/ml as cut-off level. PCT was more specific for bacterial infections in this study than CRP. Further research is needed with larger numbers to conclusively prove that this specific cut-off for PCT is significant