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.

Knee joint infection after an ACL reconstruction procedure is infrequently but might be a devastating clinical problem, if not diagnosed promptly and treated wisely.

The results of functional outcomes in these patients are not well known because there aren't large patient series in the literature.

The objective of this study was to evaluate the prevalence and determine the adequate management of septic arthritis following ACL reconstruction and to assess the patient functional outcomes.

The authors conducted a retrospective multicentric analysis of septic arthritis cases occurring after arthroscopically assisted ACL reconstructions (hamstrings and BTB), in patients submitted to surgery between 2010 to 2014. The study reviewed patients submitted do ACL reconstruction, that presented objective clinical suspicion of joint infection, in post-operative acute and sub-acute phases, associated with high inflammatory seric parameters (CRP >=10,0, ESR>=30,0) and synovial effusion laboratory parameters highly suggestive (PMN >=80, leucocytes >=3000).

All this patients were treated with antibiotic empiric suppressive therapy and then directed antibiotherapy according to antibiotic sensitivity profile, then the patients were submitted to arthroscopic lavage procedure, without arthropump, but with debris and fibrotic tissue removal preserving always the ACL plasty. The functional outcomes analyzed were the Lysholm and the IKDC score.

Eleven (2.2 %) out of 490 patients analyzed in the sudy were diagnosed with a post-operative septic arthritis. The microbiologic exams showed coagulase-negative Staphylococcus was present in 5 patients (S. lugdunensis in 4 cases and S. capitis in 1 case), Staphylococcus Aureus in 2 patients (1 MSSA and 1 MRSA). In four patients, the micro-organism was not identified.

The studied patients had a mean follow-up of 28 ± 16 months, the Lysholm score was 74.8 ± 12.2, the IKDC score was 66.4 ± 20.5.

Functional outcomes in the control group were better than those obtained in the infected group.

(Lysholm score 88.2 ± 9.4 (NS); IKDC score 86.6 ± 6.8 (NS). All patients retained their reconstructed ACL. None of the patients relapsed or need other intervention because of ACL failure and chronic instability.

The prevalence of septic arthritis after an ACL reconstruction in this series was 2.2 %, slightly higher than other international series (0.14 to 1.7 %). Arthroscopic lavages along with antibiotic treatment showed to be a secure procedure and allowed the preservation of the ACL plasties, without infection relapse. But the functional outcomes after active intra-articular infection were largely inferior to those obtained in patients without infection, probably to uncontrolled and intense inflammatory local response.

To quantify the duration of symptoms and the treatment modalities employed prior to surgery in patients undergoing lumbar and cervical nerve root decompression and to assess the evidence of these non-surgical treatments.

Pre- and post operative questionnaires completed by consecutive patients.

514 people undergoing consecutive cervical or lumbar nerve root decompression between March 2007 to October 2009.

Pre-operative severity and duration of pain, functional limitations and treatment received. Post-operative pain severity and change in functional limitations.

Evidence in the literature for efficacy of treatment modalities employed.

Mean duration of pre-operative symptoms was 23 months (range 1 to 360). 91% took regular medication for pain, 83% received one or more physical therapy, 24% received injection therapy.

There was improvement in both pain scores (mean pre-op 7.3; post-op 3.0) and 78% of the commonly reported functional limitations, walking, sleep and work.

We found extremely limited evidence to support the other treatment modalities employed.

Patients spend many months unnecessarily in pain, consuming considerable resources and may suffer significant side effects from ineffective treatment for pain emanating from nerve root compression. Surgical nerve root decompression relieves pain and restores function. Despite this a specialist opinion is often delayed. Early referral for specialist opinion is almost certainly more humane, cost effective, and time-limits the journey on the not so magic roundabout.