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This site requires JavaScript to function properly.Please enable JavaScript in your web browser. AbstractSeptic arthritis is the most rapidly destructive joint disease, but its early diagnosis remains challenging; delayed or inadequate treatment, even by expert physicians, can lead to irreversible joint destruction. Between 25% and 50% of patients develop irreversible loss of joint function, which is especially concerning in elderly patients. To understand the factors influencing the outcome of septic arthritis, the authors reviewed patients aged older than 50 years who had undergone debridement surgery for primary septic arthritis at their institution between 1998 and 2008. Ninety-two patients (92 knees) were enrolled in the study; 14 did not meet inclusion criteria and were excluded from the final analysis. Of the 78 included patients, 7 underwent arthrodesis, 22 underwent total knee arthroplasty, 19 were indicated for total knee arthroplasty for severe knee joint osteoarthritis but did not undergo surgery by the end of this study, and the remaining 30 had no or mild symptoms of osteoarthrosis and did not receive any surgical procedure.
Staphylococcus aureus was the most common pathogenic agent (38%), followed by mixed bacterial infection (10%).
Several factors negatively influenced the final clinical outcome, including delayed treatment, advanced macroscopic staging made during debridement surgery, performing multiple debridement surgeries, and a larger Lysholm score difference pre- and posttreatment. More antibiotics administered, longer duration of antibiotic treatment, and more pathogenic agents present were also significantly correlated with poor outcome. Its yearly incidence in Western Europe is 4 to 10 per 100,000, but can be higher among those with diabetes mellitus and previous joint pathology, especially rheumatoid arthritis.1–4The diagnosis of septic arthritis can be challenging because the differential diagnosis of 1 or more hot, swollen joints can indicate various conditions.
As a consequence, delayed or inadequate treatment can lead to irreversible joint destruction, even in expert hands. Past clinical experience has shown progression of degeneration after acute knee joint infection.6 To the authors’ knowledge, no previous study has focused on the elderly population.
Therefore, the purpose of this study was to review a database of elderly patients with knee joint infection who were treated and followed up at the authors’ institution.Materials and MethodsThe clinical data of patients diagnosed with a knee joint infection at the authors’ institution between 1998 and 2008 were reviewed.
A total of 92 patients (92 knees) were enrolled in the study.Each patient’s general condition was evaluated at admission.
The patients’ underlying disease and surgical history were obtained after septic arthritis diagnosis. The causes of infection were recorded and analyzed along with the final outcome.Delay Before TreatmentDelays before treatment were recorded for each patient. The relationship between the delays and final outcomes was analyzed.Surgery and Antibiotic TreatmentAll patients underwent surgical debridement, either by arthroscopy or the traditional open method. The macroscopic appearance of joint destruction was classified according to the 4-stage classification system reported previously by Vispo Seara et al (Table 1).8 Surgical debridement was performed thoroughly, with all infected materials and bony fragments being removed carefully. The antibiotic route of administration was changed to oral if C-reactive protein levels and white blood cell counts had returned to normal levels.


In these cases, oral antibiotics were continued for a minimum of 4 weeks until the joint fluid was clear and C-reactive protein levels tended to remain within the normal range. Repeat surgical debridement was performed if symptoms persisted and lab data showed no clinical improvement after antibiotic treatment.Macroscopic staging was associated with the final outcome using Fisher’s exact test. The number of infective pathogens present, number of debridement surgeries performed, number of antibiotics administered, and duration of antibiotic treatment were also associated with final outcome by using the Kruskal-Wallis test. The number of infective pathogens was correlated with the number of debridement surgeries using Spearman’s correlation.Image and Clinical Performance EvaluationImaging data, functional performance, subjective functional performance by Lysholm knee scoring scale,9,10 and range of motion (ROM) were compared pre- and posttreatment.
The results were analyzed using Spearman’s correlation.Biplanar imaging studies were performed.
The Kellgren-Lawrence classification of knee joint osteoarthrosis was applied to evaluate the degree of knee joint osteoarthrosis (Table 2).11 The change in osteoarthrosis degree was calculated.
The medical history of each patient was recorded, and the number of patients per medical condition was calculated (Figure 1).
In 13 (14%) patients, no microorganism was identified, but in 11 of them, antibiotics had been administered at another hospital prior to culture. These patients were included in the current study because they presented with clinical symptoms, laboratory blood values, and histological findings compatible with joint infection. In 12 of these patients, gram-negative bacterial infection was found: 4 (5%) cases of Pseudomonas aeruginosa, 4 (5%) cases of Escherichia coli, 2 (2%) cases of Klebsiella pneumoniae, and 2 (2%) cases of Salmonella enteritidis. Six patients died within 3 months after initial diagnosis due to late-stage cancer or severe infection.
Seven patients underwent arthrodesis, 22 underwent total knee arthroplasty (TKA), 19 patients were indicated for TKA for severe knee joint osteoarthritis but did not undergo TKA by the conclusion of this study, and the remaining 30 patients had no or mild symptoms of osteoarthrosis and did not receive any surgical procedures (Table 3). The imaging series performed pre- and posttreatment and at final outcome are shown in Figures 3 through 6.
Thirty-three patients underwent arthroscopic debridement surgery and 45 underwent open debridement surgery. Anteroposterior (C) and lateral (D) radiographs 2 months posttreatment showing severe joint space narrowing, osteophyte formation, and flexion contracture.
Anteroposterior (C) and lateral (D) radiographs 5 months posttreatment showing the affected site with severe cartilage destruction and severe joint space narrowing. Anteroposterior (E) and lateral (F) radiographs 3 years posttreatment and after the patient had undergone total knee arthroplasty.
Postoperatively, the patient developed septic arthritis of the left knee resulting from compartment syndrome of the lower left leg. Anteroposterior (C) and lateral (D) radiographs 4 months posttreatment showing progression of cartilage destruction and joint space narrowing.
Anteroposterior (C) and lateral (D) radiographs 6 months posttreatment showing a mild progression of knee joint degeneration.


Anteroposterior (E) and lateral (F) radiographs 5 years posttreatment showing a mild degree of degeneration.The etiology of infection was associated with the final outcome (Table 3). In the arthrodesis group, trauma- or injury-related knee joint infection was noted in 5 (71%) patients; this percentage was significantly higher than in the other 3 groups.
However, no significant correlation existed between the cause of infection and the final outcome. The percentage of those having no specific cause of infection was higher in the TKA group (45%). Hematogenous infection was more common in those indicated for TKA (42%) and in those with mild sequelae (43%). No statistically significant correlation existed between the etiology of infection and the clinical outcome.Delay Before TreatmentDelay before treatment was recorded (Table 4). The number of patients who began treatment more than 3 weeks after the onset of clinical symptoms was 6 (86%) in the arthrodesis group, 18 (82%) in the TKA group, and 18 (79%) in the indicated for TKA group. No patient in these 3 groups began treatment within the first week after the onset of the symptoms.
In the indicated for TKA group, fewer patients had severe degeneration; 7 (37%) patients each were stages III and IV, respectively, and the remaining 5 (26%) were stage II.
In the mild symptoms group, 7 (23%) patients were stage IV, 10 (33%) were stage III, 12 (40%) were stage II, and 1 (3%) was stage I. A delay in treatment of more than 3 weeks resulted in a significant decrease in knee joint ROM and increased the possibility of joint replacement or arthrodesis (Figure 11; Table 4). Recent infection of other sites, including cutaneous infection, may also increase the risk of knee joint sepsis. According to Kaandorp et al,16 knee joint sepsis may result from direct inoculation of bacteria from trauma or hematogenous transmission of the pathogen.
Trauma of the affected limb accounted for 26% of cases in the current study, and the percentage of patients with recent infections of the body was as high as 34.6%. Bacteria may be introduced during joint surgery, fluid aspiration, or local corticosteroid injection,1,6,17 but this route was less common in the current study (9%). No definite predisposing factor exists for the development of septic arthritis, but previous infection of the knee joint is a good candidate.In the current study, staphylococci were the most common causative pathogens.
This is in agreement with a previous study that showed that Staphylococcus aureus was responsible for primary septic arthritis in 37% to 56% of patients.17–19 Gram-negative bacilli was common in intravenous drug users, elderly patients, and seriously immunocompromised patients4,5 and accounted for 14% of all pathogens in the current study. Mycobacterium tuberculosis, although uncommon in bacterial arthritis, was found in 3% of the current cases.



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22.03.2014, author: admin


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