Stage-dependant management of septic arthritis of the shoulder in adults

Diagnostic and therapeutic standards relating to septic conditions of the shoulder are rarely documented in the literature. For this study, patients suffering from septic shoulder arthritis were prospectively enrolled. Staging was based on the criteria of Gächter (Stutz et al., Knee Surg Sports Traumatol Arthrosc 8:270–274, 2000), and assessment of functional outcome was based on a self-assessed Constant score (Boehm et al., Unfallchirurg 107:397–402, 2004). Patients were separated into three groups according to the CEBI-classification reported by Pfeiffenberger and Meiss (Arch Orthop Trauma Surg 115:325–331, 1996). Forty-three patients were enrolled. Group I contained 21% of patients, while 23% were assigned to group II, and 56% to group III. Staphylococcus aureus was found in 71%. Eight patients were treated arthroscopically, and 35 received open surgery. None of the implants could be preserved. The mean self-assessed Constant score after 26 ± 7 months was 74 ± 9 points in group I, 63 ± 14 points in group II, and 53 ± 14 points in group III. Diagnostic work-up consisted of laboratory analysis including CRP and joint aspiration. Arthroscopic procedures can be effective when implemented early. With regard to implants and chronic symptoms, primary removal should be critically reconsidered.     

Septic arthritis of the shoulder in adults

Septic arthritis of the shoulder is uncommon in adults. We reviewed the cases of eighteen patients who were followed for a minimum of one year. The patients ranged in age from forty-two to eighty-nine years. All but one patient had at least one serious associated disease. Eight patients had had an injection or aspiration of the shoulder before development of the infection. All but one patient had had a delay in diagnosis. At the time of admission to the hospital, the erythrocyte sedimentation rate was always elevated, but the body temperature and white blood-cell count were not. After treatment, the functional result was usually poor: only five patients regained forward flexion to 90 degrees or more, eight patients had no active motion of the glenohumeral joint, and two patients died. Arthrotomy appeared to afford a better result than did repeated aspiration.     

Arthroscopic management of septic arthritis of the shoulder joint

BACKGROUND: Nineteen patients with septic arthritis of the glenohumeral joint were treated with a combination of arthroscopic irrigation and débridement and systemic antibiotics according to bacterial sensitivity. We retrospectively reviewed the series to determine the efficacy and safety of this treatment. METHODS: There were seventeen men and two women, with a mean age of fifty-nine years. Underlying medical disease was present in thirteen patients, with six of them having diabetes. The average duration of symptoms prior to the arthroscopic lavage was three weeks. Fifteen patients had had local injections into the shoulder joint. The arthroscopic staging of the infection was based on the modified criteria of G?chter. The functional outcome was evaluated with use of the UCLA scoring system. RESULTS: As determined at arthroscopy, one infection was classified as stage I; seven, as stage II; nine, as stage III; and two, as stage IV. Staphylococcus was the most common organism identified. The infection was eradicated completely with a single arthroscopic procedure in fourteen patients. The mean UCLA score at the time of the last follow-up was 26 points, with a mean score of 23.7 points for the eleven patients with a rotator cuff tear and 29 points for the eight with an intact rotator cuff. Patients who had had symptoms for no more than two weeks prior to the arthroscopic lavage had better results than those who had had symptoms for longer than two weeks. CONCLUSIONS: Arthroscopic débridement for the treatment of septic arthritis of the shoulder is safe and efficient, particularly in the early stages of the disease. Underlying medical diseases such as diabetes, prior injections, or a preexisting rotator cuff tear were seen in a high proportion of these patients.     

Arthroscopic treatment for septic arthritis of the shoulder in an infant

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, débridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40°C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and débridement, may be one of the options for treating septic arthritis of an infants shoulder.     

Acute hematogenous septic arthritis of the knee in adults

Purpose of study

To evaluate the factors associated with acute hematogenous septic arthritis of the knee in adults and to assess the outcome after open knee arthrotomy.

Methods

We performed a prospective evaluation of 26 adult patients with acute nongonococcal septic arthritis of the knee presenting within 7 days. All patients underwent open knee arthrotomy, and final evaluation by means of Knee society score of the affected knee was compared with the contra lateral normal knee.

Results

The average duration of symptoms at the time of presentation was 3.9 days. Staphylococcus aureus was the commonest bacteria isolated in 17 (65.4 %) patients. The average duration of follow-up in our study was 18.5 months. In our study, Knee society score decreases as the age of the patient advances (P < 0.05) and also it was found to be low (P < 0.05) in the affected knee as compared to contra lateral normal knee.

Conclusion

Our study shows that age of the patient at presentation is critical as it shows significant reduction in knee score. This explains that the septic arthritis may contribute to the progression of age-related degeneration of the knee joint. There appears to be no definite contributing factors or conditions associated with acute hematogenous septic arthritis of the knee in adults, although further study may be warranted regarding this matter.     

Arthrodesis of the shoulder after septic arthritis. Long-term results

We analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = 0.2808; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks. The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (< 50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients.     

Advanced septic arthritis of the shoulder treated by a two-stage arthroplasty

BACKGROUND The usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited.AIM To evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.METHODS We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand(DASH) score and subjective shoulder value(SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.RESULTS Mean age was 61 years(range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo(range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively.CONCLUSION Short interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.     

Arthroscopic washout of the shoulder for septic arthritis in infants. A new technique

The operative treatment of septic arthritis of the shoulder in infants has been facilitated by the use of a 30 degrees wrist arthroscope. We have treated three children under the age of three years using this technique. After initial aspiration of the joint, an arthroscope was inserted using the posterior approach. Washout was performed under direct vision and complete clearance of pus allowed assessment of the inflammation and the damage to articular cartilage. The procedure was minimally invasive and gave excellent cosmesis without compromising care. Full recovery was achieved with a single intervention.     

Arthroscopic surgery for septic arthritis of the hip joint in 4 adults

Purpose: Arthroscopic surgery for septic coxarthritis has not become a well-established technique despite its minimally invasive nature. The authors performed arthroscopic surgery and intraoperative high-volume irrigation on 4 adult patients with septic coxarthritis. This minimally invasive procedure was successful in treating these patients, and there was no recurrence of arthritis or other complications. The purpose of this article is to introduce this 3-directional-approach method of arthroscopic surgery for septic coxarthritis. Type of Study: Case study of arthroscopic surgery for septic arthritis of the hip joint in 4 adults. Methods: There were 3 women and 1 man with an average age of 58 years. The length of time from onset of symptoms to surgery averaged 36 days. One patient had diabetes; another had subarachnoid hemorrhage and was being treated with steroidal drugs. The etiologic agent was found to be Staphylococcus aureus infection in 2 patients, Serratia sp. in 1 patient, and group-B Streptococcus in 1 patient. Three-directional-approach arthroscopic surgery and intraoperative high-volume irrigation were performed using 20 to 25 L of physiologic saline on the 4 patients. Continuous postoperative intra-articular irrigation was not performed. Results: Inflammatory reactions subsided within 4 weeks of surgery in 3 of the 4 patients and within 6 weeks in the other patient. At the time of the final examination, the postoperative follow-up period ranged from 1 to 6 years and none of the patients had ankylosis of the hip joint. Conclusions: Three-directional-approach arthroscopic surgery in combination with intraoperative large-volume irrigation is an effective technique for treating septic arthritis of the hip joint because the joint can be preserved and it is less invasive than other open arthrotomy techniques.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 290–297     

Total hip arthroplasty for primary septic arthritis of the hip in adults

Two-stage total hip arthroplasties (THA) performed after primary septic arthritis of hip were studied to evaluate the surgical outcomes and complications. Of 28 cases, the reinfection rate was 14% and complication rate was 36%. At an average follow-up period of 77 months, the outcome in 22 patients (79%) was rated as good or excellent, 4 as fair, and 2 as poor. Leg length discrepancy improved from a preoperative mean of 2.89 cm to a postoperative mean of 0.61 cm. Despite a higher complication rate, two-stage THA was still deemed a worthy procedure because hip function was significantly improved in patients with primary septic arthritis of the hip.

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Résumé  L’arthroplastie totale de la hanche en deux temps après arthrite septique primaire a été étudiée à propos de 28 cas. Le taux de récidive infectieuse était de 14% et celui des complications de 36%. A un suivi de 77 mois le résultat était excellent ou bon pour 22 patients (79%), moyen pour 4 et mauvais pour deux. L’inégalité de longueur des membres s’est améliorée d’une valeur moyenne pré-opératoire de 2,89cm à une valeur moyenne de 0,61cm. En dépit d’un taux de complication élevé l’arthroplastie en deux temps demeure une méthode valable qui améliore significativement la fonction des patients après une arthrite septique primaire de la hanche.

     

Bilateral shoulder septic arthritis due to suspected bacterial endocarditis: A case report

IntroductionSeptic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment. It is typically caused by occult bacteremia which allows bacteria to seed the joint or local invasion of a soft tissue infection. Most cases of septic arthritis are caused by gram-positive bacteria, with the most common culprit being Staphylococcus Aureus. The reason septic arthritis is an orthopedic emergency is because of rapid destruction to cartilage. The mechanism of injury to cartilage is two-fold: bacterial enzymes are directly toxic to joint cartilage, and buildup of exudate can tamponade blood flow and cause anoxic injury. Typically, the knee is the most commonly involved joint. This is followed by the hip, ankle, elbow, wrist, and shoulder in descending order of occurrence. Polyarticular disease makes up a small percentage of these cases and if present, it is usually asymmetric and will involve at least one knee joint.Presentation of caseBilateral joint septic arthritis is relatively rare. We present an uncommon case of atraumatic bilateral septic shoulders in an elderly man with a history of heart disease and insidious bilateral shoulder pain after golfing 18 holes. This presentation is unique not only in its rarity but also in its impact on our understanding of septic arthritis in the setting of medical comorbidities and a relatively unimpressive presentation. With a recent golfing day just prior to presentation, differential diagnoses other than septic arthritis included deltoid/rotator cuff muscle strain, acute on chronic rotator cuff tendinosis, acute on chronic rotator cuff tearing, acute flare up of osteoarthritis, rheumatoid arthritis, or crystalline arthropathy. With elevated inflammatory markers and an equivocal physical examination, our patient underwent advanced imaging via MRI and subsequent bilateral glenohumeral joint diagnostic aspirations that were consistent with septic arthritis due to his complaining of contralateral shoulder pain shortly after his admission. Immediately after said diagnosis was made, the patient was taken back for emergent bilateral open irrigation and debridement, as septic arthritis is an orthopedic emergency, and went on to recover appropriately on culture-directed intravenous antibiotic therapy.Discussion/conclusionThis case report is impactful with regard to clinical practice for multiple reasons. First and foremost it is a cautionary tale for all clinicians with regard to the level of suspicion one must have for polyarticular septic arthritis in the setting of the multiply painful patient. Second, it demonstrates the utility of advanced imaging in the equivocal patient. Lastly, it underscores the importance of prompt diagnosis and treatment, validating the existing algorithm for septic arthritis.     

Factors affecting the outcome of septic arthritis of the shoulder joint with arthroscopic management

BackgroundGood results have been reported with arthroscopic therapy of septic arthritis of the shoulder; however, few studies have focused on the risk factors for failure of arthroscopic surgery. The purpose of this study was to identify the risk factors affecting the recurrence or death post-surgery in cases of septic arthritis of the shoulder.MethodsWe retrospectively assessed the records of patients who underwent surgical treatment for septic arthritis of the shoulder between 2009 and 2019. Patients were divided into 2 groups based on complete recovery, recurrence, or death after a single arthroscopic surgery: the eradicated group and the recurred/death group. To identify risk factors for the failure of arthroscopic surgery for septic arthritis of the shoulder, the following parameters were considered: age, sex, presentation of a rotator cuff tear, the arthroscopic staging of the infection, diabetes mellitus, the causative organism, preoperative white blood cell count, and C-reactive protein level in blood. We compared two groups with respect to the presence of potential risk factors.ResultsThis study included 22 patients with a mean age of 67.9 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgery in 17 patients (77.3%). However, failure of the surgery resulting in recurrence or death was observed in 5 patients (22.7%). No significant differences were observed in other parameters between the two groups except for the causative organism. Methicillin-resistant Staphylococcus aureus was found in 1 patient (5.9%) in the eradicated group. On the other hand, Methicillin-resistant S. aureus was found in 3 patients (60%) in the recurred/death group (p = 0.024).ConclusionMost patients with septic arthritis of the shoulder are effectively treated with a single arthroscopic surgery. This study suggests that Methicillin-resistant S. aureus as the causative organism may be the most important prognostic factor in these cases.     

Severe septic arthritis of the shoulder with an axillary nerve lesion in a 4-year-old child

Septic arthritis in children frequently affects the joints of the lower extremity, namely the hip and the knee [1–3]. Infection in the glenohumeral joint is rare [4–7], representing 4% of all joint infections [4, 5]. Arthralgia, joint swelling, fever and pseudoparalysis are the most commonly observed symptoms [1, 4, 5, 8]. Diagnosis and thus appropriate management are often delayed [4] and therefore early disease recognition and treatment play a significant role in minimising the risk of developing complications such as joint surface destruction, growth arrest, adjacent osteomyelitis, and loss of joint movement [1, 4–6]. Brachial plexopathy, is infrequently reported [13], and a lesion to the axillary nerve specifically has not yet been reported in literature to our knowledge. Treatment aims include adequate washout and debridement of the joint with the objective of relieving pain and restoring function [5]. This can be achieved either via arthrotomy or arthroscopically [2, 5]. However there is currently no clear consensus with regard to which management option leads to improved outcome [3, 8], because of the lack of studies describing the results of surgical intervention [9]. The case of a 4-year-old boy with a delayed diagnosis of septic arthritis of the right shoulder with massive abscess formation and an axillary nerve lesion is presented.     

Anaerobic septic arthritis

During a 3 1/2 year period anaerobic septic arthritis was diagnosed in 43 patients (46 joints). The hip and knee accounted for 83% of the infected joints. Anaerobic infections complicated elective musculoskeletal surgery in 23 patients, including 21 with total joint arthroplasties. An additional 12 patients developed septic arthritis following surgical treatment of traumatic injuries of an extremity. Gram-positive cocci were the anaerobes most commonly found in these two groups of surgical patients, accounting for 64% of the isolates; Peptococcus magnus was the most common organism. In contrast, gram-negative bacilli (especially Bacteroides fragilis) comprised 63% of the anaerobes isolated from eight patients with chronic debilitating diseases who had not had prior surgery. Only anaerobes were recovered from approximately half of all the patients with septic arthritis while mixed aerobic-anaerobic cultures accounted for the remainder. Adequate treatment required aggressive surgery and prolonged (minimum of three weeks) antimicrobial therapy. Infected total joint arthroplasties had to be removed. Loss of joint function occurred in six patients with posttraumatic infections when surgery was delayed or antimicrobials were inadequate. Outcome was poorest in the patients with chronic debilitating diseases, four of whom died.     

Humeral shortening and inferior subluxation as sequelae of septic arthritis of the shoulder in neonates and infants

BACKGROUND: Although humeral shortening as a sequel of septic arthritis of the shoulder in infants has been reported in previous studies, functional disorders of the shoulder resulting from humeral shortening have not yet been clarified. In this study, we retrospectively investigated the long-term outcome of septic arthritis of the shoulder in neonates and infants and examined the relationship between growth disturbance of the humerus and decreased range of motion with respect to glenohumeral joint laxity. METHODS: We reviewed the cases of fifteen patients (sixteen shoulders) with an age of a few days to 2.6 years at the onset of the disease who were followed from 5.0 to 17.9 years. We noted the initial treatment method and evaluated humeral length and shoulder function at the time of the final follow-up. For the final treatment results, we classified the shoulders with normal findings on radiographs as Grade I, those with humeral head deformity as Grade II, and those with humeral head deformity with inferior subluxation as Grade III. RESULTS: Primary treatment included arthrotomy in ten shoulders. The delay between the onset of the disease and surgery ranged from three to twenty-six days. At the time of the final follow-up, the results were Grade I in five shoulders, Grade II in six shoulders, and Grade III in five shoulders. The mean humeral shortening was 0.1 cm for Grade-I shoulders, 0.9 cm for Grade-II shoulders, and 7.3 cm for Grade-III shoulders. All Grade-III shoulders had >or=3 cm of shortening, and four of the five Grade-III shoulders showed limitation of elevation (abduction of <130 degrees ). None of the Grade-III shoulders had undergone arthrotomy within ten days after the onset of the disease. CONCLUSIONS: Inferior subluxation of the humeral head related to shoulder dysfunction resulting from early childhood septic arthritis accompanied humeral shortening of >or=3 cm and was only observed in patients who did not undergo arthrotomy of the shoulder within ten days after the onset of the infection.