Septic Arthritis

Acute septic arthritis results from bacterial invasion of a joint space, which can occur
through hematogenous spread, direct inoculation from trauma or surgery, or contiguous
spread from an adjacent site of osteomyelitis or cellulitis. Despite in-depth research into
the pathophysiology and treatment of acute septic arthritis, the morbidity and mortality
are still significant, especially in patients at the extremes of age. Even with the currently
available treatment regimens and antibiotics, serious complications may result. Delay in
diagnosis and failure to begin treatment promptly are the most common reasons for late
complications of infection. Studies now focus on identifying specific types of bacterial
etiologies and predisposing risk factors and on the host’s response to the infection,
particularly interleukin-1 (IL-1) and how it affects the destruction of articular cartilage.

Acute septic arthritis can occur at any age, but young children and elderly individuals are
most susceptible. An immature immune system, immune compromise for any reason,
neoplasms, alcoholism, diabetes mellitus, rheumatoid arthritis, systemic lupus
erythematosus, malnutrition, chronic hepatic or renal failure, intravenous drug use, and
previous joint trauma or arthritis predispose an individual to septic arthritis and alter the
normal bacterial etiology. Therefore a thorough history and physical examination should
be done.

Septic arthritis occurs most frequently in adults; however, the most serious sequelae from
infection occur in children, especially if a hip joint is involved and treatment has been
delayed. Age-dependent anatomical variables may be responsible for the serious
complications in children, such as destruction of the epiphysis and associated avascular
necrosis from increased intracapsular pressure and septic effusion.

In neonates, Streptococcus is the most common causative organism for acquired

infection. In neonates who are hospitalized, however, Staphylococcus, Candida, and
gram-negative bacilli are the most likely causes. Haemophilus influenzae type B also
may be the cause of septic arthritis in children under 2 years of age.

In adults, Neisseria gonorrhoeae is the most common infecting organism. This infection
commonly occurs in young adults and has a slightly different presentation than other
types of infectious arthritis. Often the infection is polyarticular and may be associated
with a papular rash. Joint cultures often are negative, but cultures from the pharynx or
urethra may be positive. Gonococcal arthritis generally has a favorable outcome when
treated with appropriate antibiotics, and drainage usually is not necessary. The most
common nongonococcal cause of septic arthritis in adults is Staphylococcus aureus. As in
children, adults typically have monoarticular involvement, and the infecting organism
spreads by the hematogenous route. The hips and knees are the most frequently affected
sites.

Hematogenous spread of infection occurs frequently because the vascular spaces of the
synovium lack a basement membrane, allowing the contents of the vascular space
relatively easy access to the joint space. Polyarticular disease is seen more frequently in
adults with rheumatoid arthritis.

Diagnosing acute septic arthritis can be difficult, especially in neonates, in whom

inflammatory responses are blunted and signs such as fever, swelling, erythema, and pain
may be minimal or lacking. The only finding in a neonate may be infection at another site
(e.g., the umbilical catheter), irritability, failure to thrive, asymmetry of limb position, or
displeasure at being handled.

If a joint is suspected of being infected, aspiration with a large-bore needle should be

performed promptly and before antibiotic therapy is begun. Careful skin preparation
before aspiration is mandatory, and the fluid obtained should be sent for immediate Gram
staining, culture, cell counts, and crystal analysis. In children and adults with normal
immune systems, the diagnosis can be made based on the findings from the joint aspirate.
Measuring erythrocyte sedimentation rates or C-reactive protein levels may be helpful in
following the treatment course. Typically, synovial leukocyte counts above 50,000/mm3
are indicative of infectious arthritis.

Three essential principles in the management of acute septic arthritis:

 the joint must be adequately drained,
 antibiotics must be given to diminish the systemic effects of sepsis,
 the joint must be rested in a stable position.

If the diagnosis is made early and the involved joint is superficial, such as the elbow or
ankle, aspiration should be performed and repeated if necessary, appropriate antibiotics
should be administered, the joint should be splinted in a position of function, and the
patient should be observed for a decrease in pain, swelling, and temperature and for
improved joint mobility. Infections caused by less virulent organisms usually respond
promptly to treatment. If the response is not favorable and repeat aspiration does not
show a decrease in the synovial leukocyte count within 24 to 48 hours, open surgical
drainage is necessary. If purulent material is deeply situated in a joint, such as the
shoulder or hip, open surgical drainage should be carried out. Arthroscopic drainage is a
good alternative to open drainage in many instances, especially for infections involving
the knee, elbow, shoulder, or ankle.

Initial antibiotic treatment is empirically based on the patient’s age and the risk factors.
Empirical antibiotic therapy should be used until culture and sensitivity results are
available. Although some infections clear up within 7 days, antibiotic regimens often
should be continued for 4 to 6 weeks, depending on the clinical course.

As the infection resolves, therapy to restore normal joint function is begun, including
functional splinting initially to prevent deformity, isometric muscle strengthening, and
active range-of-motion exercises. Salter, Bell, and Keeley have shown the beneficial
effects of continuous passive motion in inhibiting the formation of adhesions and pannus
and in promoting better nutrition for the cartilage during the healing phase. Patients being
treated for infectious arthritis often have varying degrees of deformity, and treatment with
traction, dynamic splints, serial casting, and passive exercises may be useful.

In the residual stage the infection has completely subsided but the joint or joints involved
are left with deformity or limitation of motion, and treatment is directed at correction and
functional restoration of the joint. However, the possibility of reactivating the infection
should be considered when any necessary procedure is undertaken at this stage.

Nonunion was more common when the fractures were

(1) open,
(2) infected,
(3) segmental, with impaired blood supply, usually to the middle fragment,
(4) comminuted by severe trauma,
(5) insecurely fixed,
(6) immobilized for an insufficient time,
(7) treated by ill-advised open reduction,
(8) distracted either by traction or by a plate and screws.

Status of soft tissues and neurovascular structures. .

With current techniques of bone grafting, internal fixation, and external fixation,
definitive surgery in many instances can be performed earlier, and rehabilitation of the
joints and soft tissues can thus be started earlier. The condition of the soft tissues
surrounding a nonunion must be considered in treatment planning. Unyielding scar
tissues, especially on the concave side of a deformity,may result in skin necrosis; deep
scarring may prevent bone transport or grafting; and the need for skin grafting or flap
coverage may influence treatment selection. Soft tissue contractures must be considered
if treatment of the nonunion will result in lengthening of the extremity.

In patients with histories of vascular injuries or those with weak or absent peripheral
pulses, an arteriogram may be indicated to evaluate vascular status. A significant vascular
abnormality may limit treatment methods and fracture healing. Vascular abnormalities
should be corrected.

Any nerve injuries should be carefully evaluated; if possible, the nerve should be
repaired. Occasionally an extremity must be shortened to gain length in repairing a nerve
defect. To avoid nerve damage the Ilizarov technique may be considered for gradual
lengthening and treatment of the nonunion. When the nerves are so damaged that
sensation and muscle power in a lower extremity are permanently lost, amputation
usually is the practical choice.

Hypervascular nonunions are subdivided as follows:

1. ‘‘Elephant foot’’ nonunions. These are hypertrophic and rich in callus. They result
from insecure fixation, inadequate immobilization, or premature weight-bearing
in areduced fracture with viable fragments.
2. ‘‘Horse hoof’’ nonunions. These are mildly hypertrophic and poor in callus. They
typically occur after a moderately unstable fixation with plate and screws. The
ends of the fragments show some callus, insufficient for union, and possibly a
little sclerosis.
3. Oligotrophic nonunions. These are not hypertrophic, and callus is absent. They
typically occur after major displacement of a fracture, distraction of the
fragments, or internal fixation without accurate apposition of the fragments.

In the second type the nonunion is avascular (atrophic) or inert and is incapable of
biological reaction. Studies of strontium 85 uptake in these nonunions indicate a poor
blood supply in the ends of the fragments.
Avascular nonunions are subdivided as follows:

1. Torsion wedge nonunions. These are characterized by the presence of an

intermediate fragment in which the blood supply is decreased or absent. The
intermediate fragment has healed to one main fragment but not to the other. These
typically are seen in tibial fractures treated by plate and screws.
2. Comminuted nonunions. These are characterized by the presence of one or more
intermediate fragments that are necrotic. The roentgenograms show absence of
any sign of callus formation. Typically these nonunions result in the breakage of
any plate used in stabilizing the acute fracture.
3. Defect nonunions. These are characterized by the loss of a fragment of the
diaphysis of a bone. The ends of the fragments are viable, but union across the
defect is impossible. As time passes the ends of the fragments become atrophic.
These nonunions occur after open fractures, sequestration in osteomyelitis, and
resection of tumors.
4. Atrophic nonunions. These are usually the final result when intermediate
fragments are missing and scar tissue that lacks osteogenic potential is left in their
place. The ends of the fragments have become osteoporotic and atrophic.

GENERAL TREATMENT OF NONUNIONS

Reduction of fragments. When the fragments are in good position but are separated by
fibrous tissue, extensive dissection usually is undesirable; leaving periosteum, callus, and
fibrous tissue intact about the major fragments preserves their vascularity and stability,
and, after a bridging graft or grafts have united with the fragments, the intervening
fibrous tissue and callus ossify.

Displaced, and especially bayonet, nonunions of any long bone can be reduced by
gradual traction in a simple pin fixator before closed intramedullary nailing. In
cooperative patients posttraumatic shortening usually can be corrected rapidly; we have
been able to obtain lengthening of up to 1 cm per day in divided increments. The external
fixator is applied for a few days to restore length, the fixator is removed, and closed
intramedullary nailing is performed. We have had no problems with infections after a
brief period of external fixation. Alternatively, an Ilizarov frame can be used to restore
length, appose fragments, and stabilize the fragments until union.

Plating and bone grafting of displaced nonunions of most long bones require a more
extensive operation. Scar tissue about the nonunion must be excised so that the grafts can
be covered by relatively normal tissue. The fragments are then mobilized, preserving
their normal soft tissue attachments as much as possible, their rounded ends are resected
so that contact will be maximal, their medullary canals are cleared of fibrous tissue to aid
in medullary osteogenesis, and they are then apposed as closely as possible.

Bone grafting. For many years, the most frequently used method of treatment of
nonunions has been bone grafting, and numerous techniques have been described.
Autogenous bone graft, allograft bone, or synthetic bone substitute, used alone or in
conjunction with internal fixation, may help to stimulate bone formation.
Onlay bone graft. Massive cortical grafts combine fixation and osteogenesis in treating
nonunions of the long bones.
Dual onlay graft. Because union in congenital pseudar throsis of the tibia is hard to
obtain. Two cortical onlay grafts are placed opposite each other on the host bone across
the nonunion and are fixed with the same set of screws.
Cancellous insert grafts. Nicoll described a technique of bridging gaps in long bones
with solid blocks of cancellous bone and fixing the fragments with metal plates. This
procedure has been useful in patients with defects less than 2.5 cm long.

Stabilization of fragments. As in fresh fractures, physical forces play a part in the

success or failure of treatment; although absolute fixation is unnecessary, shearing, rotary,
and distracting forces must be minimal after surgery. Adequate stabilization can be
obtained by internal fixation such as plates and screws or intramedullary nails or by
external fixation such as the Ilizarovdevice.
Internal fixation. Internal fixation in the treatment of nonunions, as in acute fractures,
should provide sufficient stability for fracture healing without excessive rigidity. The
choice of internal fixation depends on the type of nonunion, the condition of the soft
tissues and bone, the size and position of the bone fragments, and the size of the bony
defect. Plate and screw fixation, with or without bone grafting, usually is adequate for
hypertrophic nonunions if the bone is not osteoporotic and the fragments are large enough
for firm screw fixation. Intramedullary nailing, especially interlocked nailing, is useful in
nonunions of long bones, such as the tibia, femur, and humerus. If alignment is
acceptable or closed reduction can be obtained, the procedure can be performed without
opening the fracture site. Bone grafting usually is not required. When open technique is
required, usually only limited exposure and dissection are required. Early weight-bearing
is possible and the late effects of ‘‘stress shielding’’ do not occur. The primary
contraindication for intramedullary nailing is current or prior infection; however,
intramedullary nailing frequently is successful as a salvage operation for infected
nonunions.

External fixation. The Ilizarov external fixator is a labor intensive but very effective tool
in the treatment of nonunions, especially those associated with defects, shortening, and
deformities. More traditional type pin external fixators, using the Ilizarov principles, also
can be used in the management of nonunions, especially when complicated by infection.
Recently, hybrid circular frames attached to uniplanar external fixators have decreased
some of the problems associated with this demanding technique. External fixation can be
used for temporary or definitive stabilization. One advantage of external fixation is that it
is relatively noninvasive and does not disturb soft tissues surrounding the nonunion.
Other advantages are its ability to correct deformity and provide stable fixation.

Electrical and electromagnetic stimulation. Improvements in electrical and

electromagnetic bone growth stimulators are currently under way. Bone growth
stimulators usually are used in conjunction with cast immobilization and weight-bearing.
External electrical stimulation is especially advantageous in infected nonunion
management or when surgical intervention is contraindicated. At least three electrical and
electromagnetic methods are available for the treatment of nonunions.

FACTORS COMPLICATING NONUNION

Nonunions may be complicated by infection, poor soft tissue quality, short periarticular
fragments, or significant deformity.

Infection. Considerable judgment is required to treat a nonunion of an infected fracture.

Three entirely different methods of treatment have been most often recommended for this
difficult problem. The first is the ‘‘conventional,’’ or classic, method used for many
decades. The second is the ‘‘active,’’ or modern, method described more recently by
Weber and Cech and others. One or the other of these methods can be carried out wholly
or in part, depending on the circumstances in a given patient and the judgment of the
surgeon. The two are described separately here, but the surgeon can elect to use parts of
each in a single patient. The third method is treatment by pulsed electromagnetic fields.
This noninvasive method developed by Bassett et al. can be used in the presence of
infection. The Ilizarov method is a more recent method of treating infected nonunions
that has similarities to both the conventional and active methods.

Conventional treatment. The objects of the conventional method are to convert an

infected and draining nonunion into one that has not drained for several months and then
to promote healing of the nonunion by bone grafting. This method of treatment often
requires 1 or more years to complete and usually results in stiffness of adjacent joints.
Sometimes when the nonunion is in an extremity, amputation is preferable, since
treatment may fail.

The skin over the bone is made as nearly normal as possible. Three operations may be
necessary to provide this type of skin. In the first the wound is thoroughly saucerized, and
all foreign and infected or devitalized materials are removed to provide a vascular bed.
Any gross overlapping and displacement of the fragments are corrected through the
wound. Fixing the fracture internally has some advantages, but the use of foreign
materials in an infected fracture may be unwise. With rare exceptions an intramedullary
nail should not be used. If plates and screws are used, drainage almost always persists
until they are removed, but they do allow the fracture to become stabilized by fibrous
tissue in satisfactory position. Steinmann pins can be inserted through the bone proximal
and distal to the fracture and incorporated in a cast; the cast can then be windowed for
dressing the wound. An external fixator also can be used. This method is safer, but
fixation is less secure than when a plate is used. Antibiotics are used both parenterally
and locally after surgery. After 4 to 7 days, when a thin layer of granulation tissue has
covered the wound, a split-thickness skin graft is applied. The split graft is replaced by a
full-thickness pedicled skin graft 4 to 6 weeks after the wound has healed from the
operation. A local rotation flap or vascularized free flap can be used to fill the soft tissue
defect left by the debridement. In our experience infections can be more easily controlled
when new, highly vascular, soft tissue is used to cover the fracture, especially infected
nonunions of the distal tibia. Bone grafting is deferred until the graft has completely
healed and has become stabilized. In some patients the fracture may then unite, and
grafting is unnecessary.

When the clinical signs of infection have subsided, the skin over the bone is good, and
nonunion persists, bone grafting must be considered. There may never be a safe time to
graft the nonunion, for whether an infection has been completely eradicated or is merely
quiescent cannot be surely determined; yet a time must be selected, or the operation must
be abandoned. The character and duration of the infection, the time of the last drainage,
and the general condition of the extremity all must be considered.

When an infection has been active chiefly in the soft tissues or about sequestra, the risk
of reactivating it by surgery is much less than when it has involved the cortex and
medullary canal of the major fragments; when it has been prolonged and destructive, all
the surrounding structures are presumed to have been deeply penetrated, and a dormant
infection is likely. Pocketed in cortical bone, bacteria may lie dormant for years, only to
become active again after surgery or some other trauma. This danger is inherent in the
treatment of ununited open fractures and must be accepted. The use of antibiotics before
and after surgery has reduced the danger, since they can often control an infection within
the limits of a vascular area, but they cannot be expected to sterilize an avascular area
that they cannot penetrate. Although the length of time since the last drainage is not in
itself a reliable index of safety, reconstructive operations usually should be delayed until
at least 6 months after all signs of infection have disappeared.

Controlling infection before attempting bone grafting always has been a sound clinical
principle in the conventional treatment of nonunions. However, there are exceptions to
this principle, especially in the tibia. Jones and Barnett, Freeland and Mutz, Jones,
Marmor, and others have reported successful bone grafting in tibial nonunions even in the
presence of draining sinuses. In sequestration or gross infection, the bone is saucerized
through an anterior approach, the incision is closed, and the infection is treated with
antibiotics by irrigation and suction

The first step is restoration of bony continuity. This takes absolute priority over treatment
of the infection. The nonunion is exposed through the old scar and sinuses. The ends of
the fragments are then decorticated subperiosteally, forming many small osteoperiosteal
grafts; any grafts that become detached are discarded. Next all devitalized and infected
bone and soft tissues are removed. Then the fragments are aligned and stabilized, usually
by an external fixation device. Compression is applied across the nonunion if possible.
Weber and Eech then insert autogenous cancellous bone grafts. Internal fixation with a
plate is used only when drainage has already ceased, and then the approach is away from
the area of old drainage, or when no other method of fixation is possible and the infection
is mild. When the fracture already has been firmly fixed with a plate or intramedullary
nail, the fixation is not disturbed and the operation is carried out as described, except
decortication is omitted when an intramedullary nail has been used. Finally a tube for
suction drainage is inserted, and as much of the wound as possible is closed; any
remaining open area is covered by iodoform gauze. Systemic antibiotics are given.
If necessary for union, a second decortication with or without the addition of cancellous
iliac bone grafts is carried out. After the nonunion has healed, any residual sequestra are
removed and split-thickness skin grafts are applied to any remaining defect in the skin.

Ilizarov method. According to Ilizarov, to eliminate infection and obtain union,

vascularity must be increased. In his approach, this is achieved by corticotomy and the
application of his circular external fixator. Catagni reported that, although union was
obtained, infection was not always eliminated. He recommends open debridement to
totally remove necrotic and infected segments before osteosynthesis to eliminate the bone
gap. For hypertrophic nonunions with minimal infection and no sequestered bone, he
recommends compression to increase formation of repair callus and vascularity. He
reports that with this technique infection is spontaneously eliminated. Monofocal
compression also is used for infected hypertrophic nonunions with deformity. For
atrophic nonunions with diffuse infection or sequestered bone, open resection of the
infected segment is performed and bifocal compression is used. If skin quality is poor, the
bone is stabilized with the external fixator after resection of necrotic bone. When skin
conditions improve and the infection has regressed, corticotomy is performed and bifocal
compression is applied.

Ilizarov method. Combinations of several of the methods described for infection can be
used for treatment of the separate components of a complex nonunion, but the Ilizarov
method allows simultaneous treatment of all components, including angular, rotary, and
translational deformities, shortening, and segmental bone loss (Figure 52-13). Although
dramatic results can be obtained, this method is technically demanding and requires
thorough training and experience. Its use is not recommended except by surgeons
knowledgeable in its biological basis and the techniques required for its safe, effective
application. The development of hybrid circular frames attached to uniplanar external
fixators has decreased some of the problems associated with this demanding technique.

Deformities of as much as 10 or 15 degrees can be corrected immediately by frame

application; larger deformities should be corrected gradually. Hypertrophic nonunions
can be treated by gradual correction of the deformity, followed by compression. Atrophic
nonunions with shortening can be treated by compression at the nonunion accompanied
by a corticotomy or cortical osteotomy in the metaphyseal region of the same bone and
gradual lengthening through the corticotomy. Ilizarov has shown marked
hypervascularity of the limb and bone after corticotomy and gradual distraction.
Conceivably the corticotomy provides some of the same biological benefits as a bone
graft. Nonunions with segmental bone loss can be treated by corticotomy and gradual
transport of a bone fragment to the principal fragment. The leading edge of this
transported fragment frequently requires freshening or bone grafting at the time of arrival
to the other fragment.
Although infected nonunions frequently have been successfully treated without
debridement, followed by bone transport into the region and soft tissue coverage.

Reference:
Williams KD Infectious Arthritis in Campbell's Operative Orthopaedics, Terry J. Canal
ed, Mosby CD online, 1999; Chapter 15