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Current concepts review: Septic arthritis of the knee pathophysiology, diagnostics, and therapy

Übersicht: Behandlungskonzepte der bakteriellen Kniegelenksinfektion Pathophysiologie, Diagnostik, und Therapie

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Zusammenfassung

Die Behandlung der bakteriellen Kniegelenksinfektion erfolgt durch die arthroskopische Revision mit Spülung und Debridement sowie systemischer Gabe von Antibiotika. Dieser Artikel fasst die relevanten Untersuchungen zu Pathophysiologie, Infektklassifikation, klinischen Symptome mit dazugehöriger Diagnostik und stadiengerechter Therapie der Kniegelenksinfektion zusammen. Die wichtigsten Behandlungsprinzipien sind die Gelenkdekompression mit Eliminierung der Bakterien sowie proteolytischer und lysosomaler Enzyme durch eine intensive Gelenkspülung. Das Debridement sollte auf nekrotische synoviale und periartikuläte Strukturen begrenzt bleiben mit der Zielsetzung die Synovia als natürliche Barriere und immunkompetentes Organ zu erhalten. Gute Ausheilungsergebnisse konnten durch die arthroskopische Spülung mit Debridement bei stadiengerechter Therapie erzielt werden. Die Infektklassifikation nach Gächter mit den Stadien I–IV wurde dabei am häufigsten genutzt, wobei diese die pathophysiologischen Stadien widerspiegelt. Für die Infektstadien I–III ist die arthroskopische Gelenkrevision mit Spülung und Debridement effektiv, die bei persistierendem Infektgeschehen auch wiederholt werden kann. Die Häufigkeit der wiederholten arthroskopischen Spülung hängt von dem primären Infektstadium ab und schwankt zwischen 0 und 41% der Fälle. Für das Infektstadium IV nach Gächter sowie für persisitierende Infektionen trotz mehrfacher arthroskopischer Spülung weniger schwerer Infektstadien (I–III) wird die offene Gelenkrevision empfohlen. Die Ausheilungsrate der Kniegelenksinfektionen durch die arthroskopische Revision liegt derzeit bei 90 bis 100 %.

Summary

Treatments for bacterial arthritis of the knee joint are arthroscopic irrigation and debridement with systemic antibiotic medication. This article summarizes the relevant data of pathophysiology, stage of infection, symptoms, and diagnostics as well as stage-dependent treatment of bacterial arthritis of the knee joint. The major treatment principles are joint decompression, elimination of the causative organisms by intensive irrigation of the joint with elimination of proteolytic and lysosomal enzymes. Debridement of necrotic soft tissues with the aim of preserving the synovial membrane as an immune-competent structure, and a natural barrier, is recommended. Good results in treating knee infections have been achieved with arthroscopic joint revision and stage-dependent surgical therapy. The infection staging I–IV suggested by Gächter was used most commonly, which mainly reflects the pathophysiologic infection stages. For stages I–III, arthroscopic joint decompression with joint irrigation and debridement is effective and can be repeated in cases of persisting infection. The incidence of repeated arthroscopic joint irrigation depends on the initial stage of the infection and varies between 0 and 41% of the cases. For stage IV infections, the open revision is needed or in seldom cases of therapy failure under initial or repeated arthroscopic joint revision. The success rate of healing infections by arthroscopic irrigation was high with 90–100%.

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References

  • Smith JW, Piercy EA. Infectious arthritis. Clin Infect Dis 1995;20:225–31

    Article  PubMed  CAS  Google Scholar 

  • Vincent GM, Amirault JD. Septic arthritis in the elderly. Clin Orthop 1990;251:241–5

    PubMed  Google Scholar 

  • Esterhai J, Gelb I. Adult septic arthritis. Orthop Clin North Am 1991;22:503–14

    PubMed  Google Scholar 

  • Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001;40:24–30

    Article  CAS  Google Scholar 

  • Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumathol 2008;20:457–62

    Article  CAS  Google Scholar 

  • Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet 2010;375:846–55

    Article  PubMed  Google Scholar 

  • Mathews CJ, Kingsley G, Field M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis 2007;66:440–5

    PubMed  CAS  Google Scholar 

  • Vispo Sera JL, Barthel T, Schmitz H, et al. Arthroscopic treatment of septic joints: prognostic factors. Arch Orthop Trauma Surg 2002;122:204–11

    Article  Google Scholar 

  • Lungershausen W, Markgraf E, Dorow C, et al. Joint empyema. Chirurg 1998;69:828–35

    Article  PubMed  CAS  Google Scholar 

  • Stutz G, Kuster MS, Kleinstück F, et al. Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthrosc 2000;8:270–4

    Article  PubMed  CAS  Google Scholar 

  • Lane JG, Falahee MH, Wojtys EM, et al. Pyarthrosis of the knee. Treatment considerations. Clin Orthop 1990;252:198–204

    Google Scholar 

  • Tarkowski A, Collins LV, Gjertsson I, et al. Model systems: modeling human staphylococcal arthritis and sepsis in the mouse. Trends Microbiol 2001;9:321–6

    Article  PubMed  CAS  Google Scholar 

  • Hultgren O, Eugster HP, Sedgwick JD, et al. TNF/lymphotoxin-alpha double-mutant mice resist septic arthritis but display increased mortality in response to Staphylococcus aureus. J Immunol 1998;161:5937–42

    PubMed  CAS  Google Scholar 

  • Hultgren OH, Svensson L, Tarkowski A. Critical role of signalling through IL-1 receptor for development of arthritis and sepsis during Staphylococcus aureus infection. J Immunol 2002;168:5207–12

    PubMed  CAS  Google Scholar 

  • Abdelnour A, Arvidson S, Bremell T, et al. The accessory gene regulator (arg) controls Staphylococcus aureus virulence in a murine arthritis model. Infect Immun 1993;61:3879–85

    PubMed  CAS  Google Scholar 

  • Deng GM, Tarkowski A. The features of arthritis induced by CpG motfis in bacterial DNA. Arthritis Rheum 2000;43:356–64

    Article  PubMed  CAS  Google Scholar 

  • Foster TJ, Hook M. Surface protein adhesins of Staphylococcus aureus. Trends Microbiol 1998;6:484–8

    Article  PubMed  CAS  Google Scholar 

  • Nilsson IM, Patti JM, Bremell T, et al. Vaccination with a recombinant fragment of collagen adhesin provides protection against Staphylococcus aureus-mediated septic death. J Clin Invest 1998;101:2640–9

    Article  PubMed  CAS  Google Scholar 

  • Josefsson E, Hartford O, O'Brien L, et al. Protection against experimental Staphylococcus aureus arthritis by vaccination with clumping factor A, a novel virulence determinant. J Infect Dis 2001;184:1572–80

    Article  PubMed  CAS  Google Scholar 

  • Swaminathan A, Massasso D, Gotis-Graham I, et al. Fulminant methicillin-sensitive Staphylococcus aureus infection in a healthy adolescent, highlighting 'Panton-Valentine leucocidin syndrome'. Intern Med J 2006;36:744–7

    Article  PubMed  CAS  Google Scholar 

  • Martinez-Agiular G, Avalos-Mishaan A, Hulten K, et al. Community-acquired, methicillin-resistent and methicillin-susceptible Staphylococcuc aureus musculoskeletal infections in children. Pediatr Infect Dis J 2004;23:701–6

    Article  Google Scholar 

  • Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop 2006;26:703–8

    Article  PubMed  Google Scholar 

  • Jerosch J, Hofstetter I, Schröder M, et al. Septic arthritis: Arthroscopic management with local antibiotic treatment. Acta Orthop Bel 1995;61:126–34

    CAS  Google Scholar 

  • Farooq MA, Devitt AT. Perceived efficacy and risks of infection following intraarticular injections: a survey of orthopaedic surgeons. Ir J Med Sci 2005;174:26–32

    Article  PubMed  CAS  Google Scholar 

  • Charalambous CP, Tryfonidis M, Sadiq S, et al. Septic arthritis following intra-articular steroid injection of the knee – a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol 2003;22:386–90

    Article  PubMed  CAS  Google Scholar 

  • Gächter A. Joint infection – arthroscopic lavage – hints and tricks. Arthroskopie 1994:7:98–102

    Google Scholar 

  • Jerosch J (ed.). Arthroscopic therapy of bacterial arthritis. In: Infections of the musculoskeletal system – Diagnostic and, therapy. Thieme: Stuttgart, New York; 1995

    Google Scholar 

  • Van Tongel A, Stuyck J, Bellemans J, et al. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. A retrospective analysis of incidence, management and outcome. Am J Sports Med 2007;35:1059–1063

    Article  PubMed  Google Scholar 

  • Wörsdörfer O, Fleischmann W. Suction irrigation drains for local infection treatment of the bone and joint. In: Burri C, Neugebauer R (eds) Infection of bones and joints. Current problems in surgery and orthopaedics, Vol. 34. Huber: Bern, Stuttgart, Toronto; 1990

    Google Scholar 

  • Draijer F, Lorentzen T, Nissen R, Havemann D. Functional treatment of surgically treated empyema of the knee joint. Unfallchirurg 1994;97:273–7

    PubMed  CAS  Google Scholar 

  • Weston V, Coakley G. Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis. J Antimicrobiol Chemo 2006;58:492–3

    Article  CAS  Google Scholar 

  • Schollin-Borg M, Michaelsson K, Rahme H. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy 2003;19:941–7

    Article  PubMed  Google Scholar 

  • Armstrong RW, Bolding F, Joseph R. Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors. Arthroscpoy 1992;8:213–23

    Article  CAS  Google Scholar 

  • Blevins FT, Salgado J, Wascher DC, Koster F. Septic arthritis following arthroscopic meniscus repair: a cluster of three cases. Arthroscopy 1999;15:35–40

    Article  PubMed  CAS  Google Scholar 

  • Coakley G, Mathews C, Field M, et al. on behalf of the British Society for Rheumatology Standards, Guidelines and Audit Working Group. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (Oxford) 2006;45:1039–41

    Google Scholar 

  • Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in asingle UK health district 1982–1991. Ann Rheum Dis 1999;58:214–9

    Article  PubMed  CAS  Google Scholar 

  • Le Dantec L, Maury F, Flipo RM, et al. Peripheral pyogenic arthritis : a study of one hundred seventy-nine cases. Rev Rheum Engl Ed 1996;63:103–10

    CAS  Google Scholar 

  • Li SF, Henderson J, Dickman E, et al. Laboratory tests in adults with monoarticular arthritis: can they rule out a septic joint? Acad Emerg Med 2004;11:276–80

    Article  PubMed  Google Scholar 

  • Soderquist B, Jones I, Fredlund H, Vikerfors T. Bacterial or crystal-associated arthritis? Discriminating ability of serum inflammatory markers. Scand J Infect Dis 1998;30:591–6

    Article  PubMed  CAS  Google Scholar 

  • Hugle T, Schuetz P, Mueller B, et al. Serum procalcitonin for discriminiation between septic and non-septic arthritis. Clin. Exp Rheumatol 2008;26:453–6

    PubMed  CAS  Google Scholar 

  • Swan A, Amer H, Dieppe P. The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Ann Rheum Dis 2002;61:493–8

    Article  PubMed  CAS  Google Scholar 

  • Li SF, Cassidy C, Chang C, et al. Diagnostic utility of laboratory tests in septic arthritis. Emerg Med J 2007;24:75–7

    Article  PubMed  CAS  Google Scholar 

  • Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have septic arthritis? JAMA 2007;297:1478–88

    Article  PubMed  CAS  Google Scholar 

  • Coutlakis PJ, Roberts WN, Wise CM. Another look at synovial fluid leukocytosis and infection. J Clin Rheumatol 2002;8:67–71

    Article  PubMed  Google Scholar 

  • McGillicuddy DC, Shah KH, Friedberg RP, et al. How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis? Am J Emerg Med 2007;25:749–52

    Article  PubMed  Google Scholar 

  • Abdullah S, Young-Min SA, Hudson SJ. Gross synovial fluid analysis in the differential diagnosis of joint effusion. J Clin Pathol 2007;60:1144–7

    Article  PubMed  CAS  Google Scholar 

  • Kallio P, Michelsson JE, Lalla M, Holm T. C-reactive protein in tibial fractures. J Bone Joint Surg Br: 72:1990;615–7

    PubMed  CAS  Google Scholar 

  • Parsien JS, Shaffer B. Arthroscopic management of pyarthrosis. Clin Orthop 1992;275:243–7

    Google Scholar 

  • Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am 2006;88:869–82

    Article  PubMed  Google Scholar 

  • Mariani BD, Booth RE Jr, Levine MJ, Gardner TA, Tuan RS. Molecular detection of infection in total knee arthroplasty: a clinical correlation. J Musculoscelet Res 1999;3:93–107

    Article  Google Scholar 

  • Yang S, Lin S, Kelen GD, Quinn TC, Dick JD, Gaydos CA, Rothman RE. Quantitative multiprobe PCR assay for simultaneous detection and identification to species level of bacterial pathogens. J Clin Microbiol 2002;40:3449–54

    Article  PubMed  CAS  Google Scholar 

  • Huletsky A, Giroux R, Rossbach V, Gagnon M, Vaillancourt M, Bernier M, Gagnon F, Truchon K, Bastian M, Picard FJ, van Belkum A, Ouellette M, Roy PH, Bergeron MG. New real-time PCR assay for rapid detection of methicillin-resistant Staphylococcus aureus directly from specimens containing a mixture of staphylococci. J Clin Microbiol 2004;24:1875–84

    Article  Google Scholar 

  • Birmingham P, Helm JM, Manner PA, Tuan RS. Simulated joint infection assessment by rapid detection of live bacteria with real-time reverse transcription polymerase chain reaction. J Bone Joint Surg Am 2008;90:602–8

    Article  PubMed  Google Scholar 

  • Williams RJ, Laurencin CT, Warren RF, Speciale AC, Brause BD, O'Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med 1997;25:261–7

    Article  PubMed  Google Scholar 

  • Nord KD, Dore DD, Deeney VF, Armstrong AL, Cundy PJ, Cole BF, Ehrlich MG. Evaluation of treatment modalities for septic arthritis with histological grading and analysis of levels of uronic acid, neutral protease, and interleukin-1. J Bone Joint Surg Am 1995;77:258–65

    PubMed  CAS  Google Scholar 

  • Stengel D, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Systematic review and meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infect Dis 2001;1:175–88

    Article  PubMed  CAS  Google Scholar 

  • Dubost JJ, Soubrier M, De Champs C, Ristori JM, Bussière JL, Sauvezie B. No changes in the distribution of organisms responsible for septic arthritis over a 20 year period. Ann Rheum Dis 2002;61:267–9

    Article  PubMed  CAS  Google Scholar 

  • Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial joint infections in England and Wales: analysis of bacterial isolites over a four year period. Br J Rheumatol 1997;36:370–3

    Article  PubMed  CAS  Google Scholar 

  • Kaandorp CJE, Krijnen P, Moens HJB, et al. The outcome of bacterial arthritis. A prospective community-based study. Arth Rheum 1997;40:884–92

    Article  CAS  Google Scholar 

  • Gemmell CG, Edwards DI, Fraise AP, et al. Guidelines for the prophylaxis and treatment of methicillin-resistent Staphylococcus aureus (MRSA) infections in the UK. JAC 2006;57:589–608

    PubMed  CAS  Google Scholar 

  • Graninger W, Wenisch C, Wiesinger E et al. Experience with outpatient intravenous teicoplanin therapy for chronic osteomyelitis. Eur J Clin Microbiol Infect Dis 1995;14:643–7

    Article  PubMed  CAS  Google Scholar 

  • Graziani AL, Lawson LA, Gibson GA, et al. Vancomycin concentrations in infected and non-infected human bone. Antimicrob Agents Chemother 1988;32:1320–2

    PubMed  CAS  Google Scholar 

  • Amorena B, Gracia E, Monzon M. et al. Antibiotic susceptibility assay for S. aureus in biofilms developed in vitro. J Antimicrob Chemother 1999;44:43–55

    Article  PubMed  CAS  Google Scholar 

  • Ike RW. Tidal irrigation in septic arthritis of the knee: a potential alternative to surgery. J Rheum 1993;20:2104–111

    PubMed  CAS  Google Scholar 

  • Salter R, Bell RS, Frederick WK. The protective effect of continous passive motion on living articular cartilage in acute septic arthritis. An experimental investigation in the rabbit. Clin Orthop 1981;159:223–47

    PubMed  Google Scholar 

  • Wirtz DC, Marth M, Miltner O, Schneider U, Zielkens KW. Septic arthritis of the knee in adults: treatment by arthroscopy or arthrotomy? Int Orthop 2001;25:239–41

    Article  PubMed  CAS  Google Scholar 

  • Gächter A. Arthroscopic lavage for joint infections. Orthopaed Traumatol 1993;2:104–6

    Article  Google Scholar 

  • Ballabaud L, Gaudias J, Boeri C, Jenny J-Y, Kehr P. Results of treatment of septic knee arthritis: a retrospective series of 40 cases. Knee Surg Sports Traumatol Arthrosc 2007;15:387–92

    Article  Google Scholar 

  • Jerosch J, Schröder M, Steinbeck J, Halm H. Arthroscopic therapy of bacterial arthritis. Arthroskopie 1994;7:115–22

    Google Scholar 

  • Riel K-A, Primbs J, Bernett P. Arthroscopic distension irrigation in acute postoperative infection of the knee joint – long term follow up. Chirurg 1994;65:1023–7

    PubMed  CAS  Google Scholar 

  • Turcić J, Gjetvaj G, Androcec V, Hancević J, Alfirević I, Cavcić J, Smud D. Mathematical model of hydrodynamic flow in irrigation-suction drainage. Unfallchirurg 1996;99:435–9

    PubMed  Google Scholar 

  • Jackson RW, Parsons CJ. Distension-irrigation treatment of major joint sepsis. Clin Orthop Rel Res 1973;96:160–4

    Google Scholar 

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  1. Berufsgenossenschaftliche Unfallklinik Tübingen, Germany

    Atesch Ateschrang, Dirk Albrecht, Steffen Schroeter, Kuno Weise & Jürgen Dolderer

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  1. Atesch Ateschrang
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  2. Dirk Albrecht
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Ateschrang, A., Albrecht, D., Schroeter, S. et al. Current concepts review: Septic arthritis of the knee pathophysiology, diagnostics, and therapy. Wien Klin Wochenschr 123, 191–197 (2011). https://doi.org/10.1007/s00508-011-1554-y

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