Abstract
Background:
Septic arthritis is a disabling disease that requires early diagnosis and prompt management for optimal outcome. Late presentations with deformities were noticed in our clinic. The aim of this study was to determine the pattern of septic arthritis in our environment.
Methods:
This was an 18-month prospective study in a Nigerian teaching hospital. Thirty-nine consecutive patients with 45 incidences of septic arthritis were studied. Joint aspirates were taken for microbiologic investigation.
Results:
Patient ages ranged between 0.5-60 years and the mean age was 7.4 years. The male to female ratio was 2.9:1, and the knee was the most commonly affected joint. The duration of symptoms before presentation ranged between 4-17 days with a mean of 11.1± 3.6 days. Twenty-five (64.1%) of the patients were on inadequate antibiotics before presentation. Seventy-three percent of septic arthritis involving the upper limb joints occurred below the age of one year and 92.3% of the involved lower limb joints occurred after one year of age.
Conclusion:
The upper limb joints were significantly affected below one year of age and the joints of the lower limb were more involved after one year of age (p=0.001). Improper prescription of antibiotics before presentation to the hospital was noticed in 64.1% and should be discouraged.
INTRODUCTION
Septic arthritis is a pyogenic infection within a joint that is a surgical emergency. Not only can it rapidly destroy a joint or irreversibly impair joint function, but it may also be fatal, especially when it occurs in a neonate. Neonatal septic arthritis can result in permanent skeletal deformity.1 Although septic arthritis can occur at any age, children are particularly susceptible and must be treated rapidly.9 Septic arthritis has been reported to be more common in males.3 An overview of the joints involved shows that the large joints are more often involved, and the knee is the most commonly involved joint.3,5,6,7,8,10 The risk is higher when the joint is traumatized. The causative organisms are diverse in septic arthritis, but Staphylococcus aureus infection is the most common.6,8,10,11 The recognition of septic arthritis in the young before excessive infection has occurred is often difficult; thus, there is a need to maintain a high index of suspicion.
Diagnosis can be made based on clinical findings but can also be aided by ultrasound, which allows early diagnosis of joint effusion with high accuracy.5,12 This diagnosis must be made and definitive management instituted promptly in order to avoid severe complications which are difficult and unrewarding to manage. Definitive management includes parenteral antibiotics, immobilization, and open or arthroscopic arthrotomy.6,10,13
MATERIALS AND METHODS
This is an 18-month prospective study carried out at Wesley Guild Hospital Ilesa in Osun State, Nigeria. The patients with features of septic arthritis were recruited upon their presentation to the hospital. History and clinical examination were obtained and data were entered into a prepared form. Thirty-nine patients with 45 cases of septic arthritis were included in the study. Aspirates were obtained from all of the joints, and samples were sent for gram staining (GS) and microscopic culture and sensitivity (MCS) in 41 aspirates. This was not done in four samples because of equipment failure when the samples were taken.
Arthrotomy was carried out on the affected joints in 33 patients under the combination of sedation (with diazepam) and local anesthesia, and under general anesthesia in six patients with septic arthritis of the hip. The patients were placed on a parenteral antibiotic which was converted to an oral antibiotic after their temperature patterns returned to normal. When the wrist, elbow, and knee were involved, immobilization was done with a back-slab of Plaster of Paris; skin traction was applied for septic arthritis of the hip, and collar-and-cuff for septic arthritis of the shoulder. The patients were followed for nine months.
The data were analyzed using 11.0 SPSS (Statistical Programme for Social Sciences) Inc., Standard Version 2001.
RESULTS
A total of 39 patients with 45 cases of septic arthritis were studied. Twenty-nine were male and ten were female with a male to female ratio of 2.9:1. Patients' ages ranged between 0.5-60 years. Thirty-four of the patients were children between the ages of 0.5-15 years with a mean age of 4.4 ± 4.2 years, while five were adults between 17 and 60 years old with a mean age of 28.2 ± 18.6 years. The duration of symptoms before presentation ranged between 4 and 17 days with a mean of 11.1 ± 3.6 days. These symptoms included fever in 29 patients (74.3 %), joint pain in 27 patients (69.2%), and a limping gait in 19 patients (48.7%). Twenty five (64.1%) of the patients had already been treated with various inadequate antibiotics before presentation.
Trauma preceded the development of joint pathology in six patients. Three of the patients studied had systemic illnesses, which were sickle cell disease, a convalescent stage of meningitis, and septicemia. The patients with meningitis and septicemia developed polyarticular septic arthritis.
In these 39 patients, 34 had monoarticular septic arthritis and five had polyarticular involvement for a total of 45 infected joints. The frequencies of the joints involved are shown in Table 1, while the limb involvement as related to the age of the patient is shown in Table 2. Two patients had septic arthritis involving five joints in both the upper and lower limbs. Twenty-one (87.5%) out of the 24 patients with septic arthritis of the lower limb joints were above two years of age. The results of the cultures are shown in Table 3.
TABLE 1. Frequency of Joints Involved.
| Joint | Number |
|---|---|
| Total | 45 |
| Knee | 17 |
| Shoulder | 11 |
| Hip | 11 |
| Ankle | 3 |
| Wrist | 2 |
| Elbow | 1 |
TABLE 2. Age Versus Limb Involvement.
| Limb involved | No. of patients ≤1 year | No. of patients > 1 year | Total no. of patients | No. of joints involved |
|---|---|---|---|---|
| P=0.001 | x2=16.58 | |||
| Septic arthritis of upper limb joints only | 8 | 3 | 11 | 12 |
| Septic arthritis of lower limb joints only | 2 | 24 | 26 | 28 |
| Total | 10 | 27 | 37 | 40 |
Two patients with septic arthritis of both upper and lower limbs are excluded from the table.
TABLE 3. Culture Results.
| Causative agent | Frequency |
|---|---|
| Total | 41 |
| Staphylococcus aureus | 16 |
| Escherichia coli | 9 |
| Alpha-hemolytic Streptococcus | 1 |
| Klebsiella | 1 |
| No growth | 14 |
Four joint aspirates were not cultured because of faulty equipment.
DISCUSSION
In developed countries, favorable long-term outcome of septic arthritis is not uncommon.2 This cannot be said of developing countries like Nigeria, where septic arthritis is a disabling and life-threatening disease that requires early diagnosis for optimal outcome.4 In this study, the knee was found to be the most common joint involved, and this agrees with other studies done elsewhere. 5,6,7,10 It was observed that 72.7% of septic arthritis cases involving the upper limb joints occurred in patients below the age of one year, and 92.3% of the cases of the lower limb joints occurred after the age of one year. A literature search did not reveal similar observations from anywhere in the world prior to this study. An explanation for these findings could be that microtrauma is repeatedly inflicted on a child's upper limbs while the child is being lifted and carried, as most children do not start walking until approximately one year of age. Also, in this environment, different twisting maneuvers on the upper limbs are carried out while bathing or feeding these children. Thus, the upper limb joints could be more prone to septic arthritis below one year of age. When the child starts walking (usually after one year), the lower limb joints are more often traumatized than the upper limbs joints, which may explain the occurrence of septic arthritis in lower limbs more often than the upper limb joints after age one.
Staphylococcus aureus was the most common organism found, which agrees with previous works,3,6,8,10,11 but Escherichia coli was the second most common organism in our series. This differs from the work done by Stutz et al., where Escherichia coli was the fourth most common organism.11 In 14 aspirates from 12 patients, there was no growth. Ten of these patients were already on inadequate dosages of either parenteral or oral antibiotic prescribed by parents or health institutions for two to seven days before presenting to our unit. Involvement of two or more joints was seen in patients who were initially being treated for septicemia and meningitis. The overwhelming systemic infections would have accounted for the vulnerability of these patients to polyarticular septic arthritis. Close follow-up is needed to monitor the growth of the affected limbs until skeletal maturity;10 but sadly, most of the patients were lost to follow up within nine months. Therefore, more deformities secondary to septic arthritis will probably be seen at our institution.
We concluded that the upper limb joints were significantly affected below the age of one year while the joints of the lower limb were more involved after the age of one year (p=0.001). There is a need to educate patients about early presentation, avoidance of improper use of antibiotics, and regular follow-up after the acute pathology.
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