4. Septic arthritis Flashcards
Normal partial IgG in foals
More than 800 mg/dl ??? Or 400-800???
If lower than 400 —> can result in bacteraemia/septicaemia
Types of infection
- S-type
- E-type
- P-type
S-type
• Only synovial fluid and synovial
membran
• Young foal less than 2 weeks old
• Tarsocrular, stifle, MCP/MTP
• Joint effusion
• Lameness +/-
E-type
• Articular epiphyseal complex
• Older foals with multiple joints
P-type
• Majotity of cases
• Older foals (weeks to months)
• Long bones physis and joints
• Enerobacteriacae( E. Coli, Salm.)
Streptococcus, Rhodococcus
• Prognosis poor
Clinical signs of septic arthritis
• Lameness, joint swelling
• Periarticular edema, pain
• Neutrophylic leukocytosis
• Hyperfibrinogenemia
• Radiographic findings– lysis
• Synovial fluid analysis !
Adults septic infection
• Penetrating traumatic injury
• Iatrogenic following surgery or
intrasynovial injections
• Surgical risk factors
• Draft breeds
• Tibiotarsal joint arthroscopy
• Digital felxor tendon sheath arth.
• Removal large OCD fragmnets
• Intraarticular injection
• Veterinarian experince level
• Injection site preparation method
• Use of steril glove
Septic joints
• Infection rates were significantly lower
• Veterinarians prepped their own injection sites
• Use steril gloves
• Clipping of hair
Clinical signs of septic joint
• Hematogenous spread rare and can be associated with septic bursitis– subchondral bone lysis
Presence of bone or tendon
involvement– decreased survival
• Early recognition and aggressive treatment– better prognosis
• Treated within 24 hours of synovial contamination
• Befor 6 hours better prognosis
• Staphylococcus aureus (34,3%)
• Penetrating wounds– mixed bacterial population
Diagnosis of septic joint
• Synovial fluid analysis
• Fluid color range from normal yellow to dark orange or red
• WBC over 20G/L
• TP greater than 3,5 g/dl
• Cytology- presence of 90% degenerate neutrophils
• SAA 1000-2000 mg/L
• Microbiology
• Positive culture from synovial fluid 64-89% (what kind of bacteria, what antibiotic to use?)
• Radiographic images
• Increased soft tissue swelling
• Lytic subchondral defect
• CT/MRI
Treatment of septic joint
Synovial sepsis is serious potentially life threatening and perfomance limiting condition
• Synovial lavage! of high volume
• Removal of foriegn material
• Debridement of contaminated and tissue
• Removal of inflammatory cells and mediator
• Lavage
• Drains
• Open drainage
• Endoscopic surgery with drains
• Ideally effective high-volume lavage under general anesthesia
• Remove fibrin clots
• Endoscopic lavage include rapid accurate fluid delivery, accurate debridement evaluation of joint surface
• Lavage should be performed with balanced electrolyte solution
Debridement and drainage
• Arthroscopic lavage and debridement and synoviectomy
• Septic osteomyelitis– aggressive surgical debridement combined with local antimicrobial therapy
Open joint injury
• Joint surface is visible
• Foamy discharge during motion
• Waterlike yellow discharge
• Suspect from location
• Needs diagnostic intraarticular
puncture
• Using a probe is not advised!
• Septic joint:
• Joint effusio, swelling
• Palpation: warm, painful
• Lameness 4/5
WBC: more than 40 g/l
TP: more than 2g/dl
Cytology: ne. Granulocyta
Opened joint injury
- Emergency intervention is needed (<6 hours) !!
- Pre and perioperativ AB
- Most important:
joint lavage, if possible: via an
arthroscopic approach for debridement
of fibrin clot etc.
• Joint puncture away from injured field
• Great amount of sterile fluid (more liters) is needed for lavage
• Intraarticular AB therapy
• Local debridement, wound closure!
DON’T LEAVE IT OPENED!
AB applied in case of septic joint
• IV ab.: gentamycin
• IM ab.: penicillin, amoxicillin+clav
• Joint lavage: IA ab.
• joint drain
Cefazolin, amikacin
Why there is fibrin accumulation in case of the septic joint
Regional limb perfusion
• Tourniquet should be placed above and below the area to be treated
• The largest veins (cephalic/saphenous) are used
• Use a wide-elastic Esmarch
• Butterfly catheter
• Optimal volume– 60 ml
• 20-30 minutes
Interarticular treatment
• Every 24 to 48 hours
• Amikacin/ceftiofur/cefazolin/gentamycin mainly
• Imipenem/ vancomycin
• Antibiotic impregnated biomaterials
• More commonly used in bone
and implant infections
• Collagen sponges
Analgesia
• Septic synovial structure– non-weight bearing lameness
• High risk of support limb laminitis
• Recumbent for prolonged period
• Decubital ulceration
• Weight loss
• Pain management
• NSAIDs (pain;killing and prevention of laminitis)
• Phenylbutazone
• Flunixin-meglumine
• Ketoprofen
• Toxic side effect- ulceration
• Omeprazole / sucralfate
• Epidural anesthesia
Septic podotrochlear bursitis
• Street nail
• Puncture of solar surface of the hoof
• Mostly hind limb
• Moderate to severe supporting lameness
• The hoof is warmer than the normal, digital pulsation
• Foreign body or puncture wound
• Based on location, direction, depth of injury– radiological examination
• Navicular bursa, DIP joint, digital flexor tendon sheath - bursoscopy
Street nail
• The entire hoof is trimmed
• Puncture tract carefully cleaned
and disinfected
• Steril metal probe inserted
• Contrast material in bursa –
integrity of synovial membrane
Street nail. Surgical treatment
Surgical debridement of puncture wounds
Initial debridement of sole (standing)
Aseptic treatment/bursoscopy (in general
anesthesia)
Lateral recumbency– tourniquet
Bursoscopy– direct/tenoscopic apporach
Systemic antibiotic administered for 2 weeks
Regional intravenous perfusion repeted several time
Guarded prognosis
