Septic arthritis following joint injections: a 17 years retrospective study in an Academic General Hospital.

Marco Mattia Larghi; Miriam Grassi; Emanuele Placenza; Luca Faugno; Pietro Cerveri; Alfonso Manzotti

doi:10.23750/abm.v92i6.10425

Septic arthritis following joint injections: a 17 years retrospective study in an Academic General Hospital.

Authors

Marco Mattia Larghi School of Medicine and Residency Program in Orthopaedics, Università degli studi di Milano, Milan Italy https://orcid.org/0000-0003-1416-0868
Miriam Grassi Orthopaedic and Trauma Department, “Luigi Sacco” Hospital, ASST FBF-Sacco, Milan, Italy
Emanuele Placenza School of Medicine and Residency Program in Orthopaedics, Università degli studi di Milano, Milan Italy
Luca Faugno School of Medicine and Residency Program in Orthopaedics, Università degli studi di Milano, Milan Italy
Pietro Cerveri Department of Electronics, Information and Bioengeenering, Politecnico di Milano, Milan, Italy
Alfonso Manzotti Orthopaedic and Trauma Department, “Luigi Sacco” Hospital, ASST FBF-Sacco, Milan, Italy

DOI: https://doi.org/10.23750/abm.v92i6.10425

Keywords:

Septic arthritis; Treatment; Arthritis; Joint Injection; Intra-articular injection; osteoarthritis;

Abstract

Background:

Septic arthritis following intra-articular infiltrations is an uncommon devastating complication correlated to high costs for the health service and often to poor outcomes. The purpose of this study is to assess a 17-years experience in a single academic multispecialist hospital managing this uncommon complication in Orthopaedic practice.

Methods:

Patients with diagnosis of septic arthritis following joint injections treated in our hospital from January 2002 to December 2019 were included in the study. Clinical and demographic data, pathogens, injected agent, conservative/surgical treatments were reviewed. Patient were classified according to the ore operative Charlson Comorbidity Index (CCI) and the Cierny-Mader Classification(CMC). Furthermore follow-up outcome and time occurred to infection eradication were registered.

Results:

We included in the study 11 patients with a median age of 74 years old (IQR= 61.5 - 79). The median CCI was 3 (IQR= 2 - 5) and the majority of patients belong to CMC = B class. Septic arthritis occurred mainly following corticosteroids injections and more frequently involving knees. The pathogen more often isolated was Staphylococcus aureus. Five (45%) patients referred an history of multiple intrarticular injections. 7 patients (64%) had a complete resolution following an arthroscopic debridement, 4 (36%) patients underwent to a 2-stage replacement and one of them hesitated in an arthrodesis because of a recurrent periprothesic joint infection and extensor apparatus insufficiency.

Conclusion:

The authors observed a potential increased risk of septic arthritis following joint injection in patients with history of multiple injections and poor health/immunological conditions. They recommend an early arthroscopic debridement as the treatment of choice especially in septic knees performed in a multispecialist dedicated center

References

Uthman I, Raynauld JP, Haraoui B. Intra-articular therapy in osteoarthritis. Postgrad Med J. 2003 Aug;79(934):449-53. Review. PubMed PMID: 12954956; PubMed Central PMCID: PMC1742771.
Neustadt DH. Intra-articular injections for osteoarthritis of the knee. Cleve Clin J Med. 2006 Oct;73(10):897-8, 901-4, 906-11. Review. PubMed PMID: 17044315.
Manfreda F, Rinonapoli G, Nardi A, Antinolfi P, Caraffa A. A Fatal Sepsis Caused by Hyaluronate Knee Injection: How Much the Medical History and the Informed Consent Might Be Important?. Case Rep Orthop. 2017;2017:1518401. doi:10.1155/2017/151840
Lee YK, Kim KC, Ha YC, Koo KH. Utilization of Hyaluronate and Incidence of Septic Knee Arthritis in Adults: Results from the Korean National Claim Registry. Clin Orthop Surg. 2015 Sep;7(3):318-22. doi: 10.4055/cios.2015.7.3.318. Epub 2015 Aug 13. PubMed PMID: 26330953; PubMed Central PMCID: PMC4553279.
Kumar N, Newman RJ. Complications of intra- and peri-articular steroid injections. Br J Gen Pract. 1999 Jun;49(443):465-6. PubMed PMID: 10562748; PubMed Central PMCID: PMC1313446.
Seyman D, Ozen NS, Inan D, Ongut G, Ogunc D. Pseudomonas aeruginosa septic arthritis of knee after intra-articular ozone injection. New Microbiol. 2012 Jul;35(3):345-8. Epub 2012 Jun 30. PubMed PMID: 22842605.
Geirsson AJ, Statkevicius S, Víkingsson A. Septic arthritis in Iceland 1990-2002: increasing incidence due to iatrogenic infections. Ann Rheum Dis. 2008;67(5):638–643. doi:10.1136/ard.2007.077131
Kaandorp CJ, Dinant HJ, van de Laar MA, Moens HJ, Prins AP, Dijkmans BA. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. 1997 Aug;56(8):470-5. PubMed PMID: 9306869; PubMed Central PMCID: PMC1752430.
Abram SGF, Alvand A, Judge A, Beard DJ, Price AJ. Mortality and adverse joint outcomes following septic arthritis of the native knee: a longitudinal cohort study of patients receiving arthroscopic washout. Lancet Infect Dis. 2020 Mar;20(3):341-349. doi: 10.1016/S1473-3099(19)30419-0. Epub 2019 Dec 17
Hassan AS, Rao A, Manadan AM, Block JA. Peripheral Bacterial Septic Arthritis: Review of Diagnosis and Management. J Clin Rheumatol. 2017 Dec;23(8):435-442. doi: 10.1097/RHU.0000000000000588. Review. PubMed PMID: 28926460.
Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010 Mar 6;375(9717):846-55. doi:10.1016/S0140-6736(09)61595-6. Review. PubMed PMID: 20206778.12[12]
Helito CP, Teixeira PR, Oliveira PR, et al. Septic arthritis of the knee: clinical and laboratory comparison of groups with different etiologies. Clinics (Sao Paulo). 2016;71(12):715–719. Published 2016 Dec 1. doi:10.6061/clinics/2016(12)07
García-Arias M, Balsa A, Mola EM. Septic arthritis. Best Pract Res Clin Rheumatol. 2011 Jun;25(3):407-21. doi: 10.1016/j.berh.2011.02.001. Review. PubMed PMID: 22100289.
Singh JA, Yu S. The burden of septic arthritis on the U.S. inpatient care: A national study. PLoS One. 2017;12(8):e0182577. Published 2017 Aug 15. doi:10.1371/journal.pone.0182577
Ferrand J, El Samad Y, Brunschweiler B, Grados F, Dehamchia-Rehailia N, Séjourne A, Schmit JL, Gabrion A, Fardellone P, Paccou J. Morbimortality in adult patients with septic arthritis: a three-year hospital-based study. BMC Infect Dis. 2016 Jun 1;16:239. doi: 10.1186/s12879-016-1540-0. PubMed PMID: 27246346; PubMed Central PMCID: PMC4888402.
Newman JH. Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis. 1976 Jun;35(3):198-205. PubMed PMID: 984899; PubMed Central PMCID: PMC1006541.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-83. PubMed PMID: 3558716.
Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003 Sep;(414):7-24. PubMed PMID: 12966271.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clinical Orthopaedics & Related Research. 1987;214:160–164.
Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989 Nov;(248):13-4. PubMed PMID: 2805470.
Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969 Jun;51(4):737-55.
Park SK, Choi YS, Kim HJ. Hypopigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection. Korean J Anesthesiol. 2013;65(6 Suppl):S59‐S61. doi:10.4097/kjae.2013.65.6S.S59
Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. 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 Dec;22(6):386-90. Epub 2003 Oct 15. PubMed PMID: 14677011.
Mohamed M, Patel S, Plavnik K, Liu E, Casey K, Hossain MA. Retrospective Analysis of Septic Arthritis Caused by Intra-Articular Viscosupplementation and Steroid Injections in a Single Outpatient Center. J Clin Med Res. 2019 Jul;11(7):480-483. doi: 10.14740/jocmr3838. Epub 2019 Jun 11. PubMed PMID: 31236165; PubMed Central PMCID: PMC6575118.
Liu SH, Dubé CE, Eaton CB, Driban JB, McAlindon TE, Lapane KL. Longterm Effectiveness of Intraarticular Injections on Patient-reported Symptoms in Knee Osteoarthritis. J Rheumatol. 2018 Aug;45(9):1316-1324. doi: 10.3899/jrheum.171385. Epub 2018 Jun 15. PubMed PMID: 29907665; PubMed Central PMCID: PMC6119626.
Xu C, Peng H, Li R, Chai W, Li X, Fu J, Liu K, Yu B, Jia C, Chen J. Risk factors and clinical characteristics of deep knee infection in patients with intra-articular injections: A matched retrospective cohort analysis. Semin Arthritis Rheum. 2018 Jun;47(6):911-916. doi: 10.1016/j.semarthrit.2017.10.013. Epub 2017 Oct 20. PubMed PMID: 29129326.
von Essen R, Savolainen HA. Bacterial infection following intra-articular injection. A brief review. Scand J Rheumatol. 1989;18(1):7-12. Review. PubMed PMID: 2649978.
Shemesh S, Heller S, Salai M, Velkes S. Septic arthritis of the knee following intraarticular injections in elderly patients: report of six patients. Isr Med Assoc J. 2011;13(12):757-760.
Ross K, Mehr J, Carothers B, Greeley R, Benowitz I, McHugh L, Henry D, DiFedele L, Adler E, Naqvi S, Lifshitz E, Tan C, Montana B. Outbreak of Septic Arthritis Associated with Intra-Articular Injections at an Outpatient Practice - New Jersey, 2017. MMWR Morb Mortal Wkly Rep. 2017 Jul 28;66(29):777-779. doi: 10.15585/mmwr.mm6629a3. Erratum in: MMWR Morb Mortal Wkly Rep. 2018 Apr 13;67(14):432. PubMed PMID: 28749922; PubMed Central PMCID: PMC5657811.