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Introduction: Joint disease is a common orthopaedic problem. They often occur in younger people and tend to be destructive. This can lead to widespread disability and morbidity. Diagnosis is clinical aided with conventional radiological and laboratory investigations. They are sometime equivocal and treatment is empirical and symptomatic. The evaluation of synovial fluid and synovial biopsy should be an important part of investigative procedure in patients presenting with joint effusion. Materials and Methods: Fifty patients with joint diseases visiting orthopaedic OPD and admitted at orthopaedic wards of BGS Global Institute of Medical Sciences, Bangalore formed the material of present study. Patients were informed about study in all respects and informed written consent was obtained. The period of study was from August 2013 to September 2016. Detailed clinical and radiological screenings were done. This was followed by synovial fluid analysis and closed needle biopsy in each case. The result of this study was then compared with that of previous studies. Results and analysis: A complete correlation between clinico-radiological, synovial fluid findings and closed needle biopsy for diagnosis of the definite pathology was seen in 34 (68%) cases. In 8 cases (16%) where the clinico-radiological and synovial analyses were equivocal and inconclusive, synovial biopsy only gave conclusive diagnosis of definite pathology. In another 8 cases (16%) the clinical radiological, synovial fluid findings and even the histologic study by closed needle biopsy were inconclusive for any definite disease and were labeled as chronic nonspecific synovitis. These cases were proved chronic nonspecific synovitis also by open biopsy. Conclusion: Synovial fluid analysis and synovial biopsy will help in coming to a conclusive diagnosis in cases where radiological and laboratory investigations are equivocal. This can be done simultaneously through same site of aspiration with Parker Pearson

Background The incidence of septic arthritis is 2–10/100,000. Morbidity is higher with persistent joint dysfunction in up to 30%. Osteoarthritic knee with infection presents a rare challenge, with no established approach for treatment exists. We present our experience of managing infected degenerative joint disease (DJD) with two-stage primary arthroplasty similar to the management of periprosthetic joint infection. Patients and methods Four patients presented to us between 2016 and 2018 with advanced DJD associated with coexistent joint sepsis with or without adjacent osteomyelitis. The diagnosis of joint sepsis with periarticular osteomyelitis was made based on clinical presentation, radiographic findings, inflammatory serological markers, and culture of knee joint aspirate. All were operated with primary arthroplasty in two stages of debridement with a static spacer followed by antibiotics and implantation. Discussion With no established method of treating DJD superadded with infection, our experience adds valuable information in treating the same. Our 2-staged primary arthroplasty had a short antibiotic duration between stages, a mean of 63.5 days, and stopped within 3 days of 2ndstage reducing hospital stay, morbidity, and cost. Our approach is a very viable method of treating infected DJD with a minimum drug holiday time of two weeks before implantation with a better outcome, reducing the recurrence rate of infection. Though a small number with a minimum follow-up of 24 months, we believe we provide valuable additional information. Conclusion All patients had painless return to early activities with no signs of recurrent infection. Our approach is a very viable and could serve as a cost-effective method treatment for an infected arthritic knee.

Objective: The aim of this study is to characterise the clinical and microbiological profile of adult patients treated at our orthopaedic unit with septic arthritic between 2006 and 2017. Materials and Methods: A total of 70 patients who were admitted with a diagnosis of septic arthritis between 2006 and 2017 were included in the study. The patients' clinical and epidemiological characteristics were surveyed; microbiological profile and the complications relating to the patients' treatment were identified. Results: Septic arthritis was more common among males (83%). About 75% of the patients presented with a history of fever. The knee was the most commonly affected joint (71%), followed by the hip. While C-reactive protein was found to be consistently >75, total blood white blood cell (WBC) counts were found not to be reflective of the presence of infection with a mean WBC count of only 13,561/cu.mm, and Gram stain examination had a poor sensitivity of 47%. Among the co-morbidities, the most prevalent association was with diabetes mellitus. The infectious agent most frequently isolated was Staphylococcus aureus(42.85%). The antibiotic sensitivity pattern has evolved since the early years, with resistant strains becoming increasingly prevalent. Unusually, high incidence of streptococci was noted (30%), contrary to the published literature. One-third of the patients had multi-resistant organisms. Septic arthritis left 70% of the patients with a significant residual disability at 6 months follow-up and had 4.25% mortality. Conclusion: Changing sensitivity patterns of microbes in septic arthritis point to a need for reconsidering empirical antibiotic therapy. Joint damage following infection can lead to significant disability.

Leptospirosis is a zoonotic disease caused by spirochetal bacterial of the genus Leptospira affecting virtually all mammals. The infection has a broad range of effects, from mild clinical manifestation to multiple organ failure, and ultimately death. A 5-months-old male unvaccinated dog was admitted to the University Veterinary Teaching Hospital presenting dullness, dehydration, jaundiced mucous, bloody diarrhea, vomiting, and hyporexia. Microscopic agglutination test (MAT) detected serological titers of 1:1.600 for serogroup Canicola. After five days of monitoring by the medical team he developed fever and swelling of carpal and tarsal joints, accompanied by functional limitation. Initial antimicrobial treatment was instituted for leptospirosis. Polyarthritis responsiveness to glucocorticoid therapy was observed through decreasing signs of inflammation of the affected joints. The diagnosis of leptospirosis was further confirmed by molecular investigation for Leptospira spp. on blood and synovial fluid samples. Amplification and sequencing of the secY partial gene characterized the infective bacterial as Leptospira interrogans. From the 7th day the respiratory condition worsened and on Day 14 the patient evolved to death, when necropsy and histological evaluation were performed. Prominent anatomopathological findings included: fibrinous polyarthritis, bronchointerstitial pneumonia, intense hepatocyte dissociation, cholestasis, and periportal multifocal hepatitis, diffuse acute tubular necrosis, and significant dystrophic mineralization in the renal parenchyma, lungs, and atrial endocardium. Here, we present a case report of systemic clinical manifestations polyarthritis associated with the presence of leptospiras in the synovial fluid. We highlight the need for richer knowledge about the different clinical manifestations of leptospirosis.

Background The aim of this study was to describe the clinical and microbiological characteristics of infective arthritis and to analyze risk factors for Gram-negative bacterial infections that cause infective arthritis. Materials and methods Patients admitted between 2009 - 2018 with infective arthritis in a single-tertiary hospital were evaluated retrospectively. Results A total of 181 patients were enrolled in this study. Of them, 135 were native joint infection patients and 46 were prosthetic joint infection patients. The most common site of infective arthritis was the knee (63.6%), followed by the shoulder (17.7%), and the hip (9.9%). The most frequently identified microorganisms were Staphylococcus aureus (51.1%), followed by Streptococci sp. (21.1%), Enterobacteriaceae (8.4%), and coagulase-negative-Staphylococci (CNS; 8.4%). Infections due to Gram-negative bacteria and fungi made up 13.7% and 3.2% of all cases, respectively. Additionally, 20% and 4.2% of the cases involved methicillin-resistant S. aureus (MRSA) and MRCNS. We found that bacteriuria, infective arthritis in the hip, and steroid use at admission are independent risk factors for Gram-negative bacterial infections. Conclusion Infective arthritis with methicillin-resistant microorganisms reached up to about 25% in a single-tertiary hospital in Korea. In case of suspected urinary tract infection, infective arthritis of the hip joint, or steroid use at admission time among infective arthritis patients, empirical treatment covering Gram-negative microorganisms can be considered.

Introduction Modern magnetic resonance imaging (MRI) has a great sensitivity in detecting hip joint abnormalities, and because of its property of excellent visualization of soft tissue and nonionizing radiation, it is the modality of choice these days in not only adults but also pediatric musculoskeletal pathologies. Materials and Methods It was a prospective study performed in a tertiary care institute from 2016 to 2018. Total 64 cases with hip pathology attending orthopedics OPD (out patient department) and consenting to participate were included in the study. All the consenting participants were subjected to MRI scan. Results The most common pathology detected was avascular necrosis consisting of 28 cases. The next most common abnormality detected was infective arthritis, found in seven cases. Three patients were diagnosed with metastasis. Conclusion MRI is the diagnostic modality of choice for pathologies of hip for which radiographic and clinical findings are inconclusive. With MRI, one can stage the pathology to prognosticate and influence therapeutic decisions.

Acromioclavicular arthritis is one of the most common causes of pain around the shoulder joint in middle-aged and elderly population. It is because of early degeneration of the articular cartilage and disc. The disease usually remains asymptomatic, and it presents as an incidental finding on shoulder X-Ray or Magnetic resonance imaging. It can be due to primary degenerative, inflammatory, traumatic and infective arthritis. The patient may also come with the atypical location of pain like in cervical or over deltoid muscle. A thorough understanding of its anatomy, biomechanics, history and physical examination of the patient is necessary for management of this condition. Treatment options include lifestyle modification, a short course of chemotherapy, muscle strengthening, physiotherapy or local intraarticular injection of steroid. After six months of conservative treatment if the patient still has pain then operative treatment is advisable in the form of open or arthroscopic distal clavicular resection.

Objective This article aimed to describe the use and evolution of a synthetic osteochondral resurfacing (SOR) implant in the treatment of osteochondrosis dissecans (OCD) of the femoral condyle and to report the clinical, radiographic, computed tomography and magnetic resonance imaging outcomes of this technique. Methods Medical records of dogs that were treated with first-generation (G1) and second-generation (G2) SOR at a single institute were reviewed. Surgical reports and clinical examinations as well as the preoperative, postoperative, and follow-up radiographs, computed tomographic images and magnetic resonance imaging images were reviewed. Results Fourteen stifles (nine dogs) were included in the study. G1-SOR implants were employed in six stifles of four dogs and G2-SOR implants in eight stifles of five dogs. Osteochondrosis dissecans of the medial femoral condyle was confirmed as the sole pathology in all dogs treated with G1-SOR. Only one of eight OCD lesions was located on the medial condyle in the G2-SOR group with the remaining seven lesions affecting the lateral femoral condyle. At 12 weeks, 13 of 14 stifles displayed implant stability, with no subchondral bone changes or evidence of lucency around any implant. Eight of nine dogs achieved a good-excellent clinical outcome. Complications included one minor surgical site infection and one infective arthritis which required implant removal. Clinical Significance In this cohort of dogs, both G1-SOR and G2-SOR were successful and repeatable surgical procedures for dogs with OCD of the femoral condyle.

Dermatology and rheumatology are two specialties that deal with significant overlap. In this context, it is important that the dermatologists acquaint themselves with conditions presenting with arthropathy. As the first step, it is essential to know whether the origin of musculoskeletal symptom is articular or extra-articular; inflammatory or noninflammatory; acute or chronic; oligo- or poly-articular. This will help in narrowing down the differential diagnoses as well as in better correlation with the cutaneous symptoms. In this review, we discuss the skin and articular manifestations of common inflammatory and noninflammatory arthropathies including rheumatoid arthritis, spondyloarthropathies, connective tissue disorders, vasculitis, crystal arthropathies, infective arthritis, arthritis associated with degenerative, endocrine and metabolic conditions, etc. We have also added a section on the common cutaneous features associated with the treatment of rheumatologic diseases. A basic understanding of the joint pathologies and associated skin changes will help a long way in the better management of these conditions.

Rheumatoid arthritis (RA) is an inflammatory disease that has been linked to several risk factors, including periodontitis. Identification of new anti-inflammatory compounds to treat arthritis is needed. We had previously demonstrated the beneficial effect of Kava-241, a kavain-derived compound, in the management of Porphyromonas gingivalis-induced periodontitis. The present study evaluated systemic and articular effects of Kava-241 in an infective arthritis murine model triggered by P. gingivalis bacterial inoculation and primed with a collagen antibody cocktail (CIA) to induce joint inflammation and tissular destruction. Clinical inflammation score and radiological analyses of the paws were performed continuously, while histological assessment was obtained at sacrifice. Mice exposed to P. gingivalis and a CIA cocktail and treated concomitantly with Kava-241 exhibited a reduced clinical inflammatory score and a decreased number of inflammatory cells and osteoclasts within joint. Kava-241 treatment also decreased significantly tumor necrosis factor alpha (TNF-α) in serum from mice injected with a Toll-like receptor 2 or 4 (TLR-2/4) ligand, P. gingivalis-lipopolysaccharide (LPS). Finally, bone marrow-derived macrophages infected with P. gingivalis and exposed to Kava-241 displayed reduced TLR-2/4, reduced mitogen-activated protein kinase (MAPK)-related signal elements, and reduced LPS-induced TNF-α factor (LITAF), all explaining the observed reduction of TNF-α secretion. Taken together, these results emphasized the novel properties of Kava-241 in the management of inflammatory conditions, especially TNF-α-related diseases such as infective RA.

Some studies have suggested seasonal variations in pediatric orthopaedic infection. We sought to determine if there is seasonal variation in septic arthritis and/or osteomyeltis. We performed a query of a single pediatric hospital's database, iden- tifying all patients diagnosed with septic arthritis and/or osteomyelitis, age 0 through 18, from 1994 through 2010. The institution is located in a temperate climate with definite seasonal variations. Our query yielded 735 pyogenic arthritis and 104 unspecified infective arthritis diagnoses for a total of 839 combined septic arthritis cases. The query yielded 318 acute osteomyelitis, 227 chronic osteomyelitis, and 1114 unspecified osteomyelitis diagnoses for a total of 1659 combined osteomyelitis cases. We identified statistically significant differences in regard to region of body involvement, gender, age, and incidence over time. There was no statistically significant difference with regard to month or season at the time of presentation. There does not appear to be a seasonal variation in the incidence of septic arthritis or osteomyelitis in the pediatric population. This would not support the perception of an "infection season" in pediatric orthopedics. In addition, there is a stable incidence of septic arthritis and an increasing incidence of osteomyelitis noted at our institution over the last 17 years.

Background Infective arthritis with fusobacterium is rare and difficult to diagnose & initially can be misidentified as Neisseria arthritis based on microscopy results. It is associated with Lemierre9s Disease & is important to recognise. Objectives To demonstrate that a “linked up” approach between culture and PCR in the analysis of joint fluids will provide timely identification of the organism and allow for appropriate antibiotic use & to show the utility of bacterial 16S rRNA PCR in sterile site fluid analysis. Methods This is a case study of a pyogenic wrist infection with Fusobacterium necrophorum in the rheumatology department Results Our report follows a 17 year old caucasian female presenting with a history of left wrist pain, swelling and flu-like symptoms. Microscopy of joint aspirate revealed gram negative diplococci. Empirical antibiotic therapy, Ceftriaxone, was used to cover for potential gonococcus. Real-time PCR testing was negative for both gonococcus and meningococcus. However a real-time PCR assay targeting the bacterial 16S ribosomal RNA gene detected bacterial DNA1. The patient did not clinically improve and further aspirate remained positive for the 16S rRNA gene target. As all joint aspirates and other specimens remained culture negative, the decision was taken to attempt bacterial 16S rRNA PCR and sequencing on DNA extracted directly from the joint aspirate. The sequences recovered were identified as F necrophorum. This was eventually confirmed by anaerobic culture of the initial joint aspirate. A suspicion of Lemierre9s disease (thrombophlebitis of the internal jugular vein and/or bacteraemia) was raised, however jugular venous dopplers were normal. The outcome was favourable following guided antibiotic treatment. Conclusions This case illustrates that F. necrophorum infection may occur with unusual or disseminated presentation, but in the absence of the classical features of Lemierre9s syndrome. The possibility of Neisseria was recognised early & appropriate empirical antibiotic cover was used. This is important given the emergence of virulent meningococcal serogroup W ST11 strains causing infections with unusual presentation (including septic arthritis) in the UK2. Reliance on microscopy findings alone could have led to an incorrect diagnosis of gonococcal septic arthritis – a condition with very low complication rates and excellent prognosis. In contrast, non-gonococcal septic arthritis is a medical emergency with significant morbidity and mortality3. The F. necrophorum infection in this case could have had fatal complications if it had been managed as a gonococcal infection. Secondly this case highlights the utility of bacterial 16S PCR and sequencing directly from a normally sterile site, allowing accurate diagnosis and appropriate treatment. References Yang S et al (2002)Quantitative Multiprobe PCR Assay for Simultaneous Detection and Identification to Species Level of Bacterial Pathogens J Clin Micro 40(9):3449–3454. Ladhani SN, et al(2014) Increase in Endemic Neisseria meningitidis Capsular Group W Sequence Type 11 Complex Associated With Severe Invasive Disease in England and Wales. Clinical Infectious Disease 60:578–585. Shirtliff & Mader (2002) Acute septic arthritis. Clin Microbiol Rev. 15(4):527–44. Disclosure of Interest None declared

First metatarsophalangeal joint (MTPJ) arthrodesis has long been established as an effective surgical procedure for treatment of many different pathologies. These commonly include severe hallux valgus, chronic joint instability, neuromuscular disease, avascular necrosis, and arthritic conditions such as hallux rigidus, post-traumatic osteoarthritis, infective arthritis, gouty arthritis, and rheumatoid arthritis [1–25]. First MTPJ arthrodesis has also been indicated for failed procedures of the first ray including previous hallux valgus osteotomies, hallux varus deformity, and salvage of replacement and resectional arthroplasties [20, 26–38]. As with any surgical procedure, complications of first MTPJ arthrodesis may arise postoperatively, which may include infection, wound dehiscence, osteomyelitis, ischemic limb, nerve entrapment hematoma, seroma, failed hardware, delayed union, nonunion, malunion, and hallux interphalangeal joint (HIPJ) arthritis [4, 5, 13, 14, 19, 39–44]. Amputation or loss of limb may be a catastrophic sequelae as a result of one of the aforementioned complications.

Bacteria, viruses, fungi, and parasites can all cause arthritis of either acute or chronic nature, which can be divided into infective/septic, reactive, or inflammatory. Considerable advances have occurred in diagnostic techniques in the recent decades resulting in better treatment outcomes in patients with infective arthritis. Detection of emerging arthritogenic viruses has changed the epidemiology of infection-related arthritis. The role of viruses in the pathogenesis of chronic inflammatory arthritides such as rheumatoid arthritis is increasingly being recognized. We discuss the various causative agents of infective arthritis and emphasize on the approach to each type of arthritis, highlighting the diagnostic tests, along with their statistical accuracy. Various investigations including newer methods such as nucleic acid amplification using polymerase chain reaction are discussed along with the pitfalls in interpreting the tests.

Background: Tuberculosis (TB) of hip constitutes nearly 15% of all cases of osteoarticular tuberculosis. We report a retrospective study carried out on 43 children with hip TB. Materials and Methods: Forty-three children of TB hip treated between 1971 and 2000 were analysed. Twenty-four children of the early series were treated with streptomycin (S), isoniazid (H) and PAS (Pa) for 18 months (3HPaS, 15 HPa), while 19 children in the later series were treated with isoniazid (H), rifampicin (R) and ethambutol (E) or pyrazinamide (Z) for 12 months [(12 RHE(Z)]. Five out of 18 children with radiologically normal appearing type hip TB were treated with chemotherapy alone and 38 children were subjected to surgery; simple synovectomy alone in 31 hips, joint debridement in six hips, and proximal femoral varisation osteotomy in one. After surgery hips were immobilized in cast for one to three months according to the severity of the disease and patients pain tolerance, and then were mobilized under leg traction in bed gradually till pain subsided completely. Results: TB of hip healed with minimum sequelae in all children. In 18 Type one hip TB, normal hip (synovial form) anatomy was maintained, and in 25 patients with advanced lesions some defect in the femoral head and acetabulum was noticed, though painless good hip motion was maintained. Excellent to good results were obtained in 31 children (73.1%), fair in eight (18.6%), and poor in four (9.3%). In four patients with poor results, there was some residual morphological defect in the hip. None developed ankylosis of hip. Conclusion: We achieved good outcome with minimum sequelae in this series. The management goal should be aimed not only to heal the disease but also to maintain a painless mobile hip and anatomical cephalocotyloid relationship until maturity, and retard the development of secondary osteoarthritis.

As equine practitioners, we all know that diagnosing synovial sepsis can sometimes be challenging when trying to distinguish between early stage infective arthritis, with a relatively low total nucleated cell count (TNCC), and traumatic arthritis with a high white blood cell count.1 Another challenge can be obtaining enough synovial fluid, if any, to allow determination of the three most useful parameters in making the diagnosis of septic synovitis: TNCC, neutrophil percentage and total protein. Under the worst circumstances, if a very chronic septic process is encountered with extensive soft tissue trauma or infection and large wounds, synovial cavity puncture, aspiration and withdrawal may not be possible or should even be discouraged (Fig 1). In these particular circumstances, a systemic quick, affordable sensitive and specific synovial biomarker test to aid the immediate diagnosis is needed to allow clinical therapeutic decisions to be made rapidly. FIG 1 Extensive distal left hindlimb celullitis secondary to a chronic wound involving the digital flexor tendon sheath In a study by Robinson and others,2 summarised on p 425 of this week’s Veterinary Record , serum amyloid A (SAA) seems to have been identified as an ideal biomarker, supported by evidence from a large number of clinical cases that blood and synovial fluid SAA concentrations can both be used to differentiate between septic or contaminated versus …

The genus Raoultella has been separated from the genus Klebsiella in 2001. Two main species are responsible for human infections: R. ornithinolytica and R. planticola. The most frequent infections due to R. planticola include cystitis, pneumonia and bacteremia (mostly in immunocompromised hosts). To date, no joint or bone infection has been reported. We describe the first case of septic arthritis due to R. planticola following an arthroscopy with intra-articular injection of corticosteroids. Evolution was favorable after arthroscopic lavage and antibiotic therapy with quinolones. Raoultella planticola has been described rarely in human infection. It is mainly deemed responsible for cystitis, pneumonia and bacteremia (mostly in immunocompromised hosts) [1, 2, 3]. To our knowledge no case of bone or joint infection has been reported. We described here the first case of infective arthritis due to R. planticola involving a native knee joint following synovectomy and intra-articular injection of corticosteroids during arthroscopy.

Shewanella is Gram-negative motile bacillus, non fermentative and facultative anaerobe. Its natural habitat is all forms of water and soil, but has also been isolated from fish, dairy products, oils, and carcasses. Often found with microflora of the marine environment. Bacterial infections with Shewanella spp. are rare. The exposure to the marine environment, sea and diary food are considered as a risk factor for Shewanella spp. infection. Clinical infections seen are otitis, soft tissue infection, bacteremia, ear infection, eye infection, infective arthritis, osteomyelitis, infective endocarditis and peritonitis.

Musculoskeletal infection is one of the common manifestations of patients infected with human immunodeficiency virus and acquired immunodeficiency syndrome. With immune deficiency, patients are susceptible to a variety of nonopportunistic and opportunistic infections that can result in significant morbidity and mortality. Infection can involve any anatomical compartments resulting in infectious arthritis, osteomyelitis, pyomyositis, and soft tissue and skin infection. Imaging plays an important role in the early diagnosis and treatment planning for these patients. This article reviews the clinical manifestations of musculoskeletal infection together with reported causative organisms. We discuss the role of imaging and present radiological examples.

Human immunodeficiency virus (HIV), the retrovirus that causes acquired immunodeficiency syndrome (AIDS), is one of the leading causes of death among young adults worldwide.1 Despite new insights into the pathogenesis of the infection and novel antiviral approaches, the prevalence of HIV infection continues to increase, both in the developed and the underdeveloped countries. It is estimated that well over 40 million people are infected with HIV type 1 (HIV-1), the principal cause of the growing pandemic. Twenty-five years has seen the transformation of HIV infection from a fatal condition to a manageable chronic illness largely due to the speedy development of antiretroviral therapy (ART).2 The evolution of HIV pandemic has been matched by a marked transformation in the profile of rheumatologic manifestations in the era of antiretroviral therapy. With increasing number of individuals getting HIV infection, the number of HIV-infected patients with rheumatic manifestations is bound to increase. HIV can present with myriad of presentations, of which reactive arthritis, infective arthritis, diffuse infiltrative lymphocytosis syndrome (DILS), and myositis are some of the rheumatological conditions that can occur in a HIV-infected individual. The aim of this review is to provide is to give a brief review of the varied rheumatic manifestations that occur in the course of HIV infection with an update overview with a focus on the impact of ART on the change in the rheumatology spectrum.3

Septic arthropathy leads to rapid joint destruction, impairment, and disability.Staphylococcuscan be particularly virulent to bone and joints leading to adverse obstetric events. At 28 of weeks gestation, a patient presented with pyelonephritis and progressive left shoulder pain. Magnetic resonance imaging indicated early clavicular destruction and acromial involvement. Glenohumeral joint aspiration producedStaphylococcus aureus. The patient then had premature rupture of membranes and progressed rapidly to preterm delivery. Placental pathology revealed chorioamnionitis and microabscesses. Treatment of the infected joint required further surgical drainage and bone resection as well as extended antibiotics. It is important to remember that joint pain in pregnancy may indicate infective arthritis, and pyelonephritis can be a source of such an infection. Evaluation includes magnetic resonance imaging and consultation for joint aspiration. Prompt recognition and treatment are necessary to prevent joint destruction.

Bacillus species infection of the joints is a very rare occurrence, with sporadic reports in the medical literature.A 67-year-old woman with osteoarthritis developed infection in the knee joint after arthroscopy. Percutaneous needle aspiration of articular fluid performed post-operatively showed a positive culture for Bacillus species. The diagnosis of septic arthritis was, however, not confirmed as the results were considered contamination. Failure of treatment with beta-lactam antibiotics on two occasions and successful cure of infective arthritis by long-term administration of a fluoroquinolone confirmed iatrogenic clinical joint infection with Bacillus species.Any clinically suspected joint infection must be treated as septic arthritis until proved otherwise.

Background: Monoarthritis is a common rheumatological complaint. Inspite of investigations, many cases remain undiagnosed. Prompt investigation and treatment is important in acute arthritis especially septic arthritis else joint destruction, permanent disability or even death can result. This study was conducted to etiologically categorise patients as inflammatory, non-inflammatory and infective arthritis and to study the outcome. Methods: This observational prospective study conducted at a tertiary care hospital in Mumbai enrolled 40 patients above the age of 12 yrs presenting with first episode of mono-articular arthritis. They were treated with standard treatment guidelines and followed up every 3 monthly for one year. Outcome was assessed using ESR, CRP values and Health Assessment Questionnaire. Results: Mean age at diagnosis was 38 years with a male to female ratio of 1.4:1. Acute and chronic mono-articular arthritis cases were 16.2% and 83.7% respectively. Knee joint was most commonly involved (38%). Etiologically inflammatory, infectious and non-inflammatory cases were 59.5%, 29.7% and 10.8% respectively. In 21% cases etiology was tuberculosis. 27 % evolved into oligoarthritis over one year. The serial ESR, CRP values and Stanford Health Assessment Questionarre scores decreased significantly across all etiological groups with treatment. Conclusions: Knee is the most commonly affected joint in mono-articular arthritis. Tuberculosis is the most common etiology. Irrespective of the etiology, if patients are treated according to standard guidelines promptly mono-articular arthritis has a good response to therapy as assessed by the health assessment questionnaire (HAQ) and serial measurements of proinflammatory markers like ESR, CRP.

Introduction: Monoarticular arthritis which means inflammation, (infective or non-infective) of single synovial joint is a huge burden in the health care system. Chronic monoarthritis is characterized by its progressive onset and slow development, commonly presenting with mild inflammatory signs. The clinical presentation is usually nonspecific especially in the early stages. To evaluate the role of clinical, hematological and immunological features in the diagnosis of peripheral large joint monoarthritis and its correlation with radiographic studies and histopathological studies of the same. Materials: A total of 30 patients of a monoarticular joint disease were studied in which conventional radiography, MR imaging, arthroscopy and synovial biopsy as techniques for its diagnosis were compared. Results: The mean age in the present study was 21.23 years with a preponderance of male patients. MRI was found to have high sensitivity (87.5%) and specificity (85.7%) in the diagnosis of chronic inflammatory synovitis. Arthroscopy wasfound to have a sensitivity of 83-85% and specificity of 85-86% in diagnosing both inflammatory and infective synovitis. Conclusion: MRI is recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results. When assessed together with ahistopathological examination of the synovium and mycobacterial cultures, MRI imaging forms a powerful tool in diagnosing tubercular synovitis early. Arthroscopic joint evaluation should be used wherever feasible for a complete evaluation of the knee joint along arthroscopic guided biopsy. Not only does it increase the diagnostic yield of the biopsy but can also diagnose other associated conditions.

Summary The joint diseases that are encountered in chronic dialysis have been reviewed. There are two general categories: de novo disease and arthropathy anteceding ESRD. The de novo joint diseases include categories that are probably the direct result of ESRD. Microcrystalline CaOHapatite and CaPPD arthritis is associated with hyperparathyroidism and a high Ca X P. Aluminum phosphate joint disease is the result of aluminum toxicity. Both types have severe disease of the adjacent bone: osteitis fibrosa with CaOHapatite-CaPPD arthropathy and osteomalacia with aluminum phosphate. Calcium oxalate joint disease probably results from renal oxalate retention in ESRD and conversion of ascorbate to oxalate. The evidence for uric acid arthropathy in the absence of primary gout or lead toxicity is not convincing. Amyloid is the most frequent cause of the carpal tunnel syndrome and is related to retention of β-2 microglobulin. Infective arthritis may be Seen, often occumng as a result of bacteremia from an infected fistula site. A degenerative arthritis different from osteoarthritis has also been described. Pathologic fractures can occur with both amyloid deposition in bone and aluminum osteomalacia. Long-term steroid therapy can lead to avascular necrosis of femoral or humeral heads. Diabetes mellitus with neuropathy can give rise to a very destructive Charcot joint. Tendon ruptures occur, but the mechanism is obscure. It is most important that the nephrologist work closely with the rheumatologist. Carefbl and sophis ticated examination of synovial fluid and tissue is mandatory in the microcrystalling diseases. Immunohistochemical methods may be required, particularly for tissue removed during decompression of the median nerve. Together the subspecialists can establish the diagnosis and determine the appropriate therapy for the iarge number of joint disorders to which the dialysis patient is subject.

Erosive polyarthritis was diagnosed in an 11-month-old neutered male Egyptian Mau-cross cat with concurrent glucocorticoid-responsive dermatitis. Clinical signs, synovial fluid analysis, serological tests and radiographic appearance could not differentiate between immune-mediated and infective arthritis. Mycoplasma gateae was isolated by strictly anaerobic culture of the synovial fluid. Treatment with Enrofloxacin led to a rapid improvement of the cat's condition. Two months later the cat was euthanased because of severe glomerulonephritis and direct Coombs' test positive anaemia, possibly caused by mycoplasma infection. M gateae could not be isolated at post-mortem examination.

INFECTIVE arthritis is an inflammatory arthropathy caused by an infective agent which can be cultured from the affected joint(s). Bacteria are the most common cause of infective arthritis in dogs and cats in the UK. However, bacterial arthritis can resemble many other arthropathies and attempts to achieve a definitive diagnosis by culture of the offending organism are not always successful. This article sets out a diagnostic plan for suspected cases of bacterial infective arthritis and discusses current treatment recommendations in the light of recent evidence and ongoing research in both the veterinary and medical fields.

Background Septic arthritis of the knee joint requires prompt diagnosis and treatment for optimal outcomes. Pyomyositis with abscess formation is uncommon but may present with similar symptoms in the vicinity of a joint. Objective This report describes two cases of medial thigh abscess initially diagnosed and treated as septic arthritis, and highlights the need to make an accurate diagnosis. Case Report Two patients presenting with knee pain secondary to pyomyositis and abscess formation in the medial thigh were investigated with aspiration and treated subsequently with knee surgery, resulting in contamination of the knee joint in one case and delayed diagnosis with significant morbidity in both. Conclusion Failure to identify a soft tissue infection may lead to delayed diagnosis, misdirected treatment, and contamination of a normal joint. Diagnosis is best confirmed with thorough physical examination and specific imaging where available.

Gentamicin-impregnated polymethylmethacrylate beads were used to treat infective arthritis in the small tarsal joints of 11 severely lame horses. Under general anaesthesia, between five and 10 beads were placed into a 7 to 8 mm tract drilled across the affected joint and, in all except one horse, they were left in place for 14 days. Two of the horses were euthanased for reasons other than persistent tarsal joint sepsis, but the other nine survived and seven of them returned to their previous level of athletic performance.

Infective arthritis (InfectA) has a variable geographical pattern. A 'Medline' search did not yield any earlier series on epidemiological pattern of InfectA from Kuwait or the Gulf region. Therefore, an observational prospective study of sequential cases seen over a period of 4 years was carried out. Of a total of 2021 patients seen during this period, 36 (1.8%) were diagnosed to have InfectA. There were 6 (16.7%) cases of neisserial and 30 (83.3%) of non-neisserial InfectA. Predisposing factors were seen in 17 (47.2%), all with non-neisserial InfectA. Microbiological diagnosis was proven in 15 (41.7%) cases, and included Neisseria gonorrhoeae in 5, Brucella spp. in 4, Staphylococcus aureus in 3, and Neisseria meningitidis, Salmonella spp. and Mycobacterium tuberculosis in 1 each. In the remaining 21 (58.3%) cases the diagnosis was made on clinical grounds and confirmed on therapeutic response. The most common presentation of neisserial InfectA was acute polyarthritis while that of non-neisserial InfectA was acute monoarthritis. All patients recovered with little disability and no mortality.

Staphylococcus aureus is directly implicated in the bone destruction associated with infected orthopaedic implants and bacterial arthritis. The Oxford (laboratory) strain of this organism has surface-associated proteins (SAPs) which have potent osteolytic activity. In this study, we have examined the osteolytic activity of SAPs from clinical isolates and also investigated the role of the humoral immune response to such proteins. Nine patients with infected orthopaedic prostheses or infective arthritis, and six volunteers not suffering from overt S. aureus infection, were examined. The sera from 5/9 patients and 4/6 volunteers were able to neutralize the osteolytic activity of the SAPs. The SAPs were extracted from four clinical isolates and were found to have osteolytic activity, but with a wide range of efficacies and potencies. All four patients from whom the clinical isolates were obtained had serum IgG antibodies to the surface proteins from their autologous isolates as determined by ELISA. In conclusion, clinical isolates of S. aureus contain osteolytic SAPs which may be responsible for bone destruction. Apparently disease-free individuals and patients have antibodies able to block this activity. However, since the capacity of patients' sera to neutralize the activity of the SAPs derived from their own S. aureus isolate was not investigated, it is unclear whether these findings are of prognostic value.

The joints are the sites of a great variety of diseases of known and unknown etiology (Table 8.1). The joint diseases of 99mTc-MDP bone scintigraphic interest, pinhole scintigraphy in particular, include synovitis, infective arthritis, degenerative arthritis, rheumatoid arthritis, seronegative spondyloarthropathies, and metabolic articular disorders. Based on the histological characteristics, joints are divided into the fibrous, cartilaginous, and synovial types (Williams and Warwick 1989). In the respective joints, apposed bone surfaces are fastened by the connective and cartilaginous tissue and separated by the synovial lining and cavity. Table 8.2 shows typical joints that belong to each of these categories.

Bone infection (osteomyelitis, osteitis) and joint infection (septic arthritis, suppurative arthritis, infective arthritis) appear to carry a bad reputation. However, in childhood, when, the way in which the causative organisms enter and infect bone or joint is usually by the arterial blood supply, these is a good potential for cure. In developed countries the sight of a cripple with a limp, a short leg, a stiff joint and a smelly discharging sinus is rare-despite pictures in textbooks which colour the appreciation of the diseases. Bone and joint infections in children are uncommon; therefore the satisfactory experiences of those who treat a significant number of such children is not well conveyed to the medical population in general, as well as to orthopaedic surgeons, thereby leading to controversy about diagnosis and treatment. Such controversies are largely based on ignorance, emotion, uncertainty and inadequate audit of outcome. Among those who have more experience, there is little disagreement about management of bone and joint infection in childhood. This article should convince the reader that there is a rational plan for management of osteoarticular infection in childhood based upon an understanding of the pathogenesis of the diseases and clear clinical indicators on which to base decisions.

Purpose.To compare the mid-term clinical outcomes in Indian patients after total knee arthroplasty (TKA) using a fixed- or mobile-bearing prosthesis.Methods.120 consecutive patients (50 men and 70 women) aged 55 to 76 (mean, 63) years who had arthritis of the knee with similar deformity and range of motion were randomised to undergo TKA using a fixed- or mobile-bearing prosthesis. Patients with mediolateral instability and infective arthritis were excluded. Knee Society knee and functional scores, range of motion, and the presence of flexion contracture were assessed.Results.The mean follow-up duration was 3.5 (range, 1–4.6) years. The mid-term outcome of the 2 groups was comparable. One patient with a mobile-bearing prosthesis had recurrent dislocation at postoperative week 2, owing to iatrogenic medial collateral ligament injury.Conclusion.Long-term studies of both functional and radiological outcomes are needed to determine the indications for fixed- versus mobile-bearing prostheses.

SummaryThe objective of this study was to describe seven cases of unilateral bacterial infective coxarthritis from a total of 19 cases of bacterial infective arthritis (BIA), presenting over a two year period. We recorded the history, clinical signs, diagnostic process, treatment and clinical outcome in these cases. The data were obtained from medical records, review of the radiographs, and telephone follow-up with the owners. All of the dogs in this study had severe chronic osteoarthritis secondary to hip dysplasia, which caused periodic hind limb lameness. They were all admitted with severe acute hind-limb lameness. Pelvic radiographs were performed under general anaesthesia shortly after presentation, followed immediately by arthrocentesis of the affected joint. The synovial fluid was evaluated microscopically by direct smear and a sample was sent for culture and sensitivity. An attempt was not made to drain or lavage the affected joint during the course of treatment. The initial choice of antibiotics was empiric and subsequently modified, as required, based on the sensitivity results. Four of the dogs showed a rapid return to weight-bearing after the initiation of antibiotic treatment, and all of the patients returned to their pre-BIA level of function. Neither recurrent infections nor any adverse sequela requiring further intervention were reported by the owners on telephone follow-up.

An otherwise healthy 36-year-old man was hospitalised due to a traumatic tear of the meniscus in the left knee. An arthroscopy was performed and his meniscus was partially resected. Thirty days later, he was rehospitalised with arthritis in the left knee and cellulitis on the left tibia. Helicobacter cinaedi was isolated from the synovial fluid, which was incubated in a BACTEC Paediatric bottle. The patient was treated with oral rifampicin and moxifloxacin for 6 weeks with good clinical response without relapse. The source of the infection was not found. The case emphasises the importance of incubating the synovial fluid in a rich medium such as a BACTEC Peds Plus/F bottle. Physicians and microbiologists should be aware of H. cinaedi as a human pathogen causing a range of disease manifestations, including infective arthritis and cellulitis, particularly if symptoms evolve in the weeks following a surgical procedure.

Purpose: The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes. Methods: 10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively. Results: Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20°, volar flexion 15°, radial deviation 0°, ulnar deviation 15°. Conclusion: Our standardized treatment protocol can be helpful for treatment of deep NTM infection of the hand and wrist.

Objectives: To characterise the presenting signs and pathological changes of canine bacterial infective arthritis in 31 dogs, and to document the response to different treatment regimens. Risk factors that may predispose joints to bacterial infective arthritis and influence the success of treatment were also investigated. Methods: A retrospective review of cases of bacterial infective arthritis that were presented to three university veterinary referral hospitals over a five-year period (January 1997 to January 2002) was performed. Results: The elbow joint (38 per cent) and stifle joint (44 per cent) were most commonly affected. Radiographic changes consistent with pre-existing osteoarthritis were identified in 14 joints, which had no history of previous surgery (articular or periarticular) or penetrating wound. No significant difference (P=0.78) was identified between the outcome of combined surgical and medical management, and medical management alone. There were trends for poorer outcomes with increased bodyweight of the dog, longer duration of lameness and a higher nucleated cell count of the affected joint fluid at presentation. The overall infection rate for articular surgical procedures at one institution was 1.3 per cent. Clinical Significance: Medical and/or surgical management were usually successful in resolving infection (94 per cent). However, they were frequently unsuccessful in restoring full joint function; this may in part have been due to the nature of the underlying joint disease.

Gentamicin-impregnated polymethylmethacrylate beads were used in the treatment of infective synovitis in 12 horses and 10 cattle. They had either proved refractory to standard treatments (lavage, debridement, joint drainage and systemic antibiotics) or had evidence of osteomyelitis adjacent to a synovial cavity. All the animals were severely lame. All the cattle and six of the horses had radiological evidence of osteomyelitis in communication with a synovial cavity. The beads were placed intrasynovially under general anaesthesia and left in place for 14 days. One horse and one calf were euthanased owing to continued infective arthritis. The infection was eliminated from the other 20 cases and six of the horses returned to full athletic use. Eight of nine calves with E-type infective arthritis and osteomyelitis returned to their intended food production or breeding programmes.

Six patients with pre-existing rheumatic joint disease presented with overwhelming septicaemia but without overt signs of joint inflammation. Joint aspirates demonstrated multifocal staphylococcal infective arthritis. Despite intensive care all six died from the infection or its immediate sequelae. The contrast between this clinical entity and classical infective arthritis, presenting with one or more swollen, tender joints, is discussed.

A 35-year old woman presented to her GP with a 2-day history of sore throat, myalgia and fever. A provisional diagnosis of acute viral pharyngitis was made and conservative treatment with analgesia recommended. However, her symptoms increased in severity with the addition of severe pain in the left thigh and hip necessitating hospital admission 5 days later. On examination, she was tachycardic, tachypnoeic and hypotensive with basal crepitations in the right lung and reduced mobility of the left hip. She had a neutrophil leucocytosis (33×103/litre) and a high C-reactive protein level of 230 g/litre. The chest X-ray showed consolidation of the right middle lobe with multiple nodular infiltrates throughout both lung fields. Aspiration of the hip joint showed numerous white cells but the culture was sterile. Severe community-acquired pneumonia and infective arthritis of the hip were suspected and she was treated with benzylpenicillin, clarithromycin and flucloxacillin, but 36 hours following admission, her condition deteriorated because of the sepsis and she was transferred to the intensive care unit for ventilatory and inotropic support. Culture of the blood taken on admission yielded an anaerobic gram-negative rod which was subsequently identified as Fusobacterium necrophorum by the reference laboratory. As it was sensitive to penicillin, metronidazole and clindamycin, the antibiotic treatment was changed to high doses of all three. The pneumonia resolved, inflammatory markers returned to normal and the mobility of her left hip improved; 14 days after admission, she was well enough to be discharged home with oral amoxicillin and metronidazole for a further 4 weeks and appropriate outpatient follow-up.

A case of recurrent vesicogluteal fistula due to a spiculated sequestrum of the acetabulum, a sequela to treatment including excision of the head of the femur for infective arthritis of the right hip, is reported.

A patient with rheumatoid arthritis taking prednisone developed Blastocystis hominis acute diarrhoea, which was associated with increased inflammation and effusion of the left knee. B hominis organisms were found in synovial fluid from the left knee. The patient responded dramatically to metronidazole treatment. B hominis may become disseminated in immunosuppressed patients with diarrhoea and may cause infective arthritis.

Summary We describe two cases of septic arthritis occurring in association with lower urinary tract infection in elderly men. In both cases the organism isolated from both the joint and the urine was Staphylococcus aureus. Further investigation of the urinary tract in both individuals identified bladder outflow obstruction secondary to benign prostatic hyperplasia predisposing them to infection. The urinary tract should be suspected as a focus of infection in septic arthritis in elderly men and further investigation of the urinary system may disclose a surgically correctable lesion.

Advanced immunological technology has revealed immunological abnormalities not only in some chronic and autoimmune connective tissue disorders but also in conditions like infective arthritis where infection apparently seems to play the only role. On the other hand role of infection in the pathogenesis of some connective tissue disorders has recently gained much importance from the observation of clinical, pathological and immunological similarities between these diseases and certain infectious diseases occurring in animal models. Meanwhile, knowledge gained into human leucocyte-A system and its association with certain diseases opens another angle in etiopathogenesis of certain rheumatic diseases. It has been postulated that adaptive mechanism of a microbe or the binding between the human leucocyte-A molecule and carbohydrate moiety of a microbe may set up an autoimmune reaction and in the presence of some triggering factors in the environment may lead on to disease manifestations. An attempt has been made to discuss the role of infection in the outcome of rheumatic diseases such as septic arthritis, polyarteritis nodosa, rheumatic fever, enteropathic arthritis, ankylosing spondylitis, rheumatoid arthritis and systemic lupus erythematoses in genetically susceptible individuals producing immunological abnormalities.

The main clinical features of 12 cases of bacterial endocarditis were lameness, pyrexia, lethargy, anorexia and systolic cardiac murmurs. The lameness varied from generalised stiffness to an inability to stand and walk. Multiple joint involvement was typical. Two types of joint pathology were identified. A marked synovitis with granulation tissue sometimes covering the articular cartilage was present in some joints associated with the presence of bacterial organisms. Other joints proved sterile and showed a milder synovial pathology. In many dogs both an infective arthritis and a non-infective arthritis co-existed. Bilaterally symmetrical joint involvement was typical of the non-infective arthritis. The pathogenesis of the latter was likely to involve the deposition of circulating immune complexes (bacterial antigens, antibody and complement) in the synovium. The infective arthritis was presumed to be secondary to embolic disease, ie, the spread of infected emboli from the heart valve to the joints. Treatment was unsuccessful in all cases.

Bacterial infections of joints produce an inflammatory arthropathy. Most cases appear to be due to the haematogenous localisation of bacteria in a joint and trauma may predispose a joint to infection. Two clinical syndromes are identified; the classic acute onset case and a more chronic local grade infection syndrome. Affected joints are usually thickened and show pain on manipulation. The synovial fluid has increased numbers of white cells, most of which are polymorphonuclear leucocytes. Peripheral blood analysis may be normal and only a few dogs show systemic illness. Radiography in the early stage, will only show soft tissue changes; periosteal new bone and bony destruction are seen in longer standing cases. The carpus was the most frequently affected joint and the larger breeds, particularly the males, were over-represented. Various organisms were isolated but haemolytic Streptococcus and Staphylococcus intermedius were the most common. Culture of the synovial membrane was more sensitive than the synovial fluid. Antibiotic therapy for several weeks was generally successful providing an early diagnosis was made. In a few cases, steroid responsive synovial inflammation persisted in the absence of viable bacterial organisms.

(1) A series of six cases of ankylosing spondylitis was shown to illustrate the benefit gained, even in very long-standing cases, by the following regime: ( a) Complete rest in a plaster shell. ( b) Gradual correction of kyphosis by adding thin layers of padding under the dorsolumbar junction, and subtracting similar layers of padding from under the head, to increase extension in the spine. ( c) Deep-breathing exercises practised constantly while the patient is lying in a plaster shell. ( d) Daily physiotherapy. ( e) The fitting of a Goldthwaite spinal brace to maintain the position of maximum correction that has been obtained. The improvement was manifested in all cases by alleviation of symptoms, improvement in posture, and increased chest expansion. (2) A series of six cases of arthritis of the knee was shown, including rheumatoid arthritis, infective arthritis and osteo-arthritis, illustrating treatment by rest plasters, followed by: ( a) Arthrotomy and lavage—where swelling and effusion persist, and ( b) Bone drilling—where bone changes are marked and there is constant pain at rest. Improvement was manifested by relief of symptoms, subsidence of signs of inflammation, and restoration of a considerable degree of movement. (3) A case of arthritis of the tarsal and metatarsal joints, illustrating relief of symptoms afforded by the application of a plaster boot.