Semin Musculoskelet Radiol 2025; 29(02): 293-301
DOI: 10.1055/s-0045-1802352
Review Article

Septic Arthritis: Current Concepts

Bryce D. Beutler
1   Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, California
,
Carina Chang
2   Department of Anesthesiology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
,
3   Department of Radiology, University of California, San Francisco, San Francisco, California
› Institutsangaben

Abstract

Septic arthritis is a major cause of morbidity and mortality worldwide, with survivors often facing long-term functional impairments. Prompt diagnosis is crucial to decrease complications such as cartilage loss, osteomyelitis, and reduced mobility. Imaging plays a central role in the diagnosis, as well as offering guidance for diagnostic aspiration. Because septic arthritis may involve any joint in the body, both native and prosthetic, different imaging modalities may be more applicable in various scenarios. We describe the hallmark imaging findings of septic arthritis in radiography, ultrasound, computed tomography, magnetic resonance imaging, and nuclear medicine scintigraphy, as well as the associated complications.



Publikationsverlauf

Artikel online veröffentlicht:
31. März 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 He M, Arthur Vithran DT, Pan L. et al. An update on recent progress of the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis: a review. Front Cell Infect Microbiol 2023; 13: 1193645
  • 2 Chiappini E, Mastrolia MV, Galli L, De Martino M, Lazzeri S. Septic arthritis in children in resource limited and non-resource limited countries: an update on diagnosis and treatment. Expert Rev Anti Infect Ther 2016; 14 (11) 1087-1096
  • 3 Morgan DS, Fisher D, Merianos A, Currie BJ. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117 (03) 423-428
  • 4 Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001; 40 (01) 24-30
  • 5 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; 20 (03) 341-349
  • 6 Ferrand J, El Samad Y, Brunschweiler B. et al. Morbimortality in adult patients with septic arthritis: a three-year hospital-based study. BMC Infect Dis 2016; 16: 239
  • 7 Long B, Koyfman A, Gottlieb M. Evaluation and management of septic arthritis and its mimics in the emergency department. West J Emerg Med 2019; 20 (02) 331-341
  • 8 Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med 2011; 18 (08) 781-796 . Published correction appears in Acad Emerg Med 2011;18(9):1011
  • 9 Kaandorp CJ, Van Schaardenburg D, Krijnen P, Habbema JD, van de Laar MA. Risk factors for septic arthritis in patients with joint disease. A prospective study. Arthritis Rheum 1995; 38 (12) 1819-1825
  • 10 Al-Khalisy HM, Nikiforov I, Mansoora Q, Goldman J, Cheriyath P. Septic arthritis in the temporomandibular joint. N Am J Med Sci 2015; 7 (10) 480-482
  • 11 Ross JJ, Ard KL. Septic arthritis of the spinal facet joint: review of 117 cases. Open Forum Infect Dis 2024; 11 (03) ofae091
  • 12 Myerson MS, Miller SD, Henderson MR, Saxby T. Staged arthrodesis for salvage of the septic hallux metatarsophalangeal joint. Clin Orthop Relat Res 1994; (307) 174-181
  • 13 Wu KA, Kugelman DN, Seidelman JL, Seyler TM. Native joint septic arthritis. Antibiotics (Basel) 2024; 13 (07) 596
  • 14 Roerdink RL, Huijbregts HJTAM, van Lieshout AWT, Dietvorst M, van der Zwaard BC. The difference between native septic arthritis and prosthetic joint infections: a review of literature. J Orthop Surg (Hong Kong) 2019; 27 (02) 2309499019860468
  • 15 Carter K, Doern C, Jo CH, Copley LA. The clinical usefulness of polymerase chain reaction as a supplemental diagnostic tool in the evaluation and the treatment of children with septic arthritis. J Pediatr Orthop 2016; 36 (02) 167-172
  • 16 Shohat N, Bauer T, Buttaro M. et al. Hip and knee section, What is the definition of a periprosthetic joint infection (PJI) of the knee and the hip? Can the same criteria be used for both joints? Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34 (2S): S325-S327
  • 17 Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81 (12) 1662-1670
  • 18 Bisht RU, Burns JD, Smith CL, Kang P, Shrader MW, Belthur MV. The modified Kocher criteria for septic hip: does it apply to the knee?. J Child Orthop 2022; 16 (03) 233-237
  • 19 Chan BY, Crawford AM, Kobes PH. et al. Septic arthritis: an evidence-based review of diagnosis and image-guided aspiration. AJR Am J Roentgenol 2020; 215 (03) 568-581
  • 20 Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology 2008; 248 (02) 378-389
  • 21 Tigges S, Stiles RG, Roberson JR. Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol 1994; 163 (02) 377-380
  • 22 Dubost JJ, Fis I, Denis P. et al. Polyarticular septic arthritis. Medicine (Baltimore) 1993; 72 (05) 296-310
  • 23 Joo EJ, Kim B, Sohn KM, Kym S, Kim J. Administering antibiotics for less than four weeks increases the risk of relapse in culture-positive septic arthritis of native joints. J Clin Med 2023; 12 (21) 6808
  • 24 Kaeley GS, Bakewell C, Deodhar A. The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review. Arthritis Res Ther 2020; 22 (01) 1
  • 25 Hadduck TA, van Holsbeeck MT, Girish G. et al. Value of ultrasound before joint aspiration. AJR Am J Roentgenol 2013; 201 (03) W453-W459
  • 26 Provo J, Teramoto M, Foley J, Roesly H, Gee C, Cushman DM. Comparing fluoroscopic versus ultrasound guidance in glenohumeral joint aspiration. PM R 2023; 15 (06) 697-704
  • 27 Randelli F, Brioschi M, Randelli P, Ambrogi F, Sdao S, Aliprandi A. Fluoroscopy- vs ultrasound-guided aspiration techniques in the management of periprosthetic joint infection: which is the best?. Radiol Med 2018; 123 (01) 28-35
  • 28 Thom C, Ahmed A, Kongkatong M, Moak J. Point-of-care hip ultrasound leads to expedited results in emergency department patients with suspected septic arthritis. J Am Coll Emerg Physicians Open 2020; 1 (04) 512-520
  • 29 Kumar J, Bandhu S, Kumar A, Alam S. Extra-osseous fat fluid level: a specific sign for osteomyelitis. Skeletal Radiol 2007; 36 (Suppl. 01) S101-S104
  • 30 Monsalve J, Kan JH, Schallert EK, Bisset GS, Zhang W, Rosenfeld SB. Septic arthritis in children: frequency of coexisting unsuspected osteomyelitis and implications on imaging work-up and management. AJR Am J Roentgenol 2015; 204 (06) 1289-1295
  • 31 McCarthy JJ, Dormans JP, Kozin SH, Pizzutillo PD. Musculoskeletal infections in children: basic treatment principles and recent advancements. Instr Course Lect 2005; 54: 515-528
  • 32 El-Sobky T, Mahmoud S. Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills. EFORT Open Rev 2021; 6 (07) 584-592
  • 33 Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plast Surg 2009; 23 (02) 80-89
  • 34 Termaat MF, Raijmakers PG, Scholten HJ, Bakker FC, Patka P, Haarman HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am 2005; 87 (11) 2464-2471
  • 35 Cronin CG, Gervais DA, Hahn PF, Arellano R, Guimaraes AR, Mueller PR. Treatment of deep intramuscular and musculoskeletal abscess: experience with 99 CT-guided percutaneous catheter drainage procedures. AJR Am J Roentgenol 2011; 196 (05) 1182-1188
  • 36 Letter HP, Limback J, Wasyliw C, Bancroft L, Scherer K. Synovial cutaneous fistula complicating a reverse total shoulder arthroplasty. Radiol Case Rep 2016; 11 (02) 98-101
  • 37 Chaudhari H, Mahendrakar S, Baskin SE, Reddi AS. Contrast-induced acute kidney injury: evidence in support of its existence and a review of its pathogenesis and management. Int J Nephrol Renovasc Dis 2022; 15: 253-266
  • 38 Chiappini E, Mastrangelo G, Lazzeri S. A case of acute osteomyelitis: an update on diagnosis and treatment. Int J Environ Res Public Health 2016; 13 (06) 539
  • 39 Pugmire BS, Shailam R, Gee MS. Role of MRI in the diagnosis and treatment of osteomyelitis in pediatric patients. World J Radiol 2014; 6 (08) 530-537
  • 40 Hong AS, Levin D, Parker L, Rao VM, Ross-Degnan D, Wharam JF. Trends in diagnostic imaging utilization among Medicare and commercially insured adults from 2003 through 2016. Radiology 2020; 294 (02) 342-350
  • 41 Foti G, Longo C, Sorgato C. et al. Osteomyelitis of the lower limb: diagnostic accuracy of dual-energy CT versus MRI. Diagnostics (Basel) 2023; 13 (04) 703
  • 42 Tehranzadeh J, Wang F, Mesgarzadeh M. Magnetic resonance imaging of osteomyelitis. Crit Rev Diagn Imaging 1992; 33 (06) 495-534
  • 43 Galley J, Sutter R, Stern C, Filli L, Rahm S, Pfirrmann CWA. Diagnosis of periprosthetic hip joint infection using MRI with metal artifact reduction at 1.5 T. Radiology 2020; 296 (01) 98-108
  • 44 Khodarahmi I, Brinkmann IM, Lin DJ. et al. New-generation low-field magnetic resonance imaging of hip arthroplasty implants using slice encoding for metal artifact correction: first in vitro experience at 0.55 T and comparison with 1.5 T. Invest Radiol 2022; 57 (08) 517-526
  • 45 Rosenfeld S, Bernstein DT, Daram S, Dawson J, Zhang W. Predicting the presence of adjacent infections in septic arthritis in children. J Pediatr Orthop 2016; 36 (01) 70-74
  • 46 Refakis CA, Arkader A, Baldwin KD, Spiegel DA, Sankar WN. Predicting periarticular infection in children with septic arthritis of the hip: regionally derived criteria may not apply to all populations. J Pediatr Orthop 2019; 39 (05) 268-274
  • 47 Hopkins KL, Li KC, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skeletal Radiol 1995; 24 (05) 325-330
  • 48 Karchevsky M, Schweitzer ME, Morrison WB, Parellada JA. MRI findings of septic arthritis and associated osteomyelitis in adults. AJR Am J Roentgenol 2004; 182 (01) 119-122
  • 49 Markhardt BK, Woo K, Nguyen JC. Evaluation of suspected musculoskeletal infection in children over 2 years of age using only fluid-sensitive sequences at MRI. Eur Radiol 2019; 29 (10) 5682-5690
  • 50 Nguyen JC, Yi PH, Woo KM, Rosas HG. Detection of pediatric musculoskeletal pathology using the fluid-sensitive sequence. Pediatr Radiol 2019; 49 (01) 114-121
  • 51 Garg V, Singh V, Kalia RB, Regmi A, Yasam R, Sinha SK. Role of magnetic resonance imaging in concomitant periarticular infections in septic arthritis of large joints in children: a systematic review. J West Afr Coll Surg 2024; 14 (01) 83-89
  • 52 Corin N, Bennet S, Hill J, Thomas S. Magnetic resonance imaging in the evaluation of suspected hip sepsis in children. J Child Orthop 2022; 16 (05) 409-415
  • 53 Griswold BG, Sheppard E, Pitts C, Gilbert SR, Khoury JG. The introduction of a preoperative MRI protocol significantly reduces unplanned return to the operating room in the treatment of pediatric osteoarticular infections. J Pediatr Orthop 2020; 40 (02) 97-102
  • 54 Gottschalk HP, Moor MA, Muhamad AR, Wenger DR, Yaszay B. Improving diagnostic efficiency: analysis of pelvic MRI versus emergency hip aspiration for suspected hip sepsis. J Pediatr Orthop 2014; 34 (03) 300-306
  • 55 Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. Phys Sportsmed 2008; 36 (01) nihpa116823
  • 56 El-Maghraby TA, Moustafa HM, Pauwels EK. Nuclear medicine methods for evaluation of skeletal infection among other diagnostic modalities. Q J Nucl Med Mol Imaging 2006; 50 (03) 167-192
  • 57 Palestro CJ, Love C, Tronco GG, Tomas MB, Rini JN. Combined labeled leukocyte and technetium 99m sulfur colloid bone marrow imaging for diagnosing musculoskeletal infection. Radiographics 2006; 26 (03) 859-870
  • 58 Simonsen L, Buhl A, Oersnes T, Duus B. White blood cell scintigraphy for differentiation of infection and aseptic loosening: a retrospective study of 76 painful hip prostheses. Acta Orthop 2007; 78 (05) 640-647
  • 59 Pakos EE, Koumoullis HD, Fotopoulos AD, Ioannidis JP. Osteomyelitis: antigranulocyte scintigraphy with 99mTC radiolabeled monoclonal antibodies for diagnosis–meta-analysis. Radiology 2007; 245 (03) 732-741 Published correction appears in Radiology 2013;268(1):307
  • 60 Kwee RM, Kwee TC. 18F-FDG PET for diagnosing infections in prosthetic joints. PET Clin 2020; 15 (02) 197-205
  • 61 Palestro CJ, Love C, Miller TT. Infection and musculoskeletal conditions: Imaging of musculoskeletal infections. Best Pract Res Clin Rheumatol 2006; 20 (06) 1197-1218
  • 62 Uno K, Matsui N, Nohira K. et al. Indium-111 leukocyte imaging in patients with rheumatoid arthritis. J Nucl Med 1986; 27 (03) 339-344
  • 63 Palestro CJ, Vega A, Kim CK, Swyer AJ, Goldsmith SJ. Appearance of acute gouty arthritis on indium-111-labeled leukocyte scintigraphy. J Nucl Med 1990; 31 (05) 682-684
  • 64 American Academy of Orthopaedic Surgeons Board of Directors. Diagnosis and prevention of periprosthetic joint infections. Evidence-based clinical practice guideline. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/pji/pji-clinical-practice-guideline-final-2-17-21.pdf. Accessed January 7, 2025
  • 65 Johnson SM, Saint John BE, Dine AP. Local anesthetics as antimicrobial agents: a review. Surg Infect (Larchmt) 2008; 9 (02) 205-213
  • 66 Abdel Karim M, Andrawis J, Bengoa F. et al. Hip and knee section, Diagnosis, algorithm. Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34 (2S): S339-S350