So, ladies and gentlemen, dear colleagues, my name is Marianne Kosina, and I'm a practitioner working with cattle in Germany. Our topic for this session is septic arthritis, with a focus on conservative interventional therapy. Each practitioner knows pictures like this severe lame animals with Swollen joints?
Joint diseases range on the 2nd place as a cause of flameness in cattle with approximately 14%. 1 of these diseases is septic arthritis. According definition, septic arthritis is an inflammation of the joint caused by microorganisms, usually bacteria.
There are 4 stadiums or forms of septic arthritis based on exudate, namely zeros, fibrinose, purulent, arose, and of course, intermediate form of these, for example, serofibrinose or fibrino purulent. If there is affected only one joint, we speak about arthritis. By affection, two and more joints, we speak about polyarthritis.
There are 3 different ways how the microorganisms, it means bacteria can reach the joint. Primary as a direct inoculation in the case of perforating trauma or iatrogenic performed non-steroid function. Secondary, because of infection next to the joint, for example, phlegmment bursitis, abscess epiphysitis.
And tertiary via hematogenous seeding from other organ systems, for example, navel, intestine, lung, other, uterus, claw, and other organs. In a clinical presentation of septic arthritis dominates lameness. Lameness is severe to non-weight bearing, in most cases acute, occurring within a few days.
The joint itself is distended. Joint pouches are well palpable and visible, and we can see characteristic posture of affected limb. Periphery of the joint is swollen, painful, worm.
In some cases, we can see injuries in this area. In the case of longstanding arthritis, muscle atrophy, the puberty, or deformities of contralateral limb because of overloading are present. Not seldom show affected animals alteration of general condition.
They can have fever, decreased appetite, or decreased production. Treatment strategy includes 3 important parts. Decreasing bacterial load, controlling of the inflammatory process, and pain management.
To decrease bacterial load, antibiotics are necessary. To identify bacterium from the joint fluid and to test its sensitivity is helpful. For this reason, punction of the joint should be performed.
Arthrocentesis must be performed on fixated limb after surgical preparation wearing gloves. Needles with a white lumen and different lengths are recommended. Microscopical examination follows immediately after collection of the synoviacay.
Assessment of amount, colour, turbidity, viscosity, additives, and odour give us the first information about stadium of arthritis. Later on, biochemical assessment of total protein and cytological examination of cell count and percentage of neutrophils could be helpful. The key role in the laboratory diagnostic is bacteriological examination with identification of bacteria and sensitivity tests to antimicrobial drugs.
This examination or these tests are very expensive, but they are very helpful in the case where the septic arthritis is a cause of heart health problem or for valuable animals. Unfortunately, success rate of cultivation of bacteria from bovine synovial probe is very low and ranged according to literature. Between 34 and 64%.
To increase the probability of identification of bacteria in the synovia, it's recommended to use suitable transport medium. Please contact your laboratory, which one is the best. To deliver the probe for analysis as soon as possible, to by delay shipping refrigerator sample, it's recommended to use several agars and to take large volume of the sample for the later centrifugation and identification of bacteria in the sediment.
To perform all the laboratory. Tests? Take time and delaying of the treatment could be harmful for the patient.
On the other side, collection of the synovia for analysis is not routinely performed for each case under field condition, which means decision about treatment and the choice of antibiotics may be guided by literature. My chart show us identificated bacteria from 75 synovial samples of cattle suffering on septic monothritis. This is the result of a very large study from Professor Nus in year 2000.
As we can see, most of isolated bacteria are Gram-posit on the first place through a perella piogganes with a 40%. Following by Streptococcus and Staphylococcus species altogether approximately 30%. Gram-negative bacteria are isolated rare.
For example, E. Coli in 6.3%.
The similar results are presented in another studies. Here, through a perella yogenous, the most common isolated bacterium from the synovia of septic arthritis. The isolation rates are a bit higher in adult cattle than in cars.
In cows. Additionally, E. Coli plays a very important role, role by arthritis.
And during the last years, mycoplasma species is frequently isolated from synovial probe. First of all, in the young animals, in animals suffering on polyarthritis. And on the farms where septic arthritis is occurring concurrently to pneumonia or mastitis.
For our treatment, it's very important to know the sensitivity of isolated bacteria to antimicrobial drugs. This is the result of a huge study from Professor Nos 2000. We can see the highest efficacy had fluorenicol, amoxicillin, chlonic acid combination, and androfloxacin.
All of them over 90%. Very good efficacy had as well cephalosporins, ampicillin, or just simple penicillin G. The efficacy of penicillin G can be increased in combination with streptomycin or gentamicin respectively.
For the treatment of septic arthritis are less suitable sulfonamides, tetracyclines, or streptomycin. About the duration of treatment of septic arthritis with systemic antibiotics are different instructions in literature. In generally, prolonged therapy is recommended during 2 weeks, even longer.
Unfortunately, simple conservative treatment, which means only systemic antibiotics, has a very low efficacy as we can see, only 30%. Although many antibiotics are able to reach healthy joint in sufficient concentration, control of the intra-articular infection seems to be problematic. We can see On the very high positive bacterial culture from antibiotic pretreated animals, which means more or less 60% of positive bacterial culture are coming from antibiotic pretreated animals.
That's the result of the study from NOS 2000. The explanation of this phenomenon is compromised capsular profusion of affected joint because increased intra-articular pressure or edoema of synovial membrane. Of course, presence of fibrine, especially in bovine joints, is the problem because fibrine overlies synovial membrane and cartilage, and the bacteria are hidden inside of fibrine deposits, building so-called inoculum effect.
All of these decrease possibility to antibiotics kill the bacteria. And 3rd Acidic pH of the septic joint could be problematic as well. Intravenous regional antibiotics may be one option how to overcome this phenomenon.
By installation of very small amount of antibiotics, you can reach very high and effective concentration in the target tissue. This technique is suitable for the joints they start from carpus and tarsus, and is easy to combinate with anaesthesia. After surgical preparation and application of elastic tourniquet.
You make the function of the vein and finally You inject water-soluble antibiotics. To achieve complete diffusion of the antibiotics and reach the effective concentration for the 24 to 36 hours tourniquet should be released first after 30 minutes. Many antibiotics were tested for this indication, but in the field, there are two most commonly used antibiotics for this indication.
First, penicillin gnattrium in a dose 5 million international units per application. And 2nd 1. Amoxicillin in a dose 1 gramme per application.
The second very important part of the treatment is controlling the inflammatory process. The intra-articular inflammation process starts with the entrance of bacteria into the joints. The proteassis of microorganisms and their toxins takes directly damage action on the cartilage and synovial membrane.
The body on defence is following, which increased temperature, with increased intra-articular pressure, which leads to ischemia, lactate production, and decrease of pH. This contribute to destroying of the cartilage and intraarticular structures. Immune cells, by killing of the bacteria are releasing enzymes, and these accumulate inside of the joints.
Together with cell remnants, with immune complexes, and inflammatory mediators. The last ones. Stimulate chondrocytes and synoviocytes to release matrix meltaloproteinase.
This enzyme decrease synthesis of proteoglycan. The consequence of this is that the cartilage became fragile and the infection can attack the bone. So that means if the killing of the bacteria was successful because of our treatment or immune system.
The accumulate substances inside of the joints are holding up the inflammatory process, which means the evacuation of the joint content is necessary. Similarly to human medicine, stadium-based sequence therapy is recommended. This complex therapeutic approach includes systemic and local treatment.
Sequence therapy means there are a few different options how you can evacuate the content of the joint, starting with a very easy conservative intervention such as aspiration or joint leverage. The money and time-consuming surgical treatment such as arthroscopy, arthrotomy, arthrodesis. Stadium-based means you have to choose the less invasive method promising healing of the patient based on your clinical examination, which means stadium of the arthritis.
By the failure of initial therapy. The next, more invasive sequence should be performed. Now, we want to discuss conservative interventional therapy, which means joint leverage.
This technique is easy to perform under field conditions. There are two different ways how you can do do leavage of the joint. The first one called distension irrigation leverage or tidal lage, is less invasive because only one needle is needed.
This technique is suitable for smaller joints such such a shoulder or elbow, and for the joints difficult to reach, for example, hip joint. The principle of this leverage is to distend the joint and to aspirate its content or let it flow through the same needle out. This distension irrigation cycles, creating turbulences and the evacuation of content is very effective.
This is the advantage of this technique. The disadvantage of this technique is that possibly separated compartments are not reachable to one needle, so it means they stay untreated. The second option is in-out luggage.
It's called as well Tru and true luggage. This is more invasive because at least 2. Usually more needles are needed.
The technique is suitable for the large complex joints with multiple communications such as tarsus, carpus, or fatlo joint. The technique as ensure effective evacuation of separated joint compartments because in each compartment is installated one needle. The disadvantage of this technique should be building of so-called luggage pathways, which means that the evacuation of the content could be incomplete.
Luggage is very painful technique because you make puncture of inflamed joint and you make its distension repeatedly. So, appropriate anaesthesia should be performed. The first option is local intraarticular anaesthesia with a lidocaine.
Another option for, first of all, for the distal joints downwards and including carpus in Tarsus is intravenous regional anaesthesia or nerve block. For the joints, on the hind limb, large epidural anaesthesia is a very good option. If you perform this in combination thylacine and saline solution, you block only sensitive nerves, which means you can treat the animals in the standing position.
If you use local anaesthetics for large epidural anaesthesia, the patient becomes recumbent, and you have to treat them lying on the ground. This could be an advantage if you do therapy on the free yard, for example, on the pasture. And of course, alternatively, each joint could be treated under general anaesthesia as well.
The lavage starts with arthrosynthesis. On the right side, you see the picture of the fatlo John prepared for the true and true luggage. Needles are inserted in each joint pouch.
Now step by step. The oral pouch of the fatlock joint on the Function site is approximately 3 fingers proximal to the joint space. On the dorsal aspect medially and laterally.
The direction of the needle insertion is disomeddially approximately in an angle of 45 degrees. The plantar pouch of the joint. Puncture site is approximately 4 finger approximately to two close.
Immediately. Plantary from metatarsal bone. And the insertion direction for the needle is horizontally.
The solution they could be used for the leverage in the literature. There is still discussion which one is the best, is the saline solution alone or Ringer lactate should be given inside antibiotics or iodine solution. I use for the years very mild povidone iodine solution 0.1 to 0.2%, which means I put 5 to 10 millilitres of commercial wet that solution into 500 millilitres of saline solution.
10 mL into this bottle and the solution is ready to use. The question is how much volume you need. It depends on the joint you treated and of course on the stadium of the arthritis.
And generally the leverage should be performed till the fluid coming out of the joint is clear and without fibrin. After luggage is collected, antibiotic installation follows. Two options are very common in the field.
It is the first one is gentamicin, penicillin G combination, and the second one is amoxicillin alone. It follows antiseptic covering of the plankton site for at least 24 hours. If you can, you can apply a bandage over it.
In most cases, love it should be repeated. You can do it daily. I prefer to do it under failed condition every 2nd day.
Improvement of the lameness is to expect after 2 to 3 days after the start of the treatment. If there is no improvement of the lameness within 7, at least 10 days, next sequence of the local treatment should follow. Now I would like to show you a few movies, how you can do love it.
Our patient is the cow after digit amputation and 10 tenuvainotomy and tendinectomy. On the left picture, you can see. Needle inserted in the plantar pouch of the fatlock joint and on the right picture, you can see needle inserted in the dorsal pouch of the fatlock joint.
Now coming to videos, first one. The lu with . Mild ordone iodine solution.
Performed as a true and true la. Second video, another point of view, you can see that the Lava solution coming out is clear and without fibrine, so. The love which is more or less finished in the 3rd video from Planar Aspect.
The last application of Iodine solution and now application of antibiotics. Till from the another needle is coming clear antibiotics out, then you can remove all other needles and applicate through the last one, antibiotics inside. Of the joint.
Very important part of the treatment is, of course, pain management. The septic arthritis is a very painful disease, so systemic non-steroidal anti-inflammatory drugs are necessary for a couple of days. Please be careful by prolonged therapy because of higher risk of abdominal ulceration.
The animals should be kept, if possible, alone in soft padded boxes, and please, if it's possible, keep the distances to walk to the water, to the food, to the milking pailor as short as possible. By the evaluation of the prognosis not only for animal, but it's important as well for the owner. You have to consider some factors.
First of all, stadium of arthritis, which means content of the joint. Then duration of the process, bone alterations, periarticular changes, and of course, numbers of affected joints. We are speaking now all the time about conservative interventional therapy, which means laage therapy.
So this therapy has a very good prognosis by acute serro arthritis with no bone alterations and with at least moderate periodiatic larve changes. Of course, you can treat polyarthritis with a lava as well, but The effort is huge and It is very expensive treatment, so you have to clear it in before you start with the owner. On the other side Arose arthritis has in general very poor prognosis.
It's more or less in fast. The arthritis with presents of bone alteration and with huge period-articular changes or in the cases of perforating trauma. These patients should be treated surgically.
Now, let us have a look, on the healing rates, according to literature, Mr. Jackson treated calves, after failure of conservative therapy, which means systemic antibiotic, only. It could successfully treat 16 of 20 cows, which is healing rate 80% using 2 and more leverages.
No 2003. A study of septic arthritis of shoulder and hip joints. He could successfully treat 10 of 17 animals, which is healing rate approximately 60%, and he needed for this on average 4 levers.
The next very huge study we mentioned this study already a few times, not 2000. The lava was performed by 78 patients suffering arthritis. 50 of them were treated successfully, which means healing rates 64%.
Altogether. If we divide these patients, depending on the stadium of arthritis in two groups, we can see the patients with the zeros and sero fibrinose arthritis had a healing rates more or less 90%, which is excellent. If we take the group of animals with the fibrinos and purulent stadium of arthritis, healing rate is only approximately 45%.
So the difference in healing rates is really huge, depending on the stadium of arthritis. The last study showed healing rates of purulent monarthritis, very nice healing rate with 80%, which means 70 animals of 21, but you can see the effort is huge, more or less on average, 9 luggages are needed to heal the animals. We showed that the content or we showed that the content of the joint, which means stadium of arthritis, has a huge influence of the prognosis and success of the treatment.
As we saw, information about stadium of arthritis, we get immediately after puncture, but the extent of the fibrinose deposits inside of the joint is possible to evaluate only by ultrasonographic examination. Here is the example for this examination of the dorsal pouch of the fat lock joint. You can see on this picture, the probe, .
In the position on the dorsal aspect of the fatlock joint. So distal is on the left side and proximal on the right side, the same on these pictures showing us the ultrasound image. The surface of the bone is hyperechoic, and in this case, on this picture, we can see joint pouch fulfilled with anechoic fluid.
This is a zeros stadium of septic arthritis. On the second picture, the pouch of the joint is fulfilled with heterogeneous content. Some part is echoic fluid and some part is meechoic.
Compact masses of the fibrin. This is a stadium of zero fibrinose arthritis. On the third picture, you can see more or less the complete joint pouch fulfilled with the compact fibrine deposits.
This is a fibrino stadium of arthritis. The next factor of taking influence on the prognosis is duration of the arthritis. He studied the septic arthritis of shoulder and hip joint.
We dividing, we are dividing the patients into two groups, depending on the duration of the arthritis. You can see the group where the duration of the arthritis was under 10 days, which means more or less the treatment, with lava starts during the first week of the disease had. Healing rate about 75%, which is very high.
In the group of the patients with the duration of arthritis over 14 days, which means the start of the therapy was during the 3rd week of the disease. The healing rate was very poor, only 20%, 1 animal of 5. The bo alterations, is the Next factor, having, having influence on the prognosis, the bony alterations we can see on radiogramgrams by loss of at least 40% of mineralized bone matrix.
And if we have a look in the literature, there are information that These alterations are visible on the radiograms after at least 10 to 14 days, which means they appear or develops more or less during 3rd, 4th weeks of septic arthritis. On the end of the first part of our session, I would like to give you some take-home messages. First one is arthritis patients is emergency case.
By arthritis patients who have to initiate the therapy immediately after a clinical diagnosis. Arthrosynthesis is an important diagnostic tool and can be safe, performed after under field condition with very low risk of complication. Treatment is in all cases, or should it be as a combination of systemic and local therapy.
By the evaluation of exact prognosis, you need to perform detailed diagnostics and acute stadiums of arthritis has a higher healing rate. Now we are coming to the 2nd part. I would like to present to you one case report.
Our patient is 10 days old, calf, Horten Frisian, according to the information of the farmer, acute limb on the right for the limb. During clinical examination, the temperature was slightly increased, the same, the heart rate, but normal respiratory rate and general condition of the calf was undisturbed. There were pathological findings, except of locomottator apparatus only on the external navel.
There were no amnion sheet, as you can see here. The external navel was a finger thick, phlegm nose, a little bit painful, and on the top of it was a visible fistula with a yellow brownish smelly exudate. Internal naval structures there without any special finding.
By clinical examination of locomotion apparatus by standing up and the calf didn't use right for lamb, which means complete non-weight bearing. Stan, the animal was standing with the arching back, and the limbs, were positioned under the body. By locomotion or in locomotion was noticeable aversion to the locomotion.
The step was shortened and only toe tips were touching the ground. The lameness degree 4 or 5. The shoulder area appears prominent.
There were no visible injuries in this area, and the joint itself was distended, fluctuated, painful, and there was moderate, very articular fragment present. By deflection and extension probe, These probes reveal no crepitation and no abnormal movement after reflection test, lameness becomes worse, complete non-weight bearing locomotion, which means lame degree 5 or 5. Radiographic examination was performed under sedation.
First, On the affected right side in the right lateral recumbency. The right limb was pulled to the cranially and up healthy limb was pulled to the caudally. X-rays direction medialaterally, which means 90 degrees as a control.
The radiogram of the healthy left side was performed in the left lateral recumbency similarly to previous described. Here we can see radiograms of both shoulders on the right side, affected right shoulder on the left side, healthy left shoulder we can see on the affected right side moderate. Shadowing because of swelling in this area and first of all, Huge distension of the shoulder joint compared to the normal joint space on the left hand side.
There are on the right side, affected side, no bony affections on the scapula and humerus as well. Ultrasound examination follows and it was performed using portable small machine normally used for reproductive apparatus using linear probe. The position of the probe is on dorsolateral aspect of the shoulder joint, .
In the distal part of the picture is humerus, and the proximal part is scapula. We can see it here, two pictures from the same joint and dorsolateral pouch of the joint. Here is the surface of Humeus and here is the surface of scapula.
You can see the joint pouch fulfilled on this picture with anechoic fluid on next picture. In this area is Joint fulfilled with eogenic fibrine deposits. Arthrocentesis was performed under sterile condition and under.
Ultrasonographical control, coupling medium used was alcohol. We used a needle with a large volumen and 4 centimetre length. The site of ultrasynthesis for collection of synoia was chosen between pars cranialis and caudalis of tuberculomius humerary with the Direction of the needle insertion to the caudal towards opposite coastal arc.
This punction site, as I mentioned, was for a collection of the synovia. Later on, second punction was performed for . Performing through and through leverage, the second punction site is cranially to the tendon of musculos infraspinatus, approximately 1 centimetre approximately to tuberculoyoumary direction of the needle insertion is mediaventrally in angle of 40 degrees.
Here, examination of synovial fluid. You can see in the picture. On the right side and here on the table, on the left side, normal findings in the middle, the typical findings in the case of purulent arthritis and on the right side.
We can see the findings, in our case. So normally you have only less amount of synovia, you, to be able to get it, you have to do aspiration, under normal condition. It's colour free to ember coloured, and there are no additives.
It's clear and ropey. In the cases of purulent arthritis, amount is increased. It's a milky yellow to orange coloured.
There are fibrine flus, blood or pus flus. It's secured and the viscosity is decreased. It could be watery.
It could be creamy. In the case of our patient, we could get 0.5 mL of reddish bloody synovial fluid.
It was turbid watery. An examination of total protein revealed 52 grammes per litre. Normally it's under 20 grammes per litre by purulent arthritis over 10,000.
Cell content, in our case, 2000 cells per microliter, normally under 500 in the case of purulent arthritis, 10,000. The percentage of neutrophiles, was not possible to assess because a lot of cells were disintegrated, in our probe, which means this is a possible explanation of relatively low cell content, in generally in our probe. Bacterial culture was positive.
Viberstania rehalozi was bacterium isolated from our probe. It belongs to, pastoralla species and, by sensitivity tests, we were lucky because all of the antibiotics are effective to treat it. So as a local therapy, I already mentioned through and through, luggage was performed with 0.2% or on iodine solution.
You can see the patient in the lateral recumbency under sedation and here in the detail through and through lava of the shoulder joint. After lavi, gentamicin, 400 milligrammes, was insulated into the joint and, the punction site was, covered with the antiseptic, iodine salve. You can see it on this picture.
Systemic treatment, antibiotics, amoxicillin during 16 days and daily, and fluexine meglomine during 3 consecutive days. The first control was performed after 2 days. The calf was in a very good general condition, has no fever, but we can see stand, still with the arching back.
It was noticeable aversion to the locomotion and in locomotion, lameness degrees still severe, 3 to 4 or 5. So no really improvement compared to findings before the first luggage. So second luggage was performed similarly to the first luage two days ago, with that solution and gentamicin installation, we can see it.
Here in detail on the picture. And the next control was performed after 5 days. The calf was free moving on the yard and the lameness increased very clearly.
The lame. Is the degree 2 to 3 or 5. The third leage was performed similarly to two previous but set solution and gentamicin installation.
The next control after 2 weeks or 2 weeks after starting therapy. There was only slightly lameness, in our patient, 2 or 5, after standing up and improved after a few steps, to lameness degree 1 or 5. And after 3 weeks, the patient was completely lamere.
This is the last information, in this session, I would like to thank you for your attention. And I hope you can enjoy it, you can learn something new. I'm happy to be able to share my experience with you, and please take care of you and God bless you.