Arthroscopy for hip septic arthritis in children

Application of AI-assisted MRI for the identification of surgical target areas in pediatric hip and periarticular infections

OBJECTIVE

To develop an AI-assisted MRI model to identify surgical target areas in pediatric hip and periarticular infections.

METHODS

A retrospective study was conducted on the pediatric patients with hip and periarticular infections who underwent Magnetic Resonance Imaging(MRI)examinations from January 2010 to January 2023 in three hospitals in China. A total of 7970 axial Short Tau Inversion Recovery (STIR) images were selected, and the corresponding regions of osteomyelitis (label 1) and abscess (label 2) were labeled using the Labelme software. The images were randomly divided into training group, validation group, and test group at a ratio of 7:2:1. A Mask R-CNN model was constructed and optimized, and the performance of identifying label 1 and label 2 was evaluated using receiver operating characteristic (ROC) curves. Calculation of the average time it took for the model and specialists to process an image in the test group. Comparison of the accuracy of the model in the interpretation of MRI images with four orthopaedic surgeons, with statistical significance set at P < 0.05.

RESULTS

A total of 275 patients were enrolled, comprising 197 males and 78 females, with an average age of 7.10 ± 3.59 years, ranging from 0.00 to 14.00 years. The area under curve (AUC), accuracy, sensitivity, specificity, precision, and F1 score for the model to identify label 1 were 0.810, 0.976, 0.995, 0.969, 0.922, and 0.957, respectively. The AUC, accuracy, sensitivity, specificity, precision, and F1 score for the model to identify label 2 were 0.890, 0.957, 0.969, 0.915, 0.976, and 0.972, respectively. The model demonstrated a significant speed advantage, taking only 0.2 s to process an image compared to average 10 s required by the specialists. The model identified osteomyelitis with an accuracy of 0.976 and abscess with an accuracy of 0.957, both statistically better than the four orthopaedic surgeons, P < 0.05.

CONCLUSION

The Mask R-CNN model is reliable for identifying surgical target areas in pediatric hip and periarticular infections, offering a more convenient and rapid option. It can assist unexperienced physicians in pre-treatment assessments, reducing the risk of missed and misdiagnosis.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Septic arthritis in the pediatric hip joint: a systematic review of diagnosis, management, and outcomes

Septic arthritis of the pediatric hip joint (SAH) is a rare but serious orthopedic emergency requiring immediate diagnosis and management. Delayed recognition can lead to severe complications, emphasizing the need for timely intervention. This systematic review aims to provide a comprehensive analysis of SAH in the pediatric population, focusing on its diagnosis, management, and outcomes. The review included 11 studies involving 391 patients with SAH, aged between three months and 12 years. Staphylococcus aureus was identified as the most common causative pathogen, with increasing cases of methicillin-resistant strains. Diagnosis is challenging due to nonspecific clinical presentations, necessitating validated criteria and a multidisciplinary approach. Ultrasound emerged as a valuable tool for early detection, and MRI was used in challenging cases. Treatment options include hip aspiration, arthrotomy, and arthroscopy, often combined with appropriate antibiotic therapy. Success rates were comparable among different surgical procedures. Early intervention is vital for optimal outcomes. However, the review highlights the need for standardized protocols and further prospective studies to address limitations and improve understanding and management of SAH in the pediatric hip joint.

Clinical and Radiographic Outcomes and Treatment Algorithm for Septic Arthritis in Children

BACKGROUND

Septic arthritis (SA) in children is an acute inflammatory disease of the joints. If not treated promptly, it could become a surgical emergency. The incidence of the disease in children in Europe is approximately 2-7 per 100,000 children. The aim of this systematic review was to investigate which of these treatments-arthrocentesis, arthrotomy, and arthroscopy-provides better results in children and when to use them.

METHODS

Three independent authors conducted a systematic review of PubMed, ScienceDirect, and MEDLINE databases to assess studies with any level of evidence that reported the surgical outcome of SA. Two senior investigators evaluated and approved each stage's findings.

RESULTS

A total of 488 articles were found. After screening, we chose 24 articles that were suitable for full-text reading based on the inclusion and exclusion criteria. The results of our analysis showed that there are no numerically significant differences reported in the literature on clinical and radiographic outcomes by surgical technique.

CONCLUSIONS

We developed an algorithm that could be used if septic arthritis is suspected. Based on our results, the surgical technique to be used will depend on the operator who will perform it.

Comparison of Various Joint Decompression Techniques in Septic Arthritis of the Hip in Children: A Systematic Review and Meta-Analysis

The aim of this review is to conduct an analysis of existing literature on outcomes of application of various methods of joint decompression in management of septic arthritis of the hip in children. A search of literature in PubMed, Embase, and Google Scholar was conducted for identification of studies reporting on the outcomes of intervention for septic arthritis of the hip in children. Of the 17 articles selected, four were comparative studies; two of these were randomized controlled trials while the rest were single arm studies. Statistical difference was observed between the proportion of excellent clinical and radiological outcomes in arthrotomy (90%, 95% confidence interval [CI] 81-98%; 89%, 95% CI 80-98%), arthroscopy (95%, 95% CI 91-100%; 95%, 95% CI 90-99%), and arthrocentesis (98%, 95% CI 97-100%; 99%, 95% CI 97-100%), respectively. The highest overall rate of additional unplanned procedures was observed in the arthrocentesis group (24/207, 11.6%). Patients who underwent arthrocentesis had a statistically greater chance of excellent clinical and radiological outcomes, although the highest level of need for additional unplanned surgical intervention was observed in the arthrocentesis group, followed by the arthroscopy group and the arthrotomy group. Future conduct of a prospective multicentric study focusing on the developed and developing world, along with acquisition of data. such as delay of treatment and severity of disease will enable assessment of the efficacy of one technique over the other by surgeons worldwide.

Relevant factors in the diagnosis of concomitant osteomyelitis in pediatric hip septic arthritis. A series of 41 cases treated by hip arthroscopy

INTRODUCTION

Septic arthritis of the hip can appear isolated or concomitant with pelvic osteomyelitis. Delay in the diagnosis of a concomitant osteomyelitis increases the number of required surgeries and of possible complications.

PURPOSE

This study aims to establish relevant factors in the diagnosis of concomitant osteomyelitis in cases with septic arthritis of the hip among paediatric patients.

METHODS

The data were collected between 2005 and 2020. 41 pediatric patients with suspicion of septic arthritis of the hip joint, treated arthroscopically, were included. The following diagnostic test parameters were collected: ultrasound, MRI, X-Rays, blood samples, temperature, and incapacity to bear weight. The data were analysed with the sensitive analysis method using descriptive statistic.

RESULTS

41 patients were analyzed, with an average age of 6.04 y (7 months to 14 years), of which ten patients (24.39%) presented concomitant osteomyelitis. 6 out of ten patients needed secondary surgery. Regarding age, concomitant osteomyelitis was most common in the age group 4-14 years old. Average number of days of clinical symptoms before admission was 6.2 days. 36/41 cases showed CRP values higher than 2 mg/dl. 9/10 cases with concomitant osteomyelitis showed a CRP > 2 mg/dl, with an average value of 8.9 mg/dl. 22/41 patients underwent an MRI, of which nine cases presented a concomitant osteomyelitis. The probability of a child to have septic arthritis of the hip with adjacent osteomyelitis was analysed through a score based on four factors: impossibility to bear weight and/or hip pain in children in the non-walking age category, CRP > 2 mg/dl, age older than > 4 y, symptoms longer than 4 days.

CONCLUSIONS

Children at the age of walking, with incapacity to bear weight, presenting symptoms longer than 4 days and a CRP > 2 mg/dl, should receive an MRI before surgery to exclude adjacent osteomyelitis.

LEVEL OF EVIDENCE

IV.

Surgical treatment of septic arthritis of the hip in children: arthrotomy compared with repeated aspiration-lavage

PURPOSE

To review two cohorts of children treated by two different protocols (repeated needle aspiration-lavage vs. arthrotomy) for surgical treatment of septic arthritis of the hip (SAH).

METHODS

In order to compare between the two methods, the following parameters were checked: (a) Scar cosmesis was assessed by the Patient and Observer Scar Assessment Scale (POSAS). We considered satisfactory results (no scar discomfort) when POSAS was within 10% of the ideal score; (b) 24-h post-operative pain was evaluated by visual analog scale (VAS); (c) Complication rates of incomplete drainage (re-arthrotomy/therapy modification from aspiration-lavage to arthrotomy). The results were evaluated by the Student t-test or by the chi-square test.

RESULTS

Seventy-nine children (aged 2-14 years) admitted during 2009-2018 and available for at least two years of follow-up were enrolled. The POSAS score (range 12-120 points) at the latest follow-up was higher in the arthrotomy group compared with the aspiration-lavage group (18.10 ± 6.22 versus 12.27 ± 1.40, p < 0.001); 77.4% of patients treated by arthrotomy had no scar discomfort. The 24-h post-intervention VAS (range 1-10) was 5.06 ± 1.29 after arthrotomy and 4.03 ± 1.13 after aspiration-lavage, p < 0.04. Complications were three times more frequent in the aspiration-lavage group (8.8% in the arthrotomy group and 26.7% in the aspiration-lavage group, p = 0.045).

CONCLUSIONS

We conclude that the lower complication rate observed in the arthrotomy group outweighs by far scar cosmesis and post-operative pain advantages in the aspiration-lavage group. Arthrotomy as a drainage method is safer than aspiration-lavage.

A systematic review of the optimal drainage technique for septic hip arthritis in children

INTRODUCTION

The hip is one of the most commonly affected joints in paediatric septic arthritis. Drainage can be performed using arthrocentesis (articular needle aspiration), arthroscopy or arthrotomy. The objective of this systematic review was to identify the most effective drainage technique for septic hip arthritis in the paediatric population.

MATERIALS AND METHODS

The electronic MEDLINE, EMBASE and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the paediatric hip. Outcome parameters were additional drainage procedures, clinical outcomes and radiological sequelae. The quality of each of the included studies was assessed with the Methodological Index for Non-randomized Studies (MINORS) score.

RESULTS

Out of 2428 articles, 19 studies with a total of 406 hip joints were included in the systematic review. Additional arthroscopy or arthrotomy was performed in 15% of the hips treated with arthrocentesis, in 14% after arthroscopy and in 3% after arthrotomy. Inferior clinical outcomes and more radiological sequelae were seen in patients treated with an arthrotomy. A meta-analysis could not be performed due to the diversity and low quality of the studies (MINORS median 4 [range 2-15]).

CONCLUSIONS

This systematic review gives a comprehensive overview of the available literature on treatment for septic hip arthritis in children. Arthrocentesis and arthroscopic procedures may have a higher risk of additional drainage procedures in comparison with arthrotomy. However, arthrotomy might be associated with inferior outcomes in the longer term. The included studies are diverse and the scientific quality is generally low.

Klebsiella pneumoniae and Enterobacter cloacae Induced Septic Arthritis in a Healthy Adolescent: A Rare Case Report

Septic arthritis (SA) is a joint inflammation that develops secondary to infectious causes. SA in children is associated with a high rate of morbidity and mortality; therefore, it is regarded as an orthopedic emergency. Because SA of the hip joint usually mimics other musculoskeletal diseases, diagnosis remains challenging. Although this lesion usually shows a good outcome, treatment at an inappropriate time, neglect, or inadequate treatment could lead to poor outcomes. We report on the case of a healthy adolescent who complained of episodes of fever and chills, weight loss, pain in his left hip, and limping. After performing necessary workups, two differential diagnoses of tumor and SA were made. The results of Gram stain and culture of the synovial fluid after surgical excision showed Klebsiella pneumoniae and Enterobacter cloacae complex. To the best of our knowledge, this is the first report of SA due to co-infection with K. pneumoniae and E. cloacae in a healthy patient.

Tractionless Hip Arthroscopy for Septic Arthritis in Children

Surgical management of septic arthritis in young children is traditionally performed with open techniques, although arthroscopic approaches are commonly used in the knee and shoulder. Hip arthroscopy is technically demanding in small children and requires modification from traditional hip arthroscopy. The purpose of this study is to describe a safe technique to perform hip arthroscopy without traction in the pediatric hip and, secondarily, to report short-term results of a case series. Pediatric hip arthroscopy can be safely performed without traction on a radiolucent table and allows joint irrigation and debridement including drain placement through the use of 1 or 2 portals. Hip arthroscopy is a safe, valuable, minimally invasive technique in the treatment of children with septic arthritis of the hip.

Medium-term outcomes of total hip arthroplasty in juvenile patients

BACKGROUND

Juvenile hip osteoarthritis is often the end result of congenital conditions or acquired hip ailments occurred during the paediatric age. This study evaluated the middle term results of total hip arthroplasty for end-stage juvenile hip osteoarthritis.

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data on a cohort of 10 consecutive patients (12 hips), aged between 14 and 20 at operation, who underwent cementless total hip arthroplasty for end-stage juvenile secondary hip osteoarthritis in two orthopaedic tertiary referral centres between 2009 and 2018.

RESULTS

Juvenile hip osteoarthritis occurred as a consequence of developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis. All patients showed a significant improvement in Harris Hip Score (p < 0.01) at 3.3 years average follow-up (range 0.7-10.1 years).

CONCLUSION

The management of juvenile hip osteoarthritis following developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis is still challenging. Careful preoperative planning is essential to achieve good outcomes and improve the Harris Hip Score in these young patients. Total hip arthroplasty is a suitable option for end-stage secondary juvenile hip osteoarthritis, when proximal femoral osteotomies and conservative treatments fail to improve patients' symptoms and quality of life.

LEVEL OF EVIDENCE

IV.

Simplified arthroscopic lavage of pediatric septic hip: case series

Septic arthritis of the pediatric hip is a surgical emergency that requires adequate lavage to decompress the hip, reduce degradative cartilage insult, and prevent coxarthrosis. In this report, we describe a simplified arthroscopic technique that may be performed using a single portal based on fluoroscopy and surface landmarks and without regular use of traction. We present results of a series of patients who underwent the simplified arthroscopic method for the management of pediatric septic hip. Data were obtained by a retrospective chart review of 13 consecutive patients (14 hips) with pediatric septic hip treated with arthroscopic lavage from 2010 to 2015. Age at the time of surgery ranged from 3 months to 8 years with three patients less than 1 year old. Ten hips (71%) returned for a routine follow-up with an average follow-up of 22 months. All 14 hips (100%) had complete resolution of symptoms. Two hips (14%) needed revision surgery due to inadequate response after the first lavage. One hip (7%) had transient femoral nerve palsy. Hip arthroscopy is an attractive and effective option for the management of pediatric septic hip. The limited equipment required and the ease of performing our simplified technique may broaden the application to the general orthopedist for the treatment of pediatric septic hip.

Arthroscopy Versus Open Arthrotomy for Treatment of Native Hip Septic Arthritis: An Analysis of 30-Day Complications

PURPOSE

To evaluate differences in short-term complications in patients treated with open arthrotomy or arthroscopy for septic arthritis (SA) of the native hip and identify risk factors associated with return to the operating room (ROR).

METHODS

Patients who underwent hip arthrotomy or arthroscopy for native hip SA between 2007 and 2017 were queried in the Humana database via the PearlDiver research tool. Patients with a previous history of total hip arthroplasty were excluded from this study. Basic demographics and various 30-day perioperative complications, including ROR, were compared between the 2 cohorts. Multivariate analysis was performed for ROR within 30 days following arthroscopy and arthrotomy.

RESULTS

We identified 421 patients with SA of the native hip, of whom 387 (91.9%) and 34 (8.1%) were treated with open arthrotomy and arthroscopy, respectively. There were no significant differences in demographic variables between groups. On univariate analysis, the incidence of total adverse events (arthrotomy: 75.7% vs arthroscopy: 52.9%, P = .0038) was significantly greater in the open arthrotomy cohort. However, there was little difference in ROR between both cohorts (arthrotomy: 45.9% vs arthroscopy: 38.2%, P = .3836). Multivariate analysis identified preoperative septicemia or septic shock (odds ratio [OR] 1.90; 95% confidence interval [CI] 1.25-2.89, P = .0026) as a significant risk factor for ROR within 30 days after surgery. Neither arthrotomy (OR 4.93, 95% CI 0.42-115.2, P = .2174) nor arthroscopy (OR 3.55, 95% CI 0.33-78.01, P = .3077) were significant risk factors to ROR.

CONCLUSIONS

Patients with SA of the hip had similar short-term complication rates and ROR regardless of open arthrotomy or arthroscopic management. This suggests that arthroscopic management may be a safe option for the treatment of SA of the hip with potentially limited morbidity.

LEVEL OF EVIDENCE

Level IV (treatment harms investigation).

Septic Arthritis of the Hip in Children: A Critical Analysis Review

Septic arthritis of the hip is a common and potentially devastating condition in children. Septic arthritis is most commonly caused by Staphylococcus aureus, but other pathogens should be considered on the basis of patient age and presence of risk factors. Diagnosis of septic arthritis is based on history and physical examination, laboratory tests, radiographs, ultrasound, and arthrocentesis. Treatment comprises empiric antibiotics and joint debridement, and antibiotics are subsequently tailored on the basis of culture data, local resistance patterns, and clinical response. Late sequelae of septic arthritis include osteonecrosis, chondrolysis, growth disturbance, subluxation or dislocation, and progressive ankylosis. Surgical treatments to address these issues have been described.

Arthroscopic Treatment of Acute Septic Arthritis of the Hip Joint in Pediatric Patients Aged 10 Years or Younger

PURPOSE

To present the results of arthroscopic treatment of acute septic arthritis of the hip joint in children aged 10 years or younger.

METHODS

Patients with a minimum follow-up period of 2 years who underwent arthroscopic treatment (anterolateral and medial subadductor 2-portal approach) of acute septic arthritis of the hip joint between January 2014 and January 2017 were included in this retrospective case-series study. The exclusion criteria included fungal infection, late presentation (≥5 days after the onset of the symptoms), presence of concomitant osteomyelitis, osseous pathologic conditions on radiography suggesting osteomyelitis, immunocompromised condition, history of surgery or infection surgery from the affected extremity, immobility owing to neuromuscular pathologic conditions, and identification of inflammatory or reactive arthritis during follow-up. The diagnosis of septic arthritis was confirmed according to the Waldvogel criteria. Clinical outcomes were assessed according to the Bennett score and Harris Hip Score.

RESULTS

We evaluated 15 hips in 15 patients (6 female and 9 male patients) with a mean age of 5.2 years (range, 2-10 years) in this study. The mean hospital stay was 4.2 days (range, 3-7 days), and the mean antibiotic-use period was 34 days (range, 26-45 days). The most causative pathogen was Staphylococcus aureus (40%) (including methicillin-sensitive S aureus) and was isolated and cultured in all patients. All patients had full range of motion of the hip joint. All of the Bennett scores were excellent; the mean Harris Hip Score was 96.3 (range, 92.5-100) after a minimum follow-up period of 24 months (mean, 26.1 ± 3.2 months; range, 24-35 months). No patient needed additional surgical intervention. No degenerative changes or avascular necrosis developed.

CONCLUSIONS

According to our results, arthroscopic treatment is an effective choice for the treatment of acute septic arthritis of the hip joint in children aged 10 years or younger.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Indications for hip arthroscopy in pediatric patients a systematic review

The purpose of this study was to evaluate the current available literature on hip arthroscopy and determine the clinical indications in the pediatric patient population (age ≤ 18). In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), a comprehensive literature search was performed on the 23 October 2018 using PubMed, Cochrane Library, Embase and e-books to identify research surrounding the use of hip arthroscopy in the pediatrics. Exclusion criteria were studies that described joints other than the hip, animal studies, systematic reviews, open procedures and those that reported solely on patients aged 19-year-old and older. From 232 studies, 57 were reviewed in detail; 17 articles were removed as their indication fell into a category of ‘diagnostic hip arthroscopy for pain’ or no clear separation between the data on the adult and pediatric population could be made in a full text review of the paper. Eleven categories were identified as indications for hip arthroscopy in the pediatric population. At best a Grade C recommendation can be made to support the use of hip arthroscopy in the pediatric population. Our results support our hypothesis. Despite the exponential increase in hip arthroscopy over the last decade, limited evidence exists in support of its use in the pediatric (≤18) population. Our findings support the need for further research in delineating the indications for its use, as clearly arthroscopy may be advantageous in many situations, particularly in light of the alternatives.

Pediatric Septic Arthritis: An Update

Septic arthritis in children is a surgical emergency, and prompt diagnosis and treatment are mandatory. If diagnosed quickly and treated correctly, the outcomes can be good. With delay in diagnosis and without proper treatment, outcomes often are quite devastating, with growth disturbance and joint destruction.

A nationwide analysis of failed irrigation and debridement for pediatric septic arthritis of the hip

Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids' Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.

Septic Arthritis of the Hip-Risk Factors Associated With Secondary Surgery

INTRODUCTION

Septic arthritis of the hip (SAH) is a common condition encountered by pediatric orthopaedic surgeons and is treated with arthrotomy and irrigation. Depending on the response to initial treatment, some patients require surgical treatment beyond the index procedure. The purpose of this study was to investigate risk factors for repeat surgical intervention after initial arthrotomy for presumed SAH.

METHODS

A multicenter retrospective review of all children who underwent surgical arthrotomy for presumed SAH over a ten-year period was conducted. Variables queried included demographics, clinical presentation, laboratory parameters, imaging, infecting organism, presence of osteomyelitis, and surgical interventions performed. Logistic regression was used to predict the risk of a second procedure. Chi-square was used to compare patients who required further surgery and those who did not.

RESULTS

One hundred and thirty-eight patients (139 hips) qualified for inclusion. The average age at initial surgery was 6.1 years (range, zero to 17 years), and 57% of the patients were male. Concomitant osteomyelitis was diagnosed in 55 cases (40%). An infecting organism was identified from 70 (50%) index intraoperative cultures, with Staphylococcus aureus infections (methicillin-resistant Staphylococcus aureus [MRSA], 27; methicillin-sensitive Staphylococcus aureus, 25) being the most frequent. Fifty-six patients (41%) underwent subsequent surgical intervention, at an average of 5.5 days (range, 2 to 95) from the index procedure. Independent risk factors for repeat surgical procedures included presenting C-reactive protein >10 mg/dL (P = 0.002) and presenting erythrocyte sedimentation rate >40 (P = 0.011). The odds of repeat surgical intervention were significantly increased by the presence of concomitant osteomyelitis (odds ratio, 3.4; P = 0.001) and positive index intraoperative cultures for MRSA (odds ratio, 1.19; P = 0.001). Preoperative MRI before the index procedure was not universal (73/138; 53%), and acquisition of preoperative MRI was not associated with secondary surgical intervention (P = 0.389).

DISCUSSION

Forty-one percent of children in this multicenter cohort underwent at least one repeat surgical procedure after the index arthrotomy for management of presumed SAH. Risk factors for return to the operating room include elevated initial erythrocyte sedimentation rate and C-reactive protein, infection with MRSA, and presence of osteomyelitis.

LEVEL OF EVIDENCE

Level 3, case-cohort series. Type of evidence, therapeutic.

Septic arthritis of the pediatric hip: update on diagnosis and treatment

PURPOSE OF REVIEW

To review the clinical diagnosis, management and natural history of septic arthritis of the hip (SAH) in the pediatric patient, and to highlight new information that may improve the management of these patients.

RECENT FINDINGS

The basics of management of possible pediatric SAH have remained largely unchanged for generations. New questions have been raised regarding the role and timing of advanced imaging (MRI) in the evaluation of patients with possible SAH. Published criteria have been derived to guide the need for MRI studies in these patients. Validation of these guidelines continues. Recent reviews have highlighted the possibility of Lyme disease as a potential cause of monoarticular pediatric hip pain. The role of PCR technology in the diagnosis and management of SAH remains unclear at this time.

SUMMARY

The child with a limp remains a common and urgent clinical concern. There may be expanded roles for MRI and PCR to better diagnose and treat the involved joint itself, as well as any associated nonarticular area of infection. Lyme disease should remain on the list of possible differential diagnoses in this population, particularly in geographic areas where the disease vector is known to be endemic.

What's New in Pediatric Hip?

BACKGROUND

Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip.

METHODS

We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

RESULTS

A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information.

CONCLUSIONS

DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions.

LEVEL OF EVIDENCE

Level V.

[Infections of non-prosthetically treated joints]

BACKGROUND

Septic arthritis is a common orthopedic emergency. Immediate establishment of the diagnosis and administration of an adequate therapy is paramount in minimizing morbidity and mortality in this severe condition.

OBJECTIVE

The aim of the present review was to evaluate the existing evidence in order to give an overview on current best practice in diagnostics and treatment of septic arthritis in adults and children.

RESULTS

Joint infections result from either hematogenous spread or direct inoculation of bacteria into the joint, mostly iatrogenically. Predisposing risk factors include recent orthopedic joint surgery, i. v. drug abuse, pre-existing inflammatory and degenerative joint diseases and old age. Although pathogens differ in different populations and age groups Staphylococcus aureus is the single most frequently isolated causative organism, followed by streptococci. Although diagnosis is based on an integration of medical patient history, clinical and laboratory findings and imaging studies, joint fluid analysis remains the mainstay in establishing a valid diagnosis. The range of differential diagnostics is broad and includes non-infectious inflammatory joint diseases, such as gout or reactive arthritis. Once a diagnosis has been established treatment should be started immediately. Treatment is based on adequate antibiotic therapy and joint drainage until dryness. There is a paucity of studies on the optimal antibiotic regimen, route of application and duration of therapy. Moreover, no high-quality studies exist on the optimal mode of joint drainage. While superiority has yet to be shown, operative treatment in terms of arthroscopic lavage must be considered the standard of care in Germany. Finally, despite promising results in children, the role of corticosteroids as an adjunct to antibiotic treatment in adults has yet to be clarified.

Pediatric Septic Arthritis

Acute septic arthritis is a condition with the potential for joint destruction, physeal damage, and osteonecrosis, which warrants urgent identification and treatment. The organism most frequently responsible is Staphylococcus aureus; however, our understanding of pathogens continues to evolve as detection methods continue to improve. MRI has improved our ability to detect concurrent infections and is a useful clinical tool where available. The treatment course involves intravenous antibiotics followed by transition to oral antibiotics when clinically appropriate. The recommended surgical treatment of septic arthritis is open arthrotomy with decompression of the joint, irrigation, and debridement and treatment of concurrent infections.