Sequelae of septic arthritis of the hip in children: a new classification and a review of 41 hips

Reliability of Radiologic Classifications of Sequelae of Septic Arthritis of the Hip in Children

OBJECTIVE

To the best of our knowledge, there is no study comparing the inter and intraobserver reliability of current classifications for postseptic hip sequelae in children. The current study aims to assess the interobserver and intraobserver reliability of four current classifications and identify hips that could not be classified in each classification system.

METHODS

The hip radiographs of 148 consecutive children with sequelae of sepsis of the hip from 2 centers were assessed after a minimum of 2 years of follow-up after sepsis. All hips (affected and normal sides) were classified according to the 4 original descriptions of the authors of the respective classifications. If a hip did not fall into any subtype of the classification, the rater was asked to mark it as nonclassifiable and state the reason for being unable to classify the hip in the respective classification. The intraclass correlation coefficient was computed to assess the reproducibility of each classification.

RESULTS

Interrater reliability and intrarater reliability were moderate (0.57 to 0.72) while including all hips. The reliability was poor (0.35 to 0.49) in all 4 classifications, with an evaluation of only affected 180 hips. A few sequelae of infection, including caput valgus (n = 7), acetabular dysplasia (4), joint space narrowing (2), and bony ankylosis (1), were not included in any of the 4 current existing classification systems.

CONCLUSION

The reliability of all current classifications of sequelae of septic arthritis of the hip is moderate. A proportion of sequelae do not find a place in all current classifications.

LEVEL OF EVIDENCE

Level III.

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.

Late-Presenting Septic Arthritis of the Hip in Children: Variations in Presentation and a Review of 25 Hips After Surgical Debridement

INTRODUCTION

The septic arthritis of the hip (SAH) is one of the most common musculoskeletal infections occurring in pediatric populations requiring urgent intervention. This study discusses the myriad of clinical and radiological presentations of late-presenting SAH in children and the outcomes of surgical management.

METHODS

After ethical approval, we did retrospective reviews of children treated for late-presenting SAH (after five days of symptoms). We excluded late cases with established sequelae. We recorded age, duration of symptoms, clinical evaluation, and radiographs. We evaluated the final results clinically and radiologically.

RESULTS

Twenty-four patients with 25 hips were eligible for evaluation. At presentation, all had decreased or painful hip movements, but none had a fever. Radiographs revealed the following changes: hip dislocation (four), capital femoral slip (seven), proximal femur/neck osteomyelitis (six), pathological fractured neck femur (two), iliac osteomyelitis (two), and early arthritic changes (two). Hip arthrotomy was done in all cases. Frank pus was found in 21 (84%) cases. Cases with capital slip and fractured neck femur required fixation with two smooth K-wires. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in three patients and tuberculosis in two cases. Clinical outcomes showed 14 patients with poor outcomes, eight with fair, and two with good. Avascular necrosis (AVN) of the femoral head was noted in 14 hips and complete femoral head resorption in nine.

CONCLUSIONS

The late-presenting SAH in children has a myriad of presentations including dislocation and capital slip with unsatisfactory outcome. However, ongoing local infective processes may necessitate debridement. With limited salvage options available at the sequelae stage, awareness and training for early diagnosis and treatment may be the best way to improve the scenario. We recommend future multicenter randomized studies of predictive factors and indications of arthrotomy in late presenters.

Surgical (over) treatment of pediatric Lyme arthritis: a need for faster Borrelia testing

Pediatric Lyme arthritis is described but not well-characterized in urban populations. Similarities in clinical features between Lyme and septic arthritis also results in some patients with Lyme arthritis undergoing surgical treatment. The aims of this study are to (1) characterize Lyme arthritis in an urban population and (2) determine what factors predispose patients with Lyme arthritis to undergoing surgery. We performed a retrospective review of children with Lyme arthritis at a single academic institution in New York City from 2016 to 2021. Inclusion criteria were age ≤18 years, involvement of a major joint, and positive Lyme serology. Patients treated with irrigation and debridement were compared to those treated non-surgically using Chi-squared tests with a significance of P  < 0.05. A total of 106 children with Lyme arthritis were included. Mean age was 9.5 years; 61.3% were male, and 71.7% were Caucasian. 46.2% lived in regions with an average household income >$100 000; 70.8% had private insurance. Ten patients (9.4%) underwent surgery for suspected septic arthritis. The operative group was more likely to have an elevated heart rate, white blood cell count, C-reactive protein level, erythrocyte sedimentation rate level and synovial cell count ( P  < 0.05). Patients were more likely to undergo surgery if they presented to the emergency department than to the clinic ( P  = 0.03). The average time for a Lyme test to result was 43.5 h, averaging 8.7 h after the surgical start time. Lyme arthritis occurs commonly in an urban pediatric population. Surgery is performed in ~10% of Lyme arthritis patients. More efficient diagnostic tests may reduce this rate.

Sequelae of Septic Arthritis of Hip in a Child Presenting with Acetabular Defect and Hip Dislocation: A Rare Case Report and Literature Review on Successful Treatment with Steel Osteotomy

Septic arthritis of the hip in late childhood leads to different sequelae. These cases are often missed and lead to various disabilities like hip subluxation, limb length discrepancy, and limping. The primary goal is always to reproduce a concentrically reduced stable hip. We are presenting a 13-year child with sequelae of septic arthritis of the hip with dislocation. The child had septic arthritis of the hip two years back. The patient had a superolateral acetabular defect and was treated with triple innominate steel osteotomy. The osteotomy increased the acetabular head coverage and gave a stable congruent hip to the child. Late childhood septic arthritis cases can produce acetabular defects without involving the femoral head leading to dislocation. Such cases can be effectively treated with triple innominate pelvic osteotomy, giving good head coverage with stable congruent hips.

An update on recent progress of the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis: a review

Acute septic arthritis is on the rise among all patients. Acute septic arthritis must be extensively assessed, identified, and treated to prevent fatal consequences. Antimicrobial therapy administered intravenously has long been considered the gold standard for treating acute osteoarticular infections. According to clinical research, parenteral antibiotics for a few days, followed by oral antibiotics, are safe and effective for treating infections without complications. This article focuses on bringing physicians up-to-date on the most recent findings and discussions about the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis. In recent years, the emergence of antibiotic-resistant, particularly aggressive bacterial species has highlighted the need for more research to enhance treatment approaches and develop innovative diagnosis methods and drugs that might combat better in all patients. This article aims to furnish radiologists, orthopaedic surgeons, and other medical practitioners with contemporary insights on the subject matter and foster collaborative efforts to improve patient outcomes. This review represents the initial comprehensive update encompassing patients across all age groups.

Seasonal Variation of Pediatric Septic Arthritis in the United States: A PHIS Database Study

BACKGROUND

The presence of seasonal patterns in pediatric septic arthritis cases is a common orthopaedic teaching. Seasonal variation has been seen in centers outside of the United States and with other inflammatory and infectious joint-related conditions within the country, but it is unknown if a seasonal pattern exists among different regions of the United States. The purpose of this study was to examine the seasonal variation of septic arthritis within specific regions across the United States.

METHODS

The Pediatric Health Information System database was queried for all patients 19 years or younger who were treated for septic arthritis. Data from 34 pediatric hospitals in the Pediatric Health Information System initiative were included. Centers were organized by geographical region, and season of presentation was determined using equinoxes/solstices. χ 2 tests were performed to detect seasonal differences in septic arthritis for the entire cohort and separated by geographical region. Proportion differences along with 95% CIs were provided.

RESULTS

Between 2016 and 2019, there were 5764 cases of septic arthritis. Median age at diagnosis was 6.2 years (range: 0 to 19.0 y). Each season contributed 24% to 25% of the total septic arthritis cases, and there were no significant differences detected between the 4 seasons ( P =0.66). There was no seasonal variation seen in the Midwest, South, or West ( P =0.71, 0.98, 0.36, respectively). However, there was seasonal variation in the Northeast ( P =0.05), with fall and summer having a higher percentage of cases (28%) than the winter (21%).

CONCLUSIONS

This study showed no clear seasonal variation in septic arthritis in children across the United States using a national database of pediatric hospital centers. However, there is regional seasonal variation in the Northeast, which may relate to climate differences. With no clear seasonal variation across the United States, continued diligence is needed in diagnosing septic arthritis throughout the year.

LEVEL OF EVIDENCE

Prognostic II.

The recent bacterial etiology of childhood osteoarticular infections focusing on the vaccine initiation for Streptococcus pneumoniae and Haemophilus influenzae: A single-center retrospective analysis in Japan

Background

Pediatric acute osteomyelitis and septic arthritis can destroy growth plate cartilage and joint cartilage, causing permanent deformities and growth disorders. Preventing the contraction of osteoarticular infections is important. Various types of bacteria cause osteoarticular infections in children. Since 2013, when routine vaccination against Streptococcus pneumoniae and Haemophilus influenzae was initiated in Japan, diseases caused by these bacteria (other than osteoarticular infection) are reported to decrease. In this study, we aimed to re-confirm the actual situation including the presence of pathogenic bacteria of pediatric bone and joint infections.

Methods

The subjects were patients of 15 years old or younger who had been diagnosed with acute osteomyelitis or septic arthritis and received initial treatment in our hospital from April 1995 to March 2019. We obtained information from the medical records and analyzed them statistically.

Results

There were 65 patients with 65 bones with acute osteomyelitis, and 120 patients with 124 joints with septic arthritis. The pathogenic bacteria were identified in 26 (40.0%) osteomyelitis patients and 59 (49.2%) septic arthritis patients. Staphylococcus aureus was the most common pathogenic bacterium, and S. pneumoniae and H. influenzae were identified in four and seven patients respectively, frequently in younger patients. After routine vaccination against S. pneumoniae and H. influenzae, these bacteria were no longer detected in patients under five years old.

Conclusions

The efficacy of the S. pneumoniae and H. influenzae vaccine against orthopedic infectious diseases in Japan was indicated.

Preliminary results: continuous double luminal catheter drainage for the management of septic hip arthritis in children

Septic arthritis in children is considered an orthopedic surgical emergency, which requires prompt intervention to prevent later sequela. In the last decades, several minimal invasive techniques were suggested as an alternative to the standard treatment of septic arthritis in the pediatric hip via open arthrotomy. We aimed to investigate the efficacy and safety of a new minimal invasive technique-double luminal catheter drainage (DLDC)-in treating septic hip arthritis in children. Retrospective case series analysis was performed on all patients 1-18 years of age diagnosed with septic hip arthritis and treated by the new suggested minimal invasive technique between the years 2009-2019 at medium-sized medical center. Five patients were treated by DLDC with a follow-up period of 12 months posttreatment. The diagnosis was based on joint aspirated fluid analysis criteria. During the follow-up period, no later sequel, including avascular necrosis, or infection recurrence were observed. The new minimal invasive treatment technique suggested in this study seems to be efficient and safe in treating septic hip arthritis in children without later sequela or the need for open arthrotomy, especially if performed early on. However, due to the small study sample, no generalization of the findings can be made as future studies with larger study samples are needed to validate the DLDC technique.

Septic sequelae of hip in children: long-term clinicoradiological outcome study

The presented retrospective study is a report of 18 patients (23 hips) with infantile post sepsis hip sequelae. There were two groups of patients. The observation group comprised of 6 patients (8 hips). The intervention group included 12 patients (15 hips) of which 12 hips had been surgically intervened for the sequelae and 3 contralateral hips which were again serially observed. The sequelae hips were classified by Choi's radiological types. The clinical evaluation was done by modified Moon's criteria. The average patient age at follow-up was 9.3 years. There were 3 type I (13%), 10 type II (43%), 2 type III (8%), and 8 Choi type IV (35%) at presentation. The Choi radiological type showed propensity to change over time/following intervention. At follow-up, there 3 type I (13%), 17 type II (74%), and 3 type IV (13%) hips. At follow-up, there were seven excellent, seven good, and four fair results. The observation group had mostly type I or II and intervention group IIIB or IV Choi types. Findings common to both groups: same Choi radiological type fared different clinically, multiple joint involvement contributed to deterioration of function and late changes in acetabulum or proximal femur lead to deterioration of clinical function. The sequelae of septic hips likely to be kept under supervised observation were Choi type I or II. In select types, intervention changed the natural history of septic sequelae significantly.

[Hip necrosis. A severe complication after intragluteal injection of quinine salt in Bangui, Central African Republic]

Introduction

Intramuscular injection of quinine has been for long the most common treatment for malaria in children in endemic areas of Africa, especially sub-Saharan Africa, and remains too often used. However, it is frequently wrongly performed by unqualified people. When administered in a poorly developed or malnourished child, the injection can be done too deeply in the hip joint instead of the gluteus muscle area.

Materials and Methods

The files of 3012 children examined in out-patient clinics in Bangui, Central African Republic, between 2011 and 2020 were reviewed. Sequelae of intramuscular injections were observed in 307 cases, including intraquadricipital injection in 170 cases (56%) and intragluteal injection in 137 cases (44%). The latter included 115 sciatic paralysis and 22 hip sequelae with stiffness, shortening of the limb, limping and pain at walking. In these 22 cases, an intragluteal injection was incriminated by the families. However, 16 files were considered as insufficient because of imprecise history or because poor quality or no radiograph was available. Although suspected of being hip necrosis, these files were excluded. Six cases presented specific clinical pictures and interpretable radiographs and were included in this study.

Results

The clinical and the radiographic aspects of this severe complication apparently not documented in the literature are analyzed. The well-known toxicity of quinine may be responsible of a necrosis involving both the femoral head and the acetabular roof, resulting in a painful joint, stiff in adduction, with limping and with an apparent marked shortening of the lower limb. Radiographs show a subtotal femoral head necrosis associated to an acetabular roof necrosis with an upward displacement of the epiphyseo-metaphysal femoral stump, the latter keeping a roughly spherical aspect and remaining well-covered and fitted in a relatively deep neo-acetabulum.

Discussion

In the African background, this picture of coxopathy occurring in childhood may suggest an avascular necrosis of the femoral head complicating a sickle-cells disease, or above all sequelae of septic osteoarthritis. Treatments are limited to the prescription of a partial weight bearing of the hip.

Conclusion

Although no irrefutable arguments are existing, the observed clinical and radiographic pictures are sufficiently clear and typical to individualize this severe iatrogenic complication which should be avoided by a good technic or by using the intravenous way when necessary.

Late sequelae of osteoarticular infections in pediatric patients: A single-center study

To review the orthopedic sequelae of pediatric patients diagnosed with osteoarticular infections (OAIs) and identify significant differences between those with and without sequelae. Medical charts between 2010 and 2016 from a tertiary-care pediatric hospital were reviewed to collect demographic and clinical data for this retrospective case series. The main inclusion criteria were: 1. age (≤10 years old); 2. absence of sickle cell anemia and immunocompromising disease or medication; 3. a minimum follow-up of 12 months with radiographs; and 4. diagnosis of osteomyelitis of long bones and/or septic arthritis. The following late sequelae were observed and aggregated: osteal deformations that led to limb-length discrepancies (LLD) superior to 5 mm, abnormal articular angulations of more than 5°, and symptomatic chondropathies visible on imaging studies after 1 year. The patients were divided into 2 subgroups: with and without sequelae. Chi-Squared tests were used for categorical variables and Mann–Whitney U tests for continuous data to identify statistically significant differences between the 2 subgroups. Among 401 patients with osteomyelitis and/or septic arthritis, 50 (12.5%) were included (24 girls and 26 boys). There were 36 (72%) cases of osteomyelitis, 8 (16%) cases of septic arthritis, and 6 (12%) cases of combined infection (3 acute/subacute and 3 chronic cases). Five (10%) patients had orthopedic sequelae at the latest follow-up. The total duration of antibiotic treatment (P = .002), infectious disease follow-up (P = .002), and the presence of sequestra (P = .005) were significantly different between subgroups. There were no statistically significant differences between the 2 subgroups for the other variables, but some trends could be discerned. Only 4/50 patients developed a sequestrum, 2 of which were in the orthopedic sequelae subgroup. Furthermore, initial C-reactive protein (CRP) values were higher in the sequelae subgroup, as were the CRP values at hospital discharge. The orthopedic follow-up was also longer in the sequelae subgroup. Finally, the delay between the onset of symptoms and the beginning of antibiotic treatment was longer in the sequelae group. Patients with orthopedic sequelae had a longer antibiotic treatment and infectious disease follow-up, and were more likely to have presented with a sequestrum. Level of evidence: IV – case series.

Management of post septic sequelae of hips with dislocation in children

BACKGROUND

Limited literature guide management of post septic sequelae of hips with dislocation in children. We studied the functional and radiological outcome of open reduction of such sequelae in 11 children. Special emphasis was given to determine the influence of surgical correction and relocation of these hips.

METHODS

Preoperative acetabular index (AI) on both sides was compared to quantify acetabular dysplasia. Radiological parameters like AI, centre edge angle (CEA), Reimer's index, centre head distance discrepancy (CHDD) and neck shaft angle (NSA) were calculated and compared with the unintervened side at follow-up. Outcome was assessed radiologically by modified Severin classification and clinically by Moon's criterion.

RESULTS

Average age at open reduction was 20.6 months and further follow-up was 48.8 months. The mean pre-operative AI on intervened side (35 degrees) differed significantly from unintervened side (22.5 degrees). The follow-up AI on intervened side (26.5 degrees) improved significantly from the pre-operative values but residual dysplasia persisted. Mean values for other radiological parameters on intervened side at follow-up were CEA 16.1 degrees, Reimer's index 31.5%, CHDD 18.6% and NSA 119 degrees. Mean shortening of 2.3 cm was documented in ten patients at final follow-up. Triradiate cartilage fused in four out of 11 hips at follow-up. Radiological outcome according to modified Severin classification was good to fair in seven patients (types II and III) whereas poor in four patients (types IV and V). Functional outcome as per Moon's criterion was excellent to good in nine patients, fair and poor in one patient each.

CONCLUSIONS

Open reduction potentially alters the natural history of post septic sequelae of hips with dislocation and contributes to better hip mechanics and function.

What factors contribute to Choi IV sequelae? A retrospective analysis of 15 septic hips

PURPOSE

Choi IV sequela is one of the most severe outcomes of septic hips. We undertook a retrospective chart review of 15 such hips in 13 patients to identify factors contributing to the formation of this sequelae.

METHODS

The study specifically focused on patient demographics (patient's age; time to arthrotomy from initial symptoms; causative organism; post arthrotomy duration when Choi IV changes were obvious) and radiological findings at the time of arthrotomy.

RESULTS

The average patient's age at time of infection was 2.9 years. Five children were infants. The time to arthrotomy from initial symptoms was mean 21.6 days. Multifocal involvement was seen in 2 patients. Concurrent arthritis and osteomyelitis was present in 8 (53%) and pathological subluxation or dislocation in 9 hips (60%). Methicillin-sensitive Staphylococcus aureus was isolated in 7 and Methicillin-resistant Staphylococcus aureus in 4 patients. The Choi IV findings were established on average 3.8 months post arthrotomy.

CONCLUSIONS

Delay in treatment, post septic dislocation and concurrent femoral osteomyelitis were factors associated with Choi IV septic sequelae. The pathology occurred irrespective of age.

The predictive value of synovial glucose level in septic arthritis

The aim of this study was to investigate the ability of the joint fluid glucose level to detect septic arthritis. Thirty joints in 30 patients with suspected septic arthritis were evaluated. When glucose level was less than 40 mg/dl, we performed arthrotomy. Eleven patients had joint fluid glucose levels less than 40 mg/dl. All 11 (100%) had positive joint fluid cultures. Conversely, 19 patients had synovial glucose levels of at least 40 mg/dl. Six (31.6%) of these had positive joint fluid cultures. The remaining 13 were diagnosed with transient synovitis. Patients with joint fluid glucose levels less than 40 mg/dl should be suspected septic arthritis.

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.

Septic arthritis of the hip and knee treated surgically in pediatric patients: Analysis of the Kids' Inpatient Database

OBJECTIVE

This study evaluated incidence over time, any association between race and demographics, and hospital-related parameters in pediatric patients with septic hip or knee arthritis.

METHODS

The Kids' Inpatient Database was used to identify all children with a diagnosis of septic hip or knee arthritis who underwent incision and drainage (1997-2012).

RESULTS

Between 1997 and 2012, overall incidence of septic arthritis of the knee (0.20-0.33 per 100,000) and hip (0.12-0.18 per 100,000) increased.

CONCLUSION

Incidence of pediatric septic joint arthritis, an emergent orthopaedic condition, has increased over time. Patient demographics may vary with respect to both age and race.

Double-Edged Sword: Musculoskeletal Infection Provoked Acute Phase Response in Children

The acute phase response has a crucial role in mounting the body's response to tissue injury. Excessive activation of the acute phase response is responsible for many complications that occur in orthopedic patients. Given that infection may be considered continuous tissue injury that persistently activates the acute phase response, children with musculoskeletal infections are at markedly increased risk for serious complications. Future strategies that modulate the acute phase response have the potential to improve treatment and prevent complications associated with musculoskeletal infection.

Arthroscopic Treatment of Septic Arthritis in Very Young Children

INTRODUCTION

Arthroscopic lavage is a well-established, minimally invasive treatment for septic arthritis (SA) in adults, but the use of arthroscopy in the pediatric population is typically restricted to sports injuries and deformity. Previous research on arthroscopic lavage of septic joints in the pediatric population has been limited to case reports and small case series of older children. As such, we aimed to evaluate the safety and efficacy of arthroscopic treatment of SA in various joints in very young children.

METHODS

Between 2011 and 2015, 24 children (aged 3 wk to 6 y) were treated for SA with arthroscopic lavage. A single portal was adequate for both inflow and outflow in most cases. A second portal was used in all knees and in other joints for synovectomy, when indicated. Drains were placed through the portal site and remained in place for 2 to 3 days. Antibiotics were managed by the infectious disease service.

RESULTS

Nine hips, 9 knees, 4 ankles, and 2 shoulders were included. Portal placement, visualization, and adequate lavage were straight forward in all joints. There was 1 transient femoral nerve palsy and no other arthroscopy-associated complications (iatrogenic damage, difficult drain placement, or conversion to open). Two patients required repeat arthroscopic lavage for disease eradication, one of which required a second admission. A third patient underwent open irrigation following arthroscopic lavage with a resultant 1.125 average procedures per subject. At final follow-up (2 to 49 mo, average 16 mo), no recurrence of infection or decreased range of motion was noted.

CONCLUSIONS

Arthroscopic lavage appears to be a safe, quick, and effective alternative to open arthrotomy for the treatment of SA in very young children. It is feasible in any large joint even in the infantile population, allowing for improved visualization and irrigation with little soft-tissue dissection and morbidity. Our relatively simple technique and positive results should encourage regular use of arthroscopic treatment of SA even in very young children.

LEVEL OF EVIDENCE

Level IV-case series.

Predictive Factors for Differentiating Between Septic Arthritis and Lyme Disease of the Knee in Children

BACKGROUND

Differentiating between septic arthritis and Lyme disease of the knee in endemic areas can be challenging and has major implications for patient management. The purpose of this study was to identify a prediction rule to differentiate septic arthritis from Lyme disease in children presenting with knee pain and effusion.

METHODS

We retrospectively reviewed the records of patients younger than 18 years of age with knee effusions who underwent arthrocentesis at our institution from 2005 to 2013. Patients with either septic arthritis (positive joint fluid culture or synovial white blood-cell count of >60,000 white blood cells/mm(3) with negative Lyme titer) or Lyme disease (positive Lyme immunoglobulin G on Western blot analysis) were included. To avoid misclassification bias, undiagnosed knee effusions and joints with both a positive culture and positive Lyme titers were excluded. Historical, clinical, and laboratory data were compared between groups to identify variables for comparison. Binary logistic regression analysis was used to identify independent predictive variables.

RESULTS

One hundred and eighty-nine patients were studied: 23 with culture-positive septic arthritis, 26 with culture-negative septic arthritis, and 140 with Lyme disease. Multivariate binary logistic regression identified pain with short arc motion, history of fever reported by the patient or a family member, C-reactive protein of >4 mg/L, and age younger than 2 years as independent predictive factors for septic arthritis. A simpler model was developed that showed that the risk of septic arthritis with none of these factors was 2%, with 1 of these factors was 18%, with 2 of these factors was 45%, with 3 of these factors was 84%, or with all 4 of these factors was 100%.

CONCLUSIONS

Although septic arthritis of the knee and Lyme monoarthritis share common features that can make them difficult to distinguish clinically, the presence of pain with short arc motion, C-reactive protein of >4.0 mg/L, patient-reported history of fever, and age younger than 2 years were independent predictive factors of septic arthritis in pediatric patients. The more factors that are present, the higher the risk of having septic arthritis.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopy for hip septic arthritis in children

BACKGROUND

Hip arthroscopy for treatment of septic arthritis in children has previously been reported with excellent short-term results. The purpose of this study was to evaluate the long-term results of hip arthroscopy for hip septic arthritis (HSA) in paediatric patients.

HYPOTHESIS

Arthroscopy still is a useful tool in the treatment of HSA, and may be superior to simple hip aspiration.

MATERIALS AND METHODS

Twelve patients with a median age of 6 years, with community-acquired infections, were diagnosed as HSA. All of them were treated using arthroscopic drainage. The duration of symptoms at presentation were a median of 3,5 days (2-20). In the younger patients (<8 years), hip joint distension was used instead of hip traction. At final check-up, the Hip Harris Score (HHS) was used and a radiographic study done.

RESULTS

Two patients required a repeat arthroscopy. All, except for one patient, achieved excellent clinical results. Two patients presented radiological changes at the last check-up. The poor results were related to late presentation for medical treatment. There was no difference between early and late results.

DISCUSSION

Hip arthroscopy for child HSA is a feasible technique even for the youngest patients, moreover the positive clinical results initially obtained are maintained over time.

LEVEL OF EVIDENCE

Level IV: retrospective series.

Concomitant septic arthritis and osteomyelitis of the hip in young children; a new pathophysiological hypothesis suggested by MRI enhancement pattern

Background

In children, septic arthritis (SA) of the hip is either primary or concomitant with acute haematogenous osteomyelitis (AHO). However, seldom, patients with isolated SA at presentation, may later show osteomyelitis in the metaphysis. The aim of this study was to elaborate a physiopathological hypothesis based on the peculiar MRI findings to explain the onset of AHO after SA.

Methods

Cases of acute infection of the hip admitted between January 2010 and December 2013 were retrospectively reviewed to assess radiographic and MRI features, as well as bacteriological findings. Only children with isolated SA were included in this study, whereas cases of concomitant SA and AHO at presentation were excluded.

Results

Ten patients met the inclusion criteria. Six (1–11 months) demonstrated, on the initial MRI, decreased perfusion on gadolinium enhanced fat-suppressed T1-weighted sequence of the femoral epiphysis and developed one month later metaphyseal AHO. Four (5–14 years) did not show decreased perfusion and did not develop AHO on follow-up. The type of germ involved influenced neither the type of enhancement pattern nor the outcome.

Conclusions

Age under one year and decreased perfusion of the affected femoral epiphysis increases the risk of secondary AHO. Our study is the first report in human medicine supporting the physiopathological hypothesis described by Alderson et al. in an animal model: primary infection can originally affect the joint, then penetrate the epiphyseal cartilage, and finally spread into the metaphyseal region through transphyseal vessels present only in the first 12/18 months of life.

Midterm results of Ilizarov hip reconstruction for late sequelae of childhood septic arthritis

The management of hip instability as a consequence of septic arthritis in childhood is difficult. Ilizarov hip reconstruction is a double-level femoral osteotomy with the objective of eliminating hip instability, through a proximal valgus–extension–derotation osteotomy and a distal varization–lengthening osteotomy for mechanical axis correction and equalization limb length. Ilizarov hip reconstruction was performed for 16 adult patients with complaints of hip pain, leg-length discrepancy, limping, reduced activity and limited abduction of the hip as a result of childhood septic arthritis. Their ages ranged from 19 to 32 years (mean 23.2 ± 4.2). Ilizarov external fixator was used in all cases. At the time of last follow-up that ranged from 60 to 132 months (mean 85.6 ± 23.5), the Harris hip score (HHS) showed excellent functional outcome in two cases (12.50 %), good in 13 cases (81.25 %) and fair in one case (6.25 %). There was no poor functional outcome in any case. Preoperatively, the mean HHS was 56.18 points, and at the time of last follow-up, it improved to a mean of 84.62 points. Pain subsided in all patients, the Trendelenburg sign became negative in all but three (19 %) patients, no patient had limb-length discrepancy, and the alignment of the extremity was reestablished in all cases. No additional operations were required. Ilizarov hip reconstruction is a valuable and durable solution for the late sequelae of childhood septic arthritis of the hip presenting in adult patients.

Septic arthritis of the neonatal hip: acute management and late reconstruction

Septic arthritis of the hip in neonates is rare but can have devastating consequences. Presenting signs and symptoms may differ from those encountered in older children, which may result in diagnostic challenge or delay. Many risk factors predispose neonates to septic arthritis, including the presence of transphyseal vessels and invasive procedures. Bacterial infection of the joint occurs via hematogenous invasion, extension from an adjacent site, or direct inoculation. A strong correlation exists between younger age at presentation and severity of residual hip deformity. Diagnosis is based on clinical examination, laboratory markers, and ultrasound evaluation. Early management includes parenteral antibiotics and surgical drainage. Late-stage management options include femoral and pelvic osteotomies, trochanteric arthroplasty, arthrodesis, pelvic support procedures, and nonsurgical measures. Early diagnosis and management continues to be the most important prognostic factor for a favorable outcome in the neonate with septic arthritis.

Use of real-time polymerase chain reaction for the diagnosis of infection and differentiation between gram-positive and gram-negative septic arthritis in children

BACKGROUND

Diagnosis and identification of the etiological agent of septic arthritis (SA) in children is an important issue, as early treatment based on accurate diagnosis of joint infections can prevent potentially disabling complications. The purpose of this study was to evaluate the efficacy of real-time polymerase chain reaction (PCR) for the diagnosis of SA in children.

PATIENTS AND METHODS

Twenty children with suspected SA who had joint pain and underwent surgical treatment were enrolled in this study. Their preoperative clinical and laboratory findings were investigated. Tissues obtained during operation were subjected to microbiological culture and real-time PCR, including methicillin-resistant Staphylococcus (MRS)-specific PCR and broad range universal PCR. Infection was confirmed if the result of microbiological culture was positive. Furthermore, abnormal clinical and laboratory findings and improvement in the symptoms and posttreatment data were also defined as the final diagnosis of infection.

RESULTS

Out of the 20 patients, 19 were diagnosed with the infection. The remaining patient was postoperatively diagnosed with juvenile idiopathic arthritis. Abnormal preoperative body temperatures, white blood cell counts, C-reactive protein levels, and erythrocyte sedimentation rates were observed in 6, 9, 15, and 12 cases, respectively. The results of microbiological culture, MRS-PCR, and universal PCR were positive in 9, 2, and 15 cases, respectively. Analysis of the melting peak in universal PCR revealed that of the 15 cases, 10 had gram-positive and 5 had gram-negative infections. The sensitivity and specificity for the diagnosis of SA were, respectively, 0.47 and 1.00 in microbiological culture and 0.79 and 1.00 in real-time PCR.

CONCLUSIONS

Successful diagnosis of infection and differentiation between gram-positive and gram-negative bacteria were achieved using MRS-PCR and universal PCR. Hence, real-time PCR is useful and has greater sensitivity than microbial culture for diagnosing SA in children.

LEVEL OF EVIDENCE

Level II diagnostic study investigating a diagnostic test.

Bilateral pathological dislocation of the hip secondary to tuberculous arthritis following disseminated tuberculosis: a case report and review of the literature

Pathological dislocation of the hip has been reported as a complication in various hip disorders. Several pathomechanisms including capsular laxity, synovial hypertrophy, and acetabular and proximal femur destruction have been described. We report a case of bilateral pathological dislocation of the hip in a 6-year-old girl secondary to tuberculous arthritis following disseminated tuberculosis, which we managed operatively. At the 18-month follow-up, the child had a clinically stable left hip despite radiological subluxation. Bilateral pathological dislocation of the hip associated with tuberculous arthritis is a rare condition and has never been reported in the literature.

Trochanteroplasty to treat sequelae of septic arthritis of the hip in infancy. Case series and review of the literature

The authors report a series of 11 patients treated surgically by trochanteroplasty for septic arthritis of the hip at our institution from 1974 to 2010. Trochanteroplasty was indicated due to the absence of a valid alternative, and because it does not rule out the option of total hip arthroplasty at a later stage.

Can early MRI distinguish between Kingella kingae and Gram-positive cocci in osteoarticular infections in young children?

BACKGROUND

K. kingae is a common causative organism in acute osteoarticular infections (OAIs) in children under 4 years of age. Differentiation between K. kingae and Gram-positive cocci (GPC) is of great interest therapeutically.

OBJECTIVE

Our aim was to identify early distinguishing MRI features of OAIs.

MATERIALS AND METHODS

Thirty-one children younger than 4 years of age with OAI underwent MRI at presentation. Of these, 21 were caused by K. kingae and ten by GPC. Bone and soft tissue reaction, epiphyseal cartilage involvement, bone and subperiosteal abscess formation were compared between the two groups. Interobserver agreement was measured.

RESULTS

Bone reaction was less frequent (P = 0.0066) and soft tissue reaction less severe (P = 0.0087) in the K. kingae group. Epiphysis cartilage abscesses were present only in the K. kingae group (P = 0.0118). No difference was found for bone abscess (P = 0.1411), subperiosteal abscess (P = 1) or joint effusion (P = 0.4414). Interobserver agreement was good for all criteria.

CONCLUSION

MRI is useful in differentiating K. kingae from GPC in OAI. Cartilaginous involvement and modest soft tissue and bone reaction suggest K. kingae.

Extra capsular extrusion of femoral capital epiphysis - an unusual presentation of sequelae of septic arthritis of hip

Presentations of sequelae of septic hip in infants have been classified by various researchers, depending on the presence or absence of femoral capital epiphysis in acetabulum. This case report describes an unusual presentation of sequelae of septic arthritis of hip in which femoral capital epiphysis had extruded outside the capsule of hip joint in a 1 year and 6-months-old boy.

Management of post septic hip dislocations when the capital femoral epiphysis is present

Delayed or missed diagnosis of septic arthritis of hip in children results in various sequelae. The group of post septic hip dislocations when the capital femoral epiphysis (CFE) is present has not been described in the commonly used classifications. This is a retrospective series of 21 hips in 18 children. The presence of the CFE was confirmed radiologically or at the time of intervention. The mean follow-up after intervention was 6.3 years. Interventions for dislocations included closed reduction ± adductor tenotomy, open reduction ± supplementary femoral procedures, and acetabular procedures. Results were evaluated clinically with Ponseti hip scoring and radiologically with the modified Severin grading. Closed reduction was successful in seven of 20 hips (35%) and open reduction in 13 of 14 hips. At follow-up, good clinical result was seen in nine of 18 cases (50%). The mean neck shaft angle was 129° in all hips and 124° after femoral varus osteotomy. There was one redislocation and three subluxations. The modified Severin classification was class 2 in five hips (good), class 3 in 12 hips (fair), class 4 in three hips (poor), and class 6 in one hip (failure). Septic hip dislocation with CFE present is a distinct entity. MRI is helpful for planning treatment. A significant number of patients need open reduction with other procedures. Femoral varus osteotomy may contribute to coxa vara. In the short term, intervention results in a stable, functional, and mobile hip.

Bilateral septic arthritis of the hip with osteitis and psoas abcess in a 17-year-old adolescent

Septic arthritis remains an important and serious disease of the young because of its high potential to cause permanent sequelae. The hip is the most commonly involved joint in infants and in the young (35%). Most often, patients have a single joint involved. We report here a rare case of septic arthritis reaching both hips, shown by a severe septicemic shock and complicated unusually by a psoas abcess and osteitis in an immunocompetent adolescent.

Causative organisms and their antibiotic resistance patterns for childhood septic arthritis in china between 1989 and 2008

The goal of this study was to evaluate the array of causative organisms for septic arthritis in children and their antibiotic resistance patterns over a 20-year period at a single medical center. The medical records of children younger than 16 years with septic arthritis admitted to a hospital in China from 1989 to 2008 were retrospectively reviewed. A total of 158 cases of septic arthritis were studied, 70 from 1989 to 1998 and 88 from 1999 to 2008. Between the first and second decades, occurrence of serious illnesses decreased significantly from 44.3% to 28.4% (P<.04). The positive percentage was only 55.6% in the first decade and 44.82% in the second decade. The causative organisms of major significance between the 2 decades changed little, except methicillin-resistant Staphylococcus aureus (MRSA) increasing significantly. Staphylococci remained the major causative organisms for joint infection. The percentage of Staphylococcus aureus resistance to various antibiotics increased: 85% to 100% for penicillin, 58.8% to 75% for erythromycin, 0% to 31.3% for cefazolin, and 15% to 29.4% for multi-resistance. In the second decade, 4 MRSA stains were multi-resistant. However, gentamincin resistance remained at the same level. Antibiotic resistance of coagulase-negative staphylococci and gram-negative bacilli changed little. The incidences of osteomyelitis and joint dislocation decreased significantly, from 15.7% to 6% and 28.6% to 14.8%, respectively (P<.04). The distribution of causative organisms of septic arthritis in young patients changed slightly during the 20-year period, while antibiotic resistance of the major causative organisms increased and the incidences of serious illness-osteomyelitis and joint dislocation-decreased significantly.

Evaluation of the modified Albee arthroplasty for femoral head loss secondary to septic arthritis in young children

BACKGROUND

Surgical treatment options for femoral head deficiency in infants secondary to septic arthritis of the hip are varied and associated with uncertain long-term outcomes. The modified Albee arthroplasty has been considered an acceptable procedure; however, the long-term outcomes of this procedure have not been reported, to our knowledge. We evaluated the long-term outcomes of the modified Albee arthroplasty in young patients with severe sequelae of septic arthritis of the hip.

METHODS

We retrospectively studied twenty-one children (twenty-one hips) in whom Choi type-IVB sequelae of septic arthritis of the hip had been treated with a modified Albee arthroplasty and six patients with the same sequelae who had been managed with simple observation. The Trendelenburg sign, pain, the range of motion, hip function, the Harris hip score, and limb-length discrepancy were assessed clinically. Remodeling of the femoral head, hip stability, and arthritic changes in the hip were evaluated radiographically.

RESULTS

The twenty-one patients with the modified Albee arthroplasty were followed for an average of 121.2 +/- 38.6 months and had better outcomes, in terms of the Trendelenburg sign, the Harris hip score, pain, the hip range of motion, and limb-length discrepancy, than the six patients who underwent simple observation. Patients who were two years of age or younger at the time of the arthroplasty exhibited a significantly less severe limb-length discrepancy and less loss of motion than those who were older than two at the time of the surgery. Furthermore, limb-length discrepancy was positively correlated and the range of motion of the hip and the Harris hip scores were negatively correlated with the patient's age at the time of the surgery, suggesting that early surgery in patients with severe sequelae of septic arthritis of the hip is associated with a better clinical outcome.

CONCLUSIONS

The modified Albee arthroplasty is a feasible and clinically useful procedure for the treatment of severe sequelae of septic arthritis of the hip, particularly in children who are two years of age or younger.

Greater trochanteric preserving hip arthroplasty in the treatment of infantile septic arthritis: long-term results

BACKGROUND

Balanced forces around the hip joint are critical for normal development of the hip joint, so it should be considered in every hip reconstructive procedure.

METHODS

In seven children with complete destruction of the femoral head and neck due to septic arthritis, a reconstructive hip surgery was done to reconstruct the femoral head without sacrificing the greater trochanter and its muscles completely. The technique consists of a modified greater trochanter arthroplasty with only a medial portion of the greater trochanter and a varus femoral osteotomy.

RESULTS

The average age of the children at surgery was 17 months (range 8-36 months) and the patients were followed for an average of 16.6 years (range 10.9-20.1 years). The average number of second operative procedures for each patient was 2 (range 1-4). The follow-up evaluation for each patient included documentation of pain, hip range of motion, and assessment of gait. In addition, the current leg-length discrepancy, final coverage and stability of the hip joint were documented. At final evaluation, all patients had a pain-free stable hip and two patients had near-normal hip range of motion. All patients have had satisfactory surgery results.

CONCLUSIONS

By this kind of hip reconstruction, we could provide a stable painless hip joint with special attention to the greater trochanter's role on hip biomechanics.

Comparison of bacteriologically proven septic arthritis of the hip and knee in children, a preliminary study

The hip and knee are the commonest joints affected by septic arthritis in the pediatric age group. Both can present as a limping, unwell child and can be difficult to diagnose. The primary aim of this study is to review and compare characteristics of pediatric patients with culture positive septic arthritis of the hip to those with culture positive septic arthritis of the knee. We retrospectively reviewed all patients who were clinically diagnosed with acute septic arthritis of either hip or knee in a tertiary pediatric hospital for a period of 3 years. Twelve of 29 patients who underwent arthrotomy for presumed septic arthritis of the hip and 7 of 37 patients who underwent arthrotomy for presumed septic arthritis of the knee had positive joint cultures. Patients with septic arthritis of the knee were much younger than that with septic arthritis of the hip. Patients with presumed septic arthritis of the knee based on clinical picture were less likely to have a positive synovial fluid culture. Children with septic arthritis of the knee did not follow Kocher criteria in the same way that children with septic arthritis of the hip did.

Failed vascularized proximal fibular epiphyseal transfer for hip reconstruction following infection in children

PURPOSE

Treatment of the sequellae of hip infection with epiphyseal destruction in children has had limited success to date. The aim of this study was to report mid-term results after hip epiphyseal reconstruction using a proximal vascularized fibular graft in three children presenting with massive epiphyseal destruction of the proximal femur following infection.

METHODS

Three children suffered from hip articular destruction type IVB according to the Choi classification after neonatal septic arthritis. The mean age at reconstruction was 4.3 years (range 3-6 years). The Hunka et al. criteria were used to evaluate the functional results, and the clinical evaluation was based on the Musculo-Skeletal Tumor Society (MSTS) score. Growth and fusion of the graft and hip morphology were evaluated on simple X-rays and by magnetic resonance imaging (MRI). A ratio between cephalic diameter and inter-acetabular gap was defined on the MRI scan as the "acetabular filling index".

RESULTS

No intraoperative complication was reported. With a mean follow-up of 4.8 years (3-6 years), the MSTS score was 22.7/30 (range 20-26), while the average lower limb length discrepancy was 3 cm. Patient 1 required a secondary derotation osteotomy of the femur because of abnormal external rotation and a bad result due to the unexplained occurrence of a painful and stiff hip joint. A secondary distal transfer of the greater trochanter was performed in patient 2, and good results based on Hunka et al.'s criteria were achieved. The X-rays of patients 1 and 2 showed signs of bone growth and a major remodeling process; the MRI filling indices were 83 and 67%, respectively. Patient 3 developed an early slipped capital (fibular) epiphysis 1 month postoperatively, which was treated by percutaneous pinning; this early complication led to a bad result with full resorption of the graft.

CONCLUSIONS

In contrast to its success in upper limb reconstruction, in this series of three patients with hip articular destruction, articular reconstruction using a vascularized proximal fibula graft was disappointing and led to unsatisfactory results in terms of hip reconstruction. Such a procedure is complex and highly demanding, necessitating extremely intensive post-operative care. An early slipped capital epiphysis can lead to full graft resorption. Consequently, despite important adaptation and remodeling of the graft, the authors do not recommend this procedure at this location.