Septic arthritis - Definition Hematogenous bacterial infection of thehip, usually in infants or toddlers, with or without involvementof the proximal femoral metaphysis. Synonym: Septic coxitis
Hip - commonest septic joint condition during growth, reaching a distinctpeak in frequency during infancy. via hematogenous transmission, resulting in colonization of thejoint with bacteria in infants - occur from propagation of adjacentproximal femoral osteomyelitis
septic arthritis of the hip - a surgicalemergency diagnosis be made ASAP to prevent jointdamage; - then immediate arthrotomy, regardless ofthe Graim Stain results; - younger child, more pressing is needbecause of higher risk of permanent disability;
Kocher criteria: (for child with painful hip)- includes: non-weight-bearing on affect side,sed rate greater than 40 mm/hr, fever, and aWBC count of >12,000 mm3;- when 4/4 criteria are met, there is a99% chance that the child has septic arthritis;- when 3/4 criteria are met, there is a93% chance of septic arthritis; - when 2/4 criteria are met, there is a40% chance of septic arthritis; - when 1/4 criteria are met, there is a3% chance of septic arthritis;
Organisms Staph. Aureus, E coli, streptococci, klebsiella pneumoniae Acinetobacter.
epiphyseal plate prevents infection from enteringjoint space in older children but apparently does not act as a barrier in infants synovial membrane inserting distally to epiphysis, allowing bacteria to spread directly from themetaphysis to joint space;
metaphysis of shoulder, hip, radial head, andankle remain intracapsular during earlychildhood the hip joint seems especially prone to sepsisfrom adjacent osteomyelitis synovial reflections over the metaphysealbone decrease with age;
Examination Limp pain in groin area that occasionally radiatesdown the medial side of thigh;- progressive accompanied by spasm ofthe hip muscles- hip in flexion and external rotation &decreased internal rotation compared to thenormal hip- patient resists all attempts to move hip;- palpate the SI joint for local tenderness;
Treatment Identify organism Sensitive antibiotics Prompt administration to prevent tissue damage Surgery - debridement
Detection of sequelae history, medical documentation, clinicalexamination, radiographs, arthrography andsonography. Head of femur- purely cartilaginous - moresusceptible to direct destructive activity of pus& inflammatory products Increase in intracapsular pressure –tamponade – AVN of head
often diagnosed late- leading to irreversibledamage to the articular cartilage, blood supply tothe epiphysis absorption of head and neck, resulting in severe shortening and disability.
Hunka’s Classification Type I – Minimal Femoral Head changes Type IIA – femoral head deformity with a normalgrowth plate Type IIB - femoral head deformity with growtharrest Type III – Pseudoarthrosis of femoral neck
Type IVA – complete destruction of proximalfemoral epiphysis, with a stable neck segment. Type IVB - complete destruction of proximalfemoral epiphysis, with an unstable necksegment. Type V – Complete destruction of the head andneck to the intertrochanteric line, with dislocationof the hip
Goal of Management stabilizing the hip achieve normal function with no residualdeformity or disability improving the gait. not achieved even with the best of treatment
poor prognostic factors Delay in diagnosis - most important factor. An infection that occurred before 22 weeks of age Prematurity Symptoms that lasted longer than 4 days.
Reconstructive operations delayed for months/years after the infection has subsided. Reasons: The danger of reactivating the old infection isreduced; Allows the status of the proximal femur andfemoral head to be definitely determined Allows strength and general character of the boneto improve with time
Chois classification Type IA: No residual deformity Type IB: mild coxa magna. It needs noreconstruction. Type IIA: coxa brevia with deformed head TypeIIB: progressive coxa vara or coxavalgus- asymmetric premature closure ofproximal femoral physis.It needs surgical intervention to preventsubluxation.
Type IIIA: Slipping at femoral neck with severeanteversion/retroversion Type IIIB: pseudoarthrosis - realignmentsurgery for proximal femur or bone grafting. Type IVA: Destruction of the head and neck offemur with the presence of remnant of medialbase of neck. Type IVB: Complete loss of femoral head &neckComplex clinical problems with limb lengthinequality -needs reconstructive surgery
Complications dislocation, subluxation, acetabular dysplasia, coxa vara, coxa breva, absence of the head & neck of the femur, and degenerative (postinfectious) arthritis;
Harmon or LEpiscopo reconstruction - newfemoral neck is fashioned to articulate with theacetabulum . epiphyseodesis of the contralateral limb, lengthening of the ipsilateral tibia.
Type I & IIA – Abduction orthosis initially,observation till skeletal maturity Type IIB – Epiphysiodesis of remaining physiswith/without greater trochanteric physis Type IIIA – Femoral Osteotomy – correct versionand neck shaft angle Type IIIB – Osteotomy + bone grafting
Type IV – Greater trochanteric arthrooplasty Femoral & acetabular osteotomy Arthrodesis Ilizarov hip reconstruction Microvascular reconstruction
procedures performed at any stage are lessfavorable than natural history of the deformity; - hip dislocation:- infantile hip sepsis causes destruction ofthe femoral headhigh-riding dislocation and failure of acetabulardevelopment.
- leg length descrepancy- the proximal femoral epiphysis may bedestroyed –LLD-3-4 inches;- femoral lengthening should not beattempted if hip stability is not present; if an acetabulum is present, surgical reductionw/ trochanteric arthroplasty and pelvicosteotomies may be successful - lesssuccessful than closed treatment of the hip use of shoe lift, and later distal femoralepiphysiodesis to treat leg length difference;