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Septic arthritis sequelae

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    Septic arthritis sequelae Septic arthritis sequelae Presentation Transcript

    • Sequelae of Septic Arthritis Hip inChildren
    • 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;
    • Differential diagnosis Acute osteomyelitis - tenderness and swellingover the metaphysis Acute rheumatoid arthritis Transient synovitis Tuberculosis Acute rheumatic fever Cellulitis Haemarthrosis
    • Investigations synovial fluid exam (total cell count) C-reactive protein: ESR Joint aspiration X-ray, CT, MRI Ultrasound
    • 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;
    • Hip stabilisation/Reconstruction Arthrodesis Pelvic osteotomy – PembertonAcetabuloplasty/salter/chiari Proximal femoral osteotomy - Schanz Trochanteric arthroplasty (Colonna) combinedwith proximal femoral osteotomy
    •  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;
    • Prevention is better!!!