septic arthritis hip,

1. SEPTIC ARTHRITIS SEQUELAE
Dr Sabique
Junior Resident
Dept of Orthopaedics , GMC Calicut
Moderator – Dr Manoj kumar CV
Assistant professor , orthopaedics

2. Septic arthritis
• Pathologic microbial invasion of joint space f/b
inflamation
• Syn :
▫ Pyogenic arthritis
▫ Infective arthritis
▫ Suppurative arthritis

3. Pathogenesis
• Synovial inflammation
• Joint cavity is distended with neutrophil and
fibrin exudates
• Mesothelium lining of synovial mem is
destroyed, replaced by granulation tissue
• Articular erosion by chondrolysis occurs
• Subsequent growth plate damage, dislocation of
joint, avascular necrosis with bony or fibrous
ankylosis

4. • Vascular tamponade produced by increased
intra articular pressure is main cause for
avascular necrosis of Capital femoral epiphysis

5. Sequelae of septic arthritis
• Depends upon age of occurrence and delay in
treatment
• Neonates and infants, proximal femoral
epiphysis may not developed, if septic arthritis
untreated, leading to complete destruction and
unstable hip – TOM SMITHS’S ARTHRITIS

6. • Systemic sequelae
▫ Toxic shock syndrome , multi organ failure

7. • Orthopaedic sequelae
▫ Multifocal bone and joint sepsis
▫ Partial / complete joint destruction
▫ Bony / fibrous ankylosis
▫ Subluxation / dislocation leading to instability
▫ Fractures
▫ Growth arrest – limb length discrepancy
▫ Persistent infection
▫ Abscess

8. • Hip
▫ Coxa magna , coxa breva
▫ Coxa vara, coxa valga
▫ Soft tissue contracture , deformities
▫ Abductor insufficiency
▫ Pseudoarthrosis of neck of femur
▫ Pathological dislocation - joint instability
▫ Stiff hip – bony ankylosis
▫ Leg length discrepancy
▫ Acetabular dysplasia
▫ Pelvic abscess

9. Clinical features
• Asymptomatic
• Pain – fibrous ankylosis , abductor insufficiency
• Gait disturbances – shortening , abductor
insufficiency, contracture, joint ankylosis

10. Poor prognostic factors
1. Infection that occurred before 22 weeks of age
2. Prematurity
3. Symptoms lasted longer than 4 days
4. Delay in diagnosis (3days)

11. Classifications septic arthritis sequelae
of hip
1. HUNKA 1982
2. CHOI 1990
3. FORLIN AND MILANI 2008
4. JOHARI
5. EYRE BROOK

12. HUNKA CLASSIFICSTION

15. Choi classification
• Modification of hunka clasification
• Based on nature and extend of proximal femoral
involvement

17. Forlin and Milani classification
• Simpler
• Based on instability and destruction of proximal
femur

18. Johari classification
• Depend on stability of hip and presence of
capital femoral epiphysis

19. TREATMENT OF SEPTIC ARTHRITIS
SEQUELAE
• Need to be delayed
1. Danger of reactivation of old infection
2. Strength and general states of bone improves
with time
3. Status of proximal femur and femoral head
should be definitely determined
4. High chance of remodelling – minor
deformities getting corrected

20. Conservative
1. Moderate coxa magna
2. Coxa vara <100, coxa valga <150
3. Resolving avascular necrosis femoral head which
has not yet undergone major deformities
Abduction cast, bracing, traction
- Till reossification is considered sufficient for
unprotected weight bearing

21. Surgical management
1. To stabilise joint
2. To correct deformity
3. To equalize length
4. Retain mobility
5. Relieve pain if present and minimize the risk of
pain developing later

22. To stabilise hip
• Arthodesis
• Pelvic osteotomies
• Proximal femoral osteotomies
• Trochanteric arthroplasty
• Harmon or L’episcopo reconstruction

23. To correct deformity
• Realignment / Derotation Osteotomies
• Flexion adduction contracture
▫ Soft tissue release /adductor tenotomy
• Ankylosed in flexion and adduction
▫ Intertrochanteric osteotomy fixing hip in 300
flexion and 200-300 abduction

24. To equalize length
• Soft tissue release
• Osteotomies
• Epiphysiodesis of other limb (for anticipated
discrepency of 2.5-5 cm)
• Lengthening of involved limb (discrepancy > 5-
6cm ) – Ilizarov’s

25. To stabilise hip
TROCHANTERIC ARTHROPLASTY
• Described by colonna
• Trochanter placed into acetabulum
• Abductors transferred distally
• Femur angulated
• Unsatisfactory in 1/3rd patients below 6yr and
virtually all patients above 6yr

28. Harmon or L’Episcopo reconstruction
• Head is destroyed but remnant of neck covered
by unossified hyaline cartilage
• Upper end of femur split in sagittal plane and
medial fragment is angulated

30. Pelvic osteotomies
• Salters osteotomy
• Chiari osteotomy
• Pemberton osteotomy
• Degas osteotomy
• Provides supports for the proximal femur when
head and neck is absorbed

31. Proximal femoral osteotomy
SCHANZ OSTEOTOMY
• Angulation at ischial tuberosity level
• Turn Shaft from adducted to abducted position
• Useful when remnant of neck which remain in
acetabulum is large enough
• Decrease lurch and increase functional limb
length.

33. Pelvis support osteotomy
• Double level femoral osteotomy
• Eliminates trendelenberg and short limb gait in
young adults with unstable hip
• 1. Proximal valgus extension osteotomy at the
level where femur abuts pelvis
• 2. Distal osteotomy to restore the limb
alignment bringing knee and ankle joint lines in
coronal plane

35. To correct deformity
• Intertrochanteric varus osteotomy – coxa valga
• Valgus osteotomy
• Derotation osteotomy

37. To Releive pain
• If a near normal relationship between femoral
head and acetabulum cannot be restored and if
movement of hip produces pain
1. Arthrodesis – abolish movement at hip
2. Excise deformed femoral head remnant

38. EXCISION OR GIRDLESTONE
ARTHROPLASTY
• Excision of head and neck upto intertrochanteric
line
• Remove infection, relieve pain, good range of
motion
• Instability, shortening avg of 3.5cm, limping

39. ARTHRODESIS
• Provide stable painless hip
• 300 flexion, 0-50 abduction, 150 external rotation
• Abbot and Fischer arthrodesis – 3 stage
▫ Deformity correction - traction
▫ Arthrodesis in 450 abduction
▫ Final positioning with subtrochanteric osteotomy

40. ILIZAROV’S HIP RECONSTRUCTION
• Includes
▫ Proximal femoral pelvic support osteotomy
▫ Gradual distraction at distal femoral osteotomy
• Addresses
▫ Hip stability
▫ Abductor insufficiency
▫ Limb length discrepancy

43. Total hip arthroplasty
• Definite procedure after skeletal maturity
• Loosening, failure, dislocation, fracture,
infection
• Excessive scarring, wasting and inadequate soft
tissue cover, malalignment and component
mismatch
• ILIOFEMORAL DISTRACTION AND TOTAL
HIP ARTHROPLASTY

45. Choi classification
• Modification of hunka clasification
• Based on nature and extend of proximal femoral
involvement

48. Management algorithm according to
choi classification
• Type 1A – Observation
• Type 1B – Individualise containment
• Type 2A – containment (pelvic osteotomy),
trochanteric epiphysiodesis in childhood or
trochanteric advancement at skeletal maturity
• Type 2B – realignment femoral osteotomy +
growth arrest of PFE to prevent recurrence +
contralateral epiphysiodesis

49. • Type 3A – realignment femoral osteotomy with
derotation component
• Type 3B – valgus osteotomy + bone grafting
• Type 4A - <6yr – harmon operation, distal
tansfer of GT and abductors
>6yr – treat like type 4 B
• Type 4B - <6yr – trochanteric arthroplasty +
varus osteotomy + acetabuloplasty
>6yr – Ilizarov’s reconstruction
osteotomy

51. Take home
• Septic arthritis is an emergency – life threatening
as well as crippling
• Early diagnosis and intervention halt progression
of disease enabling normal life
• Prevention of complications and sequelae should be
prioritized.
• Sequelae – appropriate and timely intervention
aiming at a PAINLESS, STABLE and MOBILE
JOINT

52. Referance
• Campell’s operative orthopaedic
• Tachdjian’s paeditric orthopaedics
• Pediatric orthopedic deformities – Frederic shapiro
• Essential orthopaedics – varshney
• Paediatric orthopaedics – benjamin joseph
• Pathogenesis and sequels septic arthritis of hip in
children – Balaji zacharia
• Management of sequelae of septic arthritis – dr greg
firth
• Davangere notes
• Internet

53. • Thank u