This document discusses septic arthritis of the hip in children. It defines septic arthritis and notes that the hip is the most commonly infected joint in children. Early diagnosis and treatment is important to prevent joint damage. Signs include limping, groin pain, and limited hip movement. Treatment involves identifying the organism, administering sensitive antibiotics, and potentially surgery. Long term sequelae can include joint deformities, leg length discrepancies, and arthritis. Various classification systems and treatment approaches are presented. Prevention of septic arthritis through early diagnosis and management is emphasized.

1. Sequelae of Septic Arthritis Hip in
Children

2. Septic arthritis - Definition
 Hematogenous bacterial infection of the hip,
usually
 in infants or toddlers, with or without involvement
of
 the proximal femoral metaphysis.
 Synonym: Septic coxitis

3.  Hip - commonest septic joint
 condition during growth, reaching a distinct
peak in frequency during infancy.
 via hematogenous
 transmission, resulting in colonization of the
joint with bacteria
 in infants - occur from propagation of adjacent
proximal femoral osteomyelitis

4.  septic arthritis of the hip - a surgical
emergency
 diagnosis be made ASAP to prevent joint
damage;
 - then immediate arthrotomy, regardless of
the Graim Stain results;
 - younger child, more pressing is need
because of higher risk of permanent disability;

6.  Kocher criteria: (for child with painful hip)
- includes: non-weight-bearing on affect side,
sed rate greater than 40 mm/hr, fever, and a
WBC count of >12,000 mm3;
- when 4/4 criteria are met, there is a
99% chance that the child has septic arthritis;

- when 3/4 criteria are met, there is a
93% chance of septic arthritis;
 - when 2/4 criteria are met, there is a
40% chance of septic arthritis;
 - when 1/4 criteria are met, there is a
3% chance of septic arthritis;

7. Organisms
 Staph. Aureus,
 E coli,
 streptococci,
 klebsiella pneumoniae
 Acinetobacter.

8.  epiphyseal plate prevents infection from entering
joint 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 the
metaphysis to joint space;

9.  metaphysis of shoulder, hip, radial head, and
ankle remain intracapsular during early
childhood
 the hip joint seems especially prone to sepsis
from adjacent osteomyelitis
 synovial reflections over the metaphyseal
bone decrease with age;

10. Examination
 Limp
 pain in groin area that occasionally radiates
down the medial side of thigh;
- progressive accompanied by spasm of
the hip muscles
- hip in flexion and external rotation &
decreased internal rotation compared to the
normal hip
- patient resists all attempts to move hip;
- palpate the SI joint for local tenderness;

11. Differential diagnosis
 Acute osteomyelitis - tenderness and swelling
over the metaphysis
 Acute rheumatoid arthritis
 Transient synovitis
 Tuberculosis
 Acute rheumatic fever
 Cellulitis
 Haemarthrosis

12. Investigations
 synovial fluid exam (total cell count)
 C-reactive protein:
 ESR
 Joint aspiration
 X-ray, CT, MRI
 Ultrasound

13. Treatment
 Identify organism
 Sensitive antibiotics
 Prompt administration to prevent tissue damage
 Surgery - debridement

14. Detection of sequelae
 history, medical documentation, clinical
examination, radiographs, arthrography and
sonography.
 Head of femur- purely cartilaginous - more
susceptible to direct destructive activity of pus
& inflammatory products
 Increase in intracapsular pressure –
tamponade – AVN of head

15.  often diagnosed late- leading to irreversible
damage to the articular cartilage, blood supply to
the epiphysis
 absorption of head and neck,
 resulting in severe shortening and disability.

16. Hunka’s Classification
 Type I – Minimal Femoral Head changes
 Type IIA – femoral head deformity with a normal
growth plate
 Type IIB - femoral head deformity with growth
arrest
 Type III – Pseudoarthrosis of femoral neck

17.  Type IVA – complete destruction of proximal
femoral epiphysis, with a stable neck segment.
 Type IVB - complete destruction of proximal
femoral epiphysis, with an unstable neck
segment.
 Type V – Complete destruction of the head and
neck to the intertrochanteric line, with dislocation
of the hip

18. Goal of Management
 stabilizing the hip
 achieve normal function with no residual
deformity or disability
 improving the gait.
 not achieved even with the best of treatment

19. 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.

20.  Reconstructive operations delayed for months/
years after the infection has subsided.
 Reasons:
 The danger of reactivating the old infection is
reduced;
 Allows the status of the proximal femur and
femoral head to be definitely determined
 Allows strength and general character of the bone
to improve with time

21. Choi's classification
 Type IA: No residual deformity
 Type IB: mild coxa magna. It needs no
reconstruction.
 Type IIA: coxa brevia with deformed head
 TypeIIB: progressive coxa vara or coxa
valgus- asymmetric premature closure of
proximal femoral physis.
It needs surgical intervention to prevent
subluxation.

22.  Type IIIA: Slipping at femoral neck with severe
anteversion/retroversion
 Type IIIB: pseudoarthrosis - realignment
surgery for proximal femur or bone grafting.
 Type IVA: Destruction of the head and neck of
femur with the presence of remnant of medial
base of neck.
 Type IVB: Complete loss of femoral head &
neck
Complex clinical problems with limb length
inequality -needs reconstructive surgery

24. Complications
 dislocation, subluxation,
 acetabular dysplasia,
 coxa vara, coxa breva,
 absence of the head & neck of the femur, and
 degenerative (postinfectious) arthritis;

25. Hip stabilisation/Reconstruction
 Arthrodesis
 Pelvic osteotomy – Pemberton
Acetabuloplasty/salter/chiari
 Proximal femoral osteotomy - Schanz
 Trochanteric arthroplasty (Colonna) combined
with proximal femoral osteotomy

26.  Harmon or L'Episcopo reconstruction - new
femoral neck is fashioned to articulate with the
acetabulum .
 epiphyseodesis of the contralateral limb,
 lengthening of the ipsilateral tibia.

28.  Type I & IIA – Abduction orthosis initially,
observation till skeletal maturity
 Type IIB – Epiphysiodesis of remaining physis
with/without greater trochanteric physis
 Type IIIA – Femoral Osteotomy – correct version
and neck shaft angle
 Type IIIB – Osteotomy + bone grafting

29.  Type IV – Greater trochanteric arthrooplasty
 Femoral & acetabular osteotomy
 Arthrodesis
 Ilizarov hip reconstruction
 Microvascular reconstruction

30.  procedures performed at any stage are less
favorable than natural history of the deformity;
 - hip dislocation:
- infantile hip sepsis causes destruction of
the femoral head
high-riding dislocation and failure of acetabular
development.

31.  - leg length descrepancy
- the proximal femoral epiphysis may be
destroyed –LLD-3-4 inches;
- femoral lengthening should not be
attempted if hip stability is not present;
 if an acetabulum is present, surgical reduction
w/ trochanteric arthroplasty and pelvic
osteotomies may be successful - less
successful than closed treatment of the hip
 use of shoe lift, and later distal femoral
epiphysiodesis to treat leg length difference;

32. Prevention is better!!!