Septic arthritis sequelae

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;

5. 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;

6. Organisms Staph. Aureus, E coli, streptococci, klebsiella pneumoniae Acinetobacter.

7. 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;

8. 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;

9. 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;

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

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

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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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.

21. 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

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

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

24. 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.

25. 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

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

27. 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.

28. - 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;

29. Prevention is better!!!