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!!!