Combined Technique for Draining Septic Arthritis of the Pediatric Hip Matthew J

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Combined Technique for Draining Septic Arthritis of the Pediatric Hip Matthew J. Smith, MD, Richard A. White, MD, and Barry J. Gainor, MD

Abstract sedimentation rate and white blood cell Technique Recent literature suggests that, count very likely has septic arthritis of A small, slightly oblique incision is in older children, acute cases of the hip.1,2 Diagnosis can be confirmed made centered over the femoral neck septic arthritis may be treated with joint aspiration, and symptom (Figure 1). with aspiration and intravenous duration may necessitate arthrotomy.3,4 A standard anterior approach to the antibiotics. However, when surgical decompression is required, The infected hip may be irrigat- hip is taken, and a portion of the joint the technique described in this ed and débrided several ways. In capsule is excised. report has several advantages. the past, the posterior approach was Any fluid is sampled for culture, It can be performed with an inci- used to expose the hip completely. and copious irrigation is used for sion of approximately 1 to 2 inches Some surgeons felt that the poste- lavage. and a posterior stab wound of <1 rior wound, packed open superfi- To maximize postoperative cm; it preserves anatomic planes cially, allows continued drainage of decompression, the surgeon passes a and poses less risk to the circumflex femoral vessels (as with the anterior approach); and it allows fluid to drain when the patient is supine (as with the posterior approach). “ [This] technique...has advantages of both anterior and posterior approaches.” eptic arthritis occurs in people of various ages and continues to be a potentially severe problem the hip with the child supine. The small clamp bluntly from the anteri- Sin the pediatric population. Untreated posterior approach, however, poses or arthrotomy through the posterior septic arthritis of the hip can be significant risks, including damage capsule, and just posterior to the glu- devastating. Sequelae include physis to the epiphyseal arteries leading to teus medius to tent the skin proximal destruction, epiphysis osteonecrosis, avascular necrosis, significant injury to the greater trochanter. osteomyelitis, leg-length discrepancy, to the abductors, and a large capsular A stab incision is made over and hip dislocation. defect that may increase risk for hip the clamp, and a gravity drain is Timely diagnosis and treatment are dislocation. In 1997, Rosenblatt and 5 important in maximizing outcomes. A Bennett found complications in 22 child with hip pain, fever, inability to of 33 hips drained through a posterior bear weight, and elevated erythrocyte approach but in 0 of 16 hips drained through an anterior approach. Most pediatric orthopedists pre- 6 Dr. Smith is Assistant Professor, Dr. White fer an anterior hip approach, which is Assistant Professor, and Dr. Gainor is offers rapid access to the capsule and Professor, Department of Orthopaedic preserves the musculature around the Surgery, University of Missouri, Columbia, joint. Risk for injury to the epiphyse- Missouri. al blood supply is also decreased with Requests for reprints: Richard A. White, the anterior approach. After surgery, a MD, Department of Orthopaedic Surgery, suction drain is generally required to University of Missouri, MC213, DC053.00, prevent accumulation of tissue fluid 1 Hospital Dr, Columbia, MO 65212 (tel, and inflammatory mediators from the 573-882-3104; fax, 573-882-1760; e-mail, inflamed synovium. [email protected]). In this report, we present a tech-

Am J Orthop. 2007;36(3):165-166. nique that can be performed quickly Copyright 2007, Quadrant HealthCom and that has advantages of both ante- Figure 1. Small anterior incision over Inc. rior and posterior approaches. femoral neck.

March 2007 165 Draining Septic Arthritis of the Pediatric Hip

Discussion References Recent literature suggests that, in 1. Kocher MS, Mandiga R, Murphy JM, et al. older children, acute cases of septic A clinical practice guideline for treatment of arthritis may be treated with aspi- septic arthritis in children: efficacy in improv- ration and intravenous antibiotics.2 ing process of care and effect on outcome of However, when surgical decom- septic arthritis of the hip. J Bone Joint Surg Am. 2003;85:994-999. pression is required, the technique 2. Kocher MS, Mandiga R, Zurakowski D, et described in this report has several al. Validation of a clinical prediction rule for advantages: the differentiation between septic arthritis It can be performed with an inci- and transient synovitis of the hip in children. sion of approximately 1 to 2 inches J Bone Joint Surg Am. 2004;86:1629- and a posterior stab wound of <1 1635. Figure 2. Passage of clamp cm; it preserves anatomic planes and 3. Wilson NI, Di Paola M. Acute septic arthritis in through incision and capsulotomy, poses less risk to the circumflex infancy and childhood. 10 years’ experience. through posterior capsule, and stab femoral vessels (as with the anterior J Bone Joint Surg Br. 1986;68:584-587. incision. Drain passed retrograde approach); and it allows fluid to drain 4. Herndon WA, Knauer S, Sullivan JA, Gross RH. Management of septic arthritis in children. into capsule. when the patient is supine (as with J Pediatric Orthop. 1986;6:576-578. the posterior approach). 5. Rosenblatt L, Bennett OM. The surgical passed retrograde into the capsule approach to acute septic arthritis of the (Figure 2). Authors’ Disclosure hip joint in childhood: a retrospective study. The drain is sutured into place Statement and Orthop Trans. 1997;21:79. posteriorly, and the anterior surgical Acknowledgments 6. Herring JA. Bone and joint infections. In: incision is loosely approximated with The authors report no actual or poten- Herring JA, ed. Tachdjian’s Pediatric polypropylene suture. The drain can tial conflicts of interest in relation to Orthopaedics. 3rd ed. Philadelphia, Pa: be removed in 48 hours. this article. Saunders; 2002:1841-1877.

166 The American Journal of Orthopedics®