Access this article online Website: Editorial Commentary www.afrjpaedsurg.org DOI: 10.4103/0189-6725.93292 PMID: *** Septic arthritis of the hip joint in children is Quick Response Code: an emergency

Erich Rutz

I read with a great interest the article on “Septic hip transmission, resulting in a bacterial colonisation of dislocations in children in a developing country” the joint. published in the May-August 2011 issue 2 of the African Journal of Paediatric Surgery.[1] Septic arthritis in The crucial differentiation between septic arthritis children is always an emergency and it frequently affects and transient synovitis of the hip in children can be the joints of the lower extremity, namely the hip and difficult.[6] In 1999, Kocher et al.[7] introduced four knee.[2,3] Septic arthritis of the hip is a haematogenous positive predictive indicators (99.6%) of septic arthritis. bacterial infection, usually in infants and toddlers. It These include the following: is the commonest septic joint condition during growth, • fever (temperature ≥38.5°C) but in general all other joints can be affected.[4] Early • inability to bear weight diagnosis and treatment of septic arthritis of the hip is • white blood-cell count (WBC) > 12.0 x 109 cells/L, of utmost importance. A missed infection can destroy and the hip joint for lifetime. If the joint effusion and thus • erythrocyte sedimentation rate (ESR) ≥ 40 mm/hour the intra-articular pressure persists for several days or weeks a hip subluxation or even dislocation may occur. C-reactive protein (CRP) has been added later as a fifth Furthermore, any purulent effusion persisting more than predictor (CRP ≥20 mg/l). Transient synovitis of the four days in a joint will result in irreversible damage hip is the most common cause of hip pain in school- to the joint cartilage and the growth plates. The most age children. Conversely, septic arthritis of the hip common organisms implicated have been methicillin- is rare. Although recent studies have provided some sensitive Staphylococcus aureus, Streptococcus clinical prediction rules,[7] they are no substitute for pneumoniae and Haemophilus influenzae.[5] experience and good judgement. Careful history and physical examination also remain important. In septic The infection parameters are not always evident, arthritis, the child is usually sick, deteriorating by the especially in newborns. The infant is either very sick hour, and will not weight-bear on the involved side. as in cases of septicaemia, direct intervention toward A nearby pelvic osteomyelitis or psoas abscess may lifesaving acts, or shows only slight signs of infection mimic a septic hip. Other rare possible causes are as the temperature rises. Typical clinical findings and pelvic abscess, septic sacroiliac joint, appendicitis or signs are poor general condition of the child, severe some gynaecologic conditions. Immediate diagnostic pain when moving the joint, loss of weight bearing puncture is always necessary if septic arthritis is ability, limping and septic appearance of these young suspected. patients. The diagnosis can be often difficult in infants [8] since temperatures indicating sepsis may be absent. In a recently published paper, three different stages Careful clinical examination of the patient is essential of septic arthritis of the hip and treatment options were and a key point for successful treatment. The aetiology described: of the infection in childhood is a haematogenous • acute stage: short history and no radiologically visible complications Department of Pediatric Orthopaedic, University Children’s Hospital • recommended treatment: repeated arthroscopic Basle, Basle, Switzerland irrigation of the hip joint (if arthroscope is not Address for correspondence: available: use two wide cannulae) till no effusion Dr. Erich Rutz, or bacteria and clear fluid. Pediatric Orthopaedic Department, University Children’s Hospital Basle, CH-4005 Basle, Switzerland. • chronic stage: long history and radiologically visible E-mail: [email protected] complications (destruction or dislocation of the

African Journal of Paediatric Surgery January-April 2012 / Vol 9 / Issue 1 1 Rutz: Septic arthritis of the hip joint in children

femoral head) In all cases, if septic arthritis is suspected by clinical • recommended treatment: arthrotomy and examination and the findings of positive predictive exploration of the hip joint, irrigation and open factors such as fever, inability to weight bear, and – if reduction of the hip joint, no irrigation drain, spica available - abnormal blood results (ESR, WBC or CRP) cast in case of dislocation. immediate puncture of the hip joint is indicated.[2,7,9] • defective situation: widespread destruction of This should be performed by an experienced person the femoral head and neck, high riding greater who can perform the puncture in addition to the trochanter surgical revision by arthroscopy or arthrotomy since • recommended treatment: reconstructive surgery, no time should be lost. Septic arthritis of the hip joint but always difficult. in children is an emergency!

Antibiotic treatment should always be adapted after REFERENCES bacteriological testing, and WBC and CRP should be nd th th 1. Ngom G, Ngaringuem O, Munyali DA, Fall M, Ndour O, Ndoye checked on the 2 , 5 and 8 day. M. Septic hip dislocations in children in a developing country. Afr J Paediatr Surg 2011;8:190-3. Therefore, septic hip dislocation is a very difficult 2. Bennett OM, Namnyak SS. Acute septic arthritis of the hip joint in situation.[8] The authors of the article “Septic hip infancy and childhood. Clin Orthop Relat Res 1992;281:123-32. 3. Kang SN, Sanghera T, Mangwani J, Paterson JM, Ramachandran dislocation in children in a developing country” M. The management of septic arthritis in children: Systematic describe very nicely their experience from 1998 to review of the English language literature. J Bone Joint Surg Br 2006. During this period, 19 patients with septic hip 2009;91:1127-33. dislocation were included in the study. The mean 4. Michelotti F, Camathias C, Gaston M, Rutz E. Severe septic arthritis of the shoulder with an axillary nerve lesion in a 4-year-old child. follow-up was 5.2 years. Twelve patients suffered J Orthop Sci 2011;16:821-4. from late hip dislocations of more than 3 weeks. 5. Young TP, Maas L, Thorp AW, Brown L. Etiology of septic arthritis There were eight patients with good results (reduced in children: An update for the new millennium. Am J Emerg Med 2011;29:899-902. dislocation and no signs of inflammation) and 11 6. Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip patients with bad results (persisting dislocation and in children: The value of clinical prediction algorithms. J Bone Joint inflammatory syndrome). The good results related to Surg Br 2010;92:1289-93. seven recent dislocations and only one late dislocation. 7. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: An The poor results were demonstrated exclusively in evidence-based clinical prediction algorithm. J Bone Joint Surg Am late dislocations. The authors concluded that the 1999;81:1662-70. good results are related almost exclusively to recent 8. Rutz E, Brunner R. Septic arthritis of the hip - Current concepts. Hip Int 2009;19 Suppl 6:S9-12. dislocations, but arthrotomy and immobilisation must 9. Fabry G. Clinical practice: The hip from birth to adolescence. Eur be performed early. This paper shows very clearly J Pediatr 2010;169:143-8. that septic joint conditions in children require early diagnosis and treatment. Once the joint is affected, Cite this article as: Rutz E. Septic arthritis of the hip joint in children is an treatment is very difficult and good outcome is not emergency. Afr J Paediatr Surg 2012;9:1-2. guaranteed. Source of Support: Nil. Confl ict of Interest: None declared.

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