SURGICAL TECHNIQUES PEDIATRIC 2023, Jun, 14 | 12:00 am

Pediatric Septic Hip Arthritis: What You Need to Know

Pediatric septic hip arthritis is a serious condition that occurs when bacteria infect the hip joint of a child. It can cause severe pain, swelling, redness and fever, and may lead to permanent damage to the joint or even life-threatening complications if not treated promptly. In this blog post, we will explain what causes pediatric septic hip arthritis, how it is diagnosed and treated, and what are the possible outcomes and complications.

What causes pediatric septic hip arthritis?

Pediatric septic hip arthritis is usually caused by bacteria that enter the bloodstream from another source of infection, such as a skin wound, an ear infection or a respiratory infection. The bacteria then travel to the hip joint and multiply there, causing inflammation and pus formation. The most common bacteria that cause pediatric septic hip arthritis are:
• Staphylococcus aureus, which is found on the skin and in the nose of many people. It can cause skin infections, abscesses, pneumonia and toxic shock syndrome. It is also the most common cause of pediatric septic hip arthritis in children over 2 years of age1.
• Group B streptococcus, which is found in the vagina and rectum of some pregnant women. It can cause serious infections in newborns, such as meningitis, pneumonia and sepsis. It is also the most common cause of pediatric septic hip arthritis in infants who acquire it during birth1.
• Neisseria gonorrhoeae, which is a sexually transmitted infection that can cause urethritis, cervicitis, pelvic inflammatory disease and infertility. It can also cause disseminated gonococcal infection, which involves multiple joints, skin lesions and fever. It is still the most common cause of pediatric septic hip arthritis in adolescents1.
• Group A beta-hemolytic streptococcus, which is a common cause of strep throat, scarlet fever and rheumatic fever. It can also cause invasive infections such as necrotizing fasciitis, toxic shock syndrome and septic arthritis. It is the most common cause of pediatric septic hip arthritis following varicella (chickenpox) infection1.
• HACEK organisms, which are a group of bacteria that live in the mouth and throat. They include Haemophilus, Actinobacillus, Cardiobacterium, Eikenella and Kingella. They can cause endocarditis (infection of the heart valves), meningitis and septic arthritis. Kingella kingae is especially common in children under 4 years of age12.
Some factors that increase the risk of pediatric septic hip arthritis are:
• Prematurity
• Cesarean section
• Treatment in the neonatal intensive care unit
• Invasive procedures such as umbilical catheterization, venous catheterization or heel puncture
• Immunocompromise or immunosuppression
• Recent use of antibiotics

How is pediatric septic hip arthritis diagnosed?

Pediatric septic hip arthritis can be difficult to diagnose because it can mimic other conditions such as transient synovitis (a benign inflammation of the joint), osteomyelitis (a bone infection), trauma or rheumatic diseases. However, early diagnosis is crucial to prevent irreversible damage to the joint or systemic complications.
The diagnosis of pediatric septic hip arthritis is based on:
• Clinical history and physical examination: The child may have a history of fever, malaise, irritability or reduced appetite. The child may also have a history of recent infection or trauma. The affected joint may be swollen, red, warm and tender to touch. The child may refuse to move or bear weight on the affected limb. The child may also have signs of systemic infection such as tachycardia (fast heart rate), tachypnea (fast breathing rate) or hypotension (low blood pressure).
• Laboratory tests: Blood tests may show elevated levels of white blood cells (leukocytosis), inflammatory markers (such as C-reactive protein or erythrocyte sedimentation rate) or procalcitonin (a marker of bacterial infection). Blood cultures may identify the causative organism in some cases. However, up to 55% of cases may have negative blood cultures1. A joint aspiration (removing fluid from the joint with a needle) is the definitive test to confirm the diagnosis. The joint fluid may show increased white blood cells (especially neutrophils), decreased glucose, increased protein and positive cultures for bacteria. However, joint aspiration may be technically difficult or contraindicated in some cases, such as when the joint is very small or when there is a risk of bleeding.
• Imaging tests: X-rays may show signs of joint effusion (fluid accumulation), soft tissue swelling or bone erosion. However, these signs may not be evident in the early stages of the infection. Ultrasound may show joint effusion, synovial thickening or abscess formation. It can also guide the joint aspiration procedure. Magnetic resonance imaging (MRI) may show more detailed information about the joint and surrounding tissues, such as cartilage damage, bone marrow edema or osteomyelitis. However, MRI is expensive, time-consuming and requires sedation in young children.

How is pediatric septic hip arthritis treated?

Pediatric septic hip arthritis is considered a surgical emergency and requires prompt recognition and treatment. The main goals of treatment are:
• Antibiotic therapy: The child should receive intravenous antibiotics as soon as possible after the diagnosis is suspected or confirmed. The choice of antibiotics depends on the age of the child, the suspected or identified organism, the local resistance patterns and the allergy history. The most common antibiotics used are:
o First-generation cephalosporins (such as cefazolin or cephalexin), which are effective against most gram-positive bacteria, including S. aureus and group B streptococcus.
o Clindamycin, which is effective against most gram-positive bacteria, including MRSA and group A beta-hemolytic streptococcus. It also has anti-toxin properties that may reduce the inflammation and tissue damage caused by some bacteria.
o Vancomycin, which is effective against MRSA and other resistant gram-positive bacteria. It is used in areas with high rates of clindamycin- and methicillin-resistant S. aureus or in cases of severe infection or allergy to other antibiotics.
o Third-generation cephalosporins (such as ceftriaxone or cefotaxime), which are effective against most gram-negative bacteria, including E. coli and N. gonorrhoeae.
o Aminoglycosides (such as gentamicin or tobramycin), which are effective against some gram-negative bacteria, especially Pseudomonas aeruginosa. They are usually used in combination with other antibiotics.
o Penicillin, which is effective against N. gonorrhoeae and some group A beta-hemolytic streptococcus strains.
The duration of antibiotic therapy depends on the clinical response, the laboratory results and the imaging findings. A typical course is 2–4 days of intravenous antibiotics followed by 2 weeks of oral antibiotics1. However, longer courses may be required in complicated cases, such as when there is osteomyelitis, abscess formation or poor response to treatment.
• Surgical drainage: The child should undergo surgical drainage of the infected joint as soon as possible after the diagnosis is confirmed or strongly suspected. The surgical procedure involves making a small incision over the joint, inserting a needle or a trocar into the joint space, aspirating the pus and irrigating the joint with saline solution. The procedure may be repeated several times until the joint fluid is clear. The joint may be left open with a drain or closed with sutures depending on the surgeon’s preference and the condition of the joint. The surgical drainage helps to reduce the pressure within the joint, remove the bacteria and inflammatory debris, improve the blood flow to the joint and enhance the penetration of antibiotics into the joint.

What are the possible outcomes and complications?

The prognosis of pediatric septic hip arthritis depends on several factors, such as:
• The age of the child
• The type and virulence of the organism
• The duration and severity of the infection
• The timeliness and adequacy of treatment
• The presence of comorbidities or immunodeficiency
With early diagnosis and treatment, most children recover completely without any sequelae1. However, some children may develop complications such as:
• Osteonecrosis (death of bone tissue) of the femoral head, which may lead to collapse and deformity of the hip joint
• Osteoarthritis (degeneration of cartilage) of the hip joint, which may cause pain, stiffness and reduced mobility
• Growth disturbance of the femoral head or neck, which may cause leg length discrepancy or angular deformity
Recurrent infection of the ssam joint or other joints1. Recurrent infection may be due to incomplete eradication of the bacteria, persistent focus of infection elsewhere in the body, immunodeficiency or resistance to antibiotics.
The long-term outcome of pediatric septic hip arthritis depends on the extent of joint damage and the development of complications. Some children may have normal joint function and no symptoms after recovery. However, some children may have chronic pain, stiffness, reduced mobility, leg length discrepancy or deformity of the hip joint. These children may require further surgical interventions such as osteotomy (cutting and realigning the bone), arthroplasty (replacing the joint) or arthrodesis (fusing the joint).

How can pediatric septic hip arthritis be prevented?

Pediatric septic hip arthritis is a potentially preventable condition. Some measures that may help to prevent it are:
• Vaccination: Vaccines can protect against some of the bacteria that cause pediatric septic hip arthritis, such as S. pneumoniae, H. influenzae type b and N. meningitidis. Children should receive the recommended vaccines according to their age and health status.
• Hygiene: Good hygiene practices can reduce the risk of skin infections and transmission of bacteria, such as washing hands frequently, keeping wounds clean and covered, avoiding sharing personal items and avoiding contact with people who have infections.
• Prompt treatment: Any infection or trauma that may cause bacteremia (bacteria in the blood) should be treated promptly and appropriately with antibiotics or other measures. Any signs or symptoms of joint infection should be reported to a doctor immediately for evaluation and treatment.

Conclusion

Pediatric septic hip arthritis is a serious condition that requires early diagnosis and treatment to prevent irreversible damage to the joint or life-threatening complications. The most common cause is S. aureus, but other bacteria may also be involved depending on the age and risk factors of the child. The diagnosis is based on clinical history, physical examination, laboratory tests and joint aspiration. The treatment consists of antibiotic therapy and surgical drainage of the infected joint. The prognosis depends on several factors, such as the type and virulence of the organism, the duration and severity of the infection, the timeliness and adequacy of treatment and the presence of comorbidities or immunodeficiency. Some children may recover completely without any sequelae, but some children may develop complications such as osteonecrosis, osteoarthritis, growth disturbance or recurrent infection. Pediatric septic hip arthritis can be prevented by vaccination, hygiene and prompt treatment of infections or traumas that may cause bacteremia.
 

 summary:

 
Pediatric septic hip arthritis is a condition that occurs when bacteria infect the hip joint of a child. It can cause severe pain, swelling, redness and fever, and may lead to permanent damage to the joint or even life-threatening complications if not treated promptly. The most common cause is Staphylococcus aureus, but other bacteria may also be involved depending on the age and risk factors of the child. The diagnosis is based on clinical history, physical examination, laboratory tests and joint aspiration. The treatment consists of antibiotic therapy and surgical drainage of the infected joint. The prognosis depends on several factors, such as the type and virulence of the organism, the duration and severity of the infection, the timeliness and adequacy of treatment and the presence of comorbidities or immunodeficiency. Some children may recover completely without any sequelae, but some children may develop complications such as osteonecrosis, osteoarthritis, growth disturbance or recurrent infection. Pediatric septic hip arthritis can be prevented by vaccination, hygiene and prompt treatment of infections or traumas that may cause bacteremia.

References

1. Krogstad P. Osteomyelitis and septic arthritis. In: Feigin RD, Cherry JD, editors. Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Saunders; 2009. pp. 725–748. [Google Scholar]
2. Pääkkönen M, Peltola H. Management of a child with suspected acute septic arthritis. Arch Dis Child. 2012;97(3):287–292. [PubMed] [Google Scholar]
3. Yagupsky P. Kingella kingae: carriage, transmission, and disease. Clin Microbiol Rev. 2015;28(1):54–79. [PMC free article] [PubMed] [Google Scholar]
4. Pääkkönen M, Kallio MJ, Lankinen P, Peltola H, Kallio PE. Preceding trauma in childhood hematogenous bone and joint infections. J Pediatr Orthop B. 2014;23(2):196–199. [PubMed] [Google Scholar]
5. Ju KL, Zurakowski D, Kocher MS. Differentiating between methicillin-resistant and methicillin-sensitive Staphylococcus aureus osteomyelitis in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 2011;93(18):1693–1701. [PubMed] [Google Scholar]
6. Yagupsky P, Dubnov-Raz G, Gené A, Ephros M, Israeli-Spanish Kin-gella kingae Research Group Differentiating Kingella kingae septic arthritis of the hip from transient synovitis in young children. J Pediatr. 2014;165(5):985–989. [PubMed] [Google Scholar]
7. Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. J Bone Joint Surg Br. 2010;92(9):1289–1293. [PubMed] [Google Scholar]
8. Pääkkönen M, Kallio MJ, Kallio PE, Peltola H. Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections. Clin Orthop Relat Res. 2010;468(3):861–866. [PMC free article] [PubMed] [Google Scholar]
9. Lyon RM, Evanich JD. Culture-negative septic arthritis in children. J Pediatr Orthop. 1999;19(5):655–659. [PubMed] [Google Scholar]
10. Peltola H, Pääkkönen M, Kallio P, Kallio MJ, OM-SA Study Group Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood – a prospective quasi-randomized controlled trial. Clin Microbiol Infect. 2012;18(6):582–589. [PubMed] [Google Scholar]
11. Liu C, Bayer A, Cosgrove SE, et al.Infectious Diseases Society of America Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18–e55. [PubMed] [Google Scholar]
12. Mera RM, Miller LA, Amrine-Madsen H, Sahm DF. Impact of new clinical testing laboratory standards institute Streptococcus pneumoniae penicillin susceptibility testing breakpoints on reported resistance changes over time. Microb Drug Resist. 2011;17(1):47–52. [PubMed] [Google Scholar]
13. Peltola H, Kallio MJT, Unkila-Kallio L. Reduced incidence of septic arthritis in children by Haemophilus influenza type-b vaccination. Implications for treatment. J Bone Joint Surg Br. 1998;80(3):471–473. [PubMed] [Google Scholar]
14. Saphyakhajon P, Joshi AY, Huskins WC, Henry NK, Boyce TG. Empiric antibiotic therapy for acute osteoarticular infections with suspected methicillin-resistant Staphylococcus aureus or Kingella. Pediatr Infect Dis J. 2008;27(8):765–767. [PubMed] [Google Scholar]
15. Sherman JW, Conte JE., Jr Ceftriaxone treatment of multidrug-resistant salmonella osteomyelitis. Am J Med. 1987;83(1):137–138. [PubMed] [Google Scholar]
16. Bradley JS, Jackson MA, Committee on Infectious Diseases. American Academy of Pediatrics The use of systemic and topical fluoroquino-lones. Pediatrics. 2011;128(4):e1034–e1045. [PubMed] [Google Scholar]
17. Peltola H, Pääkkönen M, Kallio P, Kallio MJ, Osteomyelitis-Septic Arthritis (OM-SA) Study Group Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis. Clin Infect Dis. 2009;48(9):1201–1210. [PubMed] [Google Scholar]
18. Peltola H, Pääkkönen M. Acute osteomyelitis in children. N Engl J Med. 2014;370(4):352–360. [PubMed] [Google Scholar]
19. Fogel I, Amir J, Bar-On E, Harel L. Dexamethasone therapy for septic arthritis in children. Pediatrics. 2015;136(4):e776–e782. [PubMed] [Google Scholar]
20. Carrillo-Marquez MA, Hulten KG, Hammerman W, Mason EO, Kaplan SL. USA300 is the predominant genotype causing Staphylococcus aureus septic arthritis in children. Pediatr Infect Dis J. 2009;28(12):1076–1080. [PubMed] [Google Scholar]
21. Ilharreborde B. Sequelae of pediatric osteoarticular infection. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S129–S137. [PubMed] [Google Scholar]
22. Givon U, Liberman B, Schindler A, Blankstein A, Ganel A. Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations. J Pediatr Orthop. 2004;24(3):266–270. [PubMed] [Google Scholar]
23. Pääkkönen M, Kallio MJ, Peltola H, Kallio PE. Pediatric septic hip with or without arthrotomy: retrospective analysis of 62 consecutive nonneonatal culture-positive cases. J Pediatr Orthop B. 2010;19(3):264–269. [PubMed] [Google Scholar]
24. Agout C, Lakhal W, Fournier J, de Bodman C, Bonnard C. Arthroscopic treatment of septic arthritis of the knee in children. Orthop Traumatol Surg Res. 2015;101(8 Suppl):S333–S336. [PubMed] [Google Scholar]
25. Edmonds EW, Lin C, Farnsworth CL, Bomar JD, Upasani VV. A medial portal for hip arthroscomy in children with septic arthritis: a safety study. J Pediatr Orthop. 2016 Sep 3; Epub. [PubMed] [Google Scholar]
26. Lavy CB. Septic arthritis in Western and sub-Saharan African children – a review. Int Orthop. 2007;31(2):137–144. [PMC free article] [PubMed] [Google Scholar]
 

  • Pediatric septic hip arthritis
  • Hip joint infection
  • Staphylococcus aureus
  • Antibiotic therapy
  • Surgical drainage