Transcript of Septic arthritis sequelae
- 1. Sequelae of Septic Arthritis Hip inChildren
- 2. Septic arthritis - Definition Hematogenous bacterial
infection of thehip, usually in infants or toddlers, with or
without involvementof the proximal femoral metaphysis. Synonym:
Septic coxitis
- 3. Hip - commonest septic joint condition during growth,
reaching a distinctpeak in frequency during infancy. via
hematogenous transmission, resulting in colonization of thejoint
with bacteria in infants - occur from propagation of
adjacentproximal femoral osteomyelitis
- 4. septic arthritis of the hip - a surgicalemergency diagnosis
be made ASAP to prevent jointdamage; - then immediate arthrotomy,
regardless ofthe Graim Stain results; - younger child, more
pressing is needbecause 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 aWBC count of >12,000 mm3;- when 4/4 criteria are
met, there is a99% chance that the child has septic arthritis;-
when 3/4 criteria are met, there is a93% chance of septic
arthritis; - when 2/4 criteria are met, there is a40% chance of
septic arthritis; - when 1/4 criteria are met, there is a3% chance
of septic arthritis;
- 6. Organisms Staph. Aureus, E coli, streptococci, klebsiella
pneumoniae Acinetobacter.
- 7. epiphyseal plate prevents infection from enteringjoint 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 themetaphysis to joint space;
- 8. metaphysis of shoulder, hip, radial head, andankle remain
intracapsular during earlychildhood the hip joint seems especially
prone to sepsisfrom adjacent osteomyelitis synovial reflections
over the metaphysealbone decrease with age;
- 9. Examination Limp pain in groin area that occasionally
radiatesdown the medial side of thigh;- progressive accompanied by
spasm ofthe hip muscles- hip in flexion and external rotation
&decreased internal rotation compared to thenormal hip- patient
resists all attempts to move hip;- palpate the SI joint for local
tenderness;
- 10. Differential diagnosis Acute osteomyelitis - tenderness and
swellingover 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,
clinicalexamination, radiographs, arthrography andsonography. Head
of femur- purely cartilaginous - moresusceptible to direct
destructive activity of pus& inflammatory products Increase in
intracapsular pressure tamponade AVN of head
- 14. often diagnosed late- leading to irreversibledamage to the
articular cartilage, blood supply tothe epiphysis absorption of
head and neck, resulting in severe shortening and disability.
- 15. Hunkas Classification Type I Minimal Femoral Head changes
Type IIA femoral head deformity with a normalgrowth plate Type IIB
- femoral head deformity with growtharrest Type III Pseudoarthrosis
of femoral neck
- 16. Type IVA complete destruction of proximalfemoral epiphysis,
with a stable neck segment. Type IVB - complete destruction of
proximalfemoral epiphysis, with an unstable necksegment. Type V
Complete destruction of the head andneck to the intertrochanteric
line, with dislocationof the hip
- 17. Goal of Management stabilizing the hip achieve normal
function with no residualdeformity 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 isreduced; Allows the status of the proximal femur
andfemoral head to be definitely determined Allows strength and
general character of the boneto improve with time
- 20. Chois classification Type IA: No residual deformity Type
IB: mild coxa magna. It needs noreconstruction. Type IIA: coxa
brevia with deformed head TypeIIB: progressive coxa vara or
coxavalgus- asymmetric premature closure ofproximal femoral
physis.It needs surgical intervention to preventsubluxation.
- 21. Type IIIA: Slipping at femoral neck with
severeanteversion/retroversion Type IIIB: pseudoarthrosis -
realignmentsurgery for proximal femur or bone grafting. Type IVA:
Destruction of the head and neck offemur with the presence of
remnant of medialbase of neck. Type IVB: Complete loss of femoral
head &neckComplex clinical problems with limb lengthinequality
-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 PembertonAcetabuloplasty/salter/chiari Proximal femoral
osteotomy - Schanz Trochanteric arthroplasty (Colonna) combinedwith
proximal femoral osteotomy
- 24. Harmon or LEpiscopo reconstruction - newfemoral neck is
fashioned to articulate with theacetabulum . 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
physiswith/without greater trochanteric physis Type IIIA Femoral
Osteotomy correct versionand 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 lessfavorable than
natural history of the deformity; - hip dislocation:- infantile hip
sepsis causes destruction ofthe femoral headhigh-riding dislocation
and failure of acetabulardevelopment.
- 28. - leg length descrepancy- the proximal femoral epiphysis
may bedestroyed LLD-3-4 inches;- femoral lengthening should not
beattempted if hip stability is not present; if an acetabulum is
present, surgical reductionw/ trochanteric arthroplasty and
pelvicosteotomies may be successful - lesssuccessful than closed
treatment of the hip use of shoe lift, and later distal
femoralepiphysiodesis to treat leg length difference;
- 29. Prevention is better!!!