Case Report

SEPTIC ARTRITIS IN PRETERM NEONATES

By:
Ni Putu Mayasri Wulandari

Supervisor:
Dr. I Wayan Dharma Artana, Sp.A(K)
Dr. Made Sukmawati, Sp.A
Dr. I Wayan Subawa, Sp.OT

Department of Child Health Medical School

Udayana University
Sanglah Hospital
Denpasar
2014

SEPTIC ARTRITIS IN PRETERM NEONATES

*Ni Putu Mayasri Wulandari, * I.W. Dharma Artana, *Made Sukmawati, ** I Wayan Subawa
Department of Child Health*, Orthopedic Surgery**
Medical School of Udayana University, Sanglah Hospital
ABSTRACT
Acute septic artritis in infancy and childhood is uncommon condition, the joint most commonly
involved are the hip in infants and the knee or shoulder joint in older childen. In neonates, typical
symptoms and signs of hip infection can be unclear or absent, which makes the diagnosis
particularly difficult. It has an ongoing importance because of its sequele. Delayed or inadequate
treatment can result joint destruction. Therefore, early diagnosis as well as prompt and effective
treatment are essential for avoiding severe outcomes
We report a case of hip septic arthritis. A preterm neonate was treated with hyalin membrane
disease grade 1 and clinically sepsis. On 1 month age, there were a swelling in right hip region
that make very restricted movement of right lower extremity. The X-ray of right hip joint
revealed widening of right hip joint with suspicion of joint effusion, and ultrasound examination
showed widening joint space of right hip joint 0,86 cm and joint effusion with maximal thickness
0,48 cm. Patient treated with immobilization of right hip joint and first line antibiotic
intravenously for 3 weeks with good result and no complication until discharge from hospital
Keywords: septic arthritis, neonates

INTRODUCTION
Septic arthritis is a bacterial infection of the synovium and subsequently of all the structures
within the joint, which causes an intense inflammatory reaction, possibly leading to destruction
of the articular cartilage and later of the complete joint. Most cases occur by haematogenous
dissemination of bacteria, and only a few cases by direct inoculation of pathogens. It usually
affects infants and toddlers.1 The joint most commonly involved are the hip in infants and the
knee or shoulder joint in older childen. Ussually only one joint affected, and about 10 percent of
patient have more than one joint involved.2,3
Acute septic artritis in infancy and childhood is uncommon condition, the incidence
approximately range from 5-12 cases per 100.000 person-years. In South Africa the incidence of
hip septic artritis in pediatric estimated to be 1 : 20.000. Approximately one-third of the patients
with septic artritis are children younger than 2 years age.

1,4

Eventhough septic artritis is a rare

disease, it has an ongoing importance because of its sequele. Delayed or inadequate treatment
can result joint destruction, especially when the hip joint of an infant is involved. Therefore,
early diagnosis as well as prompt and effective treatment are essential for avoiding severe
outcomes.2,4 There are significant differences between infection occuring in infancy and that in
the older children. Neonatal disease, being the more frequent, the more deceptive in presentation
and the more devastating merits spesial attention.2
The most common causative organism of septic artritis in all age groups is
Staphylococcus aureus.3 A joint becomes infected when an infectious agent enters the synovium.
The main routes by which pathogens accumulate in the joints are the following: (a)
haematogenously, with the consequent lodging of the pathogen in synovial capillaries; (b)
infected contiguous foci; (c) neighboring soft-tissue sepsis; and (d) by direct inoculation due to
trauma or an iatrogenic event, such as diagnostic or therapeutic arthrocentesis or joint surgery.

4,5

The synovium is a well-vascularised structure with no limiting basement plate, and this allows
easy access by bacteria. Once bacteria reach the joint space, the low fluid shear conditions allow
bacterial adherence and infection. In addition, the production of host matrix proteins may
promote the attachment of bacteria and the progression of the infection. Following colonization
of the synovial fluid (SF), bacteria proliferate rapidly and generate an acute inflammatory
response.4,6

Children with septic arthritis of the hip may present a variety of clinical symptoms.
Systemic symptoms such as fever, malaise and poor appetite are often seen. In neonates typical
symptoms and signs of hip infection can be unclear or absent, which makes the diagnosis
particularly difficult.1 Toddlers may complain of a spontaneous onset of progressive hip, groin or
thigh pain, demonstrate a limp or abnormal gait, or refuse to bear weight. Often the affected limb
is held in a relieving posture (slightly flexed, externally rotated and abducted to reduce
intracapsular pressure. While infant will show symptom such as swelling, warmth, erythema and
pain on palpation or passive movement of the hip, unilateral edema, lack of active movement of
the leg, asymmetrical buttock crease, and abnormal posture of the leg.1,2,5,7
The risk factors for this disease include prematurity, respiratory distress syndrome, low
birth weight (<1,500 g), parenteral nutrition, invasive procedures such as femoral venipuncture,
and umbilical catheterization.7 The definitive diagnosis of septic arthritis is made by direct
demonstration of bacteria in the synovial fluid or after culture of the pathogen. The diagnosis is
based, in most cases, on clinical symptoms and a detailed history, a careful examination and test
results. Blood tests show increased levels of erythrocyte sedimentation rate (ESR), C-reactive
protein (CRP) and white blood cell count (WBC). However, the absence of elevated acute-phase
reactants does not exclude the diagnosis of septic arthritis. Radiographs of the affected site are
usually quite helpful. Distension of the joint capsule and increased opacity within the joint,
displacement of muscle surrounding the joint by the capsular distension, increased distance
between the subchondral ends of bone and occasionally subluxation of the joint are frequently
evident early in the course of the disease. Ultrasonography is useful for detecting fluid effusions
as low as 12 ml and for examining otherwise inaccessible joints, such as the hip. Aspiration of
SF from a swollen joint is mandatory for establishing the correct diagnosis. In septic arthritis, the
SF usually has a turbid appearance with a WBC > 50,000/mm3. Low joint-fluid glucose levels
(<40 mg dL or less than half the serum glucose concentration) and high lactate levels are
frequent findings in septic arthritis.4
There are three principles management to perform: first, the joint must be adequately
drained; second, antibiotics must be given to diminish the systemic effects of sepsis; and third,
the joint must be rested in a stable position. Early antibiotic treatment should be based on clinical
presentation, patient history, and organisms likely to be involved and Gram-staining results.
Successful management of septic arthritis also includes prompt removal of purulent material

from the joint space. It has been suggested that needle aspiration is preferable as compared with
surgical treatment as an initial mode of drainage. Moreover, needle aspiration during the first 7
days of treatment has been demonstrated to be a successful treatment. Decreased SF volume and
a lower WBC with a smaller percentage of polymorphonuclear leucocytes indicate that the
treatment was effective. When needle aspiration is incomplete and the effusion persists beyond 7
days, it is necessary to perform an arthroscopy or open drainage. Arthroscopy is useful and less
invasive than open surgery for accessing deep joints such as the hip. Arthrotomy should be
performed in clinical situations when urgent decompression is required to relieve neuropathy or
compromised blood supply, when conservative drainage techniques have failed, when the joint is
seriously damaged by pre-existing articular disease and, finally, when septic arthritis is
complicated by underlying osteomyelitis. During the acute phase of infection, optimal
positioning of the affected joint is essential to avoid subsequent deformities and contractures.
Splints may be useful to maintain the joint in its correct functional position, and isotonic exercise
has to be initiated to prevent muscular atrophy.2,4,5
Delaying treatment for as little as 4 days can result in poor outcomes, along with young
age (infancy), infection of Staphylococcus aureus, and the presence of osteomyelitis on the
proximal femur. The risk of permanent loss of joint function is nearly 40%. The complication of
septic arthritis in the hip include early osteoarthritis, damage of the growth plate with
discrepancy of leg length, hip dislocation due to distension and destruction of the joint capsule,
limb deformity secondary to avascular necrosis femoral head/neck, pseudoarthrosis of femoral
neck, premature closure proximal femoral physis, and premature closure triradiate cartilage,
severe limitation of motion, generalized sepsis, or osteonecrosis and complete loss of the femoral
head and neck as the worst case scenario.

CASE REPORT
BWY, a male newborn delivered at 27-28 weeks gestation with spontaneous labour in private
hospital then reffered to Sanglah hospital. No history of mother illness before enduring
pregnancy, the etiology of prematurity was iminens premature labour. Antenatal care was
performed on obstetrician every 1 month. Soon after assessment in pediatric emergency unit ,

patient transferred to NICU ward with diagnose preterm neonate + very low birth weight infant +
moderate asphyxia + respiratory distress et causa hyalin membrane disease grade I + suspect
early onset neonatal sepsis. Patient treated with CPAP support, intravenous fluid drip dextrosa
10% with total parenteral nutrition, and first line antibiotic. Vitamin K was performed on first
hour of life. On 3 days of life, patient got apneu that response to tactile stimulation. Then apneu
of prematurity added to the assessment and patient got additional aminophylin on his therapy.
Patient was the second child in the family, he was born with moderate asphyxia (APGAR
score 5-6-7) with body weight of 1060 grams, body length of 36 cm, appropriate for gestational
age. Mother also has history of premature labor on her first child.
On 9 days of life, the result of blood culture taken on first day showed no growth in both
side. With improvement on septic marker, the assessment turn to preterm neonate + very low
birth weight infant + moderate asphyxia + respiratory distress et causa hyalin membrane disease
grade I + apneu of prematurity + clinically sepsis, and the first line antibiotic continued for 14
days. On 15 days age, patient showed better condition, both clinically and laboratory finding,
then the antibiotic stopped and patient transferred to non-infectious NICU ward. During
treatment in this ward, he got stabile condition with increased body weight until 1360 gram on
30 days age (32-33 weeks cronologically) using preterm formula 27 ml each 3 hours. He had one
time tranfusion of PRC due to haemoglobin level decrease to 8,5 g/dL.
After 1 month of therapy, we found a swelling in right hip region on 33 days age, single
lump with size 3 cm in diameter, redness, firm border, tenderness, and pain on pressure. This
swelling make very restricted movement of right lower extremity, patient always bend his right
knee on flexi potition. Patient became irritable if we try to pull down right leg into extensions
potition, while keep calm if we pull the other leg. Swelling of right hip get bigger and more red
day by day. The patient has no other illness, no lethargy, no fever, no respiratory distress, no
jaundice, nor any metabolic problems.
On that day we found swelling on right hip, physical examination revealed an alert
newborn, the heart rate was 140 times per minute, regular, and the respiration rate was 42 times
per minute, regular. The body temperature was 37.2oC. The head was normal in shaped and the
hair was tough, black in colour, and the fontanel was flat. There was no jaundice on sclera,
neither conjunctiva injection, anemia, and sunken. The pupil light reflect was normal. The ear,

nose, and throat examination were in normal limit. The sucking

reflex was normal. There were no lymph nodes enlargement found
on the neck. The chest was symmetrical both on rest and movement,
breath sound was bronchovesicular without rales or wheezing, the
first and second heart sound were normal, regular and no murmur in
auscultation. There were no lymph nodes enlargement found on both
of axillaes. On abdominal region there were no distension, normal bowel sound and normal skin
elasticity. Liver was just palpable and there is no spleen enlargement.
On right hip joint there was single mass with size 3 cm in diameter, redness, firm
boundaries, tenderness, and pain on pressure, with very restricted movement of right lower
extremity. (Figure 1 and 2). Patient then consulted to orthopedic surgeon division.

Figure 1. Swelling of right hip joint

Figure 2. Swelling of right hip joint

On the orthopedic examination of right hip joint, look : there were an edema with
erythema surface. There were neither deformity nor a wound was noted; feel : tender, warm, and
pain on palpation; and move : restricted movement of right hip joint. Then patient planned to
have septic marker examination (CBC, IT ratio, procalcitonin), Erythrocyte sedimentation rate,
and X-ray of right hip joint.

The laboratories finding on 36 days of life, revealed: the leukocyte count was 10.02
K/uL, neutrophil count 2,8 K/uL, the hemoglobin level was 9.48 g/dL, the hematocrite was 29.2
%, platelet count was 411 K/uL, IT ratio was 0,02, and procalcitonin result was 0,25 ng/ml.
There were raised ESR where ESR I was 10 mm (normal 0 - 2 mm) and ESR II was 35 mm
(normal 2 11 mm). The electrolytes serum revealed sodium was 136 mmol/L, potassium was
5.06 mmol/L, chloride was 105 mmol/L, calcium was 8.8 mg/dL. The total bilirubin level was
0.43 mg/dL, direct bilirubin level was 0.2 mg/dL, indirect bilirubin level was 0.14 mg/dL, total
protein was 4.78 g/dL, albumin level was 2.94 g/dL, and globulin was 1.84 mg/dL,.
The result of first X-ray of right hip joint revealed there was widening of right hip joint
with suspicion of joint effusion, there were normal subcondral bone layer and trabecular, and
there were no sign of bone erosion or destruction (Figure 3). Based on these finding, patient
continued to have ultrasound examination of hip joint. On 39 old days, he underwent an
ultrasound examination with result widening joint space of right hip joint 0,86 cm and joint
effusion with maximal thickness 0,48 cm, there were no destruction of cortex and subcortex
acetabulum, normal soft tissue around the joint, and post CDUS showed no sign of abnormal
hypervascularitation. While left hip joint showed normal joint space with 0,47 cm in wide with
no joint effusion (Figure 4).

Figure 3. First Pelvic AP X-ray

Figure 4. Ultrasonography of right hip joint

Based on clinical manifestation, laboratories finding, X-ray and the ultrasound result,
then the diagnosis turn to septic arthritis on right hip joint + respiratory distress et causa hyalin
membrane disease grade I + clinically sepsis + preterm neonate + very low birth weight infant +
moderate asphyxia + apneu of prematurity + bilateral immature retina. The patient transferred
back to infectious NICU ward and treated with first line antibiotic with ampicillin 50 mg/kg/dose
~75 mg every 8 hours and amikacin 7,5 mg/kg/dose ~12 mg every 8 hours administered
intravenously planned for 2 weeks, with blood culture was performed before antibiotic
admission. Immobilization of right extremity also performed to prevent further damage of hip
joint.
One week after treatment the infection signs was decreased significantly, the swelling of
right hip joint diminished but didnt normal yet, no more erythema on skin, on palpation there
were still pain on palpation, and range of movement (ROM) patient get better. The evaluation of
septic marker also showed improvement. After 8 days of antibiotic administration, there was no
growth on blood culture result. Patient then transferred to level II Neonatology care and

continued his treatment there. Ongoing 2 weeks after treatment as planned before, orthopedic
division took a right hip X-Ray for reevaluation, with result there was widening of joint space
still, without bony damaged was present (Figure 5). The treatment decided to be continued for
another 1 week. After 3 weeks of antibiotic administration, clinically there were no edema and
pain on palpation, laboratory finding also showed normal result, then antibiotic stopped and the
patient can be discharge from hospital in few days after that.

Figure 5. Second pelvic AP X-ray after 2 weeks treatment

DISCUSSION
Septic Arthritis in infant is rare, where there is a bacterial infection of the synovium and
subsequently of all the structures within the joint, which causes an intense inflammatory
reaction, possibly leading to destruction of the articular cartilage and later of the complete joint. 1
It usually affects single joint of infants and toddlers. The joint most commonly involved are the
hip in infants and the knee or shoulder joint in older childen. 1-3 In this case, the patient is an
infant that born prematurely with single septic artritis in his right hip joint.
Septic arthritis intheearly infancy areusually theresultofhematogenous spreadof
infection, and so their risk factors are closely related to the risk factors of bacteremia. 4,5
Prematurity, respiratory distress syndrome, low birth weight (<1,500 g), parenteral nutrition,
invasive procedures such as femoral venipuncture, and umbilical catheterizationhavebeennoted
tobethesignificantriskfactorsinneonates.7 In this case, the patient is premature baby with very
low birth weight (1060 gram) and had episode of respiratory distress syndrome on his early life.

Invasive procedure like insertion of vein access for intravenous fluid drip also make greater risk
for having septic arthritis. Patient had diagnosed with early onset sepsis based on clinic and
laboratory finding, but the blood culture showed no growth of any bacteria in both side. This
could be the spreading of sepsis hematogenously caused local infection in the hip, and develop
into septic arthritis.
In general, the clinical signs and symptoms of septic arthritis are nonspecific and
insidious,especiallyinneonatewheresepticarthritis being more frequent, more deceptive in
presentation and the more devastating. It makes most case often missed or delayed diagnosed.
The parent usually complained irritable baby with sign of infection such as fever, malaise or poor
apetite. Mostinfantsarenotbroughtformedicalattentionuntillocalsignssuchas swelling,
warmth, erythema and pain on palpation or passive movement of the hip, unilateral edema, lack
of active movement of the leg, asymmetrical buttock crease, and abnormal posture of the leg..In
thiscase,patientpresentwithswelling in right hip region, with size 3 cm in diameter, redness,
firm border, tenderness, pain on palpation that make very restricted movement of right lower
extremity. Patient had no fever during the illness.
The most common pathogen of this infection in all age groups is Staphylococcus aureus.
Several groups have reported an etiologic shift toward Group B Streptococcus. In this case, there
were no microorganism agent was found on blood culture. Positive result on blood culture
examination only in 15% patient with sepsis, this could explain there were no growth of
microorganism on both side.
The definitive diagnosis of septic arthritis is made by direct demonstration of bacteria in
the synovial fluid or after culture of the pathogen. The diagnosis is based, in most cases, on
clinical symptoms and a detailed history, a careful examination and test results. Blood tests show
increased levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and white
blood cell count (WBC). However, the absence of elevated acute-phase reactants does not
exclude the diagnosis of septic arthritis. In patient, the WBC was normal, while there is an
increased level of ESR. We evaluate the procalcitonin on the patient rather than CRP, with the
result there was moderate risk of infection.
Radiographs of the affected site are usually quite helpful. Distension of the joint capsule
and increased opacity within the joint, displacement of muscle surrounding the joint by the

10

capsular distension, increased distance between the subchondral ends of bone and occasionally
subluxation of the joint are frequently evident early in the course of the disease. Ultrasonography
is useful for detecting fluid effusions as low as 12 ml and for examining otherwise inaccessible
joints, such as the hip. While in this case, we found widening of right hip joint with suspicion of
joint effusion, with normal subcondral bone layer and trabecular, and there were no sign of bone
erosion or destruction on X-ray examination. The ultrasonography showed widening joint space
of right hip joint 0,86 cm and joint effusion with maximal thickness 0,48 cm, there were no
destruction of cortex and subcortex acetabulum, normal soft tissue around the joint. Aspiration of
SF from a swollen joint is mandatory for establishing the correct diagnosis. In septic arthritis, the
SF usually has a turbid appearance with a WBC > 50,000/mm3. Low joint-fluid glucose levels
(<40 mg dL or less than half the serum glucose concentration) and high lactate levels are
frequent findings in septic arthritis.4 In this patient, we didnt performed aspiration of synovial
fluid, with consideration there is only minimal joint effusion based on X-ray and ultrasonography
finding.
Broad-spectrum antibiotics should be started as soon as possible after a blood culture and
after a joint has been aspirated to obtain fluid for culture. In general, isolated septic arthritis
should be treated for at least 2 to 3 weeks, but septic arthritis due to Staphylococcus aureus
usually re-quires 4 to 6 weeks of antibiotic therapy. If septic arthritis is associated with
concomitant osteomyelitis, the duration of antibiotic therapy should be 4 to 6 weeks. In hospitals
where methicillin-resistant organisms are prevalent, one of the glycopeptides must be considered
as the drug of first choice. Subsequent antibiotics therapy is based on culture results. We give
first line antibiotic with ampicillin 50 mg/kg/dose ~75 mg every 8 hours and amikacin 7,5
mg/kg/dose ~12 mg every 8 hours administered intravenously for 3 weeks to the patient, with
good result after the treatment.
Septic arthritis of the hip in children has multiple sequelae and may result in severe
disability. Significant morbidity can be prevented by early recognition and treatment.The risk of
permanent loss of joint function is nearly 40% on septic arthritis. The complication of septic
arthritis in the hip include early osteoarthritis, damage of the growth plate with discrepancy of
leg length, hip dislocation due to distension and destruction of the joint capsule, limb deformity
secondary to avascular necrosis femoral head/neck, pseudoarthrosis of femoral neck, premature

11

closure proximal femoral physis, and premature closure triradiate cartilage, severe limitation of
motion, generalized sepsis, or osteonecrosis and complete loss of the femoral head and neck as
the worst case scenario. In patient after complete treatment, we didnt found any complication
due to the septic arthritis, but we still need further evaluation for late sequelae of septic arthritis
to ensure a good long term outcomes.

SUMMARY
A premature male newborn, admitted to neonatology intensive care unit of Sanglah
Hospital due to hyalin membrane disease grade 1 and clinically sepsis. After 1 month of therapy,
we found a swelling in right hip region with size 3 cm in diameter, redness, firm border,
tenderness, and pain on palpation. This swelling make very restricted movement of right lower
extremity. On laboratory examination there were raised procalcitonin 0,25 ng/ml and raised ESR
(ESR I was 10 mm and ESR II was 35 mm). The first X-ray of right hip joint revealed widening
of right hip joint with suspicion of joint effusion, and ultrasound examination showed widening
joint space of right hip joint 0,86 cm and joint effusion with maximal thickness 0,48 cm, there
were no destruction of cortex and subcortex acetabulum, normal soft tissue around the joint, and
post CDUS showed no sign of abnormal hypervascularitation. Aspiration of synovial fluid did
not performed in this patient due to there is only minimal fluid accumulated in right hip joint.
Patient was diagnosed with septic arthritis of right hip joint, based on consultation with
orthopedic surgeon division and treated with first line antibiotic with ampicillin 50 mg/kg/dose
~75 mg every 8 hours and amikacin 7,5 mg/kg/dose ~12 mg every 8 hours administered
intravenously. Immobilization of right extremity also performed to prevent further damage of hip
joint. Ongoing 2 weeks after treatment, orthopedic division took a right hip X-Ray for
reevaluation, with result there was widening of joint space still, without bony damaged was
present. The treatment decided to be continued for another 1 week. After 3 weeks of antibiotic
administration, clinically there were no edema and pain on palpation, laboratory finding also
showed normal result, then antibiotic stopped and the patient can be discharge from hospital.

12

EVIDENCE BASED PRACTICE

Case: A premature male newborn, admitted to neonatology intensive care unit of Sanglah
Hospital due to hyalin membrane disease grade 1 and clinically sepsis. After 1 month of therapy,
we found a swelling in right hip region with size 3 cm in diameter, redness, firm border,
tenderness, and pain on palpation. This swelling make very restricted movement of right lower
extremity. On laboratory examination there were raised procalcitonin 0,25 ng/ml and raised ESR
(ESR I was 10 mm and ESR II was 35 mm). The first X-ray of right hip joint revealed widening
of right hip joint with suspicion of joint effusion, and ultrasound examination showed widening
joint space of right hip joint 0,86 cm and joint effusion with maximal thickness 0,48 cm.
Aspiration of synovial fluid did not performed in this patient due to there is only minimal fluid
accumulated in right hip joint. Patient was diagnosed with septic arthritis of right hip joint, based
on consultation with orthopedic surgeon division and treated with first line antibiotic with
ampicillin 50 mg/kg/dose ~75 mg every 8 hours and amikacin 7,5 mg/kg/dose ~12 mg every 8
hours administered intravenously. Immobilization of right extremity also performed to prevent
further damage of hip joint. After 3 weeks of antibiotic administration, clinically there were no
edema and pain on palpation, laboratory finding also showed normal result, then antibiotic
stopped and the patient can be discharge from hospital. We didnt found any complication due to
the septic arthritis, but we still need further evaluation for late sequelae of septic arthritis to
ensure a good long term outcomes.
Problem: What is the long-term outcome of the neonate with hip septic arthritis?
PICO
Based on the problem above, components of PICO can be described as follows:
Population/problem

: neonate with hip septic arthritis

Intervention

:-

Comparison

:-

Outcome

: long term outcomes

CLINICAL QUESTION
What is the long-term outcome of the neonate with hip septic arthritis?

13

SEARCH STRATEGY
Keywords: neonate AND hip septic arthritis AND outcomes
SEARCH RESULT
Late Sequelae of Hip Septic Arthitis in Children
Taghi Baghdadi, Sadegh Saberi, Amir Sobhani Eraghi, Aidin Arabzadeh, and Shirin
Mardookhpour
Acta Medica Iranica 2012; 50(7):463-7

JOURNAL SUMMARY
Late Sequelae of Hip Septic Arthritis in Children
Taghi Baghdadi, Sadegh Saberi, Amir Sobhani Eraghi, Aidin Arabzadeh, and Shirin
Mardookhpour
Acta Medica Iranica 2012; 50(7):463-7

Background/Aim: Septic arthritis of the hip in children has multiple sequelae and may result in
severe disability. Significant morbidity can be prevented by early recognition and treatment.
Delay of the diagnosis and treatment of septic arthritis of the hip (SAH) may result in a spectrum
of pathologic changes. The purpose of this study was to review our experience with treatment of
the late sequelae of septic arthritis of the hip in infants and we present a series of patients with
squeal of SAH.
Materials and Methods: The authors retrospectively reviewed the medical records, clinical
examinations and radiographs of all patients who had been treated at the Imam Khomeini
hospital between 1986 and 2001 for SAH.
Results: A total of 13 children with 14 hips with sequelae of septic arthritis of the hip. All of
children had history of hip septic arthritis before age of 4 years. Six were male subjects, and 7
were female subjects. We evaluated the history, clinical findings and radiographs of all children
who had been treated at the Imam Khomeini hospital between 1986 and 2001 for septic arthritis
of the hip. Final results of operations in patients include range of motion, presence or absence

14

pain, joint stability, limb-length discrepancy were assessed. Three hips had mild pain in usual
daily activities and one patient with cerebral palsy experienced hip instability. Most of patients
(80%) had flexion contracture about 10-15 degrees. Final results showed average limb length
discrepancy was about 2.8 cm.
Conclusion: Septic arthritis of the hip in children may result in a spectrum of residual problems
and the significant complications can be averted by early detection and treatment. Treatment in
younger age cause better outcome.

CRITICAL APPRAISAL ON PROGNOSIS

Late Sequelae of Hip Septic Arthritis in Children
Taghi Baghdadi, Sadegh Saberi, Amir Sobhani Eraghi, Aidin Arabzadeh, and Shirin
Mardookhpour
Acta Medica Iranica 2012; 50(7):463-7
I. Is this evidence about prognosis valid?
1. Was a defined, representative sample of patients
assembled at a common point in the course of their
disease?
2. Was follow-up of study patients sufficiently long
and complete?
3. Were objective outcome criteria applied in a blind
fashion?
4. If subgroup with different prognosis are identified:
-Was there adjustment for important prognosis factor?
- Was there validation in an independent group of testset patient?
Conclusion: valid
II. Is this valid evidence about prognosis important?
1. How likely are the outcomes over time?

2. How precise are the prognostic estimates?

Yes, the investigator performed

retrospective review of 13 patients
treated as hip septic arthritis
Yes, they performed review of children
with hip septic arthritis followed-up
until the complication or sequelae
appear
Yes, The outcome knows after reviews
of medical records.
No, there were no adjustment and no
validation.

80% patient had flexion

contracture about 10-15 degrees,
and average limb length
discrepancy was about 2.8 cm
It could not be measured because

15

no analysis was done.

Conclusion : Important
III. Can we apply this valid, important evidence about prognosis to our patient?
1. Is our patient so different from those in the study that its
No, our patient characteristic is
results cannot apply?
similar to the subject.
2. Will this evidence make a clinically important impact on
Yes, significant complications
our conclusion about what to offer or tell our patient?
can be averted by early detection
and prompt treatment
Conclusion: Applicable
Level of evidence IV
Grade of recommendation B

16

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