ACUTE
SEPTIC
ARTHRITIS
IN
10 YEARS’
N.
From
We
have reviewed
was confirmed
the
61 children
by bacteriology
INFANCY
M.
Hospitalfor
treated
for septic
or by radiographic
CHILDHOOD
EXPERIENCE
I. L. WILSON,
Royal
AND
DI
PAOLA
Sick
Children,
arthritis
changes.
from
Glasgow
1972 to 1981.
Routine
arthrotomy
The diagnosis
in all cases
was not performed,
patients had a joint aspiration.
The management
and outcome
are described.
We suggest that arthrotomy
should be selective rather than mandatory.
Septic
arthritis
but most
of the hip in
but in the older child an infected hip can be treated by aspiration if the duration of
symptoms is less than four days; arthrotomy
may be needed ifthere has been more delay. Infectedjoints
other
than the hip can be satisfactorily
managed by aspiration.
infants
requires
arthrotomy,
Septic arthritis
of infancy
was first described
Smith who, in 1874, reported
21 cases with
by Thomas
a mortality
of
over 50%. The introduction
of antibiotics
substantially
improved
the prognosis,
the mortality
falling
to less than
1% (Gillespie
1973) though
the results
of treatment
still
included
significant
complications
(Eyre-Brook
1960;
Lloyd-Roberts
alone were
1960;
Borella
et al. 1963).
not sufficient
and all published
series
of
intervention
cases
also
agreed
that
was required.
Antibiotics
reports
some
form
As early
as
of
of direct
1946, Ellis
had suggested
the addition
of aspiration
but subsequent
papers
have
advocated
more
aggressive
treatment
by
routine
arthrotomy
(Watkins,
Samilson
and
Winters
1956;
Samilson,
Bersani
and Watkins
1958).
Paterson
(1970)
concluded
that,
for successful
treatment
of acute
septic
arthritis,
was essential.
an arthrotomy
He also condemned
aspiration.
Our study
was stimulated
Nade
(1983),
who stressed
the
information
on joint
sepsis
within
the
five days
therapeutic
of onset
use of
joint
emphatic
support
arthrotomy
routinely
selective
to Paterson’s
over
NIL.
Wilson,
BSc, FRCS
Department
of Orthopaedic
6NT,
Scotland.
for
1986 British
0301-620X/86/41
584
reprints
a 10-year
Consultant
Larkfield
treatment,the
treatment
the
need
for
period
from
Registrar
Infirmary,
1972.
Glasgow
G 11
the
Orthopaedic
Surgeon
Road,
Greenock,
Renfrewshire
be sent
Society
to Mr
of Bone
NIL.
and
Joint
Wilson.
Surgery
AND
case
review
records
of those
children
results
of
its outcome.
investigations,
Children
who
were
recalled
because
the poorer
for clinical
prognosis
and
at that
and
detailed
more
METHODS
treated
for Sick Children,
Glasgow,
for
during
the
10-year
period
from
duration
of symptoms
before
infections
the nature
had had
of
hip
radiological
site merited
analysis.
RESULTS
From
1972
to 1981
there
were
95 children
with
a
presumed
diagnosis
ofacute
septic arthritis.
We included
only cases with definite
infection
in our series,
excluding
31 cases
diagnosed
and treated
successfully
on clinical
alone
penetrating
the typical
confirmatory
positive
changes.
months,
and
three
with
infection
secondary
wounds.
All the 61 remaining
clinical
features
of acute
septic
bacteriology
in 56 ; the
to
patients
had
arthritis
with
five
without
bacteriology
all had typical
late
The ages ranged
from one month
and 38 (62%) were male.
Pyrexia
radiographic
to 1 2 years
was recorded
in 51 of these
cases
and elevation
of the ESR
above
1 5 mm in the first hour in 50, but a white
blood
count
raised above
1 1 000 was seen in only 21 cases
(34%).
Blood culture
was positive
in only 41% but jointfluid
obtained
by aspiration
or arthrotomy
yielded
positive
cultures
in 80%
and
71% of cases
respectively.
The
aureus
most
should
Editorial
23 $2.00
examined
commonest
FRCS
Glas,
Inverclyde
Royal
Hospital,
PA16 OXN,
Scotland.
©
on
is not performed
is usual, with only
the results
of this
Glas, Orthopaedic
Surgery,
Western
M. Di Paola,
Requests
views
;
to treatment
We
at the Royal
Hospital
acute
septic
arthritis
1972,
recording
the
grounds
by a review
article
by
need
for further
clinical
in children.
He
gave
in all cases.
Arthrotomy
at our centre
joint aspiration
use of arthrotomy.
We report
approach
MATERIALS
pathogen
(Table
frequent,
years
isolated.
two
infections
identified
was
Staphylococcus
I). The
Haemophilus
spp were
the next
being found in 1 1 of the 16 children
under
of age from
There
were
in children
THE
whom
a causative
only
two cases
over
JOURNAL
two
OF
years
BONE
organism
of
was
Haemophilus
old.
AND
JOINT
SURGERY
9
ACUTE
Table
I. Organism
cultured
from
56 cases
SEPTIC
of acute
ARThRITIS
septic
Organism
of cases
27
aureus
INFANCY
arthrotomy.
In the
I0
!laernophi/us
para-influen:ae
3
had
Streptococcus
piogenes
8
or
suffered
delay
Streptococcus
pneumoniae
2
arthrotomy
Streptococcus
riridans
I
aspirated
I
Of the
fully treated,
Anaerobic
Gram-positive
cocci
Meningococcus
All children
of the
involved
were
joint,
joint
depending
treatment
was
parenterally
responded.
treated
the
with
period
bed
rest
with a change
to the oral route
The most
favoured
antibiotic
cloxacillin
and ampicillin,
was given
12 had fucidic
acid and erythromycin
were
treated
with
a cephalosporin.
of the
antibiotic
and given
as the patient
combination,
to 44 patients,
while
; the remaining
five
This
“best
guess”
cases
antibiotic
In all,
single
without
43 patients
combination
was
duration
of treatment
mean
had
joint
procedure
performed
radiographic
control.
aspiration,
usually
later
the ankle
involved
lar joint
multiple
divided
and
joint
our
one year
29 older
the wrist
once
involvement.
patients
of age,
children
into
each.
For
three
21 older children
with infection
patients
analysis
: 1 1 infants
with hip infection
of other
joints.
had
we
under
VOL.
other
68-B,
NO.
than
4,
the hip,
AUGUST
five had
1986
the
onset
of symptoms.
had apparently
in 13 has been
clinical
had
and
radiological
four were
antibiotics
been successconfirmed
by
review.
treated
and
One
of
the
forces
and
is
not be traced.
in Table
III.
by antibiotics
joint
aspiration
alone,
and
two had had an arthrotomy
one because
technical
failure
of aspiration
in the series.
tions
in this group
were performed
within
but
only
of the only
All aspirafour days of
-
the
onset
of symptoms.
In the group of 29 children
over one year of age with
infections
ofjoints
other
than the hip, followed
up for a
mean of 1 1 months,
there were failures
in one elbow
and
one
wrist.
These
cases
were
referred
two
and
three
weeks
respectively
after the onset of symptoms,
and both have
resulted
in joint
space
narrowing.
These
substantial
delays
were due to the misdiagnosis
ofjuvenile
rheumatoid
arthritis
in one case
and,
by a fracture
in the other,
in the
same
to the masking
limb.
Both
cases
Table II.
follow-up
Resultsoftreatment
28 months
in I I infants
underone
yearofage.
mean
Joint
Number
Failure
Outcome
Hip
5
3
Femoral
head necrosis
(oxa
magna
I
Knee
3
1
Genu
Ankle
3
0
valgum
2
I
a good
outcome
Table
septic
III. The
arthritis
management
in children
which
over one
resulted
in a normal
year of age
joint
after
and
In the group of 1 1 infants
there were four failures
of
treatment
(Table
II). The two hips with successful
results
had antibiotics
and arthrotomy
within
five days of the
onset
of symptoms
whereas
the three
failures
did not,
although
one ofthem
had antibiotics
andjoint
aspiration
within
48 hours ofonset.
Ofthe
six infants
with infection
in joints
after
None
had had an
one hip had been
and the elbow
acromioclavicu-
Three
further
groups
infection
as a
under
general
anaesthesia
A second
aspiration
was
in 14. The shoulder
in two patients,
the
days
intervention.
days though
15 hips which
the outcome
of symptoms
performed
on seven
knee joints
and two ankle
joints.
Four
joints
underwent
arthrotomy
after
an
initial
aspiration,
while
10 joints
had a primary
arthrotomy.
Irrigation
was not performed
and antibiotic
was instilled
on only 10 occasions
at aspiration
and six at arthrotomy.
The hip joint
was involved
in 26 patients,
the knee
in 19 and
were each
four
Surprisingly,
most had
splintage
three
initial
in surgical
within
five
remaining
two is serving
in the armed
presumably
satisfactory;
the other
could
The management
of these
1 5 is shown
was satisfactory
in 58 cases (95%), though
in 32 of
patients
one of the two antibiotics
was changed
more bacteriological
information
was available.
In
the
hip
Failure
could
not be related
to the age
patient,
the organism
involved
or to
in antibiotic
therapy,
but all six had
recent
choice
these
when
shown
to be ineffective.
The
was 23.2 days (s.d. 14.8).
with
I
and
Initial
basis,
children
one developed
antibiotics
and
I
of immobilisation
on clinical
progress.
chosen
on a “best
guess”
of 21 older
coxa magna.
sex of the
moderate
delay
2
a/bus
group
while
early
by
were
six failures.
After
a mean
follow-up
of 65
months, four had necrosis
of the femoral
head and two
influen:ae
Staphylococcus
585
CHILDHOOD
there
Ilaernophilu.s
Coliforms
AND
antibiotics
and joint
aspiration,
genu
valgum
after
treatment
arthritis
Number
Staphv/ococcus
IN
after
Joint
Management
Hip
None
Aspiration
Arthrotomy
Aspiration
Other
joints
None
Aspiration
Arthrotomy
in addition
and
arthrotomy
to rest, antibiotics
etc.
Number
4
9
I
I
3
21
3
586
had
NIL.
permanent
radiographic
and arthrotomy.
were
treated
changes
Most of the
with
antibiotics
successful
outcome,
despite
two weeks.
The mean
delay
one to 14 days.
other
despite
WILSON,
antibiotics
patients
in this group
and
aspiration
with
a
delay
in treatment
was 5.2 days with
of up to
a range of
All
the
patients
radiographic
studied
had
confirmed
change.
To
DI
PAOLA
early
year
presentation,
of
age
hip
be
can
infection
managed
in
children
satisfactorily
over
antibiotics
and joint
aspiration.
Although
four children
were
satisfactorily
with antibiotics
alone
we cannot
advocate
this
the six
initially
failures
in the
with antibiotics
older
and
hip
only
one
with
treated
because
group
were
later
had an
treated
arthro-
tomy which
did not alter the final outcome.
We therefore
feel that antibiotics
must be combined
with either
joint
DISCUSSION
septic arthritis
M.
the
clinical
diagnosis
by bacteriology
have
included
of
aspiration
or arthrotomy;
aspiration
as well as diagnostic.
therapeutic
or subsequent
those
with
an
unconfirmed
but clinically
convincing
diagnosis
who
responded to treatment
would
have
shed
a favourable
light on the management
used for these cases.
We aimed
to evaluate
the factors
which
may
be related
to the
prognosis
of definite
acute joint
infection.
We have regarded
any residual
clinical
or radiogra-
appears
to
be
In 29 older
children
with
infection
of joints
other
than
the hip, delay
was not so crucial
full recovery
ensued
in 27 (93%)
despite
delays
of up to two weeks.
Only two, who had even longer
delays
and were treated
by arthrotomy,
had residual
abnormalities.
In this group,
;
21 good
strongly
results
suggests
were obtained
without
arthrotomy;
that this procedure
is unnecessary
this
and
phic
these
abnormality
as failures
and have
included
among
three
cases
of coxa
magna
although
they
had a
virtually full range of painless
movement.
We classified
that aspiration
is satisfactory,
as well as being
the main
source
of bacteriological
specimens.
The specific
therapeutic
value
of aspiration
in this
group
cannot
be
them
as failures
because
we felt that such joints
have a
less certain
future
than completely
normal
hips.
It is accepted
that delay in treatment
increases
the
chance
of a poor
result,
but the point
at which
delay
becomes
significant
is uncertain.
Samilson
et al. (1958)
reported
that 77% ofall complications
in their series were
in patients
treated
seven
days
or more
after
onset.
Paterson
(1970) felt that the limit was five days, but both
studies
stressed
that this delay
was not only in starting
assessed
since
followed
antibiotics
children
(Wiley
antibiotics
our
failures
but
also
in carrying
out
recently
Morrey,
Bianco
and
good results
in all nine patients
of onset,
regardless
may
therefore
be
an arthrotomy.
Rhodes
treated
of the type
a function
(1975)
within
of treatment.
not only
of
More
then
we
can
to be worse.
In older children
a reasonably
accurate
expect
the
results
in the
of
the
successful
Borella
antibiotics
and arthrotomy.
better.
It is recognised
that
three
and
Our
results
seem
infants
fare
worse
Fraser
in five
hips
This
in babies
is usually
of symp-
results
followed
this policy
for
than
under
one
similar
to those reported
(1983)
who both
found
only staphylococci
and
the
spp
are
the
the age group from
Koontz
1966).
most
safest
tion.
gives
good
all have
would
children,
not reported
was suspected
but
suggest
of
common
advice
the 13 hips with a good result
would
an unnecessary
arthrotomy.
This
approach
results
by
year
that,
had
also
in
not
with
tive
against
The
most
and
is changed
progress permits.
necessary
ideal
and
reported
are
bacteria.
initial
to oral
administration
Intra-articular
drugs
of
THE
the
route
may
duration
to two
therapy
should
cover
penicillincocci
and,
especially
in the
effective
against
Haemophilus
and ampicillin
together
are effecof
parenteral
arthroin this
six months
available,
effective
drug
Our
out
by Nelson
(1972)
and Newman
a wide variety
of bacteria,
not
streptococci.
We have confirmed
Haemophilus
organisms
affecting
years
(Nelson
and
immediate
hip infection
bacteriological
sensitivities
should
be changed
to the
confirmed.
older
is borne
group.
Conversely,
for infection
of other joints
in young
infants
our results
suggest
that,
as in older
children,
aspiration
and antibiotic
therapy
is satisfactory.
Although
blood
culture
was positive
only
half as
often
as culture
of joint
fluid,
the former
procedure
should
not be omitted.
Our
bacteriological
results
are
younger
our good
advocate
1979).
marginally
Initial
antibiotic
resistant
Gram-positive
younger
child,
be
influenzae.
Cloxacillin
subsequently
six
Prognosis
delay
in
that
meant
surgery
for those
in whom
the diagnosis
had
failures
in their
group
of 43 patients
similarly
treated
with
antibiotics
and aspiration,
while
Samilson
et al.
(1958)
had seven
failures
in 36 patients
treated
with
toms.
In our
series
there
were
no failures
when
antibiotics
were coupled
withjoint
aspiration
within
four
days of the onset
of symptoms.
There
was one failure
after aspiration
on the fourth
day; according
to Paterson
(1970)
there
would
have been a satisfactory
outcome
if
treatment
had included
arthrotomy.
This may be true but
it should
be noted that had we always
followed
Paterson’s
have
detail,
results
et al. (1963)
age. Both
tomy;
we
patients
with hip infection,
there
figure
for the duration
(1 1%)
alone.
reported
four days
commencing
antibiotics
but
also
of the
timing
of
arthrotomy
or aspiration.
The difficulty
in babies
and
young
infants
is in reaching
an early
diagnosis
of hip
infection
(Lunseth
and Heiple
1979) and estimates
of
duration
of symptoms
are potentially
inaccurate.
If we
accept
that the timing
of treatment
in hip infection
is
crucial,
three
be
undesirable
antibiotic
JOURNAL
tissue
(Ruedy
BONE
levels,
when
clinical
are probably
not
therapy
OF
Once
treatment
combina-
1973).
is
AND
not
JOINT
The
known;
SURGERY
ACUTE
recommendations
range
from
to over three months
(Stetson,
1968).
Our
treatment
Our
splintage
definite
impression
is
should
be given.
ARTHRITIS
IN
two weeks
(Nelson
1972)
DePonte
and Southwick
that
at least
three
weeks’
symptoms
for
less than
arthritis
In
four
days
hip
can
be
centres.
REFE
Clark
Ellis
fractures.
2nd ed.
VOL.
VH.
Orthopaedic
surgery
and
Pe,ziei//in : Its practica/
app/ication.
I 950 : I 94-204.
68-B,
NO.
4,
AUGUST
Royal Hospital
us to review
their
RE NCES
Borella
L, Coobar
JE, Summitt
RL,
childhood. J Pediatr
1963:62:742-7.
1986
GM.
Septic
arthritis
R. Septic
arthritis
femur
arthritis
of the hip
in infants.
of childhood.
and osteomyelitis
of the
J Bone Joint
Surg
(Br]
C/in
Orthop
in
In: Fleming
A, ed.
London
: Butterworth,
1973:96:152-9.
of infancy
: some observations
J Bone
Joint
Surg
(Br]
Lunseth
PA,
children.
septic
Nade
Heiple
KG.
C/in Orthop
Prognosis
in
1979:139:81-5.
S. Acute septic arthritis
Surg (Br] l983;65-B:234-
Nelson JD. The bacterial
arthritis
in infants
JD,
Nelson
review
in infancy
41.
Paterson
Bone
Koontz
WC.
of I 17 cases.
DC.
Joint
Acute
.Surg
and
etiology
and antibiotic
and children.
Pediatrics
arthritis
arthritis
treatment
septic
hip
in
children
J Bone
Joint
management
of septic
1972:50:437-40.
and
of the changing
1983:1 1 :508-9.
of
the
in
childhood.
suppurative
arthritis
in infancy
(Br]
l970;52-B:474-82.
J. Antibiotic
1973:96:150-I.
of
Septic
arthritis
in infants
Pediatrics
1966:38:966-71.
Newman
RJ. The clinical
implications
septic arthritis.
IRCS
Med Sci
Reudy
surgeonsofthe
for allowing
Septic
of the
1-20.
Lloyd-Roberts
GC. Suppurative
arthritis
upon
prognosis
and
management.
1960:42-B
:7(36-20.
by
We would like tothank
theorthopaedic
for Sick Children.
Yorkhill.
Glasgow
patients.
587
CHILDHOOD
Money
BF, Bianco AJ Jr, Rhodes
KH. Septic
Orthop C/in North Am
l975;6(4):923-34.
aspiration,
but
with
later
diagnosis
an
arthrotomy
may be needed.
In joints
other
than the hip
aspiration
has been satisfactory.
Controlled
studies
are required
to define
further
the
roles of arthrotomy
and aspiration.
Septic
arthritis
is
rare, with many
variables,
so that further
investigation
will
require
prospective
collaborative
studies
from
several
AND
Gillespie
of the hip in young
the older
child
with
a septic
INFANCY
Eyre-Brook
AL.
upper
end
I960;42-B:l
results
suggest
that
in addition
to bed rest,
and systemic
antibiotics,
joint aspiration
has a
role in the management
of acute
septic
arthritis
in children.
Acute
septic
infants
requires
arthrotomy.
treated
SEPTIC
children:
a
epidemiology
and
arthritis.
of
childhood.
C/in
J
Ort hop
Samilson
RL, Bersani FA, Watkins
MB. Acute suppurative
arthritis
infants
and children:
the importance
of early
diagnosis
surgical drainage. Pediatrics
1958:21 :798-804.
in
and
Smith
Rep
T. On the
1874:10:189-204.
acute
arthritis
of
infants.
St
Barts
Stetson
JW, DePonte
RJ, Southwick
WO. Acute septic
hip in children. C/in Orthop 1968:56:105-16.
Watkins
MB, Samilson
RL, Winters
DM. Acute
Bone Joint Surg (Am]
1956;38-A:I3I3-20.
Wiley
JJ,
Fraser
GA.
1979;22 :326-30.
Septic
arthritis
in
arthritis
suppurative
childhood.
Hosp
of the
arthritis.
Can
J
Surg
J