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;
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;
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;