IS ARTHROTOMY A LEGITIMATE OPTION FOR THE TREATMENT OF SEPTIC HIP ARTHRITIS IN CHILDREN?

Abstract

Purpose of the study: Joint puncture-wash-out is generally recommended for septic arthritis in children, but the debate is still open concerning the proper attitude for the hip joint. The purpose of this work was to examine our failure cases after treatment of septic hip arthritis using the puncture-wash-out option. We wanted to know whether first-intention primary arthrotomy might be a valid option.

Material and methods: We reviewed retrospective 29 cases of septic hip arthritis treated initially by puncture-wash-out between January 1996 and June 2003. We excluded all cases of first intention arthrotomy. The series included 19 boys and ten girls aged four years three months on average at time of diagnosis (age range 8 months to 9 years). Mean follow-up was one year five months (range 1 month the 4 years). Mean delay to diagnosis was two days (range 0–6 days). In addition to intravenous antibiotics, the 29 hips were drained and washed out with saline solution under general anesthesia until a clear wash-out was obtained. Surgical revision (arthrotomy) was required for seven patients within 3 to 21 days.

Results: Outcome was assessed at days 2, 5, and 10. Assessment variables were pain relief, normal blood tests, and apyrexia. Seven children required surgical revision for arthrotomy due to persistent clinical or biological disorders. Cure was achieved after all seven arthrotomies. At last follow-up, there was no difference, clinically or radiographically, between the children treated by puncture-wash-out or by arthrotomy. The factors which appeared to be the most significant to distinguish the two groups were, at admission: time to diagnosis and management greater than four days and C-reactive protein > 100. On day 5, the most significant factors were persistent joint pain and C-reactive protein > 100.

Discussion: These results suggest that puncture-wash-out remains a simple and reliable treatment but that it has its limitations: a synovial biopsy cannot be obtained, visual examination of the joint cartilage is not possible, trepanation of the metaphysis is not possible. Our factors favoring poorer outcome are similar to those reported in the literature to which can be added age less than one year. When these factors are present, first-intention arthrotomy should be discussed.