REVIE
ARTICLE
JK-PRACTITIONER
MANAGEMENT OF SEQUELAE
IN INFANCY
SC Goel MS, FAMS, Vivek Logam MS
HISTORICAL ASPECT.
The first well-documented descnption of septic arthritis
sn children was given by Thomas Smith, an English surgeon,
in 1874! He reported 21 cases of pyogenic arthritis
nyo ing primanty the hip jomt in infants, 13 of which
died and 8 recovered but were crippled Thus, for many
years, this disease was known as ‘Tom Smith's disease
The destructive effect of staphylococcal infection on
articular cartilage was first shown by Dallas Phemister in
1924? The contribution of Keefer’, Curtiss’, and others sn
understanding the pathophysiology of septic arthritis cannot
be overemphasized Pressure changes mduced in the jot
from infection were demonstrated later Recently,
lysosomes
a possible mechamsm involved in the
pathogenesis of septic arthritis have formed an arca of
great interest®?
FACTORS INFLUENCING THE OUTCOME OF
SEPTIC ARTHRITIS OF HIP
Sequelae of septic arthritss can present n different ways
There are various factors that mfluence its outcome and
presentation
Iyreinsic Factors
Age at onset of Infection:
Most published reports suggest thatneonates and infants
are more likely to have poor prognosis than older children*?
Premature births are even more likely to fare badly'*"
Immunity:
‘The relative mmmaturity of mmune system in premature
births, neonates and young mfants makes this group most
vulnerable? Abnormalities of immunoglobulins.
complements or phagocytes are present in more than half
patients of septic arthritis"
Vascular anatomy of femoral head:
Transphyseal spread of mfection to the epiphysis
through vascular channels occurs in infants up to two
years!" Such vessels gradually get obliterated an older
‘IK-Practitioner 2003; 10(3). 169-178
OF SEPTIC ARTHRITIS OF HIP
children Thrombosis of these vessels leads to ischemia
and subsequent mfective lysis of the growth plate This, 1f
occurs before ossification of femoral head, may result m
complete necrosis and resorption of femoral head and neck
ending up m a knob of bone at proximal femur?
Intracapsular pressure:
Elevated intracapsular pressure due to mfection’ may
cause occlusion and thrombosis of retmacular vessels It
may also predispose to subluxation or dislocation which
farther compromises the vascular supply of capital femoral
epiphysis
Concomitant Osteomyelitis of Proximal Femur:
This results im a far worse prognosis as compared to
infection localized to the synovium of hip yomnt!! 16
Infecting Orga
‘Most reports have suggested that the most common
organism causing septic arthnis 1s Staphylococcus aureus
and 1s usually associated with a worse prognosis than with
other infective organisms"! Dyrect destructive
effect of staphylokinase on articular cartilage has also been
demonstrated”
Delay in diagnosis and administering treatment:
Itas the single most important factor determming the
‘outcome! Critical period beyond which delay
becomes significant has been reported to lie between 4-7
days im various series'°!"°!*4
Adequacy of treatment:
This includes duration and type of antibiotic coverage,
post-operative immobilization, dramage and decompression,
physiotherapy programme, and follow-up
‘SEQUELAE,
Even with early recognition and emergency arthrotomy
for adequate decompression, the prognosis of septic hip
From the Department of Orthopaedics Institute of Medical Sciences, Banaras Hindu University, Varanasi
(Prof Goes Logan)
Received March 2003 Accepted April 2003
Correspondence Dr. S.C. Goel Professor and Head Department of Orthopaedics Institute of Medical Sciences Banaras
Hindu University Varanasi ~ 221 005 (INDIA) Tel No 91-542-2307599 E-mail drscgoel@hotmail com
Vol. 10.No.
‘Suly- September 2003
169still unpredictable®™ The sequelae of septic arthritis of the
hup im infant are diverse and include premature closure of
triradiate cartilage, acetabular dysplasia, mb length
discrepancy, premature or asymmetrical fusion of proximal
femoral physis, subluxation, dislocation, necrosis of the
cartilage, of head,
pseudoarthrosis of the femoral neck. and complete
destruction of femoral head and neck”? A useful
radiographic classification of such sequelae has been given
by Hunka etal’ and later modified by Chor et al! as follows,
(Fig 1)
ischemic necrosis femoral
Type I:
In these hips, the growth of proximal femoral
ossification center results in an almost normal hip (Iype 1
A) or n mild coxa magna (Type I B) Delay of ossification
mottling or fragmentation of proximal femoral os
nucleus 1s followed by a relatively rapid and complete
ossification The proximal femoral physis remains viable,
with little or no shortenmng of the femoral neck Acetabular
development 1s adequate, the long term results are good
and no reconstructive operations are needed
fic
‘Type Hi: ‘
The physis and metaphysis are involved, with resulting,
coxa vara or coxa valga (Type II B) These hips usually
have radiographic evidence of delay in ossification,
flattening and irregularity of femoral head, and coxa magna
‘The femoral neck 1s short and wide, and there 1s relatve
overgrowth of greater trochanter because of premature
closure of capital physis When there 1s early symmetrical
closure of proximal femoral physis (Type 11 A), coxa brova
with overriding of the trochanter develops, and there 15 a
resultant imp and considerable limb length discrepancy
When premature physcal closure 1s asymmetrical and
ancomplet
or valgus alignment with secondary acetabular dys
, the femoral nock progressively goes into varus
asia
‘Type IM:
In these hnps, the deformity 1s secondary to myury of
the femoral neck, resulting either in angular deformity with
severe anteversion or retroversion (Type III A) or m
pseudoarthrosis of the femorai neck with complete
epiphyseal shppmg (Type Ill B) These changes result in
alteration of acetabular development as well as mb length
discrepancy and relative trochanteric overgrowth
Type V
In the most severe cases. compromise of femoral head
and neck results exther in an unstable hip with a persistent
remnant of the femoral neck (Type IV