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    4 views7 pages

    Management of Sequalae of Septic Arthritis of Hip in Infancy

    Uploaded by

    drarunlal
    Journal Article

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    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 169 still 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

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