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Septic Arthritis of the Hip in Children

A Critical Analysis Review

Ishaan Swarup, MD Abstract

» Septic arthritis of the hip is a common and potentially devastating
Scott LaValva, BA
condition in children.
Ronit Shah, BS
» Septic arthritis is most commonly caused by Staphylococcus aureus,
Wudbhav N. Sankar, MD but other pathogens should be considered on the basis of patient age
and presence of risk factors.

Investigation performed at the » Diagnosis of septic arthritis is based on history and physical examination,
Children’s Hospital of Philadelphia, laboratory tests, radiographs, ultrasound, and arthrocentesis.
Downloaded from http://journals.lww.com/jbjsreviews by BhDMf5ePHKbH4TTImqenVP9XFeJftgMxyyX86kkqc0m4jiyskyxkDElgUpgp/HDr on 02/28/2020

Philadelphia, Pennsylvania
» Treatment comprises empiric antibiotics and joint debridement, and
antibiotics are subsequently tailored on the basis of culture data, local
resistance patterns, and clinical response.

» Late sequelae of septic arthritis include osteonecrosis, chondrolysis,

growth disturbance, subluxation or dislocation, and progressive ankylosis.
Surgical treatments to address these issues have been described.

I
nfections of the musculoskeletal
system are an important cause of
morbidity and mortality1. These
infections can be particularly dev-
astating in pediatric patients because
of differences in infectious etiologies,
decreased immunity, and the risk of com-
plications and sequelae. Septic arthritis is
less common than osteomyelitis, and as a
result it is less studied and remains an
important diagnostic and management
challenge in children2. The hip is a com-
mon location for septic arthritis in children,
and septic arthritis of the hip is a common
condition managed by general and pediat-
ric orthopaedic surgeons3. Primary septic
arthritis of the hip is characterized by infec-
tious colonization of the hip joint by micro-
organisms either through hematogenous
spread or, less commonly, direct inoculation,
resulting in inflammation of the synovium
and pyogenic effusion. The consequences of
septic arthritis in the pediatric hip can be
severe, and residual damage is more prevalent
in the hip than in other joints4.
The prevalence of infection caused by
particular organisms varies depending on
patient age, vaccination and sexual history,
drug use, regional climate, geography,
and antibiotic resistance. Similarly,
there are no standardized tests for diag-
nosis and there are several strategies
for the management of this condition.
Although several diagnostic algorithms
and evidence-based criteria have been
proposed 5 , subsequent studies have
called into question their reliability
and generalizability 6-11. Moreover,
the introduction of vaccines targeting
Haemophilus influenzae (H. influenzae) and
Streptococcus pneumoniae (S. pneumoniae)
have led to a dramatic decrease in the inci-
dence of septic arthritis secondary to these
pathogens, and in general these efforts
have led to changes in the microbiology
of septic arthritis9,12. In addition, the

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SURGERY, INCORPORATED
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JBJS REVIEWS 2020;8(2):e0103 · http://dx.doi.org/10.2106/JBJS.RVW.19.00103 1

 | Septic Ar thr itis of the Hip in Children

organism24,32, whereas Staphylococcus

TABLE I Risk Factors for Pediatric Septic Arthritis
Risk Factors
Male sex27,125-132
Age ,5 yr2,126,128,133,134
Concomitant infection: sepsis, bacteremia, adjacent osteomyelitis55,126,135,136
Increased susceptibility to infections: HIV-positive, steroid treatment, diabetes,
prematurity, low birth weight, sickle cell disease, respiratory distress syndrome,
umbilical artery catheterization44,137-140
increasing prevalence of methicillin-
resistant Staphylococcus aureus (MRSA)
is an important consideration and affects
diagnosis and management13,14.
In general, the evolving nature
of infectious disease demands continu-
ous reassessment by health-care pro-
fessionals. Several recent studies as
described in this review have focused
on the epidemiology, diagnosis, and
management of septic arthritis of the
hip, and a critical analysis of the litera-
ture is needed to provide guidance on the
diagnosis and management of this con-
dition in children. The purpose of this
review is to summarize the literature on
the epidemiology and pathophysiology
of septic arthritis of the hip in children as
well as to critically analyze diagnostic
tools and management strategies.
Epidemiology
There are constant changes in the epi-
demiology and microbiology of bone
and joint infections. These changes are
largely secondary to changes in the host
environment, which are in part due
to vaccination efforts, antibiotic usage,
and other host factors such as immu-
nity, comorbidities, and population
migration15-18. The incidence of septic
arthritis in children differs around the
world. In the U.S., it has remained
unchanged over the past 20 years at
approximately 1.07 cases per 100,000
children. However, the prevalence is
higher in other countries. For example,
Malawi has an incidence of 20 cases per
100,000 children and South Africa has
an incidence of 5 cases per 100,000
children19-21. Similarly, there is geo-
graphic variation in the types of bacteria
causing septic arthritis. More specifi-
cally, the rates of septic arthritis due to
MRSA are higher in the U.S. than in
other countries including Finland, Saudi
Arabia, and Australia22-25. The USA300
strain of MRSA is the most common
cause of community-associated MRSA
infections in the U.S26.
Approximately 32% to 40% of
all cases of septic arthritis in children
involve the hip3,20,25, and the authors of
one study reported an increase in hip
infections from 22.6% to 43% over the
past 20 years20. Males are at higher risk
for septic arthritis of the hip, with a re-
ported male-to-female ratio of 3:119.
There are several other risk factors for
septic arthritis of the hip including age
and presence of comorbidities (Table I).
Moreover, 33% to 50% of septic arthritis
cases are in children under 2 years
of age27-31. Patient age plays an impor-
tant role in determining the causative
organism of septic arthritis (Table II).
In neonates, Group-B Streptococcus
is more commonly the causative
aureus (S. aureus), S. pneumoniae, and
Kingella kingae (K. kingae) are the most
common organisms in children between
the ages of 1 and 51. In children over the age
of 5, S. aureus becomes the predominant
causative bacteria.
K. kingae is a unique organism that
has emerged as an important and com-
mon cause of septic arthritis over the
past decade largely because of the wide-
spread use of advanced molecular diag-
nostic techniques such as polymerase
chain reaction (PCR)33-35. It is a gram-
negative bacillus that inhabits the
respiratory tract. Moreover, its presen-
tation and clinical course are benign in
comparison with S. aureus, with most
patients being afebrile and having
lower median C-reactive protein (CRP)
values36,37. One study showed K. kingae
to be the most common bacterial cause
of septic arthritis in children under the
age of 3 years, and the authors of another
study noted that this bacterium was
the cause of 48% of joint infections in
children under 2. Overall, K. kingae
should be considered in the diagnosis
and management of septic arthritis of
the hip in children33,35.
Several patient risk factors are
associated with different types of bacte-
ria that cause septic arthritis of the hip.
Neisseria gonorrhoeae (N. gonorrhoeae)
should be strongly suspected in sexually
active adolescents or children with a
history of sexual abuse. Children with
sickle cell anemia are more likely to have
an infection with Salmonella species38,
and unvaccinated children are at risk for
septic arthritis due to H. influenzae.
Patients who are immunocompromised
or have medical comorbidities are at
risk for septic arthritis due to Pseudo-
monas; anaerobes such as Bacteroides,

TABLE II Most Common Bacteria Associated with Septic Arthritis of the Hip in Children

,1 Yr of Age 1-5 Yr of Age 6-10 Yr of Age .10 Yr of Age

Bacteria Group-B Strep., S. aureus, K. kingae, S. S. aureus S. aureus, N. gonorrhea

gram-negative pneumoniae, Group-A (if sexually active or abused)
bacilli Strep. (S. pyogenes), H.
influenzae (if unvaccinated)

2 FEBRUARY 2020 · VOLUME 8, ISSUE 2 · e0103


Fusobacterium, and Propionibacte-
rium; as well as fungal infections39-43.
Furthermore, HIV (human immuno-
deficiency virus)-infected children have
been found to have higher overall rates of
hip-joint infection when compared with
non-HIV-infected children, and, in a
study of children with hip-joint infec-
tion, those with HIV had substantially
higher rates of S. pneumoniae hip-joint
infection and significantly lower rates of
S. aureus hip-joint infection compared
with non-HIV-infected children44.
Finally, Lyme disease (Borrelia burgdor-
feri) should be considered in Lyme
disease-endemic areas such as the Cen-
tral, Northeast, and Western U.S45,46.
Despite modern advances in diagnosis
and microbiology, it is not possible to
identify the causative bacteria in 33% to
66% of all cases27.
Pathophysiology
There are 3 primary mechanisms by
which bacterial or fungal organisms
colonize the intra-articular space, which
is the initial step in the development of
septic arthritis. First, and most com-
mon, is hematogenous seeding of the
joint with microorganisms from the
systemic circulation during an episode of
bacteremia47-49. Importantly, the blood
supply to any joint space arises from the
synovial vasculature. Thus, the high
degree of vascularity of the synovium
coupled with the lack of a basement
membrane provides a path for bacterial
entry and colonization48,49. In experi-
mental mouse models, hematogenous
bacterial injection produced septic
arthritis within 24 hours after hema-
togenous introduction in .90% of
cases47. Clinically, it is important to
recognize the role of intravenous (IV)
lines and central line-associated blood-
stream infections (CLABSI) in caus-
ing bacteremia and a risk of septic
arthritis. Efforts should be made to
minimize these interventions, par-
ticularly in young patients. Second,
microorganisms can be directly inocu-
lated into the joint as a result of trauma,
injection, or surgery, which may lead to
atypical and/or polymicrobial infec-
FEBRUARY 2020 · VOLUME 8, ISSUE 2 · e0103
Septic Arthritis of the Hip in Children
tions50. Third, an adjacent bone or
soft-tissue infection may spread contig-
uously, resulting in bacterial extension
into the joint. Anatomical differences in
young children have been hypothesized
as an important contributor to the phe-
nomenon of concurrent osteomyelitis
and septic arthritis. Until 18 months of
age, the presence of transphyseal blood
vessels from the metaphysis may permit
the spread of metaphyseal osteomyelitis
to the joint space51-53. However, this
explanation is incomplete given the rel-
atively high prevalence of concurrent
septic arthritis and osteomyelitis in
children and adolescents older than 18
months of age54,55.
Our knowledge regarding the
molecular pathogenesis and pathophys-
iology of septic arthritis has been largely
informed by experimental animal
models47,56-58. Upon intra-articular
inoculation of infectious organisms, an
acute multicellular immune response
is elicited through the interaction of
several host and bacterial factors59,60.
Host defense against an intra-articular
infection is orchestrated predominantly
by macrophage-, neutrophil-, and
lymphocyte-derived cytokines includ-
ing tumor necrosis factor (TNF)-alpha,
proteolytic enzymes, and interleukins
(IL)-1, 4, and 1056-58. While these
factors play an important role locally,
TNF-alpha and IL-1 are also critical in
the systemic inflammatory response and
often contribute to producing a fever
and other constitutional symptoms.
Ultimately, when the infectious inocu-
lum overwhelms the inflammatory
response, progressive septic arthritis is
the outcome. In cases of infection by
S. aureus, Panton-Valentine leukocidin
(PVL) is an important cytotoxin that
causes direct leukocyte destruction and
tissue necrosis61.
The eventual cartilaginous de-
struction from septic arthritis is charac-
terized pathologically by a sequential
reduction in matrix proteoglycans and
collagen, eventually resulting in gross
morphologic changes62-65. In an exper-
imental rabbit model, the loss of gly-
cosaminoglycans was observed as early as
|
8 hours after the initial joint infection,
which highlights the importance of early
detection and treatment65. The specific
cause of cartilaginous destruction in the
setting of septic arthritis is 3-fold59,66,67.
First, there is direct damage and toxicity
to the articular cartilage from bacterial
virulence factors and cytotoxins. Sec-
ond, the cytokines and proteolytic
enzymes produced by the powerful host
inflammatory response can create col-
lateral damage to the cartilage and other
surrounding tissues. Third, increased
intra-articular pressure from the result-
ing inflammation and joint effusion
can diminish blood supply and induce
cellular necrosis. Importantly, the patho-
physiology, acuity of the clinical presen-
tation, and subsequent prognosis of the
disease with respect to systemic illness and
local cartilaginous destruction ultimately
depend on the virulence of the infecting
organism68. Advances in genetic analysis
have bolstered our understanding of
microbial virulence from a genetic stand-
point, as recent investigations have dem-
onstrated distinctive gene expression
profiles from host neutrophils in response
to different infections69,70.
Diagnosis
Hip pain is a relatively common symp-
tom in pediatric patients, although its
etiology ranges from benign, self-
limited, transient synovitis to a joint-
threatening process such as septic
arthritis or osteonecrosis71,72. Early
and accurate diagnosis is essential to
provide timely management and avoid
poor outcomes (Table III)73-78. The
most common diagnostic dilemma ari-
ses when attempting to distinguish
between septic arthritis and transient
synovitis 5,6,10,79,80, and several
studies have focused on factors that
help to distinguish between these
diagnoses5-9,71,81-83. Specifically, the
Kocher criteria consist of a 4-variable
model including history of fever, ele-
vated erythrocyte sedimentation rate
(ESR), inability to bear weight, and
peripheral leukocytosis; this model
demonstrated a 99.6% predictive
accuracy for septic arthritis compared
3
 | Septic Ar thr itis of the Hip in Children

TABLE III Diagnostic Utility of Commonly Ordered Tests for Septic Arthritis of the Hip

Pos. Predictive Neg. Predictive Multivariate

Variable Sensitivity (%) Specificity (%) Value (%) Value (%) Odds Ratio

History and physical examination

Fever (.38.5°C)5,6,69,79,80 44-82 65-100 45-100 42-99 2.6-38.6
Chills5 11 100 100 54 —
Recent antibiotics5,6 24-32 82-90 42-69 55-75 —
Non-weight-bearing5,6,79,80 60-95 31-71 10-72 57-97 5.9-24.3
Laboratory results
ESR
.20 mm/hr7,69,81,87 79-100 59-75 33-54 89-100 —
.30 mm/hr8,69 71-90 86 68 88 —
.40 mm/hr6,7,79 40-74 86-94 15-90 44-96 2.3-25.9
CRP
.20 mg/L6,79,81 60-100 71-90 25-88 67-100 14.5-30.6
.10 mg/L7 89 93 77 97 10.6
Serum leukocytes
.11,0007 cells/mm3 74 94 77 93 18.9
.12,0006,69,79 cells/mm3 40-58 71-81 11-81 37-96 1.2-14.4
.15,0008,69 cells/mm3 23-26 84 40 74 —
Synovial fluid culture5,9,69,77,81,89 35-96 — — — —
Blood culture5,8,77,81,89 13-36 — — — —
Imaging
Radiographic effusion5,7,8,81 50-100 23-62 10-66 74-100 —
MRI*
SA versus TS139 86 73 89 78 —
SA versus SA 1 PAI91,140 86-90 54-67 50-80 83-88 —
Ultrasound46,90 82-86 45-90 36-88 — —

*SA 5 septic arthritis, TS 5 transient synovitis, and PAI 5 periarticular infection.

with transient synovitis when all 4
factors were present5 (Table IV).
Alternatively, CRP has been shown
to be a strong independent predictor
of septic arthritis, and it may be used in
conjunction with ESR6,7.
History and Physical Examination
Patient history in the setting of septic
arthritis of the hip is characterized by
a combination of hip or groin pain,
limping or inability to bear weight, and
constitutional signs or symptoms such as
fever and malaise84,85. Symptoms may
vary by age, with infants exhibiting
pseudoparalysis or asymmetric kicking
and ambulatory children exhibiting
impaired or no weight-bearing. Other
historical factors that are important to
ascertain include recent illnesses or
trauma, travel history, immunization
status, and birth history, each of which
helps to evaluate for a potential source of
infection or identify likely causative
organisms86. Physical examination
comprises an assessment of vital signs
and hip examination focusing on the
ability to bear weight and range of
motion. Patients prefer to maintain
the hip in an externally rotated posi-
tion to increase intracapsular volume,
and short-arc range of motion is typi-
cally limited and painful87,88. Two
of the most predictive features of
septic arthritis are an inability to bear
weight5,7,10 and fever ($38.5°C)5,10,
each of which has been reported as an
independent predictor of an eventual
diagnosis of septic arthritis as opposed to
transient synovitis. Specifically, multi-
variate models have demonstrated a 5.9
to 24.3 greater odds of septic arthritis in
non-weight-bearing patients and a 2.6
to 38.6 greater odds in those with a fever
of $38.5°C5,7,10.
Laboratory Results
Laboratory evaluation comprises a
complete blood-cell count (CBC) with
differential, ESR, and CRP. Lyme titers
may be obtained in Lyme-disease-
endemic areas as well. The most widely
reported diagnostic threshold for white
blood-cell (WBC) count is .12,000
cells/mm3, although the sensitivity of
this finding is low (40% to 58%)6,8,71.
Traditionally, ESR was the most com-
monly used inflammatory marker in
distinguishing between septic arthritis
and transient synovitis5,10,71,81-83;
however, several authors have demon-
strated that CRP is a better predictor of
septic arthritis of the hip6,7,89.

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 Septic Arthritis of the Hip in Children |

TABLE IV Comparison of Diagnostic Performances of Predictive Algorithms

Study Variables in Model Rate of Septic Arthritis AUC*

Kocher et al. (1999)5 Fever $38.5°C 0 factors → ,0.2% 0.960

ESR $40 mm/hr 4 factors → 99.6%
Inability to bear weight
Serum WBC count .12,000/mm3
Jung et al. (2003) 82
Fever .37°C 5 factors → 99.1% 0.986
ESR .20 mm/hr
CRP .10 mg/L
Serum WBC count .11,000/mm3
Joint space difference of .2 mm
Luhmann et al. (2004)9 Fever $38.5°C 3 factors → 71% 0.771
Serum WBC count .12,000/mm3
Previous health-care visit
Kocher et al. (2004) † 10
Fever $38.5°C 0 factors → 2% 0.860
ESR $40 mm/hr 4 factors → 93%
Inability to bear weight
Serum WBC count .12,000/mm3
Caird et al. (2006)6 Fever .38.5°C 0 factors → 17% NR
Serum WBC count .12,000/mm3 5 factors → 98%
ESR .40 mm/hr
Inability to bear weight
CRP .20.0 mg/L
Sultan and Hughes (2010) 8
Fever $38.5°C 0 factors → 2.3% NR
Inability to bear weight 5 factors → 60%
Serum WBC count .12,000/mm3
ESR $40 mm/hr
CRP $20 mg/L
Singhal et al. (2011)7 Fever $38.5°C 0 factors → 1% NR
Inability to bear weight 4 factors → 87%
CRP $20 mg/L
Serum WBC count .12,000/mm3

*AUC 5 area under the curve for the predictive model, and NR 5 not reported. †Analyses performed with prospective data.

Ultimately, a WBC count of .11,000
or 12,000 cells/mm3 (odds ratio [OR] 5
1.2 to 18.9), an ESR of .40 mm/hr
(OR 5 2.3 to 25.9), and a CRP level of
.20 mg/L (OR 5 14.5 to 30.6) are
each independent predictors of septic
arthritis of the hip5-7,9,10,82. Lastly,
although blood cultures are routinely
performed and can be helpful in the
setting of sepsis, only 10% to 40% of
patients with septic arthritis have posi-
tive blood cultures5,10,46,81,90.
Imaging
Radiographs are routinely made for
patients with hip pain and an inability to
bear weight. Radiographic signs of septic
arthritis include effusion and swelling as
characterized by medial joint space
widening and periarticular fat-pad
displacement10,82,83. Additional radio-
graphic findings may be present in the
setting of concomitant osteomyelitis.
Hip ultrasound has gained popularity in
the evaluation of septic arthritis because
of its low cost, noninvasive nature, and
lack of radiation exposure. Ultrasound is
more sensitive and specific than radio-
graphs in determining the presence of a
hip effusion10,82,83,91,92; however, its
false-negative rate is as high as 14%91.
Nonetheless, while ultrasound alone is
insufficient for confirming a diagnosis of
septic arthritis, the detection of an effu-
sion on ultrasound in the setting of
clinical and laboratory features consis-
tent with septic arthritis can help guide
clinical decision-making.
The routine use of magnetic reso-
nance imaging (MRI) in the evalua-
tion of a patient with suspected septic
arthritis is controversial. MRI is often
indicated for patients with inconsistent
clinical and radiographic features and to
evaluate for concomitant periarticular
infections such as osteomyelitis93-96. A
recent study showed that pericapsular
pyomyositis was twice as common as

FEBRUARY 2020 · VOLUME 8, ISSUE 2 · e0103 5

 | Septic Ar thr itis of the Hip in Children
septic arthritis in children presenting
with an acutely irritable hip (32% versus
15%), and the authors recommended
the routine use of MRI for evaluating hip
pain in children97. Rosenfeld et al.
developed a predictive model to identify
patients at risk for septic arthritis and
concomitant periarticular infections and
subsequently provided indications for
MRI evaluation93,94. However, these
criteria may not be generalizable to all
populations, and subsequent studies
have shown limited clinical utility in
other populations96. In general, the role
of MRI is an evolving aspect in the
diagnosis of septic arthritis of the hip,
and future recommendations may
change on the basis of additional research
and advances in imaging practices.
Arthrocentesis
Ultrasound-guided arthrocentesis of the
hip provides the ability to evaluate the
WBC count (with differential) and
Gram stain/culture of the synovial
fluid98. Additionally, PCR has grown
increasingly common given its ability to
rapidly detect atypical pathogens such as
K. kingae90,99. Despite being the gold
standard in the diagnosis of septic
arthritis, synovial Gram stain and cul-
ture are positive in only 40% to 60% of
patients with septic arthritis5,75. Simi-
larly, while the most typical WBC
threshold is .50,000 cells/mm3 with
.75% polymorphonuclear cells, the
sensitivity and specificity of this finding
is limited, especially in Lyme-disease-
endemic areas46,100. In addition, septic
arthritis has been reported100 in patients
with WBC values between 25,000
and 50,000 cells/mm3. Ultimately,
evidence-based guidelines on the diag-
nostic thresholds for septic arthritis
are poor, and thus these results must
be considered in the setting of other
clinical, radiographic, and laboratory
findings. If an ultrasound-guided
arthrocentesis is not possible and there is
a high suspicion of septic arthritis of the
hip, an arthrocentesis may be performed
with the patient under general anesthe-
sia in the operating room. If the joint
fluid is frankly purulent or the Gram
6 FEBRUARY 2020
stain and cell count are consistent with arthrocentesis for diagnostic cultures,
findings of septic arthritis, surgical empiric antibiotic therapy is initiated in
management may be performed during consultation with an infectious disease
the same anesthetic session. specialist101. Antibiotics are selected
empirically to target the most common
Critical Analysis Review causative pathogens and on the basis of
Septic arthritis of the hip is diagnosed institutional microbiological data and
using a combination of several impor- antibiotic resistance levels18. Since the
tant factors (Table V). In our practice, most common causative pathogens dif-
evaluation begins with a history and fer by patient age, the empiric choice of
physical examination, with the examiner antibiotics also differs by patient age102.
looking specifically for pain with a short For infants (1 to 3 months old), empiric
arc of joint motion and assessing the treatment consists of vancomycin and
ability to bear weight (Fig. 1). If there is gentamicin to cover S. aureus and group-
continued suspicion of septic arthritis, B Streptococcus101,102. In patients
laboratory studies are obtained includ- between the ages of 3 months and 3
ing a CBC with differential, ESR, CRP, years, septic arthritis of the hip was tra-
and blood cultures, and imaging studies ditionally associated with H. influenzae.
including radiographs and hip ultra- However, immunization practices
sound are performed. If an effusion is have almost eradicated septic arthritis
present, an arthrocentesis is performed secondary to H. influenzae103. Still,
and the sample is sent for Gram stain, coverage with ceftriaxone should be
culture, cell count, and PCR analysis. considered for unimmunized chil-
Advanced imaging is reserved for patients dren102. For older children, treatment is
for whom a concomitant periarticular usually initiated with a first-generation
cephalosporin such as cefazolin to
infection is a concern or who have con-
cover S. aureus and Streptococcus102.
tinued symptoms despite negative find-
ings on laboratory and synovial analysis. Coverage for MRSA should be consid-
ered in high-risk populations or areas
Treatment with a high community prevalence of
Antibiotics and Other Medications MRSA104. As microbiological data
Children with septic arthritis of the become available, the choice of antibi-
hip should be admitted to the hospital. otics is tailored to target the causative
After specimens have been obtained via organism.
TABLE V Recommendations for Diagnosis of Septic Arthritis of
the Hip
Recommendation Grade*
Physical examination B
Blood culture B
CBC with differential B
ESR and CRP A
Arthrocentesis B
Radiographs of the hip B
Ultrasound B
MRI C
*Grade A: Good evidence (Level-I studies with consistent findings) for or against
recommending intervention. Grade B: Fair evidence (Level-II or III studies with
consistent findings) for or against recommending intervention. Grade C: Poor-
quality evidence (Level-IV or V studies with consistent findings) for or against
recommending intervention. Grade I: There is insufficient or conflicting evidence
not allowing a recommendation for or against intervention.
· VOLUME 8, ISSUE 2 · e0103

Recommendations for the dura-
tion of antibiotic treatment have evolved
over time. Historically, 2 to 4 weeks of
IV antibiotics were recommended, but
more recent data suggest that a shorter
duration of IV antibiotics followed by
oral antibiotics is safe and effective105.
The exact duration of antibiotic treat-
ment remains controversial and depends
on several factors. Treatment is almost
always initiated with IV antibiotics and
then transitioned to oral antibiotics on
the basis of the clinical response and
improvement in inflammatory marker
levels104,105. In clinical practice, it is
important to ensure patient compliance
and ensure that caregivers are able
to adequately administer antibiotics.
Recent retrospective and prospective
studies have shown no difference in
outcomes with a short course of IV
FEBRUARY 2020 · VOLUME 8, ISSUE 2 · e0103
Septic Arthritis of the Hip in Children
treatment (#7 days) followed by 10 to
30 days of total antibiotics compared
with longer courses of treatment106,107.
Clinical practice guidelines have been
recommended for the management of
septic arthritis of the hip. In a study by
Kocher et al., treatment with a clinical
practice guideline based on clinical evi-
dence was effective in improving rates of
blood tests and compliance with rec-
ommended antibiotic therapy as well as
faster transition to oral antibiotics and a
shorter hospital stay108.
Lastly, corticosteroids have also
been considered in the management of
septic arthritis. Specifically, systemic
corticosteroids are postulated to coun-
teract the inflammatory process that
may produce joint damage109. Two
randomized controlled trials involving
149 children with septic arthritis of the
|
Fig. 1
Algorithm for the diagnosis and management
of septic arthritis of the hip in children. H&P 5
history and physical examination, and ROM 5
range of motion.
hip or knee showed that corticosteroids
may decrease pain, improve time to
return to normal function, and re-
duce the number of days of antibiotic
treatment110,111. However, these find-
ings were limited by study quality, and
additional studies are needed109. Anti-
inflammatory drugs such as nonsteroidal
anti-inflammatory drugs (NSAIDs)
are commonly used in practice, and
additional studies are also needed to
determine their indications and use in
children with septic arthritis of the hip.
Operative Management
In addition to antibiotic therapy, oper-
ative management is an important
aspect of management of children with
septic arthritis of the hip. It should be
performed expeditiously regardless of
patient age or causative bacteria, and it
7
 | Septic Ar thr itis of the Hip in Children
should be performed on an emergency
basis in patients who are systemically
ill102. The goals of surgical management
are to irrigate and debride the joint,
reduce intra-articular pressure, and
obtain additional specimens for cul-
ture101. Some authors have suggested
that Lyme arthritis and Kingella infec-
tions may be treated with antibiotics
alone112,113; however, most authors
have advocated surgical arthrotomy
because titers may take several days and
joint decompression would be beneficial
in the setting of a large effusion45.
Percutaneous techniques such as
serial aspiration have been reported in
the literature114, but they are not com-
monly used in practice. In a study by
Weigl et al., 42 patients were managed
with repeated ultrasound-guided aspi-
ration and IV antibiotics and 9 of them
ultimately required surgical drainage114.
The authors concluded that an age
greater than 10 years was a risk factor for
failure of percutaneous aspiration. More
commonly, open and to a lesser extent
arthroscopic techniques are employed in
the management of septic arthritis of the
hip in children. Arthroscopic techniques
were described .20 years ago and focus
on large-volume irrigation and suction
of the joint115. Usually lateral-based
portals are used, but a medial-based
portal has also been described in the lit-
erature116. In a series of 24 patients
treated with arthroscopic irrigation and
debridement, 1 patient sustained a
transient femoral nerve palsy and 3
required a reoperation117. In another
series, of 12 patients managed with
arthroscopic techniques, 2 required
repeat arthroscopy and poor results were
correlated with late presentation118.
In general, open arthrotomy
continues to remain the most com-
mon surgical management for septic
arthritis of the hip in children119. Open
debridement allows for reduction of the
bacterial load, debridement of necrotic
tissue, joint decompression, and if
needed drilling of the metaphysis in
cases of concomitant osteomyelitis102.
A direct anterior (Smith-Petersen) or
modified anterolateral (Watson-Jones)
8 FEBRUARY 2020
approach may be used, depending on Classification systems for late
surgeon familiarity102. In a large data- sequelae after septic arthritis of the hip
base study of .3,000 children, 5.7% of have been proposed by Choi et al.123 and
them required additional surgery during by Forlin and Milani124 with the goal of
the same hospitalization, and patient guiding management. In general, man-
comorbidities such as coagulopathy and agement of residual deformity is indi-
hospital characteristics such as govern- vidualized according to the presence or
ment ownership and teaching status absence of osteonecrosis (Type I);
were associated with repeat surgery120. involvement of the epiphysis, physis,
In another study, of 138 patients, the or metaphysis (resulting in coxa breva or
rate of secondary surgical intervention coxa vara/valga (Type II); deformity or
was 41%, but 40% of this cohort had pseudarthrosis of the femoral neck
concomitant osteomyelitis. Factors (Type III); and hip stability (Type
associated with additional surgery IV)101,123. Treatment options include
included an elevated ESR and CRP level application of a cast or brace to improve
at presentation, infection with MRSA, or preserve range of motion, epiphyseal
and concomitant osteomyelitis121. drilling to improve vascularity, and
reconstruction or osteotomies to address
Outcomes deformity and stability101.
In general, patients have a good outcome
after joint debridement and antibiotic Critical Analysis Review
therapy. However, delay in treatment or Several studies provide guidance on the
misdiagnosis may result in several poor management of septic arthritis of the hip
outcomes including osteonecrosis, in children (Table VI). In suspected ca-
chondrolysis, limb-length discrepancy, ses of septic arthritis of the hip, empiric
subluxation or dislocation, growth arrest, treatment with antibiotics should be
femoral osteomyelitis, and progressive commenced after joint fluid has been
ankylosis101. There have been reports in obtained for analysis (Fig. 1). In our
the literature of mild to moderately poor practice, treatment is usually started
functional and radiographic outcomes at with cefazolin but clindamycin may be
long-term follow-up78,101,122. For used if there is concern about infection
example, Hoswell et al. reviewed out- with MRSA. Open surgical debride-
comes 1 to 20 years after treatment of ment via the direct anterior approach is
septic arthritis in 37 hips and found that performed on an urgent basis but may be
31% had impaired function according expedited when a child is systemically ill
to the Oxford score and 81% had or there is sepsis. A drain is placed in the
excellent radiographic outcomes122. operating room and remains in place
TABLE VI Recommendations for Treatment of Septic Arthritis of
the Hip
Recommendation Grade*
Antibiotics A
Corticosteroids B
Percutaneous aspiration and irrigation C
Arthroscopic irrigation and debridement B
Open irrigation and debridement B
*Grade A: Good evidence (Level-I studies with consistent findings) for or against
recommending intervention. Grade B: Fair evidence (Level-II or III studies with
consistent findings) for or against recommending intervention. Grade C: Poor-
quality evidence (Level-IV or V studies with consistent findings) for or against
recommending intervention. Grade I: There is insufficient or conflicting evidence
not allowing a recommendation for or against intervention.
· VOLUME 8, ISSUE 2 · e0103

until there is minimal output. Patients
are transitioned to oral antibiotics with
the guidance of an infectious disease
specialist and on the basis of improve-
ment in the results of clinical exami-
nation, levels of inflammatory makers,
and WBC count. The choice of anti-
biotic is based on microbiological data.
Weight-bearing and range of motion
commence after the drain is removed,
and patients are discharged with close
follow-up with an orthopaedic surgeon
and infectious disease specialist. Long-
term follow-up is usually recom-
mended to monitor for sequelae of
septic arthritis of the hip.
Conclusions
Septic arthritis of the hip is a common
and potentially devastating condition in
children. It is most commonly caused by
S. aureus, but other causative organisms
should be considered on the basis of
patient age and risk factors. The diag-
nosis of septic arthritis is based on his-
tory, physical examination, laboratory
analysis, arthrocentesis, and radiographs
or ultrasound. Antibiotics are initiated
empirically after culture specimens have
been obtained, and definitive manage-
ment comprises arthroscopic or open
surgical debridement. Antibiotic choice
and duration are based on culture
data and improvement in clinical
symptoms and laboratory findings of
marker levels. Additional studies are
needed to standardize diagnosis and
management, compare surgical tech-
niques, decrease reoperation rates, and
minimize the risk of late complications.
Ishaan Swarup, MD1,
Scott LaValva, BA2,
Ronit Shah, BS2,
Wudbhav N. Sankar, MD2
1UCSF Benioff Children’s Hospital,
Oakland, California
2Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
Email address for I. Swarup:
ishaan.swarup@ucsf.edu
ORCID iD for I. Swarup:
0000-0003-3481-3408
FEBRUARY 2020 · VOLUME 8, ISSUE 2 · e0103
Septic Arthritis of the Hip in Children
ORCID iD for S. LaValva:
0000-0003-2276-7213
ORCID iD for R. Shah:
0000-0003-2944-4193
ORCID iD for W.N. Sankar:
0000-0001-9313-8006
References
1. Arkader A, Brusalis C, Warner WC Jr,
Conway JH, Noonan K. Update in pediatric
musculoskeletal infections: when it is, when
it isn’t, and what to do. J Am Acad Orthop
Surg. 2016 Sep;24(9):e112-21.
2. Riise ØR, Kirkhus E, Handeland KS, Flatø B,
Reiseter T, Cvancarova M, Nakstad B, Wathne
KO. Childhood osteomyelitis-incidence and
differentiation from other acute onset muscu-
loskeletal features in a population-based study.
BMC Pediatr. 2008 Oct 20;8(1):45.
3. Young TP, Maas L, Thorp AW, Brown L.
Etiology of septic arthritis in children: an update
for the new millennium. Am J Emerg Med. 2011
Oct;29(8):899-902. Epub 2010 Aug 1.
4. Howard JB, Highgenboten CL, Nelson JD.
Residual effects of septic arthritis in infancy and
childhood. JAMA. 1976 Aug 23;236(8):932-5.
5. Kocher MS, Zurakowski D, Kasser JR.
Differentiating between septic arthritis and
transient synovitis of the hip in children: an
evidence-based clinical prediction algorithm. J
Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
6. Caird MS, Flynn JM, Leung YL, Millman JE,
D’Italia JG, Dormans JP. Factors distinguishing
septic arthritis from transient synovitis of the
hip in children. A prospective study. J Bone Joint
Surg Am. 2006 Jun;88(6):1251-7.
7. Singhal R, Perry DC, Khan FN, Cohen D,
Stevenson HL, James LA, Sampath JS, Bruce CE.
The use of CRP within a clinical prediction
algorithm for the differentiation of septic
arthritis and transient synovitis in children. J
Bone Joint Surg Br. 2011 Nov;93(11):1556-61.
8. Sultan J, Hughes PJ. Septic arthritis or
transient synovitis of the hip in children: the
value of clinical prediction algorithms. J Bone
Joint Surg Br. 2010 Sep;92(9):1289-93.
9. Luhmann SJ, Jones A, Schootman M,
Gordon JE, Schoenecker PL, Luhmann JD.
Differentiation between septic arthritis and
transient synovitis of the hip in children with
clinical prediction algorithms. J Bone Joint
Surg Am. 2004 May;86(5):956-62.
10. Kocher MS, Mandiga R, Zurakowski D,
Barnewolt C, Kasser JR. Validation of a clinical
prediction rule for the differentiation between
septic arthritis and transient synovitis of the hip
in children. J Bone Joint Surg Am. 2004 Aug;
86(8):1629-35.
11. Uzoigwe CE. Another look: is there a flaw
to current hip septic arthritis diagnostic
algorithms? Clin Orthop Relat Res. 2014 May;
472(5):1645-51. Epub 2013 Aug 28.
12. Bowerman SG, Green NE, Mencio GA.
Decline of bone and joint infections
attributable to haemophilus influenzae
type b. Clin Orthop Relat Res. 1997 Aug;
(341):128-33.
13. Moran GJ, Krishnadasan A, Gorwitz RJ,
Fosheim GE, McDougal LK, Carey RB, Talan DA;
EMERGEncy ID Net Study Group. Methicillin-
resistant S. aureus infections among patients in
the emergency department. N Engl J Med. 2006
Aug 17;355(7):666-74.
|
14. Frazee BW, Lynn J, Charlebois ED, Lambert
L, Lowery D, Perdreau-Remington F. High
prevalence of methicillin-resistant Staphylo-
coccus aureus in emergency department skin
and soft tissue infections. Ann Emerg Med. 2005
Mar;45(3):311-20.
15. Dormans JP, Drummond DS. Pediatric
hematogenous osteomyelitis: new trends in
presentation, diagnosis, and treatment. J Am
Acad Orthop Surg. 1994 Nov;2(6):333-41.
16. Karwowska A, Davies HD, Jadavji T.
Epidemiology and outcome of osteomyelitis
in the era of sequential intravenous-oral
therapy. Pediatr Infect Dis J. 1998 Nov;17(11):
1021-6.
17. Blyth MJ, Kincaid R, Craigen MA, Bennet GC.
The changing epidemiology of acute and
subacute haematogenous osteomyelitis in
children. J Bone Joint Surg Br. 2001 Jan;83(1):
99-102.
18. Dodwell ER. Osteomyelitis and septic
arthritis in children: current concepts. Curr Opin
Pediatr. 2013 Feb;25(1):58-63.
19. Nunn TR, Cheung WY, Rollinson PD. A
prospective study of pyogenic sepsis of the hip
in childhood. J Bone Joint Surg Br. 2007 Jan;
89(1):100-6.
20. Gafur OA, Copley LAB, Hollmig ST,
Browne RH, Thornton LA, Crawford SE. The
impact of the current epidemiology of
pediatric musculoskeletal infection on
evaluation and treatment guidelines. J
Pediatr Orthop. 2008 Oct-Nov;28(7):
777-85.
21. Lavy CBD, Peek AC, Manjolo G. The
incidence of septic arthritis in Malawian
children. Int Orthop. 2005 Jun;29(3):195-6.
Epub 2005 Apr 2.
22. Peltola H, Pääkk önen M, Kallio P, Kallio
MJT; OM-SA Study Group. Clindamycin vs.
first-generation cephalosporins for acute
osteoarticular infections of childhood—a
prospective quasi-randomized controlled
trial. Clin Microbiol Infect. 2012 Jun;18(6):
582-9. Epub 2011 Oct 19.
23. Al Saadi MM, Al Zamil FA, Bokhary NA, Al
Shamsan LA, Al Alola SA, Al Eissa YS. Acute
septic arthritis in children. Pediatr Int. 2009 Jun;
51(3):377-80.
24. Arnold SR, Elias D, Buckingham SC, Thomas
ED, Novais E, Arkader A, Howard C. Changing
patterns of acute hematogenous osteomyelitis
and septic arthritis: emergence of community-
associated methicillin-resistant Staphylococ-
cus aureus. J Pediatr Orthop. 2006 Nov-Dec;
26(6):703-8.
25. Goergens ED, McEvoy A, Watson M, Barrett
IR. Acute osteomyelitis and septic arthritis in
children. J Paediatr Child Health. 2005 Jan-Feb;
41(1-2):59-62.
26. Carrel M, Perencevich EN, David MZ.
USA300 methicillin-resistant Staphylococcus
aureus, United States, 2000-2013. Emerg Infect
Dis. 2015 Nov;21(11):1973-80.
27. Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R.
Epidemiology, etiology, and clinical features of
septic arthritis in children younger than 24
months. Arch Pediatr Adolesc Med. 1995 May;
149(5):537-40.
28. Nade S. Acute septic arthritis in infancy and
childhood. J Bone Joint Surg Br. 1983 May;65(3):
234-41.
29. Fink CW, Nelson JD. Septic arthritis and
osteomyelitis in children. Clin Rheum Dis. 1986
Aug;12(2):423-35.
9
 | Septic Ar thr itis of the Hip in Children
30. Barton LL, Dunkle LM, Habib FH. Septic
arthritis in childhood. A 13-year review. Am J Dis
Child. 1987 Aug;141(8):898-900.
31. Borella L, Goobar JE, Summitt RL, Clark GM.
Septic arthritis in childhood. J Pediatr. 1963
May;62:742-7.
32. Edwards MS, Baker CJ, Wagner ML, Taber
LH, Barrett FF. An etiologic shift in infantile
osteomyelitis: the emergence of the group B
streptococcus. J Pediatr. 1978 Oct;93(4):578-83.
33. Lundy DW, Kehl DK. Increasing prevalence
of Kingella kingae in osteoarticular infections in
young children. J Pediatr Orthop. 1998 Mar-Apr;
18(2):262-7.
34. Shuler TE, Riddle CD Jr, Potts DW.
Polymicrobic septic arthritis caused by
Kingella kingae and enterococcus. Orthopedics.
1990 Feb;13(2):254-6.
35. Yagupsky P. Kingella kingae: from medical
rarity to an emerging paediatric pathogen.
Lancet Infect Dis. 2004 Jun;4(6):358-67.
36. Basmaci R, Lorrot M, Bidet P, Doit C, Vitoux C,
Penneçot G, Mazda K, Bingen E, Ilharreborde B,
Bonacorsi S. Comparison of clinical and biologic
features of Kingella kingae and Staphylococcus
aureus arthritis at initial evaluation. Pediatr
Infect Dis J. 2011 Oct;30(10):902-4.
37. Ceroni D, Cherkaoui A, Ferey S, Kaelin A,
Schrenzel J. Kingella kingae osteoarticular
infections in young children: clinical features
and contribution of a new specific real-time PCR
assay to the diagnosis. J Pediatr Orthop. 2010
Apr-May;30(3):301-4.
38. Burnett MW, Bass JW, Cook BA. Etiology of
osteomyelitis complicating sickle cell disease.
Pediatrics. 1998 Feb;101(2):296-7.
39. Espinosa CM, Davis MM, Gilsdorf JR.
Anaerobic osteomyelitis in children. Pediatr
Infect Dis J. 2011 May;30(5):422-3.
40. Gamaletsou MN, Kontoyiannis DP, Sipsas
NV, Moriyama B, Alexander E, Roilides E, Brause
B, Walsh TJ. Candida osteomyelitis: analysis of
207 pediatric and adult cases (1970-2011). Clin
Infect Dis. 2012 Nov 15;55(10):1338-51. Epub
2012 Aug 21.
41. Beldman TF, Teunisse HA, Schouten TJ.
Septic arthritis of the hip by Fusobacterium
necrophorum after tonsillectomy: a form of
Lemierre syndrome? Eur J Pediatr. 1997 Nov;
156(11):856-7.
42. Chryssagi AM, Brusselmans CB, Rombouts JJ.
Septic arthritis of the hip due to Fusobacterium
nucleatum. Clin Rheumatol. 2001;20(3):229-31.
43. Goyal M, Sharma R, Jain Y, Gupta A, Berry
M. Unusual radiological manifestations of
Lemierre’s syndrome: a case report. Pediatr
Radiol. 1995 Nov;25(Suppl 1):S105-6.
44. Robertson AJF, Firth GB, Truda C, Ramdass
DA, Groome M, Madhi S. Epidemiology of acute
osteoarticular sepsis in a setting with a high
prevalence of pediatric HIV infection. J Pediatr
Orthop. 2012 Mar;32(2):215-9.
45. Cruz AI Jr, Aversano FJ, Seeley MA, Sankar
WN, Baldwin KD. Pediatric Lyme arthritis of the
hip: the great imitator? J Pediatr Orthop. 2017
Jul/Aug;37(5):355-61.
46. Dart AH, Michelson KA, Aronson PL, Garro
AC, Lee TJ, Glerum KM, Nigrovic PA, Kocher MS,
Bachur RG, Nigrovic LE. Hip synovial fluid
cell counts in children from a Lyme disease
endemic area. Pediatrics. 2018 May;141(5):
e20173810. Epub 2018 Apr 18.
47. Tarkowski A, Collins LV, Gjertsson I,
Hultgren OH, Jonsson IM, Sakiniene E,
10
Verdrengh M. Model systems: modeling
human staphylococcal arthritis and sepsis
in the mouse. Trends Microbiol. 2001 Jul;9(7):
321-6.
48. Wilkinson LS, Worrall JG, Sinclair HD, Edwards
JCW. Immunohistological reassessment of
accessory cell populations in normal and diseased
human synovium. Br J Rheumatol. 1990 Aug;29(4):
259-63.
49. FitzGerald O, Bresnihan B. Synovial
membrane cellularity and vascularity. Ann
Rheum Dis. 1995 Jun;54(6):511-5.
50. McNeil JC, Vallejo JG, Hultén KG, Kaplan SL.
Osteoarticular infections following open or
penetrating trauma in children in the post-
community-acquired methicillin-resistant
Staphylococcus aureus era: the impact of
Enterobacter cloacae. Pediatr Infect Dis J. 2018
Dec;37(12):1204-10.
51. Ogden JA, Lister G. The pathology of
neonatal osteomyelitis. Pediatrics. 1975 Apr;
55(4):474-8.
52. Alderson M, Speers D, Emslie K, Nade S.
Acute haematogenous osteomyelitis and septic
arthritis—a single disease. An hypothesis based
upon the presence of transphyseal blood vessels. J
Bone Joint Surg Br. 1986 Mar;68(2):268-74.
53. Trueta J. The three types of acute
haematogenous osteomyelitis. A clinical and
vascular study. J Bone Joint Surg Br. 1959
Nov;41-B(4):671-80.
54. Perlman MH, Patzakis MJ, Kumar PJ, Holtom
P. The incidence of joint involvement with
adjacent osteomyelitis in pediatric patients. J
Pediatr Orthop. 2000 Jan-Feb;20(1):40-3.
55. Montgomery CO, Siegel E, Blasier RD, Suva
LJ. Concurrent septic arthritis and osteomyelitis
in children. J Pediatr Orthop. 2013 Jun;33(4):
464-7.
56. Hultgren O, Eugster HP, Sedgwick JD,
Körner H, Tarkowski A. TNF/lymphotoxin-alpha
double-mutant mice resist septic arthritis but
display increased mortality in response to
Staphylococcus aureus. J Immunol. 1998 Dec 1;
161(11):5937-42.
57. Hultgren OH, Svensson L, Tarkowski A.
Critical role of signaling through IL-1 receptor
for development of arthritis and sepsis during
Staphylococcus aureus infection. J Immunol.
2002 May 15;168(10):5207-12.
58. Hultgren O, Kopf M, Tarkowski A. Outcome
of Staphylococcus aureus-triggered sepsis and
arthritis in IL-4-deficient mice depends on the
genetic background of the host. Eur J Immunol.
1999 Aug;29(8):2400-5.
59. Mathews CJ, Weston VC, Jones A, Field M,
Coakley G. Bacterial septic arthritis in adults.
Lancet. 2010 Mar 6;375(9717):846-55.
60. Papathanasiou I, Malizos KN, Poultsides L,
Karachalios T, Oikonomou P, Tsezou A. The
catabolic role of toll-like receptor 2 (TLR-2)
mediated by the NF-kB pathway in septic
arthritis. J Orthop Res. 2011 Feb;29(2):247-51.
Epub 2010 Aug 25.
61. Adler A, Temper V, Block CS, Abramson N,
Moses AE. Panton-Valentine leukocidin-
producing Staphylococcus aureus. Emerg
Infect Dis. 2006 Nov;12(11):1789-90.
62. Roy S, Bhawan J. Ultrastructure of articular
cartilage in pyogenic arthritis. Arch Pathol. 1975
Jan;99(1):44-7.
63. Curtiss PH Jr, Klein L. Destruction of articular
cartilage in septic arthritis. I. In vitro studies. J
Bone Joint Surg Am. 1963 Jun;45-A:797-806.
FEBRUARY 2020
64. Curtiss PH Jr, Klein L. Destruction of articular
cartilage in septic arthritis. II. In vivo studies. J
Bone Joint Surg Am. 1965 Dec;47(8):1595-604.
65. Smith RL, Schurman DJ, Kajiyama G, Mell M,
Gilkerson E. The effect of antibiotics on the
destruction of cartilage in experimental
infectious arthritis. J Bone Joint Surg Am. 1987
Sep;69(7):1063-8.
66. Goldenberg DL, Chisholm PL, Rice PA.
Experimental models of bacterial arthritis:
a microbiologic and histopathologic
characterization of the arthritis after
the intraarticular injections of Neisseria
gonorrhoeae, Staphylococcus aureus,
group A streptococci, and Escherichia coli. J
Rheumatol. 1983 Feb;10(1):5-11.
67. Abdelnour A, Arvidson S, Bremell T, Rydén
C, Tarkowski A. The accessory gene regulator
(agr) controls Staphylococcus aureus virulence
in a murine arthritis model. Infect Immun. 1993
Sep;61(9):3879-85.
68. Cruz AI Jr, Anari JB, Ramirez JM, Sankar WN,
Baldwin KD. Distinguishing pediatric Lyme
arthritis of the hip from transient synovitis and
acute bacterial septic arthritis: a systematic
review and meta-analysis. Cureus. 2018 Jan 25;
10(1):e2112.
69. Ramilo O, Allman W, Chung W, Mejias A,
Ardura M, Glaser C, Wittkowski KM, Piqueras B,
Banchereau J, Palucka AK, Chaussabel D. Gene
expression patterns in blood leukocytes
discriminate patients with acute infections.
Blood. 2007 Mar 1;109(5):2066-77. Epub 2006
Nov 14.
70. Deirmengian C, Lonner JH, Booth RE Jr. The
Mark Coventry Award: white blood cell gene
expression: a new approach toward the study
and diagnosis of infection. Clin Orthop Relat
Res. 2005 Nov;440(440):38-44.
71. Klein DM, Barbera C, Gray ST, Spero CR,
Perrier G, Teicher JL. Sensitivity of objective
parameters in the diagnosis of pediatric septic
hips. Clin Orthop Relat Res. 1997 May;(338):
153-9.
72. Fischer SU, Beattie TF. The limping child:
epidemiology, assessment and outcome. J
Bone Joint Surg Br. 1999 Nov;81(6):1029-34.
73. Fabry G, Meire E. Septic arthritis of the hip in
children: poor results after late and inadequate
treatment. J Pediatr Orthop. 1983 Sep;3(4):
461-6.
74. Morrey BF, Bianco AJ, Rhodes KH.
Suppurative arthritis of the hip in children. J
Bone Joint Surg Am. 1976 Apr;58(3):388-92.
75. Bennett OM, Namnyak SS. Acute septic
arthritis of the hip joint in infancy and
childhood. Clin Orthop Relat Res. 1992 Aug;
(281):123-32.
76. Hallel T, Salvati EA. Septic arthritis of the hip
in infancy: end result study. Clin Orthop Relat
Res. 1978 May;(132):115-28.
77. Lunseth P, Heiple K. Prognosis in septic
arthritis of the hip in children. Clin Orthop Relat
Res. 1979 Mar-Apr(139):81-5.
78. Betz RR, Cooperman DR, Wopperer JM,
Sutherland RD, White JJ Jr, Schaaf HW,
Aschliman MR, Choi IH, Bowen JR, Gillespie R.
Late sequelae of septic arthritis of the hip in
infancy and childhood. J Pediatr Orthop.
1990 May-Jun;10(3):365-72.
79. Nachemson A, Scheller S. A clinical and
radiological follow-study of transient synovitis
of the hip. Acta Orthop Scand. 1969;40(4):
479-500.
· VOLUME 8, ISSUE 2 · e0103

80. Jacobs BW. Synovitis of the hip in children
and its significance. Pediatrics. 1971 Mar;47(3):
558-66.
81. Del Beccaro MA, Champoux AN, Bockers T,
Mendelman PM. Septic arthritis versus transient
synovitis of the hip: the value of screening
laboratory tests. Ann Emerg Med. 1992 Dec;
21(12):1418-22.
82. Jung ST, Rowe SM, Moon ES, Song EK, Yoon
TR, Seo HY. Significance of laboratory and
radiologic findings for differentiating between
septic arthritis and transient synovitis of the hip.
J Pediatr Orthop. 2003 May-Jun;23(3):368-72.
83. Eich GF, Superti-Furga A, Umbricht FS, Willi
UV. The painful hip: evaluation of criteria for
clinical decision-making. Eur J Pediatr. 1999
Nov;158(11):923-8.
84. Stans AA. Musculoskeletal infection. In:
Weinstein SL, Flynn JM, editors. Lovell and
Winter’s pediatric orthopaedics. 7th ed. Wolters
Kluwer Health; 2014. p 369.
85. Wilson NI, Di Paola M. Acute septic arthritis
in infancy and childhood. 10 years’ experience. J
Bone Joint Surg Br. 1986 Aug;68(4):584-7.
86. Motwani G, Mehta R, Aroojis A, Vaidya S.
Current trends of microorganisms and their
sensitivity pattern in paediatric septic arthritis:
A prospective study from tertiary care level
hospital. J Clin Orthop Trauma. 2017 Jan-Mar;
8(1):89-92. Epub 2016 Sep 28.
87. Montgomery NI, Epps HR. Pediatric septic
arthritis. Orthop Clin North Am. 2017 Apr;48(2):
209-16.
88. Baldwin KD, Brusalis CM, Nduaguba AM,
Sankar WN. Predictive factors for differentiating
between septic arthritis and Lyme disease of
the knee in children. J Bone Joint Surg Am. 2016
May 4;98(9):721-8.
89. Levine MJ, McGuire KJ, McGowan KL, Flynn
JM. Assessment of the test characteristics of C-
reactive protein for septic arthritis in children. J
Pediatr Orthop. 2003 May-Jun;23(3):373-7.
90. Carter K, Doern C, Jo CH, Copley LAB. The
clinical usefulness of polymerase chain reaction
as a supplemental diagnostic tool in the
evaluation and the treatment of children with
septic arthritis. J Pediatr Orthop. 2016 Mar;36(2):
167-72.
91. Zamzam MM. The role of ultrasound in
differentiating septic arthritis from transient
synovitis of the hip in children. J Pediatr Orthop
B. 2006 Nov;15(6):418-22.
92. Gordon JE, Huang M, Dobbs M, Luhmann SJ,
Szymanski DA, Schoenecker PL. Causes of false-
negative ultrasound scans in the diagnosis of
septic arthritis of the hip in children. J Pediatr
Orthop. 2002 May-Jun;22(3):312-6.
93. Rosenfeld S, Bernstein DT, Daram S, Dawson
J, Zhang W. Predicting the presence of adjacent
infections in septic arthritis in children. J Pediatr
Orthop. 2016 Jan;36(1):70-4.
94. Nguyen A, Kan JH, Bisset G, Rosenfeld S.
Kocher criteria revisited in the era of MRI:
how often does the Kocher criteria identify
underlying osteomyelitis? J Pediatr Orthop.
2017 Mar;37(2):e114-9.
95. Song KS, Lee SW, Bae KC. Key role of
magnetic resonance imaging in the diagnosis
of infections around the hip and pelvic girdle
mimicking septic arthritis of the hip in children.
J Pediatr Orthop B. 2016 May;25(3):234-40.
96. Refakis CA, Arkader A, Baldwin KD, Spiegel
DA, Sankar WN. Predicting periarticular
infection in children with septic arthritis of
FEBRUARY 2020 · VOLUME 8, ISSUE 2 · e0103
Septic Arthritis of the Hip in Children
the hip: regionally derived criteria may not
apply to all populations. J Pediatr Orthop. 2019
May/Jun;39(5):268-74.
97. Mignemi ME, Menge TJ, Cole HA, Mencio
GA, Martus JE, Lovejoy S, Stutz CM, Schoenecker
JG. Epidemiology, diagnosis, and treatment of
pericapsular pyomyositis of the hip in children.
J Pediatr Orthop. 2014 Apr-May;34(3):316-25.
98. Shmerling RH, Delbanco TL, Tosteson ANA,
Trentham DE. Synovial fluid tests. What should
be ordered? JAMA. 1990 Aug 22-29;264(8):
1009-14.
99. Yagupsky P, Porsch E, St Geme JW 3rd.
Kingella kingae: an emerging pathogen in
young children. Pediatrics. 2011 Mar;127(3):
557-65. Epub 2011 Feb 14.
100. Heyworth BE, Shore BJ, Donohue KS, Miller
PE, Kocher MS, Glotzbecker MP. Management
of pediatric patients with synovial fluid white
blood-cell counts of 25,000 to 75,000 cells/mm3
after aspiration of the hip. J Bone Joint Surg Am.
2015 Mar 4;97(5):389-95.
101. Samora JB, Klingele K. Septic arthritis of
the neonatal hip: acute management and late
reconstruction. J Am Acad Orthop Surg. 2013
Oct;21(10):632-41.
102. Sucato DJ, Schwend RM, Gillespie R. Septic
arthritis of the hip in children. J Am Acad Orthop
Surg. 1997 Oct;5(5):249-60.
103. Broadhurst LE, Erickson RL, Kelley PW.
Decreases in invasive Haemophilus influenzae
diseases in US Army children, 1984 through
1991. JAMA. 1993 Jan 13;269(2):227-31.
104. Castellazzi L, Mantero M, Esposito S.
Update on the management of pediatric acute
osteomyelitis and septic arthritis. Int J Mol Sci.
2016 Jun 1;17(6):E855.
105. Kim HK, Alman B, Cole WG. A shortened
course of parenteral antibiotic therapy in the
management of acute septic arthritis of the hip.
J Pediatr Orthop. 2000 Jan-Feb;20(1):44-7.
106. Peltola H, Pääkkönen M, Kallio P, Kallio
MJT; Osteomyelitis-Septic Arthritis (OM-SA)
Study Group. Prospective, randomized trial of
10 days versus 30 days of antimicrobial
treatment, including a short-term course of
parenteral therapy, for childhood septic arthri-
tis. Clin Infect Dis. 2009 May 1;48(9):1201-10.
107. Ballock RT, Newton PO, Evans SJ,
Estabrook M, Farnsworth CL, Bradley JS. A
comparison of early versus late conversion from
intravenous to oral therapy in the treatment of
septic arthritis. J Pediatr Orthop. 2009 Sep;29(6):
636-42.
108. Kocher MS, Mandiga R, Murphy JM,
Goldmann D, Harper M, Sundel R, Ecklund K,
Kasser JR. A clinical practice guideline for
treatment of septic arthritis in children: efficacy
in improving process of care and effect on
outcome of septic arthritis of the hip. J Bone
Joint Surg Am. 2003 Jun;85(6):994-9.
109. Delgado-Noguera MF, Forero Delgadillo
JM, Franco AA, Vazquez JC, Calvache JA.
Corticosteroids for septic arthritis in children.
Cochrane Database Syst Rev. 2018 Nov 21;11:
CD012125.
110. Odio CM, Ramirez T, Arias G, Abdelnour A,
Hidalgo I, Herrera ML, Bolaños W, Alpı́zar J,
Alvarez P. Double blind, randomized, placebo-
controlled study of dexamethasone therapy for
hematogenous septic arthritis in children. Pe-
diatr Infect Dis J. 2003 Oct;22(10):883-8.
111. Harel L, Prais D, Bar-On E, Livni G, Hoffer V,
Uziel Y, Amir J. Dexamethasone therapy
for septic arthritis in children: results of a
|
randomized double-blind placebo-controlled
study. J Pediatr Orthop. 2011 Mar;31(2):211-5.
112. Aiyer A, Hennrikus W, Walrath J, Groh B,
Ostrov B. Lyme arthritis of the pediatric lower
extremity in the setting of polyarticular disease.
J Child Orthop. 2014 Aug;8(4):359-65. Epub
2014 Jul 23.
113. Lebel E, Rudensky B, Karasik M, Itzchaki M,
Schlesinger Y. Kingella kingae infections in
children. J Pediatr Orthop B. 2006 Jul;15(4):
289-92.
114. Weigl DM, Becker T, Mercado E, Bar-On E.
Percutaneous aspiration and irrigation technique
for the treatment of pediatric septic hip:
effectiveness and predictive parameters. J
Pediatr Orthop B. 2016 Nov;25(6):514-9.
115. Chung WK, Slater GL, Bates EH. Treatment
of septic arthritis of the hip by arthroscopic
lavage. J Pediatr Orthop. 1993 Jul-Aug;13(4):
444-6.
116. Edmonds EW, Lin C, Farnsworth CL,
Bomar JD, Upasani VV. A medial portal for hip
arthroscopy in children with septic arthritis: a
safety study. J Pediatr Orthop. 2018 Nov/Dec;
38(10):527-31.
117. Thompson RM, Gourineni P. Arthroscopic
treatment of septic arthritis in very young
children. J Pediatr Orthop. 2017 Jan;37(1):e53-7.
118. Sanpera I, Raluy-Collado D, Sanpera-
Iglesias J. Arthroscopy for hip septic arthritis in
children. Orthop Traumatol Surg Res. 2016 Feb;
102(1):87-9. Epub 2015 Dec 24.
119. Mooney JF 3rd, Murphy RF. Septic arthritis
of the pediatric hip: update on diagnosis and
treatment. Curr Opin Pediatr. 2019 Feb;31(1):
79-85.
120. Sabour AF, Alluri RK, Heckmann N, Heidari
KS, Rick Hatch GF 3rd, VandenBerg C. A
nationwide analysis of failed irrigation and
debridement for pediatric septic arthritis of the
hip. J Pediatr Orthop B. 2019 Sep;28(5):470-5.
121. Murphy RF, Plumblee L, Barfield WB,
Murphy JS, Fuerstenau N, Spence DD, Kelly DM,
Dow MA, Mooney JF 3rd. Septic arthritis of the
hip-risk factors associated with secondary sur-
gery. J Am Acad Orthop Surg. 2019 May 1;27(9):
321-6.
122. Hoswell RL, Johns BP, Loewenthal MR,
Dewar DC. Outcomes of paediatric septic
arthritis of the hip and knee at 1-20 years in an
Australian urban centre. ANZ J Surg. 2019 May;
89(5):562-6. Epub 2019 Apr 8.
123. Choi IH, Shin YW, Chung CY, Cho TJ, Yoo
WJ, Lee DY. Surgical treatment of the severe
sequelae of infantile septic arthritis of the hip.
Clin Orthop Relat Res. 2005 May;(434):102-9.
124. Forlin E, Milani C. Sequelae of septic
arthritis of the hip in children: a new
classification and a review of 41 hips. J
Pediatr Orthop. 2008 Jul-Aug;28(5):524-8.
125. Bram JT, Baldwin KD, Blumberg TJ. Gram
Stain is Not Clinically Relevant in Treatment of
Pediatric Septic Arthritis. J Pediatr Orthop. 2018
Oct;38(9):e536-40.
126. Okubo Y, Nochioka K, Marcia T. Nationwide
survey of pediatric septic arthritis in the
United States. J Orthop. 2017 Jun 23;14(3):
342-6.
127. Freedman J, Guller U, Benjamin DK,
Higgins LD, Pan D, Cook C, Pietrobon R. National
trends in health care utilization and racial and
socioeconomic disparities in pediatric
pyogenic arthritis. J Pediatr Orthop. 2006 Nov-
Dec;26(6):709-15.
11
 | Septic Ar thr itis of the Hip in Children
128. Chen CE, Ko JY, Li CC, Wang CJ. Acute
septic arthritis of the hip in children. Arch
Orthop Trauma Surg. 2001 Oct;121(9):521-6.
129. Deshpande PG, Wagle SU, Mehta SD,
Bharucha BA, Irani SF. Neonatal osteomyelitis and
septic arthritis. Indian Pediatr. 1990 May;27(5):453-7.
130. Wang CL, Wang SM, Yang YJ, Tsai CH, Liu CC.
Septic arthritis in children: relationship of causative
pathogens, complications, and outcome. J
Microbiol Immunol Infect. 2003 Mar;36(1):41-6.
131. Yang WJ, Im SA, Lim GY, Chun HJ, Jung NY,
Sung MS, Choi BG. MR imaging of transient
synovitis: differentiation from septic arthritis.
Pediatr Radiol. 2006 Nov;36(11):1154-8. Epub
2006 Sep 20.
132. Umer M, Hashmi P, Ahmad T, Ahmed M,
Umar M. Septic arthritis of the hip in children—Aga
Khan University Hospital experience in Pakistan. J
Pak Med Assoc. 2003 Oct;53(10):472-8.
12
133. Gordon JE, Wolff A, Luhmann SJ, Ortman
MR, Dobbs MB, Schoenecker PL. Primary and
delayed closure after open irrigation and
debridement of septic arthritis in children. J
Pediatr Orthop B. 2005 Mar;14(2):101-4.
134. Jackson MA, Burry VF, Olson LC.
Pyogenic arthritis associated with adjacent
osteomyelitis: identification of the sequela-
prone child. Pediatr Infect Dis J. 1992 Jan;
11(1):9-13.
135. Maraqa NF, Gomez MM, Rathore MH.
Outpatient parenteral antimicrobial therapy in
osteoarticular infections in children. J Pediatr
Orthop. 2002 Jul-Aug;22(4):506-10.
136. Branson J, Vallejo JG, Flores AR, Hulten KG,
Mason EO, Kaplan SL, McNeil JC. The Contemporary
Microbiology and Rates of Concomitant
Osteomyelitis in Acute Septic Arthritis.
Pediatr Infect Dis J. 2017 Mar;36(3):267-73.
FEBRUARY 2020
137. Frederiksen B, Christiansen P, Knudsen FU.
Acute osteomyelitis and septic arthritis in the
neonate, risk factors and outcome. Eur J Pediatr.
1993 Jul;152(7):577-80.
138. Dan M. Septic arthritis in young infants:
clinical and microbiologic correlations and
therapeutic implications. Rev Infect Dis. 1984
Mar-Apr;6(2):147-55.
139. Mijiyawa M, Oniankitan O, Attoh-
Mensah K, T ékou A, Lawson EK, Priuli GB,
Assimadi JK. Musculoskeletal conditions in
children attending two Togolese hospitals.
Rheumatology (Oxford). 1999 Oct;38(10):
1010-3.
140. Chacha PB. Suppurative arthritis
of the hip joint in infancy. A persistent
diagnostic problem and possible complication
of femoral venipuncture. J Bone Joint Surg Am.
1971 Apr;53(3):538-44.
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