Septic Arthritis of the Hip-Risk Factors Associated With Secondary Surgery.

INTRODUCTION

Septic arthritis of the hip (SAH) is a common condition encountered by pediatric orthopaedic surgeons and is treated with arthrotomy and irrigation. Depending on the response to initial treatment, some patients require surgical treatment beyond the index procedure. The purpose of this study was to investigate risk factors for repeat surgical intervention after initial arthrotomy for presumed SAH.

METHODS

A multicenter retrospective review of all children who underwent surgical arthrotomy for presumed SAH over a ten-year period was conducted. Variables queried included demographics, clinical presentation, laboratory parameters, imaging, infecting organism, presence of osteomyelitis, and surgical interventions performed. Logistic regression was used to predict the risk of a second procedure. Chi-square was used to compare patients who required further surgery and those who did not.

RESULTS

One hundred and thirty-eight patients (139 hips) qualified for inclusion. The average age at initial surgery was 6.1 years (range, zero to 17 years), and 57% of the patients were male. Concomitant osteomyelitis was diagnosed in 55 cases (40%). An infecting organism was identified from 70 (50%) index intraoperative cultures, with Staphylococcus aureus infections (methicillin-resistant Staphylococcus aureus [MRSA], 27; methicillin-sensitive Staphylococcus aureus, 25) being the most frequent. Fifty-six patients (41%) underwent subsequent surgical intervention, at an average of 5.5 days (range, 2 to 95) from the index procedure. Independent risk factors for repeat surgical procedures included presenting C-reactive protein >10 mg/dL (P = 0.002) and presenting erythrocyte sedimentation rate >40 (P = 0.011). The odds of repeat surgical intervention were significantly increased by the presence of concomitant osteomyelitis (odds ratio, 3.4; P = 0.001) and positive index intraoperative cultures for MRSA (odds ratio, 1.19; P = 0.001). Preoperative MRI before the index procedure was not universal (73/138; 53%), and acquisition of preoperative MRI was not associated with secondary surgical intervention (P = 0.389).

DISCUSSION

Forty-one percent of children in this multicenter cohort underwent at least one repeat surgical procedure after the index arthrotomy for management of presumed SAH. Risk factors for return to the operating room include elevated initial erythrocyte sedimentation rate and C-reactive protein, infection with MRSA, and presence of osteomyelitis.

LEVEL OF EVIDENCE

Level 3, case-cohort series. Type of evidence, therapeutic.