Division of Pediatric Emergency Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine, Sihhiye, 06100 Ankara, Turkey.
Department of Pediatrics, Hacettepe University Faculty of Medicine, Sihhiye, 06100 Ankara, Turkey.
Am J Emerg Med. 2022 Oct;60:145-151. doi: 10.1016/j.ajem.2022.08.002. Epub 2022 Aug 6.
Although Kocher criteria can distinguish a septic hip from an aseptic cause, they may not apply to a septic knee. We aimed to identify predictors to discriminate septic and aseptic causes of acute knee monoarthritis in children who underwent arthrocentesis.
We conducted a retrospective cohort study among children who underwent arthrocentesis for suspected septic arthritis of the knee. Collected data included demographic, clinical and laboratory characteristics. We performed univariate and multivariable analyses to identify predictors of the septic knee. We further investigated accuracy of different predictive models.
A total of 60 patients who underwent arthrocentesis for suspected knee septic arthritis were included in this study. Septic arthritis of the knee was confirmed in 32 (53%) patients. Age ≤ 5 years (OR 4.237, [95% CI 1.270-14.127], p = 0.019), WBC > 12,000 cells/mm (OR 5.059, [95% CI 1.424-17.970], p = 0.012), and CRP > 2 mg/dL (OR 3.180, [0.895-11.298], p = 0.074) were the most important predictors of a septic knee. Three-tier model comprising these three factors (AUC 0.766) and 4-tier model with addition of fever >38.5°C (AUC 0.776) performed better than Kocher criteria (AUC 0.677), modified Kocher criteria (AUC 0.699) and Full Model (adding age ≤ 5 years and CRP >2 mg/dL to Kocher criteria) (AUC 0.746). Full Model successfully ruled out septic arthritis if all 6 criteria were negative.
Based on these findings, we propose an algorithm to identify low, intermediate and high-risk patients for knee septic arthritis. Our proposed two-step algorithm incorporating major (age, WBC, CRP) and minor (fever, ESR, non-weight bearing) criteria can serve as a simple decision-support tool to justify arthrocentesis in children with suspected knee septic arthritis.
虽然科赫标准可以区分脓毒性髋关节和非感染性原因，但它们可能不适用于脓毒性膝关节。我们旨在确定预测因子，以区分接受关节穿刺术的儿童急性单关节炎的脓毒性和非感染性原因。
我们对接受关节穿刺术以怀疑膝关节化脓性关节炎的儿童进行了回顾性队列研究。收集的数据包括人口统计学、临床和实验室特征。我们进行了单变量和多变量分析，以确定膝关节感染的预测因子。我们进一步研究了不同预测模型的准确性。
本研究共纳入 60 例接受关节穿刺术以怀疑膝关节化脓性关节炎的患者。膝关节化脓性关节炎确诊 32 例（53%）。年龄≤5 岁（OR 4.237，[95%CI 1.270-14.127]，p=0.019）、白细胞计数（WBC）>12000 个/立方毫米（OR 5.059，[95%CI 1.424-17.970]，p=0.012）和 C 反应蛋白（CRP）>2mg/dL（OR 3.180，[0.895-11.298]，p=0.074）是膝关节感染的最重要预测因子。由这三个因素组成的三层次模型（AUC 0.766）和添加发热>38.5°C 的四层次模型（AUC 0.776）优于科赫标准（AUC 0.677）、改良科赫标准（AUC 0.699）和全模型（将年龄≤5 岁和 CRP>2mg/dL 添加到科赫标准）（AUC 0.746）。如果所有 6 项标准均为阴性，则全模型可成功排除化脓性关节炎。
基于这些发现，我们提出了一种用于识别膝关节化脓性关节炎低、中、高危患者的算法。我们提出的两步算法结合了主要（年龄、WBC、CRP）和次要（发热、ESR、非负重）标准，可以作为一种简单的决策支持工具，用于确定疑似膝关节化脓性关节炎儿童是否需要进行关节穿刺术。
