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Septic Arthritis of the Hip—Risk Factors Associated With Secondary Surgery

Murphy, Robert F., MD; Plumblee, Leah, MD; Barfield, William B., PhD; Murphy, Joshua S., MD; Fuerstenau, Nicholas, BS; Spence, David D., MD; Kelly, Derek M., MD; Dow, Matthew A., MD; Mooney, James F. III, MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: May 1, 2019 - Volume 27 - Issue 9 - p 321–326
doi: 10.5435/JAAOS-D-18-00058
Research Article

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.

From the Department of Orthopaedics (Dr. R. F. Murphy, Dr. Plumblee, Dr. Barfield, and Dr. Dow), Medical University of South Carolina, Charleston SC, Children's Orthopaedics of Atlanta, Atlanta, GA (Dr. J. S. Murphy, Mr. Fuerstenau), the Department of Orthopaedics and Biomedical Engineering, University of Tennessee–Campbell Clinic, Memphis, TN (Dr. Spence and Dr. Kelly), and Shriner's Hospital for Children, Springfield, MA (Dr. Mooney).

Correspondence to Dr. R. F. Murphy: murphyr@musc.edu

Dr. R. F. Murphy or an immediate family member serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North America. Dr. J. S. Murphy or an immediate family member serves as a paid consultant to Depuy; has received research or institutional support from OrthoPediatrics; and serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North America and the Scoliosis Research Society. Dr. Spence or an immediate family member serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North America. Dr. Kelly or an immediate family member is a member of a speakers' bureau or has made paid presentations on behalf of Medtronic; serves as a paid consultant to WishBone Surgical; and serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North America. Dr. Mooney or an immediate family member has received research or institutional support from Synthes and serves as a board member, owner, officer, or committee member of the Pediatric Orthopaedic Society of North America and the Scoliosis Research Society. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Plumblee, Dr. Barfield, and Mr. Fuerstenau.

This is assurance that each of the authors listed earlier has fully participated in each of the listed points below and qualified for manuscript authorship: (1) substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work; (2) drafting the work or revising it critically for important intellectual content; (3) final approval of the version to be published; and (4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

© 2019 by American Academy of Orthopaedic Surgeons
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