ä Although the criteria of Kocher et al. were an important advancement in our ability to diagnose septic arthritis of the hip early, the changing microbial landscape and availability of advanced imaging have rendered it insufficient for contemporary clinical use.ä Routine use of magnetic resonance imaging and recognition of disseminated disease have prompted the development of algorithms to predict concurrent osteoarticular infection in cases of septic arthritis and osteomyelitis that were previously assumed to be "isolated."ä Recent research has attempted to stratify childhood bone and joint infection (BJI) by severity to guide treatment planning. This is valuable, as patients with multifocal disease, more virulent pathogens, and immunocompromise can have longer hospital stays and require multiple surgeries.ä The increasing prevalence of clinical prediction algorithms in childhood BJI is not completely matched by quality in methodology. Clinicians need to be wary of adopting predictive algorithms prior to robust external validation.It has been >20 years since Kocher et al. pioneered a predictive algorithm that would allow more accurate diagnosis of septic arthritis (SA) of the pediatric hip 1 . Although the evaluation of childhood bone and joint infection (BJI) has evolved substantially since then, the core problem remains: how can we develop accurate, evidence-based clinical prediction algorithms that will provide informed guidance to clinicians? Interest in this field has expanded since the first study by Kocher et al. 1 . The popularity of clinical algorithms and machine learning appears to have superseded individual clinical experience with knowledge gained from modeling large data sets 2 . Furthermore, predictive modeling has the potential for identifying an elusive diagnosis or determining the probability of poor treatment outcome 3 . However, the increasing prevalence of clinical prediction algorithms is not completely matched by quality in methodology 4 . When assessing any predictive model, clinicians should establish several points, such as whether the population the model was derived from reflects their own local population, how well the model performed in external validation, and what practical impact these predictions will have on clinical decisions 3 .Clinical prediction algorithms for childhood BJI attempt to provide guidance for 3 main clinical problems: differentiating SA from transient synovitis (TS) of the hip, predicting periarticular infection, and predicting a more severe course of illness. These areas are the focus of this review, which aims to provide an informed analysis of the diagnostic algorithms available to clinicians in assessing childhood BJI and their performance in external validation.Differentiating TS from SA of the Hip The Kocher criteria 1 , in 1999, used 4 features to raise suspicion for SA: (1) an inability to weight-bear, (2) a white blood-cell count (WBC) of >12 • 10 9 cells/L, (3) an erythrocyte sedimentation rate (ESR) of ‡40 mm/hr, and (4) a temperature of >38.5°C (>1...
Routine post-operative bloods following all elective arthroplasty may be unnecessary. This retrospective cohort study aims to define the proportion of post-operative tests altering clinical management.Clinical coding identified all elective hip or knee joint replacement under Hawkes Bay District Health Board contract between September 2019-December 2020 (N=373). Uni-compartmental and bilateral replacements, procedures performed for cancer, and those with insufficient data were excluded. Demographics, perioperative technique, and medical complication data was collected. Pre- and post-operative blood tests were assessed. Outcome measures included clinical intervention for abnormal post-operative sodium (Na), creatinine (Cr), haemoglobin (Hb), or potassium (K) levels. A cost-benefit analysis assessed unnecessary testing.350 patients were Included. Median age was 71 (range 34-92), with 46.9% male. Only 26 abnormal post-operative results required intervention (7.1%). 11 interventions were for low Na, 4 for low K, and 4 for elevated Cr. Only 7 patients were transfused blood products. Older age (p=0.009) and higher ASA (p=0.02) were associated with intervention of any kind. Abnormal preoperative results significantly predicted intervention for Na (p<0.05) and Cr (p<0.05). All patients requiring treatment for K used diuretic medication. Preoperative Hb level was not associated with need for transfusion. Overall, there were 1027 unnecessary investigations resulting in $18,307 excess expenditure.Our study identified that the majority of elective arthroplasty patients do not require routine postoperative blood testing. We recommend investigations for patients with preoperative electrolyte abnormality, those taking diuretics, and patients with significant blood loss noted intra-operatively. In future, a larger, randomised controlled trial would be useful to confirm these factors.
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