Current Variation in Joint Aspiration Practice for the Evaluation of Pediatric Septic Arthritis

Abstract

Introduction: Pediatric septic arthritis (SA) is a condition that can be associated with significant morbidity. Although previous research has been on predictive care pathways, scrutiny of the literature continues to reveal wide differences in the patient evaluation and management. The purpose of this study was to define the differences in joint aspiration for the evaluation of pediatric SA across pediatric tertiary care institutions in the United States. Methods: Surgeons from 18 pediatric tertiary care centers across the United States were surveyed on current institutional practices regarding joint aspiration, laboratory studies, MRI usage, and treatment timing in the evaluation for SA. Responses were recorded by institution and analyzed to generate descriptive statistics. Results: Responses were received from all institutions asked to participate. Overall, joint specific practice variation exists regarding the person completing the aspiration, where the aspiration is performed, utilization of image guidance, and the utilization of anesthesia. Additional areas of variation included the method and calculation of cell count and the routine use of MRI. Discussion: Significant practice variations exist across pediatric tertiary care centers for the evaluation of pediatric SA. Using these data, future prospective studies can be used to unify institutional practices to minimize practice variation and ultimately improve the care delivery to pediatric patients presenting with SA.

Primary Septic Arthritis in Children Demonstrates Presumed and Confirmed Varieties Which Require Age-specific Evaluation and Treatment Strategies

“…Among 355 children categorized as primary septic arthritis, 87 were excluded: contiguous osteomyelitis (23); JIA (12); penetrating inoculation (9); transient synovitis or viral reactive arthritis (8); other inflammatory arthritis (8); PSRA (3); systemic lupus erythematosus (3); postsurgical infection (3); immunocompromised (3); other adjacent infections not involving bone (3); disseminated gonococcal illness (2); and unknown due to insufficient documentation to determine a specific etiology (10). The remaining 268 children with primary septic arthritis were divided into confirmed (n = 134) and presumed (n = 134) cohorts.…”

“…[1][2][3][4]8,11 The CORTICES group surveyed Principal Investigators from 18 Tertiary Pediatric Medical Centers and found significant differences in workflows and timelines of aspiration and intervention for septic arthritis. 8 High rates of culture-negative cases, similar appearance to inflammatory and reactive conditions and potential presence of unrecognized contiguous osteomyelitis pose obstacles to the exclusive study of primary septic arthritis. [1][2][3][4][5][6][7][8][9][10][11][12][18][19][20] As such, it is evident that there is a need for a more rigorous and systematic approach to evaluate, and treat primary septic arthritis in children.…”

“…8 High rates of culture-negative cases, similar appearance to inflammatory and reactive conditions and potential presence of unrecognized contiguous osteomyelitis pose obstacles to the exclusive study of primary septic arthritis. [1][2][3][4][5][6][7][8][9][10][11][12][18][19][20] As such, it is evident that there is a need for a more rigorous and systematic approach to evaluate, and treat primary septic arthritis in children. We undertook this study to explore opportunities to improve our understanding of primary septic arthritis and the consistency of evaluation and treatment based on accumulated experience during an 11-year timespan and a concerted effort to practice according to an institutional algorithm.…”

“…There is uncertainty and wide practice variation in the evaluation and treatment of children with primary septic arthritis 1–4,8,11. The CORTICES group surveyed Principal Investigators from 18 Tertiary Pediatric Medical Centers and found significant differences in workflows and timelines of aspiration and intervention for septic arthritis 8.…”

“…Evaluation of children suspected to have primary septic arthritis is challenging due to a variety of inflammatory and reactive conditions that mimic infection and high rate of culture-negativity 1–12. Investigators have historically differentiated septic arthritis from noninfectious conditions through prediction algorithms based on risk factors 13,14.…”