Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children

Abstract

Background: A child who has an acutely irritable hip can pose a diagnostic challenge. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation. Methods: We retrospectively reviewed the cases of children who were evaluated at a major tertiary-care children's hospital between 1979 and 1996 because of an acutely irritable hip. Diagnoses of true septic arthritis, presumed septic arthritis, and transient synovitis were explicitly defined on the basis of the white bloodcell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression analysis were used to compare groups. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested. Results: Patients who had septic arthritis differed significantly (p < 0.05) from those who had transient synovitis with regard to the erythrocyte sedimentation rate, serum white blood-cell count and differential, weight-bearing status, history of fever, temperature, evidence of effusion on radiographs, history of chills, history of recent antibiotic use, hematocrit, and gender. Patients who had true septic arthritis differed significantly (p < 0.05) from those who had presumed septic arthritis with regard to history of recent antibiotic use, history of chills, temperature, erythrocyte sedimentation rate, history of fever, gender, and serum white blood-cell differential. Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, erythrocyte sedimentation rate of at least forty millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10 9 cells per liter). The predicted probability of septic arthritis was determined for all sixteen combinations of these four predictors and is summarized as less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. The chi-square test for trend and the area under the receiver operating characteristic curve indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis. Conclusions: Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between s...

Avaliação do tratamento da artrite séptica do quadril

“…2011;46(Suppl 4): [14][15][16][17][18][19][20] Figura 1 -Paciente masculino, 6a5m, radiografia de bacia panorâmica nas projeções em AP e Lauenstein, com história de febre, dor, claudicação e limitação funcional do quadril esquerdo há dois dias (A, B). Pós-operatório de 2a2m, paciente sem queixas e radiografia sem alteração.…”

“…Eich et al (16) desenvolveram seu algoritmo orientados pelo derrame articular do quadril e pelo menos dois dos seguintes critérios: temperatura retal maior que 38 graus, VHS maior que 20mm/h e PCR maior que 20mg/L. Kocher et al (17) usaram quatro preditores para o diagnóstico diferencial de sinovite transitória e AS do quadril: história de febre, recusa em apoiar o membro inferior acometido, VHS maior que 40mm/h e contagem de leucócitos maior que 12.000cels/mm 3 . Eles encontraram um valor preditivo para AS de 40% quando os pacientes apresentavam dois critérios, 93,1% para três, e 99,6% para quatro critérios concomitantes.…”

“…Além disso, a maior quantidade Rev Bras Ortop. 2011;46(Suppl 4): [14][15][16][17][18][19][20] de cartilagem na cabeça e colo torna essas estruturas mais suscetíveis, justificando o desfecho desfavorável nos pacientes mais jovens (4,13) .…”

Fluxograma diferencial entre a artrite séptica e sinovite transitória do quadril em crianças

“…[10][11][12][13] For the performance of the proposed flowchart it was necessary to adapt some parameters used in the studies found in literature. Fever, for example, was measured by the oral temperature in the studies by Kocher et al 27,28 , Falzon et al 29 and Caird et al 18 , yet this is not evaluated in most orthopedic services in Brazil and, we therefore use the axillary temperature of 37.8 °C. 30 The leukocytosis used in the proposed flowchart (>12000cells/mm³) is justified by the greater ethnic similarity between the Brazilian population and that of the studies that used the same cut-off point, in comparison to the Korean population that considers a lower value of leukocytosis (11000cells/mm³).…”

Letter to the Editor: The 2013 Frank Stinchfield Award: Diagnosis of Infection in the Early Postoperative Period After Total Hip Arthroplasty

“…In differentiating between septic arthritis and transient synovitis of the hip in children, Kocher et al [1] stratified the risk of septic arthritis in children according to the presence of a number of clinical and serological parameters, which seems to work well in the clinical situation. Therefore, we suggest a similar approach in tackling the problem of deep periprosthetic infections.…”