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Septic epiphysitis in neonates and infants

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Septic epiphysitis in neonates and infants

  1. 1. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  2. 2. • Dr. Bahaa Ali Kornah • Prof.. Of Orthopedic • Al-Azhar University • Cairo - Egypt Septic epiphysitis IN NEONATES AND INFANTS bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  3. 3. septic arthritis of hip • An intra-articular infection in children that is considered a surgical emergency and requires prompt recognition and treatment. • septic arthritis = Infectious arthritis, = pyogenic arthritis, • bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  4. 4. septic arthritis • 0.2%-0.7% of hospital admissions • Peak incidence in the first years of 1st decade and >50 years • Males>Females bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  5. 5. BLOOD SUPPLY Crock described three major groups of vessels Extracapsular arterial ring Ascending cervical branches of arterial ring Artery of ligamentum teres bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  6. 6. Extracapsular arterial ring Arise from the MCFA & LCFA which are in turn branches of the profunda femoris in 79% of cases. In 20% arises from the femoral artery. In 1% both vessels arise from the femoral artery. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  7. 7. The MFCA & LCFA form an extracapsular circular anastomosis at the base of the femoral neck, and the ASCENDING CERVICAL CAPSULAR VESSELS arise from this. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  8. 8. They penetrate the anterior capsule at the base of the neck at the level of the intertrochanteric line. On the posterior aspect of the neck, they pass beneath the orbicular fibers of the capsule to run up the neck under the synovial reflection to reach the articular surface. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  9. 9. Within the capsule these are referred to as RETINACULAR VESSELS. There are four main groups (anterior, medial, lateral, and posterior) of which the lateral group is the largest contributor to femoral head blood supply. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  10. 10. lateral group is the most important retinacular vessels . It arise from the deep branch of the MFCA These vessels supply the main weight-bearing area of the femoral head. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  11. 11. SUBSYNOVIAL INTRA-ARTICULAR ARTERIAL RING At the articular margin of femoral head Formed by vessels that penetrate the head (epiphyseal arteries) Lateral epiphyseal vessels supplying lateral weight bearing portion most important Joined by vessels from ligamentum teres. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  12. 12. ARTERY OF LIGAMENTUM TERES Branch of Obturator artery or Medial circumflex femoral artery Gives blood supply to a small area of head of the femur Contribute little blood supply to femoral head until age 8 and then only about 20% as an adult . Not sufficient to maintain blood supply of femoral head. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  13. 13. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  14. 14. At birth main supply-lateral epiphyseal and metaphyseal vessels 4month-4year Exclusive supply from lateral epiphyseal vessels Cartilaginous growth plate is barrier. 4 to 7 year Exclusive supply by the lateral epiphyseal artery Epiphyseal plate is firm barrier More than 7year Vessels from the ligamentum teres penetrate and join the lateral epiphyseal vessels Cartilaginous growth plate is still barrier. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  15. 15. Ossification: ▪ The proximal femoral epiphysis begins to ossify at age 4 to 6 months in girls and at age 5 to 7 months in boys. The trochanteric apophysis begins to ossify at age 4 years in both sexes. ▪ By age 14 years in girls and 16 years in boys, the proximal femoral physis and trochanteric apophysis fuse. ▪ The Y-shaped growth plate that separates them (the triradiate cartilage) is fused definitively at ages 14–16 years. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  16. 16. PATHOLOGY The hip joint may become infected in one of three ways:  Haematogenous spread is more common.  Spread from an adjacent area of osteomyelitis.  Direct inoculation. (rare) femoral artery sampling. (Buxton R. A. and Moran M. 2003) bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  17. 17. • Septic arthritis affect • Enfant • Less in adult bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  18. 18. Risk factors * Prematurity * Venipuncture ( umbilical catheter ) >>incubator * Respiratory distress syndrome (RDS) * Perinatal asphyxia * Respiratory tract infection bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  19. 19. Causative organisms: • In neonates,streptococcus is the most common causative organism • In Hospitalised, Staphylococcus, candida, and gram negative bacilli are the most likely causes • Haemophylis influenzae type B is usually the cause of septic arthritis in children after 2 years of age bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  20. 20. Mechanism of infection: • Haematogenous spread of infection occurs frequently because the vascular spaces of the synovial membrane lack a basement membrane allowing the contents of the vascular space relatively easy to access the joint space bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  21. 21. • The higher incidence of infection in pediatric population is explained by ➢the intracapsular location of the femoral and ➢the unique vascular loop around the hip joint. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  22. 22. • Normal venous return from the hip flows into the veins of Batson’s plexus around the bladder, rectum, prostate, or uterus . • Retrograde flow, as occurs with Valsalva maneuvers, may result in seeding of the hip from these pelvic sources. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  23. 23. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  24. 24. Hip -shoulder -knee Single joint Multiple joints Affected Joints bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  25. 25. Diagnosis bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  26. 26. • History >>>>> clue to the diagnosis. • History recent local trauma or infections • vaccination history must be obtained, particularly with regard to vaccination against Haemophilus influenzae • recent or current antibiotics may mask symptoms • Most patients present with pain in the affected hip. • Fixed deformity • Painfull limited all movment bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  27. 27. • neonates >>>>>> Diagnosis is difficult >>>may be minimal or lacking. • The only finding in neonates ❖present of infection at another site “e.g.: an umbilical catheter” , ❖irritability , ❖failure to thrive, ❖asymmetry of limb position or ❖displeasure at being handled. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  28. 28. Clinical picture ❑ Fever ❑Painful passive mobilization severe pain with passive motion • unwillingness to move joint (pseudoparalysis) ❑ Local signs of inflammation ✓ Swelling ✓ Redness ✓ Hotness ✓ Puffiness ✓positive Thomas test, flexion deformity bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  29. 29. • Laboratory tests * C.B.C * E.S.R * C.R.P. * Blood culture * Aspiration : - presence of pus - gram stained film - culture and sensitivity Diagnosis , bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  30. 30. • Diagnostic imaging * X-ray : - Widened joint space - Lost soft tissue planes - Distended capsule * Ultrasongraphy : - Effusion. - Edema - Femoral epiphysis * Isotope bone scan : ( older children ). Diagnosis , bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  31. 31. Joint Aspiration : • a large bore needle • before antibiotic theraby is begun. • Careful skin preparation is mandatory, and fluid obtained should be send for immediate Gram stain, culture, cell counts and crystal analysis. • Typically synovial leukocyte counts above 50,000/cmm are indicative of infectious arthritis,also the proportion of polymorphneucular cells is more than 90%. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  32. 32. • Joint Aspiration • approaches >>> lateral, anterior, or medial • image gauded is better • If fluid cannot be aspirated an arthrogram should be made to verify the needle’s position. • If pus cannot be aspirated the hip should be explored , if local and systemic symptoms cannot be otherwise controlled. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  33. 33. Lateral aspiration: • Insert the needle at 45° angle with the surface of the thigh just inferior and anterior to the greater trochanter , advance the needle medially and proximally close to the bone for 5 to 10 cm. depending on the size of the patient and into the joint. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  34. 34. Anterior Aspiration: • Palpate the femoral artery in line with the inguinal ligament . Insert the needle 2.5 cm. lateral and 2.5 cm. distal to this point at a 45 ° angle to the skin surface , advance the needle 5 to 7.5 cm. medially and proximally into the joint bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  35. 35. Medial aspiration: • Flex and abduct the leg . Place the needle inferior to the adductor longus tendon and using image intensification advance it in a plane below the palpated femoral artery until the femoral head or neck is reached bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  36. 36. Causative organisms : oStaphylococcus aureus oHaemophilius influenza oStreptococci oNeisseeria meningitidis oNeisseeria gonorrhea oE. coli oPseudomonas, Klebsiella, Salmonella. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  37. 37. D&D • Transient synovitis • DDH • Proximal femoral osteomyelitis • Perthes • SCFE bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  38. 38. Treatment Urgent Aim to (1) The joint adequately drained, (2) Antibiotics >>>> to diminish the systemic effects of sepsis, and (3) The joint must be rested in a stable position. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  39. 39. Treatment 1. Antibiotic therapy. 2. Surgical Drainage. 3. Immobilization bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  40. 40. •Drainage : * Early surgical drainage is the clue to a good outcome. * Repeated aspiration is improper. * Thorough washing of the joint. * Suction drain for 1-2 days. * Hips : Anterior or posterior approach. * Knee : Parapatellar incision. * Shoulder : Deltopectoral incision. Treatment, bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  41. 41. DRAINAGE • DRAINAGE • Drainage >>posterior, medial, lateral, or anterior approach. • The anterior approach is preferred • (1)to avoid damage to the major blood supply to the femoral head • (2) the chance of postoperative dislocation is reduced, and • (3) the landmarks for the surgical approach are much clearer in a small child. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  42. 42. Anterior Drainage Make a vertical incision beginning about 1 cm below the anterosuperior iliac spine inferiorly. Expose the sartorius muscle on the medial side and the tensor fasciae latae and vastus lateralis muscles on the lateral side. Use blunt dissection to separate these muscles. Next, identify the lateral border of the rectus femoris and retract this muscle medially . This will expose the hip joint capsule. Incise the capsule, evacuate the pus, and irrigate the joint with saline. Leave the capsule open but close the skin loosely over drains. If wider exposure is required, extend the skin incision proximally onto the iliac crest and subperiosteally detach the origins of the tensor fasciae latae and gluteal muscles from the ilium. Protect the lateral femoral cutaneous nerve proximally and the branches of the lateral femoral circumflex artery distally, if possible. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  43. 43. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
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  45. 45. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  46. 46. Posterior Drainage In an adult the posterior approach will allow dependent drainage and is a more familiar approach for most orthopaedic surgeons. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  47. 47. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  48. 48. Principles of antibiotic therapy 1. Make a specific bacteriologic diagnosis, using cultures from blood, bone, tissue or synovial fluid. 2. Use the narrowest spectrum drug specific to the infection. 3. Monitor the patient for secondary foci of infection e.g. endocarditic, associated bone or joint infections. 4. Be aware of complications related to particular antibiotic e.g. renal or hepatic toxicity. 5. Convert from in hospital I. V. antibiotics to out- patient I.V. or oral administration when appropriate ( James Kasser ) Treatment , bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  49. 49. Antibiotic therapy • Intravenous antibiotics are the best for initial management. • In a newborn with a suspected musculoskeltal infection: oxacillin & gentamycin. • Between the ages of 6 months & 4 years and as the incidence of Haemophilus influenza rises significantly : cephalosporin & oxacillin are appropriate. • However, the results of the gram stained film, the culture and sensitivity should be decisive. Treatment, bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  50. 50. Immobilization : • Skin traction 2-3 weeks . • Then encourage active mobilization. Treatment, bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  51. 51. Factors affecting outcome Intrinsic Factors: *Age at onset of Infection. * Intracapsular Pressure. *Vascular anatomy of femoral head . *Immunity. *Concomitant Osteomyelitis of Proximal Femur. Extrinsic Factors: *Infecting Organism. *Delay in diagnosis and administering treatment. *Adequacy of treatment. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  52. 52. Outcome • Long term consequences If the condition is treated promptly and effectively, serious sequelae are rare. Otherwise the damage will be permanent bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  53. 53. Long term sequelae include : * Articular loss : From narrowing or obliteration of joint space to gross destruction of articular cartilage. * Destruction of the epiphysis, particularly of the proximal femur with dislocation. * Growth disturbances, particularly if associated with osteomeylitis. ( acetabulum and femure) * Limb length inequality. • Pathological dislocation. • Fibrous or bony ankylosis. Sequelae of septic arthritis in the hip joint bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  54. 54. Pathological Dislocation Pathological dislocation Manipulation Traction then manipulation immobilization immobilized in a spica cast until it is stable or until fibrous or bony ankylosis develops bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  55. 55. Pathological dislocation of hip. A, Early sequestration of epiphysis, as shown by apparent increase in density. B, After 16 months, absorption of epiphysis and part of neck.bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  56. 56. Osteomyelitis osteomyelitis of the proximal femur. results in sequestration of the femoral head in children younger than 12 years of age, the head may be totally reabsorbed or it may be replaced by new bone after its circulation is restored. In older children and adults it usually remains as an infected sequestrum and requires excision. Any of the approaches described for draining the hip may be used, but the anterior approach gives better exposure of the joint. In a child, osteomyelitis of the ilium may complicate acute septic arthritis of the hip, or the joint infection may be arise secondary to infection in the bone; in each case both the hip joint and ilium require drainage. In adults, osteomyelitis of the ilium is a less common complication, but impairment of the circulation of the femoral head may lead to pathological fracture of the neck and sequestration of the head.bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  57. 57. Pelvic Abscess • Pelvic abscess complicating acute septic arthritis of the hip is caused by either 1. suppurative infection of the iliac lymph nodes or 2. spread from the joint into the sheath of the iliopsoas, which may communicate with the joint. The abscess is retroperitoneal and tends to gravitate along the iliopsoas muscle beneath the inguinal ligament, eventually pointing in the medial thigh. . bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  58. 58. Persistent Infection • it is rare. • Usually, scarring is extensive, and draining sinuses have become established. Often the sinuses become blocked, causing recurring abscesses. • Girdlestone described a radical operation for chronic pyogenic infection about the hip. • In this operation all the infected bone, a mass of muscle also is resected to ensure drainage. • Marked shortening of the affected extremity results. For these reasons, this operation is a last resort. surgery. • bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  59. 59. Hunka classification1982 T y p e I – M i n i m a l F e m o r a l H e a d c h a n g e s T y p e I I A – f e m o r a l h e a d d e f o r m i t y w i t h a n o r m a l g r o w t h p l a t e T y p e I I B - f e m o r a l h e a d d e f o r m i t y w i t h g r o w t h a r r e s t T y p e I I I – P s e u d o a r t h r o s i s o f f e m o r a l n e c k T y p e I V A – c o m p l e t e d e s t r u c t i o n o f p r o x i m a l f e m o r a l e p i p h y s i s , w i t h a s t a b l e n e c k s e g m e n t . T y p e I V B - c o m p l e t e d e s t r u c t i o n o f p r o x i m a l f e m o r a l e p i p h y s i s , w i t h a n u n s t a b l e n e c k s e g m e n t . T y p e V – C o m p l e t e d e s t r u c t i o n o f t h e h e a d a n d n e c k t o t h e i n t e r t r o c h a n t e r i c l i n e , w i t h d i s l o c a t i o n o f t h e h i p bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  60. 60. sequelae of septic arthritis of hip • Choi Classification 2005 • Type I: Almost normal hip or mild coxa magna. It needs no reconstruction. • Type II: Deformed epiphysis, physis, metaphysis may result in coxa breva or progressive coxa vara or coxa valgus. It needs surgical intervention to prevent subluxation. • Type III: Malalignment of femoral neck, excessive anteversion or retroversion with pseudoarthrosis. It neccesitates a realignment surgery for proximal femur or bone grafting for Pseudo-arthrosis. • Type IV: Destruction of the head and neck of femur with the presence of remnant of medial base of neck. Complex clinical problems with limb length inequality -needs reconstructive surgery.3,5,6 bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  61. 61. Forlin and Milani .2008 classified into 2 groups on the basis of radiographic appearance. grade 1 • (1A) were reduced hips, with femoral head preserved or • (1B) reduced hips, with femoral head absent ; grade 2 • (2A) were dislocated hips, with the femoral head preserved or (2B) were dislocated hips, with the femoral head absent . bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  62. 62. Treatment Antibiotic : Should start as soon as septic arthritis is suspected. Amikacin is a very effective antibiotic from the beginning. * 2nd and 3rd generation cephalosporins * Gentamycin and oxacillin. * 3-6- weeks. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  63. 63. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
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  69. 69. I) Conservative treatment: The main indications for conservative treatment are: 1) Mild coax magna without angular deformity (Choi Type IB). 2) Radiological features of resolving avascular necrosis of femoral head which has not yet undergone major deformation (Choi Type IB). 3) Coxa breva without angular deformity (Choi Type IIA ). bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  70. 70. The various modalities include abduction cast, a Pavlik harness, Ilfeld brace, Scottish Rite orthosis, or Petrie walking cast. indicated --- when head is still well formed. • follow up 1. persistent instability, 2. relative trochanteric overgrowth, 3. acetabular dysplasia, 4. subluxation and/or dislocation, 5. limb length discrepancy etc. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  71. 71. A. Painful Joint Degeneration 1. Resection Arthroplasty 2. Hip Arthrodesis 3. Greater Trochanteric Arthroplasty 4. Pelvic Support Osteotomy 5. Total Hip Replacement Surgical Options bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  72. 72. B. Abductor Insufficiency 1. Greater Trochanteric Growth Arrest 2. Greater Trochanteric Transfer Distal, Lateral, Or Both 3. Pelvic Support Osteotomy 4. Arthrodesis C. Leg Length Discrepancy 1. Soft Tissue Release 2. Osteotomy 3. Epiphysiodesis 4. Lengthening 5. Pelvic Support Osteotomy bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  73. 73. D. Instability 1. Open Reduction 2. Greater Trochanteric Arthroplasty 3. Pelvic Support Osteotomy 4. Arthrodesis Or 5.Total Hip Replacement E. Loss of Motion 1. Soft Tissue Release F. Malpositioned Extremity 1. Realignment Osteotomy bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  74. 74. ❖ Septic apophysitis of the hip is common ❖ It result in severe disability. ❖ While the majority of cases may not be preventable, significant morbidity can be averted by early recognition and treatment. bahaa kornah- Al-Azahar Un.-Cairo- EGYPT
  75. 75. Thank you for your attention ‫د‬/‫قرنة‬ ‫بهاء‬ bahaa kornah- Al-Azahar Un.-Cairo- EGYPT

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