Incision and Drainage of the Septic Hip
Incision and Drainage of the Septic Hip
Patient Selection
Delay in diagnosis can be catastrophic
Treatment options include simple joint aspiration under ultrasonography guidance, formal anterior arthrotomy, and arthroscopic lavage and decompression
Most commonly affects children younger than 4 years
History of progressive reluctance to use or bear weight on affected leg; malaise and fever
May be remote history of trauma, often noncontributory
Neonates lack fever or higher inflammatory markers; pseudoparalysis or irritability of limb should arouse suspicion
With effusion, child flexes, abducts, and externally rotates hip to reduce intracapsular pressure
Rotation is poorly tolerated
Palpation of effusion usually not possible
Preoperative Imaging/Testing
AP pelvic radiograph helps rule out other pathology; greater than 2 mm of side-to-side difference from medial femoral head to medial acetabulum is diagnostic of effusion
Ultrasonography helps diagnose effusion; presents chance to obtain diagnostic aspiration
Blood work includes erythrocyte sedimentation rate, C-reactive protein, complete blood count with differential, blood culture, antistreptolysin O titer, and, where geographically indicated, Lyme titer
Differentiating between septic arthritis and transient synovitis of hip can be done using four independent, multivariate predictors: fever (temperature >39.5°C), not bearing weight on affected limb, erythrocyte sedimentation rate greater than 40 mm/hr, serum white blood cell (WBC) count greater than 12,000 cells/mm3
Elevated C-reactive protein level (>20 mg/L) was later added as fifth independent predictor
of septic arthritis
Aspirate from hip that yields synovial WBC count greater than 50,000 cells/mm3is diagnostic of septic hip
Aspirate with less than 25,000 cells/mm3may reflect an inflammatory process, such as transient synovitis
WBC value between 25,000 and 50,000 cells/mm3requires clinical examination, inflammatory markers, and aspiration results
Authors’ institution performs MRI of hip in unclear cases to differentiate septic arthritis and osteomyelitis
Base ultimate decision for surgical incision and drainage on clinical judgment
Procedure
Room Setup/Patient Positioning
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