Su çiçeğinin komplikasyonu olarak geç tanı konmuş ve sekel bırakmış infantil septik kalça dislokasyonu: bir olgu sunumu

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Introduction
Proper surgical and pharmacologic treatment of
acute childhood septic arthritis of the hip is required
to minimize the risk and severity of the late term sequelae that vary from no residual deformity to complete loss of femoral head and neck (1-5). Factors that
are directly correlated with the increased severity of
the late term sequelae are younger age, staphylococcal infection, delayed treatment, and inadequency of
surgical and pharmacologic treatment (2,3,5,6). In this
paper we present the short term results of delayed diagnosis of infantile septic arthritis of the hip as a complication of chicken pox progressing to dislocation.
Case Report
A 8-month-old male infant was admitted to the department of pediatrics with the complaints of fever and
vesicular skin lesions diagnosed as chicken pox, and
serum varicella IgM antibody level confirmed the diagnosis. Symptomatic treatment was prescribed. Three
days after the initial presentation the child was readmitted to the department of pediatrics with the erythema
extending from right upper thigh to the knee, severe
irritation with the right hip movements, and higher fever than initial presentation. Initial findings showed a
rectal temperature of 39.5 °C, white blood cell count of
36.000/mm3
, C-reactive protein level of 117 mg/L and
erythrocyte sedimentation rate of 78 mm/h. All were
supporting a bacterial infection. The child was admitted to the clinic with the diagnosis of cellulites, and
intravenous ceftriaxone and clindamycine treatment
was initiated. As the signs and symptoms regressed,
the child was discharged with oral antibiotic prescription five days after the admission to the hospital. With
the only complaint of asymmetrical lower limbs, the
child was referred to the department of orthopedics
25 days after the second presentation to the department of pediatrics. On physical examination right
lower limb was slightly shorter and right hip abduc-
* Department of Orthopedics, Haydarpaşa Education Hospital, Gulhane
Military Medical Faculty
** Department of Pediatrics, Haydarpaşa Education Hospital, Gulhane Military
Medical Faculty
Reprint request: Dr. Özcan Pehlivan, İlyas Bey Cad. No: 49/51,
Yedikule-34310, İstanbul
E-mail: ozipeh@yahoo.com
Date submitted: November 21, 2007• Date accepted: February 28, 2008292 • December 2008 • Gulhane Med J Pehlivan et al.
tion was slightly limited. There was no pain with the
hip movements. After the detailed history of the child
was obtained, laboratory tests were ordered in addition
to rontgenograms of pelvis. Serum laboratory values
demonstrated a white blood cell count of 10.800/mm3
,
C-reactive protein level of 5.2 mg/L, and erythrocyte
sedimentation rate of 61 mm/h. Rontgenograms of the
pelvis revealed right hip dislocation, destruction of the
femoral neck, ischemic necrosis of the femoral head
with decreased density and similar acetabular index
angles (20°) on both sides (Figure 1). History, increased
sedimentation rate and radiographic findings led us to
suspect a missed diagnosis of septic arthritis of the right
hip which progressed to hip dislocation with destruction of the proximal femur. Under general anesthesia
open surgical drainage, irrigation and reduction of the
hip were performed with anterior approach. During the
surgical procedure before opening the hip joint capsule,
the capsule was noted as distended and was aspirated
before performing capsulotomy for the bacteriologic
studies. Aspiration revealed a serous fluid with no sign
of pus. After capsulotomy was performed evacuation of
the fluid was done. A sample of synovial tissue was obtained for pathological evaluation. Femoral head was
noted as irregular with intact soft cartilage covering it.
After irrigation femoral head was reduced and capsuloraphy was performed. Following operation a one-andone-half-hip spica cast was applied with the hip 100° of
flexion, 45° of abduction, and neutral rotation. There
was no growth on bacteriological culture of material,
and pathological evaluation was reported as chronic
nonspecific synovitis. Six weeks after the operation
the cast was removed under general anesthesia and the
physical and fluoroscopic examination of the hip was
noted as stable and reduced hip joint. Femoral neck was
deformed and femoral head was invisible (Figure 2). A
second cast with the hip 45° of flexion and abduction
was applied with the knees out of the cast. The second
cast was hold for four weeks and then removed in the
clinic. Radiographs of the pelvis showed a destruction
of the femoral neck and a difficultly visible ossified
small femoral head. Physical examination revealed a
stable hip. We did not apply any kind of immobilization after this point and the child was called for routine
controls. He began walking independently at the age of
12 months. The last control was made at the post-operative 12 month. Physical examination showed full range
of motion of the affected hip with similar foot progression and thigh-foot angles on both sides. The child was
active without any restriction of movements except for
only slightly noticeable waddling during walking and
running. Radiographs showed an ossified femoral head
on a short femoral neck and mild acetabular dysplasia
(Figure 3). Radiographic appearance made us to classify
the condition as the Choi Type IIA hip septic arthritis
sequela (2,3,7). At this point observation with followup visits was decided.
Figure 3. At the last follow-up visit 12 months after the operation,
radiograph of the pelvis demonstrates a reduced, reossified and
deformed femoral head, short but remodeled femoral neck, and mild
acetabular dysplasia on the right side (Choi type IIA sequela)
Figure 1. At the initial presentation to the department of orthopedics,
radiograph of the pelvis demonstrates deformed proximal femoral
metaphysis and small and low density dislocated femoral head on the
right side, but similar acetabular development on both sides
Figure 2. Six weeks after the operation, radiograph of the pelvis
demonstrates deformed proximal femoral metaphysis and no visible
femoral head on the right. Note the right hip is reducedCilt 50 • Issue 4 Infantile septic hip dislocation • 293
Discussion
Acute septic arthritis of the hip is an orthopedic
emergency requiring proper management to save the
hip joint that otherwise deteriorates with time. The sequelae that might follow septic arthritis of the hip in
an infant include premature closure of the triradiate
cartilage and proximal femoral physis, osteonecrosis of
the femoral head, chronic osteomyelitis, subluxation,
dislocation, and varying degrees of proximal femoral
destruction (2,3,5-8). The most important factors that
determine the severity of the sequelae are the age of
the child, virulence of the causative organism, time interval between the beginning of the septic event in the
joint, and diagnosis and treatment (2,3,5,6).
Infecting organisms invade the hip joint by one of
the two ways; directly via the hematogenous route or
indirectly via the invasion from an adjacent focus. As
the septic process begins, destroying cascade begins
eventually. In addition to the direct toxic effects of
the inflammatory response and bacterial toxins on the
cartilage, increased intracapsular pressure further deteriorates the condition leading to subluxation, dislocation and ischemic necrosis of the femoral head (2,5).
As the diagnosis and appropriate treatment delay, the
destructive effect of the septic process increases whatever the age of the patient or the infecting organism
is. This critical period is the first 4 days after the beginning of the septic event if the goal is to have a functional and the least destroyed hip joint (2,5,6).
Suspicion is the first stage for the diagnosis. Although
the sign and symptoms in the early childhood might be
obscured, in general history of a recent infection or conditions that depress the immune system, irritation with
hip movements, limping, fever (>39 °C), high erythrocyte sedimentation rate (>40 mm/h), high serum white
blood cell count (>12.000/mm3
) and high C-reactive
protein level (>20 mg/L) all should force the physician
to suspect for the septic arthritis of the hip (5,8).
In our presented case the most probable scenario
developed as follows; immune status was depressed
by the varicella virus infection caused the bacteria,
particularly the group A-β hemolytic Streptococci, to
invade through the epidermis where the varicella vesicles were located on the thigh (9). Then they spreaded
to the hip joint directly or indirectly. The clinical picture was defined as the fasciitis of the thigh although
the clinical and laboratory findings supported an additional pathological condition that had to be suspected as septic arthritis of the hip. As the septic arthritis
of the hip was missed, every stage of the destroying
cascade of the septic event took place and progressed
with the end result of a dislocated and destroyed hip
joint. As the diagnosis of missed septic arthritis of the
hip was made, acute septic event was resolved and the
dislocated and deformed femoral head were reduced
by open surgical intervention and immobilized in a
cast until the reossified femoral head was visible on
plain radiographs as proposed by Choi et al. (2).
The presented case in this paper has a short followup period of one year. According to the criteria that
were described by Hunka et al. (4), the functional result at this point was considered satisfactory with pain
free full range of motion without any restriction of activities. Late sequelae of the septic arthritis of hip can
be described according to the radiographic appearance
at the last follow-up visit or at skeletal maturity (2,3,7).
The last radiographic evaluation of the presented case
gave us the impression as Choi type IIA sequela where
the epiphysis, physis and metaphysis are all involved
with a resulting coxa breva and a deformed head
(2,3,7). According to the algorithmic treatment protocol of Choi et al. (3), we decided to continue observation and follow-up at this point.
Although the final result is, at least functionally, satisfactory at this point, the future progression does not
seem so bright and some other operations may be required in the future as the child develops. The fate of
the hip would be changed dramatically with the proper treatment if the suspicion for the septic arthritis of
the hip would be on time within 4 days after the onset
of the septic event in the hip joint.