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

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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.

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Most cited references 39

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Evidence-based diagnostics: adult septic arthritis.

Jeremiah D. Schuur, Donald Carpenter, Jesse M. Pines … (2011)

Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality. The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy. Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2 × 2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits. The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI] = 17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR] = 6.9) or skin infection overlying a prosthetic joint (+LR = 15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0 × 10(9)-25 × 10(9)/L was 0.33; for 25 × 10(9)-50 × 10(9)/L, 1.06; for 50 × 10(9)-100 × 10(9)/L, 3.59; and exceeding 100 × 10(9)/L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (-LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3 hours. Based on 56% sensitivity and 90% specificity for sWBC counts of >50 × 10(9)/L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%. Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50 × 10(9)/L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate. © 2011 by the Society for Academic Emergency Medicine.

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Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.

M Kocher, D Zurakowski, J Kasser (1999)

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. 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 blood-cell 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. 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. 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 septic arthritis and transient synovitis of the hip in children.

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Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.

Michelle Caird, John M Flynn, Y Leung … (2006)

Distinguishing septic arthritis from transient synovitis of the hip in children can be challenging. Authors of recent retrospective studies have used presenting factors to establish algorithms for predicting septic arthritis of the hip in children. This study differs from previous work in three ways: data were collected prospectively, C-reactive protein levels were recorded, and the focus was on children in whom the findings were so suspicious for septic arthritis that hip aspiration was performed. Over four years, we prospectively collected data on every child (a total of fifty-three) who underwent hip aspiration because of a suspicion of septic arthritis at our institution. Diagnoses of confirmed septic arthritis, presumed septic arthritis, and transient synovitis were determined on the basis of the results of Gram staining, culture, and a cell count of the hip aspirate. Presenting factors and laboratory values were recorded. To evaluate the strength of predictors, we performed univariate and multivariate analysis on data from forty-eight patients who met the inclusion criteria. Univariate analysis showed that fever, the C-reactive protein level, and the erythrocyte sedimentation rate were strongly associated with the final diagnosis (p 38.5 degrees C) was the best predictor of septic arthritis followed by an elevated C-reactive protein level, an elevated erythrocyte sedimentation rate, refusal to bear weight, and an elevated serum white blood-cell count. In our study group, a C-reactive protein level of >2.0 mg/dL (>20 mg/L) was a strong independent risk factor and a valuable tool for assessing and diagnosing children suspected of having septic arthritis of the hip.

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Author and article information

Journal

Journal ID (nlm-ta): J Am Acad Orthop Surg Glob Res Rev

Journal ID (iso-abbrev): J Am Acad Orthop Surg Glob Res Rev

Journal ID (coden): JAAOS Glob Res Rev

Journal ID (pmc): JAAOS Glob Res Rev

Journal ID (publisher-id): JAAOS Glob Res Rev

Title: JAAOS Global Research & Reviews

Publisher: Wolters Kluwer (Philadelphia, PA )

ISSN (Electronic): 2474-7661

Publication date Collection: September 2020

Publication date (Electronic): 01 September 2020

Volume: 4

Issue: 9

Electronic Location Identifier: e20.00133

Affiliations

Children's Healthcare of Atlanta, Department of Pediatric Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA.

Author notes

Correspondence to Dr. Murphy: Joshua.Murphy@ 123456choa.org

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K. Aaron Shaw http://orcid.org/0000-0002-3553-2889

Article

Publisher ID: JAAOSGlobal-D-20-00133 Accession ID: 00006

DOI: 10.5435/JAAOSGlobal-D-20-00133

PMC ID: 7469993

PubMed ID: 32890012

SO-VID: 0a361dae-6303-4de1-9c59-cd2ad63130a6

Copyright © Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 02 July 2020

Date accepted : 15 July 2020

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

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Pediatric Pulse: Advancing Neonatal and Child Health

Most cited references 39

Evidence-based diagnostics: adult septic arthritis.

Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.

Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.

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