Septic Arthritis and Septic Arthritis with Contiguous Osteomyelitis Are Not Equal

Abstract

Commentary Hamilton et al. have written an article that might be summarized as a disruptive challenge to the accepted perspective that all septic arthritis is the same and that the risk profile for adverse outcomes is equal, irrespective of osseous involvement. Their article, entitled “Children with Primary Septic Arthritis Have a Markedly Lower Risk of Adverse Outcomes Than Those with Contiguous Osteomyelitis,” provides clear data that the traditional approach to treating all septic arthritis equally is an antiquated abstraction. In their article, the authors have clearly demonstrated that there is a difference between primary septic arthritis and septic arthritis with contiguous osteomyelitis, a belief long suspected by those who regularly manage these patients. Hamilton et al. showed higher rates of bacteremia, longer hospitalizations with increased use of intensive care resources, and an increased risk of complications in pediatric patients who have a combination of septic arthritis and osteomyelitis. These considerations are pertinent to all physicians who treat these children, including both orthopaedic surgeons and pediatric specialists. The greatest effect of these data is the change that they bring to the classical approach to this condition. As the consequences of undertreatment of septic arthritis with contiguous osteomyelitis can be as severe as permanent and irreversible joint damage, it is arguable that the algorithm for the treatment of children with a suspected septic joint should now always include magnetic resonance imaging (MRI). At our institution, we previously adopted the practice of performing a screening MRI examination for the majority of patients with suspected septic hips on the basis that treatment decision-making would be altered if either osteomyelitis or an abscess was present, but scant data supported our protocol. The article by Hamilton et al. confirms the importance of MRI screening and demonstrates that the identification of osteomyelitis should trigger a different treatment protocol than that used for patients in whom osteomyelitis is not detected. Specifically, patients with osteomyelitis might benefit from care by a multidisciplinary team with a more aggressive medical and surgical approach. These changes in the approach to treatment do come with an increase demand for resources and thus cost. Institutions committed to the care of pediatric orthopaedic patients will need to consider topics such as timely access to MRI, particularly sedated MRI, as well the availability of pediatric infectious specialists and pediatric orthopaedists. I would assume that, when these increased costs are compared with the potential savings that can be achieved by decreasing length of stay, reducing overall complications, and avoiding the long-term consequences, the costs are more than justifiable. A future analysis of the cost-benefit ratio also may serve to energize a larger conversation around whether these children would be better served by receiving definitive treatment in a tertiary care center. In summary, this article will have a major impact on the care of pediatric patients with septic joints and should be mandatory reading for anyone involved in the study or treatment of this pediatric pathology. I anticipate that it will become accepted as a key article on this topic.