Long-Term Outcomes of Acute Osteoarticular Infections in Children

Abstract

Background: Acute hematogenous osteomyelitis (OM) and septic arthritis require immediate diagnosis and treatment by an interdisciplinary team of pediatric infectious disease specialists and pediatric orthopedic surgeons. Adverse outcomes such as growth disturbance, bone deformity, and chronic infections have been described in older studies. However, there is only little known about long-term follow-up of patients of the last two decades. Therefore, we aimed to evaluate subjective and objective long-term outcomes of these children with osteoarticular infections treated in the millennial years.Methods: Cross-sectional study performed in two pediatric centers including patients admitted for OM and/or SA between 2005 and 2014 and follow-up consultations in 2019. Patients with symptoms of ≤2 weeks duration at initial presentation were contacted. Subjective outcomes were assessed by standardized interview, objective outcomes by clinical examination. Medical charts were used to extract data from the initial presentations. Statistical analysis was performed by non-parametric tests and Fisher's exact test.Results: Of 147 eligible patients 77 (52%) agreed to participate, of which 68 (88%) had an interview and physical examination and 9 (12%) an interview only. Thirty-three (39%) had OM, 26 (34%) SA, and 21 (27%) combined OM/SA. Median (IQR) age at follow-up was 13.3 (10.5–18.0) years with a median (IQR) follow-up of 7.1 (6.1–8.6) years. Persistent complaints including pain, functional differences and scar paresthesia, reported by 21 (28%) patients, were generally mild and only 3 (5%) required ongoing medical care. Objective sequelae including pain, limited range of motion, unilateral axis deformity or asymmetric gait were found in 8 (12%) participants. Older age, female sex, joint involvement, surgical intervention, persistent fever, and C-reactive protein elevation were associated with adverse clinical outcome.Conclusions: Adverse outcomes were observed in a considerable number of patients, most of which were minor, and only few required ongoing medical care. Long-term follow up is advisable for patients with risk factors identified during the initial presentation.This study was registered on ClinicalTrials.gov (NCT03827980).

Acute haematogenous osteomyelitis in the paediatric population: a current concepts review

“…114 Risk factors for a more prolonged hospital course and long-term complications include high-virulence organisms (such as MRSA), contiguous septic arthritis, positive cultures, younger children, location of the disease and delay in care and source control. 4,6,10,11,41,89,94,[113][114][115] Osteonecrosis or chondrolysis, seen in 8% of cases, is correlated with the initial illness severity and leads to premature arthritis. 4,6 To protect the hip from dislocation, abduction skin traction can be applied when proximal femur AHOM and hip septic arthritis is diagnosed.…”

“…Other complications include avascular necrosis, angular deformities and limb-length discrepancy due to physeal growth arrest or overgrowth. 1,5,6,12,49,50,53,54,57,60,72,76,115,121 These children can also develop joint contractures, chronic pain and gait disturbances. 9,42,76 Sequelae at one-year follow-up are higher in infants under 3 months.…”

The Utility of Routine Radiographic Monitoring in Pediatric Osteoarticular Infections

“…Recent work has demonstrated the utility of considering risk factors such as C-reactive protein elevation, age, and persistent fevers to predict disease severity and guide follow-up duration, but given the limited number of adverse events identified in this cohort, this series cannot guide the length of clinical follow-up. 13 Rather, its aim is to determine the utility of routine radiographic follow-up in these patients, regardless of duration. In fact, while the diagnostic utility of plain radiographs and inflammatory markers in this setting is well-established, there is no consensus on the role of obtaining routine radiographs in monitoring for treatment response or the presence of adverse outcomes in this patient population, despite their common use.…”

“…Stratifying which patients require longer follow-up poses a challenge to physicians given the heterogeneity in location, microorganism, and disease severity. Recent work has demonstrated the utility of considering risk factors such as C-reactive protein elevation, age, and persistent fevers to predict disease severity and guide follow-up duration, but given the limited number of adverse events identified in this cohort, this series cannot guide the length of clinical follow-up 13. Rather, its aim is to determine the utility of routine radiographic follow-up in these patients, regardless of duration.…”

Investigation and Management of Lower Limb Septic Arthritis in Children: An Update Using the Latest British Orthopaedic Association Standard for Trauma (BOAST) Guidelines

“…Growth disturbance due to damage to the growth plate may also occur in children [ 4 ]. Manz et al [ 5 ] describe long-term effects affecting growth and bone deformity in 2-40% of children with septic arthritis. The importance of early detection and prompt treatment is highlighted by the recently published British Orthopaedic Association Standard for Trauma (BOAST) on the management of pediatric musculoskeletal infections [ 6 ].…”