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Bilateral Hip Septic Arthritis

F. Anwar*,R.S. Gaheer, E. Fopma 

Department of Trauma and Orthopaedics
Dumfries and Galloway Royal infirmary
Bankend Road, Dumfries
Scotland, DG1 4AP

Address for Correspondence:
F Anwar,
25 Barnhill Road, Dumfries, DG2 9HR


Introduction:Bilateral septic arthritis of the hip is not very common clinical problem as compared to unilateral septic arthritis of the hip. Diagnosis is difficult and if not treated in time may lead to permanent damage to the joint. Salvage procedures are technically difficult and dose not yield good results.
Case Report:A patient with bilateral hip joint septic arthritis secondary to olecrenon bursitis is presented. He was managed in ITU because of his sepsis and septic arthritis was treated with antibiotics and joint washouts.
Conclusion:Outcome from septic hip arthritis can be improved if the condition is diagnosed early and treated appropriately. Delay in treatment is associated with poor outcome
Key Words: Hip, Septic, Arthritis, Bilateral.

J.Orthopaedics 2007;4(2)e14


Unlike septic arthritis of the knee, sepsis in the hip is much more difficult to diagnose. High index of suspicion, with clinical findings of hip pain and reduced movements, help in the early diagnosis. Raised inflammatory markers help to confirm the diagnosis. X-rays in the early stage may not show any changes. Early diagnosis is essential to prevent long-term sequelae and to improve the outcome especially in children1 and young adults. Good outcomes are associated if sepsis in the hip is drained surgically within 4 days of onset of symptoms in children. Presence of osteoarthritis of the hip complicates the picture thus causing delay in diagnosis. Knight et al suggested that septic arthritis should be considered in any patient with acute exacerbation of pain in an osteoarthritic joint, particularly if there is a possibility of coexisting infection elsewhere in the body2.

Bilateral hip septic arthritis is a rare entity and to date only one case has been reported associated with radiotherapy of the hip. We present a case of bilateral septic arthritis of hip in an immunocompromised patient.

Case report:

58 year old gentlemen presented to A&E with few hours’ history of sever right anterior thigh pain, radiating to his toes. He was unable to weight bear on his right leg. There was no history of any acute trauma to his right leg. He also complaint of feeling of being unwell for a day. He had a background history of type II diabetes mellitus controlled with glicalzide, asthma controlled with steroid inhalers and bilateral osteoarthritis of hips left worst than the right. He was already on a waiting list for a left total hip replacement. He had a very recent history of right olecrenon bursitis and was on oral flucloxacillin.

Clinical examination revealed sinus tachycardia with a heart rate of 130 beats/min, low blood pressure of 80/60 mm of Hg and a temperature of 38.3. He was maintaining his saturation at 99% with 2 L of oxygen. Systemic examination was unremarkable except moderate abdominal distention. He was unable to move his right leg therefore right hip movements were difficult to access.

His inflammatory markers were raised with C-reactive protein of 36 and a while cell count of 16.9. He also had deranged renal functions test with raised urea and creatinine on admission. He was put on intravenous flucloxacillin and ceftriaxone.

X-ray of his both hips and right femur did not show any acute bone trauma but there were osteoarthritic changes in his right hip with avascular necrosis of left head of femur [Fig 1,2]. Initially he was admitted under medical care without any definitive diagnosis. Orthopaedic review was arranged the same day and on examination by the orthopods the possibility of septic arthritis right hip could not be ruled out. Right hip aspiration was done and specimens were sent for cultures and gram staining. Clindamycine was added to his antibiotics upon discussion with the microbiologist. 

Figure 1: AP View of Right Hip showing osteoarthritic changes

Figure 2: AP View of Left Hip showing avascular necrosis left head of femur

In the mean time he developed septic shock and was shifted to ITU for intensive monitoring and management. He was put on ionotropes and hydrocortisone in the ITU to maintain his blood pressure. Because of progressive septic shock a decision was made to washout his right hip joint, which was carried out through posterior approach to the hip. Further specimens were sent for culture and gram staining from the hip. He subsequently grew group B streptococci from his blood and cultures, hip and wound swab from the olecrenon bursa and therefore was commenced on benzylpenicilline.

Despite the right hip washout, his blood pressure did not pick up and he started becoming increasingly acidotic with increased lactate, decreased PCO2 and decreased bicarbonate. On examining him again his left hip movements were restricted and painful this time with satisfactory right hip wound and slightly increased movements in right hip. A diagnosis of septic arthritis of left hip was made this time and left hip was washout was arranged. Hip was approached through posterior approach. Left hip joint was found to be totally destroyed with avascular necrosis. Deformed femoral head was removed, specimens were sent for culture and gram staining and hip was washed out with saline. The culture from left hip also grew group B streptococci.

Postoperatively his acidosis started improving and his renal functions became normal. He was finally weaned off from ionotropes on second postoperative day. Within a week he was out of ITU and started mobilising.

All the three strains of streptococci isolated from olecrenon bursa and both hips were subjected to PCR series and gene probing which showed that all three isolates were indistinguishable from one another. This essentially means that all the three isolates were similar and bilateral hip sepsis was secondary to streptococcus group B infection within the olecrenon bursa. 

Discussion And Review of Literature:

Septic arthritis is inflammation of a synovial membrane with purulent effusion into the joint capsule, usually due to bacterial infection. Incidence of septic arthritis is 2 to 10 per 100,000 of general population [3]. Septic arthritis used to be a life threatening condition prior to antibiotic era. Although the mortality has certainly decreased with antibiotics but the morbidity is still very high. Residual damage to the articular cartilage of the involved joint leads to long-term consequences such as osteoarthritis. 25 to 50% will develop irreversible joint destruction [4]. Septic arthritis of the hip can occur at any age group, including infants and children. Certain risk factors causes increased incidence of this potentially fatal problem. These include chronic rheumatoid arthritis, systemic infections, certain types of cancer, diabetes mellitus, sickle cell anemia, systemic lupus erythematosus (SLE), haemochromatosis, intravenous drug abusers, alcoholics, and after prosthetic joint replacements. Recent history of joint injury, surgery or patients receiving medications is also on a predisposing factor for septic arthritis. Women and male homosexuals are at greater risk for septic arthritis than are male heterosexuals.

The pathophysiology of septic arthritis of the hip is essentially the same as for any other joint. Bacteria usually gain access to the hip joint either through the blood or a break in the skin. Direct injury to the joint resulting in haematoma formation can predispose to infection. Spread of infection can also occur from an adjacent osteomyelitis or soft tissue infection. Once bacteria cross the synovial membrane they trigger an inflammatory reaction that is manifested by the presence of plasma proteins and polymorhonuclear cells within the joint, producing an effusion. This stage is still reversible if treated because of intact articular cartilage. However if left untreated, proteolytic enzymes initiate articular cartilage destruction and permanent joint damage.

The pattern of particular bacterium causing the infection varies considerably with the age of the patient [Table 1]. In all age groups staphylococcus aureus and streptococcus is the most common organism causing septic arthritis of the hip [5]. In neonates’ staph aureus, streptococcus and gram-negative anaerobes are responsible for majority of the infections. Staph aureus and Haemophilus influenzae are the main infecting organisms in infants. In children staph aureus along with salmonella become the most important organisms causing septic arthritis. Nesseria gonorrhoeae should always be suspected in younger adults and teen age.

Table 1: Common bacteria causing septic arthritis in different age groups

In the early stage of progression, it is very difficult clinically to diagnose septic arthritis of the hip. The diagnosis however becomes clearer in more advance stage when joint effusion is detected clinically. Diagnostic clinical clues include fever, red, hot, swollen hip joint with marked groin tenderness and decreased active and passive range of movements. Infants and children present diagnostic challenge, as the diagnostic signs of joint infections may not be obvious clinically. There may be no fever and symptoms like anorexia, nausea, vomiting, decreased appetite, abdominal distention and irritability may easily confuse the clinician and lead to incorrect diagnosis. In infants, the affected limb is usually flexed, abducted and externally rotated at the hip in order to relieve the pressure on the capsule. A search should be made clinically to exclude distant infections in children.

Full blood count shows increased leucocyte count and erythrocyte sedimentation rate. C-reactive protein is also diagnostic and serial measurement will help to monitor the course of treatment. Blood cultures are positive in only half of the patients with staph aureus infections. Anteroposterior and lateral plain radiographs of the hip are often normal in early stages. A periosteal reaction usually becomes visible at about 10 days and is a non-specific sign of infection. Ultrasound examination is sensitive in detecting joint effusion and therefore differentiates septic arthritis from other conditions such as soft tissue abscess and tenosynovitis. It also helps to guide joint aspiration. Gordon et al reported a 5% false negative rate of ultrasound in diagnosing septic arthritis of the hip [6]. Isotope bone scanning can diagnose acute joint infections with significant accuracy. Technetium-99m labeled phosphate compound has accuracy in excess of 80% [7]. Because the diagnosis is clinical in cases of hip joint, therefore it is not necessary to request an isotope scan in every patient. It can however be done in cases where the diagnosis is not clear and patient is clinically not unwell.

Aspirating the joint and culturing the aspirate achieve definitive diagnosis. Immediate gram stain can identify the organisms even before the results of cultures are known and guide the nature of antibiotic therapy. Aspiration is done under local anaesthetics and with the help of image intensifier. The advantages of joint aspiration are that it may be the diagnostic and therapeutic procedure in majority of the patient. Joint decompression may help to relieve the pain and increase range of joint movements.

Antibiotics should be withheld until the joint has been aspirated and specimens have been sent for culture and gram staining. Gram staining can direct the use of appropriate antibiotics, otherwise antibiotics on best guess basis or according to local hospital policy can be started. About 2 decades ago clinicians advocated the use of antibiotics and repeated aspirations for the treatment of septic arthritis [8].  However treatment of choice in septic arthritis of the hip now is arthrotomy, drainage of pus and lavage. Other techniques of draining the hip has been described in literature but are not very popularly used. Repeated closed suction and drainage of the joint has been advocated by some authors but with associated increased incidence of complications [9]. Arthroscopic drainage of the hip has the advantage of a very small scar and early mobilization but it is technically very demanding, doses not achieve complete drainage and is time consuming [10].

 The prognosis of septic arthritis of the hip depends upon the urgency with which definitive treatment is started. A poor outcome is associated with infancy, delay in treatment of greater than 4 days and proximal femoral osteomyelitis.


Septic arthritis of hip is an orthopaedic emergency with good potential of cure if diagnosed and treated early. Delay in treatment adversely affects the outcome and results in permanent joint destruction. Arthrotomy, drainage and lavage of the affected joint remain the gold standard treatment for septic arthritis of the hip. Reconstructive surgery in infants and children after acute septic arthritis is difficult and associated with increased morbidity. Total hip replacement is the treatment of choice in older patients after septic arthritis of hip.

References :

  1. Bennett OM, Namyak SS: Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop 281:123-132, 1992.

  2. Knight J, Gilbert FJ, Hutchison JD, Lesson of the Week: Septic arthritis in osteoarthritic hips. BMJ 1996; 313:40-41

  3. Kaandorp CJE, Van Schaardenburg, Krijnen P, Habbema JDF, van de Laae MAFJ. Risk factors for septic arthritis in patients with joint disease: a prospective study. Arthritis Rheum 1995; 38: 1819-1825.

  4. Goldenberg DL, Reed JI. Bacterial arthritis N Engl J Med 1985; 312: 764-771.

  5. Chen CE, Ko JY, Li CC, Wang CJ. Acute septic arthritis of the hip in children. Arch Ortop trauma Surg 2001; 121: 521-526.

  6. Gordon EJ, Huang M, Dobbs M, Luhmann SJ, Szymanski DA, Schoenecker PL. Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children. J Pediatr Orthop 2002; 22:312-316.

  7. Goldschmidt RB, Hoffman EB. Osteomyelitis and septic arthritis in children. Current Orthopaedics 1991; 5:248-255.

  8. Wilson N I L, Di Paola M. Acute septic arthritis in infancy and childhood. J Bone Joint Surg 1986; 68-B: 584587.

  9. Letts R M, Wong E. Treatment of acute osteomyelitis in children by closed-tube irrigation: a reassessment. Can J Surg 1975; 18:60-63

  10. Chung WK, Slater G L, Bates WH. Treatment of septic arthritis of the hip by arthroscopic lavage. J Pediatr Orthop 1993; 13: 444--446.

This is a peer reviewed paper 

Please cite as :F. Anwar : Bilateral Hip Septic Arthritis

J.Orthopaedics 2007;4(2)e14






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