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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 37-41

Demography and impact of initiation of definitive treatment in osteoarticular infections of infants and neonates


1 Department of Orthopaedics, KPC Medical College and Hospital, Kolkata, India
2 Department of Orthopaedics, IPGME&R, SSKM Hospital, Kolkata, India

Date of Submission24-Nov-2021
Date of Acceptance25-Nov-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Nilay K Das
Department of Orthopaedics, KPC Medical College and Hospital, Kolkata.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijors.ijors_31_21

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  Abstract 

Background: Osteoarticular infections in infants, such as osteomyelitis and septic arthritis, are a growing problem with a potential for not only systemic after-effects but also irreversible joint damage and limb deformity. Therefore, early treatment is necessary to reduce permanent damage/deformity. The purpose of this study is to find out the demography and impact of early initiation of definitive institutional management in osteoarticular infections. Materials and Methods: This study was conducted after approval by the institutional review board. All neonates and infants admitted between June 2019 and May 2021 with a clinical and laboratory diagnosis of osteoarticular infection were included in this study. Data for each patient were collected using the Hosp Gestor program. Patients having a history of pain, redness, swelling in joints associated with fever, and discharging sinus from bone were studied for unknown risk factors and atypical presentations. The impact of definitive management and sequelae were noted in all patients. Results: In this study, males were affected more than females. Osteoarticular infection of septic arthritis (53%) is the most common followed by osteomyelitis (43%) affecting predominantly the hip joint. In the majority of the cases, atypical risk factors like congenital talipes equinovarus and preterm delivery were noted. The most common organism isolated was Staphylococcus aureus (35%); however, atypical organism was Acinetobacter haemolyticus (2.5%). Among treatment methods, surgical cleaning, arthrotomy, and drainage was the most common procedure. The greater the delay in institutional visit, the more severe was the complications. Worst outcomes and sequelae are seen when the delay is >3 months, namely epiphyseal growth arrest, varus deformity, and destroyed head of the femur; good outcomes are seen when a delay is for a few days. Conclusion: Early detection and institutional visit resulted in good outcomes. This study proves the truth behind the fact that delay in diagnosis and initiation of definitive treatment causes more complications and sequelae. This study also serves as a clinical guide to identify risk factors, awareness about early detection, and effective institutional treatment of osteoarticular infections in infants and neonates.

Keywords: Infants/demography, osteoarticular infection, osteomyelitis, septic arthritis


How to cite this article:
Makur S, Karmakar A, Das NK. Demography and impact of initiation of definitive treatment in osteoarticular infections of infants and neonates. Int J Orthop Surg 2021;29:37-41

How to cite this URL:
Makur S, Karmakar A, Das NK. Demography and impact of initiation of definitive treatment in osteoarticular infections of infants and neonates. Int J Orthop Surg [serial online] 2021 [cited 2022 Jan 26];29:37-41. Available from: https://www.ijos.in/text.asp?2021/29/2/37/332935




  Introduction Top


Osteoarticular infections in infants, such as osteomyelitis and septic arthritis, are a growing problem with potential for systemic after-effects, since they can progress to irreversible joint damage and motor injury or sepsis and limb deformity.[1],[2] Growth abnormalities in septic arthritis relate to the destruction of the growth plate and epiphyseal portions by the osteomyelitis process, as well as direct destruction from the joint sepsis. Therefore, early treatment is necessary to reduce permanent damage/deformity.[1],[3] The purpose of this study is to find out the demography and impact of early initiation of definitive institutional management in osteoarticular infections.


  Materials and Methods Top


Methods

This study was conducted after approval by the institutional review board. All neonates and infants admitted between June 2019 and May 2021with a clinical and laboratory diagnosis of osteoarticular infection were included in this study. Data for each patient were collected using the Hosp Gestor program. Patients having a history of pain, redness swelling in joints associated with fever, and discharging sinus from bone were studied for unknown risk factors, atypical presentations, the role of definitive management, and sequelae. Patients whose charts were incomplete were excluded from the study.

Data collection

Data for each patient were collected using the Hosp Gestor program (https://www.hgresidencia.com.br/ortopmandaqui), which stores the charts for patients who are hospitalized in this service. Patients who were able to read and write or their parents/guardians were contacted and they signed an informed consent term before data were obtained from the database and user.

Variables

The variables analyzed were demographic characteristics: age (<1 year) and sex; type of infection (septic arthritis/osteomyelitis/osteomyelitis + septic arthritis); anatomical location of the infection; time delay from diagnosis to institutional visit (in days); history of risk factors—previous infection, comorbidities, or trauma; laboratory exams; and complications (sequelae and its management).

Sample size calculation

Sample size has been calculated with help of Epi Info 3.5.3. Epi Info is a trademark of the Centers for Disease Control and Prevention (CDC). For statistical analysis, data were entered into a Microsoft Excel spreadsheet and then analyzed by SPSS 27.0 and Graph Pad Prism (version 5). Data had been summarized as mean and standard deviation for numerical variables and as count and percentages for categorical variables. Unpaired proportions were compared by χ2 test or Fischer’s exact test, as appropriate. Two-sample t-tests for a difference in mean involved independent samples or unpaired samples. P value ≤ 0.05 was considered statistically significant.

Sample size justification

One study found that the prevalence of osteoarticular infection was 35.0%. So, for this study P = 0.35. Thus, the number of patients required for this study was 40.0, ~ 40 with power 87%. The formula used for sample size calculation was as follows:

n = 4pq/(L2)

where, n = required sample size,

P = 0.35 (as per the study by Jana Neto et al.),

q = 1−p,

L = loss% (loss of information)

Calculation:

Here P = 0.35,

q = 1−P = 1−0.35 = 0.65,

4pq = 4 × 0.35 × 0.65 = 0.9100

L2 = 0.0227

n = 4pq/(L2) = 0.9100/0.0227 = 40.0 = 40


  Results Top


The initial sample was composed of 40 patients who fit the selection criteria. Out of the 40 patients, 43% patients had osteomyelitis, 53% had septic arthritis, 4% had concomitant septic arthritis and osteomyelitis [Figure 1]. Boys were more predominantly affected (70%) with the mean age being 5.4 months, than girls (30%). Patients older than 7 months were more severely affected (50%).
Figure 1: Bar chart showing prevalence of different types osteoarticular infection

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As for the anatomical location of the infection, the most common site for septic arthritis was hip (in 76.2% of patients), which matches with the study of. The cases of osteomyelitis occurred most commonly in the tibia [Figure 2].
Figure 2: Bar chart showing prevalence of anatomical location of osteoarticular infection

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In terms of risk factors, 17 patients (35%) reported a history of infection or previous trauma, among which pulmonary diseases were most frequent (57.14%), including bronchiolitis and pneumonia.

Atypical risk factors being 20% had a history of preterm delivery, low-birth weight. Five percent had history of congenital talipes equinovarus. Five percent had a history of intramuscular injection. Five percent had a history of scabies. Five percent had a history of bacterial conjunctivitis [Figure 3].
Figure 3: Bar chart showing atypical risk factors of osteoarticular infection

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Data regarding partially treated or untreated during the visit revealed that 29 patients (72.5%) had not received any treatment during their first visit, whereas 11 patients (27.5%) had received some form of treatment outside elsewhere. Delay in diagnosis during the institutional visit was significant [Figure 4]. It is seen that the more the delay in institutional visit, the more is complications and sequelae and the poorer the outcome [Figure 5].
Figure 4: Bar chart showing data of delay in diagnosis during institutional visit

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Figure 5: Bar chart showing outcome of osteoarticular infection based on delay in treatment

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During management, C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) were assessed in all patients at the time of hospital admission. Among the patients with septic arthritis, the mean serum concentration of CRP was 11 mg/dL; for patients with osteomyelitis, this value was 9.29 mg/dL, and in cases of osteomyelitis associated with septic arthritis, the average value was 7 mg/dL. The average ESR was 58.94 mm/h, 91 mm/h, and 55 mm/h, respectively. After proper investigation, appropriate treatment was given using various surgical procedures [Table 1]. Pre- and per-operative culture sensitivity done for infected materials. The most isolated organism was Staphylococcus aureus (35%), followed by Streptococcus haemolyticus (12.5%). Atypical organism isolated was Acenitobacter haemolyticus (2.5%).
Table 1: Complications due to delay in institutional visit

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Osteoarticular infections were treated as per current concepts utilizing various surgical procedures and medications. Most of the cases underwent a surgical procedure in the form of surgical cleaning, arthrotomy, and drainage. Despite the best treatment, complications/sequelae could not be avoided [Table 2]. It is seen that the greater is the delay in an institutional visit from the diagnosis, the poorer is the outcome with a high complication rate [Table 3]. Worst outcomes are seen when the delay is greater than 3 months to years. And good outcomes are seen when the delay is for a few days.
Table 2: Treatment methods used for osteoarticular infections

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Table 3: Sequelae of osteoarticular infections

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  Discussion Top


This study analyzed the clinical and epidemiological characteristics and treatment of osteoarticular infections in infants and neonates, based on data collected from patients treated in our hospital. The results showed predominantly male patients with a mean age of 5.4 months. Most of the patients were diagnosed with septic arthritis (53%), followed by osteomyelitis (43%), and septic arthritis associated with osteomyelitis (4.5%), and in most of the cases the hip and ankle joints were affected. Grammatico-Guillon et al. analyzed 2911 patients with osteoarticular infections using the French National Hospital Database and reported similar data in relation to the greater prevalence in boys than in girls (24 vs. 19 per 100,000 inhabitants, respectively), with 52% of the cases of septic arthritis and 44% of osteomyelitis.[4] In a prospective epidemiological study, Mitha et al. found 52% of cases involved septic arthritis and 41% osteomyelitis, with 80% of cases involving the legs.[2]

Our study shows that confirmation of the diagnosis of septic arthritis, osteomyelitis, or both should be based on signs and symptoms found in imaging examinations and laboratory tests. It is also observed high CRP and ESR levels in all patients, which is similar to one study where approximately 85% of children with osteomyelitis and 100% of children associated with septic arthritis presented elevated CRP and ESR levels.[5]

According to Ceroni et al., the direct inoculation of the microorganism into the bone or joint after trauma, internal fracture fixation, or soft-tissue infections occurs less frequently in children.[6] Most pediatric bone and joint infections are hematogenous in origin, and the respiratory tract is considered the main route of entry for the pathogen. In this study, 37% of the patients reported a history of pulmonary diseases.

Kocher et al. developed guidelines to treat pediatric orthopedic infections and emphasized the inclusion of antibiotic therapy and surgery according to need.[7] The patients are usually admitted to the hospital, and remained till examinations to identify the pathogen are completed, treatment is begun with empirical antibiotics. Empirical treatment is started, and the medication is chosen according to the local prevalence of infectious agents, and early laboratory results.[8] When the results of culture are available, antimicrobial therapy may be modified depending on the microorganism and the pattern of susceptibility. The duration and administration route for antibiotic therapy depend on the virulence of the pathogen, the location of the infection, and the clinical and laboratory response to treatment.

According to Kaplan et al., transitioning from intravenous to oral administration is important to complete treatment and avoid complications.[9] It is recommended that treatment last a total of at least 3 weeks, depending on the patient’s clinical response.[9],[10],[11] In the sample analyzed in this study, all patients received intravenous antibiotic therapy during hospitalization and oral antibiotics after discharge. For Kaplan et al., multiple surgical procedures are often needed in the most serious cases of osteoarticular infection. In this present study, 80% of patients underwent at least one surgical procedure, most frequently surgical cleaning.


  Conclusion Top


This study shows that previous histories of trauma, infections, have a definitive role and are important risk factors for the development of osteoarticular infections in infants and neonates. Early detection and institutional visit resulted in good outcomes. Inappropriate or delayed treatment resulted in chronic osteomyelitis or irreversible joint destruction. Delay in diagnosis and initiation of definitive treatment causes more complications. Despite the best measures to manage the sequelae, once the damage has been done, the patient is physically challenged for the rest of his/her life.

Therefore, this study proves the truth behind the fact that delay in diagnosis and initiation of definitive treatment causes more complications and sequelae and this study serves as a clinical guide to identify risk factors, awareness about early detection, and effective institutional treatment of osteoarticular infections in infants and neonates.

Acknowledgment

This research work is done in KPC Medical College & Hospital Kolkata. Author(s) of this article thank the administration of the Institute for kind support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Statement from authors

This article represents the honest work performed at KPC Medical College & Hospital, Kolkata. All the authors have approved this final article and agreed to submit to the International Journal of Orthopaedic Surgery.

Contributions of authors

Dr. Sayantan Makur: research work, study design, analysis of data, and preparation of article. Dr. Arnab Karmakar: study design, analysis of data, and reviewed the article for final preparation. Dr. Nilay Kanti Das: supervised the research work, study design, analysis of data, and reviewed the article for final preparation.



 
  References Top

1.
Neto FCJ, Ortega CS, Goiano EO. Epidemiological study of osteoarticular infections in children. Acta Ortop Bras 2018;26:201-5.  Back to cited text no. 1
    
2.
Mitha A, Boutry N, Nectoux E, Petyt C, Lagrée M, Happiette L, et al; Hospital Network for Evaluating the Management of Infectious Diseases in Children. Community-acquired bone and joint infections in children: A 1-year prospective epidemiological study. Arch Dis Child 2015;100:126-9.  Back to cited text no. 2
    
3.
Mathews CJ, Coakley G. Septic arthritis: Current diagnostic and therapeutic algorithm. Curr Opin Rheumatol 2008;20:457-62.  Back to cited text no. 3
    
4.
Grammatico-Guillon L, MaakarounVermesse Z, Baron S, Gettner S, Rusch E, Bernard L. Paediatric bone and joint infections are more common in boys and toddlers: A national epidemiology study. Acta Paediatr 2013;102:e120-5.  Back to cited text no. 4
    
5.
Dodwell ER. Osteomyelitis and septic arthritis in children: Current concepts. Curr Opin Pediatr 2013;25:58-63.  Back to cited text no. 5
    
6.
Ceroni D, Kampouroglou G, Valaikaite R, Anderson della Llana R, Salvo D. Osteoarticular infections in young children: What has changed over the last years? Swiss Med Wkly 2014;144:w13971.  Back to cited text no. 6
    
7.
Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, et al. A clinical practice guideline for treatment of septic arthritis in children: Efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am 2003;85:994-9.  Back to cited text no. 7
    
8.
Rai A, Chakladar D, Bhowmik S, Mondal T, Nandy A, Maji B, et al. Neonatal septic arthritis: Indian perspective. Eur J Rheumatol2020;7(suppl 1):S72-7.  Back to cited text no. 8
    
9.
Kaplan SL. Recent lessons for the management of bone and joint infections. J Infect 2014;68(suppl 1):S51-6.  Back to cited text no. 9
    
10.
Gigante A, Coppa V, Marinelli M, Giampaolini N, Falcioni D, Specchia N. Acute osteomyelitis and septic arthritis in children: A systematic review of systematic reviews. Eur Rev Med Pharmacol Sci 2019;23:145-58.  Back to cited text no. 10
    
11.
Sankaran G, Zacharia B, Roy A, Purayil SP. Current clinical and bacteriological profile of septic arthritis in young infants: A prospective study from a tertiary referral centre. Eur J Orthop Surg Traumatol 2018;28:573-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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