This Article
Right arrow Full Text
Right arrow Full Text (PDF)
Right arrow Letters to the Editor: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Letters to the Editor are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowReprints and Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by KOCHER, M. S.
Right arrow Articles by KASSER, J. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by KOCHER, M. S.
Right arrow Articles by KASSER, J. R.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Technorati  
What's this?
The Journal of Bone and Joint Surgery 81:1662-70 (1999)
© 1999 The Journal of Bone and Joint Surgery, Inc.

Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm*{dagger}

MININDER S. KOCHER, M.D.{ddagger}, DAVID ZURAKOWSKI, PH.D.{ddagger} and JAMES R. KASSER, M.D.{ddagger}, BOSTON, MASSACHUSETTS

Investigation performed at Children's Hospital, Harvard Medical School, Boston

Background: 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. Methods: 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. Results: 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 109 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. Conclusions: 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.


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Technorati Technorati    What's this?


This article has been cited by other articles:


Home page
 Am. J. Roentgenol.Home page
J. H. Kan, M. A. Hilmes, J. E. Martus, C. Yu, and M. Hernanz-Schulman
Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis
Am. J. Roentgenol., November 1, 2008; 191(5): 1595 - 1600.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
K.-S. Kwack, J. H. Cho, J. H. Lee, J. H. Cho, K. K. Oh, and S. Y. Kim
Septic Arthritis Versus Transient Synovitis of the Hip: Gadolinium-Enhanced MRI Finding of Decreased Perfusion at the Femoral Epiphysis
Am. J. Roentgenol., August 1, 2007; 189(2): 437 - 445.
[Abstract] [Full Text] [PDF]

Home page
 Pediatr. Rev.Home page
M. A. Raslich and G. M. Onady
Evidence-based Medicine: Critical Appraisal of the Literature (Critical Appraisal Tools)
Pediatr. Rev., April 1, 2007; 28(4): 132 - 138.
[Full Text] [PDF]

Home page
 Emerg. Med. J.Home page
S F Li, C Cassidy, C Chang, S Gharib, and J Torres
Diagnostic utility of laboratory tests in septic arthritis
Emerg. Med. J., February 1, 2007; 24(2): 75 - 77.
[Abstract] [Full Text] [PDF]

Home page
 EDUCATION AND PRACTICEHome page
L. J McCann, L. R Wedderburn, and N. Hasson
JUVENILE IDIOPATHIC ARTHRITIS
Arch. Dis. Child. Ed. Pract., August 1, 2006; 91(2): ep29 - ep36.
[Full Text] [PDF]

Home page
 JBJSHome page
M. S. Caird, J. M. Flynn, Y. L. Leung, J. E. Millman, J. G. D'Italia, and J. P. Dormans
Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children. A Prospective Study
J. Bone Joint Surg. Am., June 1, 2006; 88(6): 1251 - 1257.
[Abstract] [Full Text] [PDF]

Home page
 Pediatr. Rev.Home page
S. M. L. Tse and R. M. Laxer
Approach to Acute Limb Pain in Childhood
Pediatr. Rev., May 1, 2006; 27(5): 170 - 180.
[Full Text] [PDF]

Home page
 TraumaHome page
P. Gibbons
The limping child
Trauma, October 1, 2005; 7(4): 185 - 194.
[Abstract] [PDF]

Home page
 NEJMHome page
M. C. Gebhardt, D. I. Rosenthal, and P. M. Arnell
Case 8-2005 - A 10-Year-Old Boy with Pain in the Right Thigh
N. Engl. J. Med., March 17, 2005; 352(11): 1122 - 1129.
[Full Text] [PDF]

Home page
 JBJSHome page
P. Yagupsky, S. J. Luhmann, A. Jones, M. Schootman, J. E. Gordon, P. L. Schoenecker, and J. D. Luhmann
Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children
J. Bone Joint Surg. Am., February 1, 2005; 87(2): 459 - 460.
[Full Text]

Home page
 ImagingHome page
K Foster
The limping child
Imaging, December 1, 2004; 16(2): 153 - 160.
[Abstract] [Full Text] [PDF]

Home page
 JBJSHome page
M. S. Kocher, R. Mandiga, D. Zurakowski, C. Barnewolt, and J. R. Kasser
Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children
J. Bone Joint Surg. Am., August 1, 2004; 86(8): 1629 - 1635.
[Abstract] [Full Text] [PDF]

Home page
 JBJSHome page
S. J. Luhmann, A. Jones, M. Schootman, J. E. Gordon, P. L. Schoenecker, and J. D. Luhmann
Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children with Clinical Prediction Algorithms
J. Bone Joint Surg. Am., May 1, 2004; 86(5): 956 - 962.
[Abstract] [Full Text] [PDF]

Home page
 JBJSHome page
J. J. McCarthy, J. P. Dormans, S. H. Kozin, and P. D. Pizzutillo
Musculoskeletal Infections in Children. Basic Treatment Principles and Recent Advancements
J. Bone Joint Surg. Am., April 1, 2004; 86(4): 850 - 863.
[Full Text] [PDF]

Home page
 JBJSHome page
M. S. Kocher and D. Zurakowski
Clinical Epidemiology and Biostatistics: A Primer for Orthopaedic Surgeons
J. Bone Joint Surg. Am., March 1, 2004; 86(3): 607 - 620.
[Full Text] [PDF]

Home page
 JBJSHome page
M. S. Kocher, R. Mandiga, J. M. Murphy, D. Goldmann, M. Harper, R. Sundel, K. Ecklund, and J. R. Kasser
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., May 28, 2003; 85(6): 994 - 999.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
L. S. Medina and D. Zurakowski
Measurement Variability and Confidence Intervals in Medicine: Why Should Radiologists Care?
Radiology, February 1, 2003; 226(2): 297 - 301.
[Abstract] [Full Text] [PDF]

Home page
 Pediatr. Rev.Home page
G. Onady and M. A. Raslich
Evidence-based Medicine for the Pediatrician
Pediatr. Rev., September 1, 2002; 23(9): 318 - 322.
[Full Text] [PDF]

Home page
 Emerg. Med. J.Home page
R. Boyd and B. Martin
Erythrocyte sedimentation rate and septic arthritis in children
Emerg. Med. J., May 1, 2001; 18(3): 212 - 213.
[Full Text]