Ultrasonography of hip joint effusions

Ultrasonography performed by an infectiologist in hip and knee prosthetic joint and native joint infections

INTRODUCTION

Clinical ultrasonography (US) by infectiologists has only recently been developing, and as now there is little literature on the subject. Our study focuses on the conditions and diagnostic performance of clinical ultrasound imaging by infectiologists in cases of hip and knee prosthetic and native joint infection.

METHODS

A retrospective study carried out between June 1^st 2019 and March 31^st 2021 in the University Hospital of Bordeaux, South-Western France. We measured US sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV), combined or not with the analysis of articular fluid, compared to the MusculoSketetal Infection Society (MSIS) score in prosthetic joints, or to expert diagnosis in native joints.

RESULTS

Fifty-four patients underwent US by an infectiologist in an infectious disease ward, including 11 (20.4%) for native joint and 43 (79.6%) for prosthetic joint. Joint effusion and/or periarticular collection were highlighted in 47 (87%) patients, and US led to 44 punctures. In all patients (n=54), Se, Sp, PPV and NPV of US alone were 91%, 19%, 64% and 57%, respectively. When US was combined with fluid analysis, Se, Sp, PPV, NPV were 68%, 100%, 100%, 64% in all patients (n=54), 86%, 100%, 100%, 60% in acute arthritis (n=17) and 50%, 100%, 100% and 65% respectively in non-acute arthritis (n=37).

CONCLUSION

These results suggest that US by infectiologists effectively diagnoses osteoarticular infections (OAIs). This approach has many applications in infectiology routines. Consequently, it would be interesting to define the contents of a first level of infectiologist competence in US clinical practice.

ACR Appropriateness Criteria® Osteomyelitis or Septic Arthritis-Child (Excluding Axial Skeleton)

Imaging plays an integral role in the evaluation of suspected musculoskeletal infections in children, not only in the accurate identification of infection such as osteomyelitis or septic arthritis, but also in guiding management. Various diagnostic modalities serve different purposes in the assessment of suspected pediatric musculoskeletal infections. The purpose of this document is to provide imaging guidance in the most frequently encountered clinical scenarios in which osteomyelitis and/or septic arthritis are suspected, outside of the axial skeleton. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion.

A Novel Three-Dimensional-Printed Ultrasound-Guided Hip Arthrocentesis Model

When evaluating patients with hip pain, clinicians may be trained to both evaluate for a hip effusion and perform ultrasound-guided arthrocentesis to evaluate the etiology of the effusion. We present a novel 3-dimensional-printed hip arthrocentesis model, which can be used to train clinicians to perform both tasks under ultrasound guidance. Our model uses a combination of a 3-dimensional-printed hip joint, as well as readily available materials such as an infant Ambu (Ballerup, Denmark) bag, syringe, intravenous line kit, and silicone. We present our experience so that others may use and adapt our model for their training purposes.

Point-of-Care Ultrasound for the Detection of Hip Effusion and Septic Arthritis in Adult Patients With Hip Pain and Negative Initial Imaging

BACKGROUND

Acute or recurrent hip pain in adults can be a challenging presentation in the emergency department. While ultrasound is routinely used in the evaluation of pediatric patients with hip pain and a new limp, it is not commonly used for this purpose in adult emergency medicine. This case series demonstrates the clinical utility of point-of-care ultrasound (POCUS) in adult patients with acute or recurrent hip pain because performance of POCUS was the critical action that led to the identification of pathologic hip effusions in this series of adults.

CASE SERIES

This case series includes 5 patients in whom clinical suspicion existed for the presence of a hip effusion and possible septic arthritis, despite nondiagnostic radiographic findings. Ultrasound was used to detect the effusion and guide subsequent arthrocentesis, imaging, or surgical intervention. In all patients, computed tomography scans or magnetic resonance imaging scans were later used to confirm the presence of effusion. In all 5 patients (2 women and 3 men, with a mean age of 47.4 years), POCUS accurately detected the presence of hip effusion. Two of 5 synovial collections were caused by septic arthritis as confirmed by synovial fluid microbiologic examination. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case series emphasizes the clinical utility of POCUS in adult patients with acute and recurrent hip pain to detect a hip effusion, particularly in patients with significant risk factors for septic arthritis. POCUS can also be used to guide further imaging, arthrocentesis, surgical consultation, and intervention.

The Use of Ultrasonography in Expediting Septic Joint Identification and Treatment: A Case Report

This case report describes the use of ultrasonography in the identification of a joint effusion to guide diagnosis and management of septic arthritis. Our patient presented with pain, swelling, and erythema of the right thumb after having punctured her thumb with a cactus thorn. Results of physical examination demonstrated tenderness and restricted range of motion. Initial imaging with plain films was unrevealing, without bony and soft tissue abnormalities; however, ultrasound imaging of the interphalangeal joint revealed a focal effusion, and the patient was started on empiric Keflex. Because a focal effusion was visualized with ultrasonography, despite negative x-ray imaging, our patient underwent expedited surgical incision and drainage, foregoing joint aspiration. Intraoperative cultures grew Enterobacter 3 days after surgery, and the empiric antibiotic was adjusted to reflect sensitivities. At 2-wk follow-up, our patient showed near-complete resolution of her symptoms. This case report demonstrates the utility of ultrasonography in the early diagnosis of septic arthritis with the presence of a joint effusion that expedited successful treatment by foregoing joint aspiration in lieu of surgical intervention.

Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department

Septic arthritis is a dangerous medical condition associated with significant morbidity and mortality. However, the differential diagnosis can be broad with conditions that mimic this disease and require different evaluation and treatment. This narrative review presents the emergency medicine evaluation and management, as well as important medical conditions that may mimic this disease. Septic arthritis commonly presents with monoarticular joint pain with erythema, warmth, swelling, and pain on palpation and movement. Fever is present in many patients, though most are low grade. Blood testing and imaging may assist with the diagnosis, but the gold standard is joint aspiration. Management includes intravenous antibiotics and orthopedic surgery consult for operative management vs. serial aspirations. Clinicians should consider mimics, such as abscess, avascular necrosis, cellulitis, crystal-induced arthropathies, Lyme disease, malignancy, osteomyelitis, reactive arthritis, rheumatoid arthritis, and transient synovitis. While monoarticular arthritis can be due to septic arthritis, other medical and surgical conditions present similarly and require different management. It is essential for the emergency clinician to be aware how to diagnose and treat these mimics.

Initial Experience of Ultrasonographic Assessment for Paediatric Patients with Hip Pain in the Emergency Department

Introduction

Hip pain is a common paediatric presentation to the emergency department. Plain radiographs have been the main imaging modality of choice in the past. There is a lack of published local emergency department experience on the assessment of non-traumatic hip pain in children using ultrasound. We undertake to describe our initial experience.

Method

Patients less than 12 years presenting with non-traumatic hip pain or knee pain suspected to be referred from hip were recruited. A 7.5 mHz linear ultrasound probe was used to detect hip effusion. Hip effusion was defined as an anterior capsular distance (ACD) of greater than 5 mm measuring from the neck of femur and a difference of greater than 2 mm from the normal side. Patients with effusion were advised admission and those not admitted would be followed up in the Emergency Department.

Result

45 patients (Male: 32; Female: 13) with a mean age of 5.4 years were recruited from November 1997 to October 1998. Hip pain and limping gait were reported in 34 and 22 patients respectively. The initial scan detected hip effusion in 31 cases (69%). Thirty four patients were admitted and the others were followed up in A&E. All patients who had hip effusion were diagnosed to have transient synovitis. Nine out of 14 patients (64.3%) who did not have hip effusion were also presumed to be due to transient synovitis in the in-hospital record. The sensitivity and specificity for ultrasound assessment of hip pain were 76.9% and 93.3% respectively. No septic arthritis was found.

Conclusion

Our experience supports ultrasound evaluation as an important evaluation tool for children presenting with irritable hip in the emergency department.

A Case of Legg-Calvé-Perthes Disease due to Transient Synovitis of the Hip

Transient synovitis (TS) of the hip develops spontaneously in childhood; it usually has a good prognosis and is a self-limiting disease. However, its pathology is not well known. We describe a case of Legg-Calvé-Perthes disease (LCPD) that seemingly developed due to TS. Even if TS is diagnosed on the basis of the patient's medical history and imaging findings, physicians should consider the possibility of LCPD and perform a careful observation if joint effusion continues and/or a symptom does not improve within 4 weeks.

Staphylococcus aureus-Associated Musculoskeletal Infections

Musculoskeletal infections caused by Staphylococcus aureus are among the most difficult-to-treat infections. S. aureus osteomyelitis is associated with a tremendous disease burden through potential for long-term relapses and functional deficits. Although considerable advances have been achieved in diagnosis and treatment of osteomyelitis, the management remains challenging and impact on quality of life is still enormous. S. aureus acute arthritis is relatively seldom in general population, but the incidence is considerably higher in patients with predisposing conditions, particularly those with rheumatoid arthritis. Rapidly destructive course with high mortality and disability rates makes urgent diagnosis and treatment of acute arthritis essential. S. aureus pyomyositis is a common disease in tropical countries, but it is very seldom in temperate regions. Nevertheless, the cases have been increasingly reported also in non-tropical countries, and the physicians should be able to timely recognize this uncommon condition and initiate appropriate treatment. The optimal management of S. aureus-associated musculoskeletal infections requires a strong interdisciplinary collaboration between all involved specialists.

Septic arthritis in immunocompetent and immunosuppressed hosts

Septic arthritis has long been considered an orthopedic emergency. Historically, Neisseria gonorrhoeae and Staphylococcus aureus have been the most common causes of septic arthritis worldwide but in the modern era of biological therapy and extensive use of prosthetic joint replacements, the spectrum of microbiological causes of septic arthritis has widened considerably. There are also new approaches to diagnosis but therapy remains a challenge, with a need for careful consideration of a combined medical and surgical approach in most cases.

Septic arthritis of the neonatal hip: acute management and late reconstruction

Septic arthritis of the hip in neonates is rare but can have devastating consequences. Presenting signs and symptoms may differ from those encountered in older children, which may result in diagnostic challenge or delay. Many risk factors predispose neonates to septic arthritis, including the presence of transphyseal vessels and invasive procedures. Bacterial infection of the joint occurs via hematogenous invasion, extension from an adjacent site, or direct inoculation. A strong correlation exists between younger age at presentation and severity of residual hip deformity. Diagnosis is based on clinical examination, laboratory markers, and ultrasound evaluation. Early management includes parenteral antibiotics and surgical drainage. Late-stage management options include femoral and pelvic osteotomies, trochanteric arthroplasty, arthrodesis, pelvic support procedures, and nonsurgical measures. Early diagnosis and management continues to be the most important prognostic factor for a favorable outcome in the neonate with septic arthritis.

Sonography for the investigation of a child with a limp

Hip pain is a common paediatric presentation and is potentially serious. While hip pain can be attributed to primary hip pathology, the hip area is also a common site for referred pain. This often poses a diagnostic challenge particularly in the young child who may not verbalise the point of pain and may not report an injury. Differential diagnoses for paediatric hip joint pain range from fracture, transient synovitis, septic arthritis with or without osteomyelitis, juvenile idiopathic arthritis (JIA, previously juvenile rheumatoid arthritis JRA), Legg-Calve-Perthes' disease (LCP), slipped capital femoral epiphysis (SCFE) to haemarthrosis in patient with a clotting disorder. Referred pain from abdominal pathology, for example; appendicitis, psoas abscess or haematoma should also be considered. The evaluation and management of hip pain requires a thorough history and physical examination. A radiograph is usually indicated to rule out any bony injury. Septic arthritis is a medical emergency requiring urgent surgical as well as medical treatment. Ultrasound of the hip joint plays a role in helping to differentiate which hips require early intervention and to guide a needle aspiration of joint fluid if indicated. In this article, we aim to review the anatomy of the hip, techniques in ultrasonographic examination and some common pathologies in the paediatric hip.

[Septic arthritis: practical diagnosis and new treatments]

Septic arthritis remains a major challenge to physicians because the increasing frequency of certain microorganisms to become in antibiotic-resistant and persistent difficulties regarding both early diagnostics and proper treatment of subjects with joint infections. This paper will review current diagnostics test and their contribution to the rapid evaluation of joint infection. Importantly, updated therapeutic suggestions will be presented which, when appropriately applied, should diminish the risks of sequelae following infectious arthritis.

[Benefit of hip ultrasound in management of the limping child]

OBJECTIVE

To evaluate the contribution of sonography of the hip in the management of nontraumatic limping in children.

PATIENTS AND METHODS

Prospective study including children consulting for nontraumatic limping (n=93). These children had a clinical examination, a biological and imaging workup (pelvis x-rays (n=88), initial sonograph of the hip (n=93), and follow-up sonograph of the hip (n=29)).

RESULTS

Ninety-three children (69 boys, 24 girls) aged from 10 months to 13 years (median, 4 years) were included and divided into two groups: The sensitivity and specificity of sonography in establishing a serious diagnosis was 57% and 59%, respectively.

CONCLUSION

The advantage of systematic hip sonography is challenged in this study because of low sensitivity and specificity. Its main advantage seems to be in its negative results, which prompt other investigations.

The role of ultrasound in differentiating septic arthritis from transient synovitis of the hip in children

A total of 154 children admitted with septic arthritis (n=81) or transient synovitis (n=73) were studied retrospectively. Ultrasound findings for 127 patients were correlated with the final diagnosis. Sensitivity, specificity and positive predictive value of ultrasound for the diagnosis of pediatric septic hip were 86.4, 89.7 and 87.9%, respectively. Unsatisfactory outcome occurred more significantly in children, for whom treatment was initiated more than 4 days after the onset of symptoms and those who had a false-negative ultrasound study. Ultrasound cannot be used safely to distinguish between pediatric septic hip and transient synovitis. It may be a method of value to detect minimal hip effusion. A predictive algorithm using clinical, laboratory and ultrasound findings could be beneficial.

Ultrasonography of the lower extremity

Ultrasonography is a useful imaging tool for various soft tissue and joint pathologies affecting the lower extremity. This article reviews the normal sonographic appearance of muscles, tendons, ligaments, nerves, bone, and cartilage. The ultrasound imaging appearance of various pathologic conditions affecting the hip, thigh, knee, lower leg, ankle,and foot are illustrated. The advantages of ultrasonography are highlighted.

Skeletal scintigraphy in the multimodality assessment of young children with acute skeletal symptoms

The authors review the scintigraphic manifestations of acute osteomyelitis, septic arthritis, transient synovitis, Legg-Calvé-Perthes disease, fractures of toddlers, and some systemic conditions that cause skeletal symptoms during childhood. They offer suggestions regarding incorporation of skeletal scintigraphy into a multimodality approach for assessing children with skeletal symptoms.

Limited effectiveness of sonography in revealing hip joint effusion: preliminary results in 21 adult patients with native and postoperative hips

OBJECTIVE

The object of this study was to determine the effectiveness of sonography in the detection of hip joint effusions in both native and postoperative adult hips using arthrocentesis as a gold standard.

MATERIALS AND METHODS

Twenty-one consecutive patients with clinical suspicion of hip joint effusion were examined on sonography by one of five musculoskeletal radiologists with experience in musculoskeletal sonography. All 21 patients underwent diagnostic arthrocentesis (fluoroscopic in 16, sonographic in five) to confirm the presence or absence of joint effusion. A retrospective analysis of the sonograms was made to assess the size of the distention of the anterior joint recess (anteroposterior dimension) and the echogenicity (anechoic or other relative to muscle), and correlation was made to the presence or absence of joint effusion.

RESULTS

Joint effusion was seen on diagnostic arthrocentesis in 10 (48%) of the 21 patients. Seven of the 21 patients had native hips and 14 had prior hip surgery. Retrospectively, no significant difference was found with regard to the size of the anterior recess distention (p = 0.34) or echogenicity (p = 0.2) when comparing the patients with and without joint effusion.

CONCLUSION

Anterior recess distention and echogenicity could not reliably be used as an indicator of adult hip joint effusion, either in native or postoperative hips. Diagnostic arthrocentesis was necessary to establish or exclude the presence of hip joint effusion.

Acute septic arthritis

Acute septic arthritis may develop as a result of hematogenous seeding, direct introduction, or extension from a contiguous focus of infection. The pathogenesis of acute septic arthritis is multifactorial and depends on the interaction of the host immune response and the adherence factors, toxins, and immunoavoidance strategies of the invading pathogen. Neisseria gonorrhoeae and Staphylococcus aureus are used in discussing the host-pathogen interaction in the pathogenesis of acute septic arthritis. While diagnosis rests on isolation of the bacterial species from synovial fluid samples, patient history, clinical presentation, laboratory findings, and imaging studies are also important. Acute nongonococcal septic arthritis is a medical emergency that can lead to significant morbidity and mortality. Therefore, prompt recognition, rapid and aggressive antimicrobial therapy, and surgical treatment are critical to ensuring a good prognosis. Even with prompt diagnosis and treatment, high mortality and morbidity rates still occur. In contrast, gonococcal arthritis is often successfully treated with antimicrobial therapy alone and demonstrates a very low rate of complications and an excellent prognosis for full return of normal joint function. In the case of prosthetic joint infections, the hardware must be eventually removed by a two-stage revision in order to cure the infection.

Targeted musculoarticular sonography in the detection of joint effusions

This article describes an advanced application for an established technology, specifically the use of bedside sonography in the assessment of the acutely painful joint in the emergency department. The sonographic windows for each of the axial synovial joints are outlined, with a brief discussion of commonly encountered pathologic conditions.

Doppler sonography of the anterior ascending cervical arteries of the hip: evaluation of healthy and painful hips in children

OBJECTIVE

We evaluated the Doppler sonography of small feeding arteries to the femoral head in children.

SUBJECTS AND METHODS

In a prospective study of 224 hips in 112 patients (mean age, 5 years 11 months), the anterior ascending cervical arteries of the hip were identified with color Doppler sonography. Subsequently, we measured the resistive index (RI) with pulsed Doppler sonography.

RESULTS

In 61% (137/224) of hips, a Doppler signal could be obtained. In asymptomatic hips (n = 64), the mean RI was 0.58. In symptomatic hips, the definitive diagnoses and mean values of RI included transient synovitis (n = 31) and 0.92, Perthes' disease (n = 9) and 0.67, and miscellaneous (n = 5) and 0.68. In 28 symptomatic hips, no definite diagnosis could be determined and the complaints spontaneously disappeared during follow-up (mean RI, 0.57). We found no statistically significant difference in the RI of symptomatic versus asymptomatic hips, except in patients with transient synovitis (p < 0.001). In 11 hips with transient synovitis that were reexamined after 4-6 weeks, the RI returned to normal (0.57). The RI in symptomatic hips showed a positive correlation with the amount of effusion (r = 0.69, p < 0.001). In symptomatic and asymptomatic hips, we found no correlation with age (p = 0.9 and 0.1, respectively).

CONCLUSION

The deep capsular vessels of the hip joint can be evaluated on Doppler sonography in more than 60% of hips. Also, the RI is age independent and correlates with the amount of effusion.

Ultrasound of the adult hip

The adult hip is a new and challenging site for evaluation with ultrasound (US). Clinically, diseases involving the hip region may be difficult to diagnose without the help of imaging. The hip region is a crossroad for numerous vascular, nervous, and muscular structures that pass between the trunk and the lower extremity. Thus, inflammatory processes and neoplasms may spread to and from the hip, buttock, thigh, pelvis, and retroperitoneum, and trauma may also effect the adjacent areas of the trunk and thigh. Because it is a crossroad, many conditions that are not specific to the hip occur in this area, including inguinal lymphadenopathy, pathology from the abdomen or the genitalia (intestinal hernia, inflammation, and infection), and even referred pain from spinal disorders. The goals of US imaging are the detection and localization of these pathological processes, the differentiation of intra-articular andextra-articular pathology, and the performance of diagnostic and therapeutic interventional procedures. This article reviews the hip anatomy, followed up by a discussion of the US evaluation and differential diagnosis of common pathology occurring in the hip area. This includes joint effusion, arthritis, loose bodies, bursitis, pseudoaneurysm, muscle and tendon diseases, as well as tumor and tumor-like lesions such as hematoma, abscess, and lymphadenopathy.

The Role of Ultrasound in the Diagnosis of Joint Hip Effusions in Small Children

There are a variety of causes for hip pain in children, including slipped capital femoral epiphysis (SCFE), toxic synovitis, septic arthritis, Perthes disease, fracture, and juvenile rheumatoid arthritis. Several of these processes can result in hip joint effusions. Although radiography is initially performed and is often diagnostic, the plain radiograph may be normal in the presence of a small joint effusion. Sonography can be used to determine whether an effusion is present and when deemed clinically appropriate, to guide a diagnostic or therapeutic arthrocentesis. When patients show signs of sepsis and effusion, an ultrasound-guided arthrocentesis can help differentiate between septic arthritis and toxic synovitis. In the evaluation of difficult cases, a bone scan or magnetic resonance imaging may be helpful to exclude the possibility of underlying osteomyelitis.

MRI and ultrasound in children with juvenile chronic arthritis

In this era of advancing imaging technology, a knowledge of the relative values of available imaging techniques is necessary to optimize the management of children with juvenile chronic arthritis (JCA). After clinical examination, plain films remain the initial investigation. The need for radiation protection must be a priority in children with JCA. Conventional radiographs allow grouping of the various arthritides (on the base of the distribution and pattern of joint space changes) and staging of disease progression. Ultrasound (US) is very sensitive in the detection of joint effusions, especially in the hip, and guides fluid aspiration. US and Doppler can be used for the evaluation of synovial hypertrophy and activity. Arthrography and to a certain extent nuclear studies have been replaced by magnetic resonance imaging (MRI). MRI can demonstrate articular cartilage, joint effusion, synovial hypertrophy, cortical and medullary bone, cartilage and bone perfusion, and fibrocartilaginous structures (menisci and ligaments). Contrast enhanced MRI is the most sensitive modality to determine whether an arthritic condition is present. However, it does not assist in establishing a specific diagnosis. MRI determines accurately the activity and the extent of the disease and is particularly useful in the early detection of articular damage. Finally, MRI is of major importance in the evaluation of response to local therapy (especially steroids) and the detection of complications.

Pediatric hip sonography. Diagnosis and differential diagnosis

As with any sonographic study, the accuracy of the examination is related to the skill and experience of the examiner. In this review of pediatric hip sonography, we have reviewed pitfalls and differential diagnoses for the infant suspected of DDH and for the older child presenting with a painful hip. The learning process for DDH evaluation is prolonged and more difficult than learning to assess the hip for effusion.

Anterior joint capsule of the normal hip and in children with transient synovitis: US study with anatomic and histologic correlation

PURPOSE

To study the anatomic components of the anterior joint capsule of the normal hip and in children with transient synovitis.

MATERIALS AND METHODS

Six cadaveric specimens were imaged with ultrasonography (US) with special attention to the anterior joint capsule. Subsequently, two specimens were analyzed histologically. These anatomic findings were correlated with the US findings in 58 healthy children and 105 children with unilateral transient synovitis.

RESULTS

The anterior joint capsule comprises an anterior and posterior layer, mainly composed of fibrous tissue, lined by only a minute synovial membrane. Both fibrous layers were identified separately at US in 98 of 116 (84%) hips of healthy subjects and in all hips with transient synovitis. Overall, the anterior layer was thicker than the posterior layer. In transient synovitis compared with normal hips, no significant thickening of both layers was present (P = .24 and .57 for the anterior and posterior layers, respectively). Normal variants include plicae, local thickening of the capsule, and pseudodiverticula.

CONCLUSION

Increased thickness of the anterior joint capsule in transient synovitis is caused entirely by effusion. There is no US evidence for additional capsule swelling or synovial hypertrophy.

Ultrasound-guided interventional procedures in the musculoskeletal system

Ultrasound is a low-cost, nonionizing, readily available diagnostic technique for the evaluation of tendons, muscles, soft tissue masses, cysts, and other fluid collections. Ultrasound is also a valuable tool for guiding a variety of musculoskeletal interventions. Procedures that can be performed under ultrasound guidance include aspiration of fluid for analysis, injection for medication, decompression of cysts, drainage of abscess and hematoma, biopsy, treatment of calcified tendinitis, and foreign body retrieval.

Septic Arthritis of the Hip in Children

Recent advances in the management of septic arthritis of the hip in children include a better understanding of the effects of infection on articular cartilage; improvements in diagnostic tests, including erythrocyte sedimentation rate, C-reactive protein analysis, and ultrasonography; and more efficacious home intravenous and oral antibiotic therapy. Early diagnosis is essential to successful treatment. Needle aspiration is the most specific diagnostic test; however, false-negative results are possible. Prompt surgical drainage and postoperative antibiotic therapy until signs of infection resolve are necessary to prevent late sequelae. Surgical treatment of limb-length inequality is more useful than attempts to salvage the destroyed or incongruent joint.

Ultrasonography is a nonspecific method in the evaluation of joints

Two cases of unilateral abnormal ultrasonographic findings in the hip joints are introduced. The correct diagnoses were detected by radiography after the failure of intra-articular glucocorticoid injections given as first aid. Ultrasonography (US) has poor specificity, since all phenomena causing effusion into the joint cavity may be detected as abnormal by US, and may include stress fractures and malignant myeloma, as we show here. In the case of an abnormal ultrasonographic finding in a joint, the recent radiological status should also be considered.

Effects of exercise and polysulfated glycosaminoglycan on the development of osteoarthritis in equine carpal joints with osteochondral defects

This study assessed the effects of postoperative exercise and intra-articular polysulfated glycosaminoglycan (PSGAG) on the repair of osteochondral defects in the carpal joints of ponies. Eighteen ponies with normal carpi had osteochondral defects (mean dimensions 2.4 cm x 0.9 cm) created arthroscopically on the dorsal aspect of the distal articular surface of the radial carpal bone. The ponies were randomized (while balancing for age [range, 2 to 15 years; median, 5.0 years]) to two groups--nine ponies were exercised and nine were stall confined. Beginning at surgery, six ponies in each group received five weekly intra-articular injections of PSGAG (250 mg) in one joint and lactated Ringer's solution in the contralateral joint; the remaining three ponies in each group received lactated Ringer's solution in both joints. The incremental exercise schedule on a circular, rotating walker was begun six days after surgery and occurred twice daily, reaching a maximum of 0.7 miles of walking and 2.7 miles of trotting by the third postoperative month. The effects of treatment on the joint tissues were determined by weekly lameness examinations and measurement of the range of carpal joint motion, carpal radiographs at six and 17 weeks after surgery, synovial fluid analysis, and cytologic evaluation of alcohol-fixed synovial fluid specimens at weeks 1 through 4 and week 17, and histology of the synovial membrane. Ultrasound images of the carpi were acquired before operation and at weeks 1, 2, 4, 8, 10, 13, and 17. Ponies were euthanatized 17 weeks after surgery. Exercise, without medication, caused more lameness throughout the study compared with no exercise. Exercised, nonmedicated ponies had the greatest limitation to carpal flexion (more painful joints), and nonexercised, nonmedicated (control) ponies had the least limitation to flexion. Radiographic scores indicated that the exercised, nonmedicated ponies had significantly (p < .05) more signs of osteoarthritis than exercised, medicated and control ponies. Ultrasonographic measurements indicated that exercise, without medication, caused the greatest increase in combined measurement of the joint capsule thickness and synovial fluid accumulation at all postoperative times. Synovial lining cell numbers in the synovial fluid from exercised ponies were significantly (p < .05) higher than in nonexercised ponies at week 1, and this trend continued at weeks 4 and 17 (p < .1). There were significantly (p < .05) more morphologic abnormalities in the synovial lining cells from exercised than from nonexercised ponies at week 17. Medication with PSGAG enabled exercised carpal joints to be flexed significantly further from weeks 2 through 6 compared with nonmedicated joints.(ABSTRACT TRUNCATED AT 400 WORDS)

Ultrasonography for diagnosis of slipped capital femoral epiphysis. Comparison with radiography in 9 cases

In 7 of 8 patients with non-acute slipped capital femoral epiphysis, the slip was visualized by ultrasound. The mean epiphyseal displacement was 6.0 mm, measured on an anterior ultrasound scan. Grading of slip severity by ultrasound was consistent with the radiographic assessment. Two patients had a moderate hip joint effusion which did not affect the final outcome, whereas one patient with an acute slip had a pronounced effusion, and necrosis of the epiphysis occurred. The anteversion angles of the affected hips were reduced as compared to those of the normal hips. It was concluded that ultrasonography was reliable in detecting pronounced and mild degrees of epiphyseal slips, whereas minimal slips could be missed. The detection of hip effusion is important because a tamponade may cause vascular impairment of the epiphysis, unless aspirated.

Ultrasonography of the painful hip. Prospective studies in 204 patients

A total number of 204 patients presenting with an acutely or subacutely painful hip joint were investigated in two prospective studies. Intraarticular fluid collections were detected in 104 patients. The joint effusions showed different echopatterns depending on etiology and duration of disease. Additional diagnostic criteria such as synovial hypertrophy and thickening of the articular capsule allowed the distinction between transient synovitis and septic arthritis. Bony changes were encountered in 40 patients with osteomyelitis, slipping femoral epiphysis or Perthes-Calvé disease. Ultrasonography is recommended as method of choice in detecting, excluding and differentiating of joint effusions.