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The diagnosis and treatment of septic hip with osteonecrosis of the femoral head

Journal of Orthopaedic Surgery and Research volume 19, Article number: 46 (2024) Cite this article

Abstract

This article aims to provide clinical doctors with references for the diagnosis and treatment of osteonecrosis of the femoral head (ONFH) accompanied with septic hip by summarizing and analyzing clinical data and postoperative follow-up information of patients treated with two-stage arthroplasty. We retrospectively analyzed ten patients who underwent two-stage arthroplasty in our hospital due to ONFH accompanied with septic hip. The diagnosis of septic hip includes erythrocyte sedimentation rate (ESR) > 30 mm/h, C-reactive protein (CRP) > 10 mg/L, pus-like synovial fluid, positive microbiological culture, and the findings of septic arthritis on magnetic resonance imaging (MRI) scan. Patient's information was evaluated based on the review of medical records, including gender, age, symptoms, risk factor of ONFH and septic arthritis, blood test, radiograph, MRI scan, microbiological culture, treatment, follow-up period and outcome. A total of ten patients were diagnosed with ONFH accompanied with septic hip. The average follow-up period was 43.5 months. None of the patients experienced failure during the follow-up period. The risk factor of ONFH was alcohol-related (60%), steroid-related (20%) and idiopathic (20%). Nine patients (90%) have no risk factor of septic arthritis and one patient (10%) has nephrotic syndrome. All patients did not experience any fever symptoms before surgery, but all showed worsening symptoms of pain. There were three patients (30%) with abnormal WBC count > 10 × 109/L. All patients had elevated ESR and/or CPR. Nine patients (90%) had positive MRI findings, and seven patients (70%) had positive microbiological culture. When patients with ONFH experience worsening hip joint pain accompanied by unexplained elevated CRP and/or ESR, it should be suspected whether ONFH is accompanied with septic hip. In these cases, MRI scans should be performed to exclude septic hip. Patients with ONFH accompanied with septic hip showed satisfactory results after two-stage arthroplasty.

Introduction

Osteonecrosis of the femoral head (ONFH) is a debilitating and potentially devastating condition that affects patients' quality of life, causing pain and dysfunction in walking [1]. It has a poorly understood pathogenesis and wide-ranging aetiologies [2]. Total hip arthroplasty (THA) is the most reliable treatment method for reducing pain and restoring mobility in end-stage of ONFH [3]. However, while improving patients' quality of life, it can also lead to the occurrence of complications [4].

Periprosthetic joint infection (PJI) is one of the most serious complications of THA [5]. Among the various treatment options, the most commonly used way in the USA and many other countries is known as two-stage arthroplasty [6,7,8]. It involves removing the prosthesis and all foreign materials, followed by a delayed implantation of a new prosthesis. PJI not only significantly jeopardizes the patient's well-being but also imposes a substantial financial burden on them [9, 10]. Consequently, many researchers have focused their attention on THA and its postoperative complications, but have tended to overlook a critical problem: ONFH accompanied with septic hip.

Septic hip is rare in patients with ONFH. Clinical symptoms of these patients usually are hidden and specific diagnostic indicators are scarce, so surgeons may overlook these patients [11, 12]. However, if THA is performed on patients with ONFH accompanied with septic hip, PJI is inevitable and will be a devastating disaster for the patient. To date, there have been few reports on septic hip in patients with ONFH. This article aims to provide clinical doctors with references for the diagnosis and treatment of ONFH accompanied with septic hip by summarizing and analyzing clinical data and postoperative follow-up information of patients who were treated with two-stage arthroplasty.

Materials and method

This is a retrospective study that included 10 patients who underwent two-stage arthroplasty in our hospital from July 2015 to October 2021 due to ONFH accompanied with septic hip. After admission screening, all patients had no other site infections. This study has been approved by the institutional review board and obtained written informed consent from all patients. Two senior surgeons performed two-stage arthroplasty for 10 patients. After admission, blood tests, ESR, and CRP were collected from all patients. Prior to the surgery, X-ray and magnetic resonance imaging (MRI) scans were conducted. Patients' information was evaluated based on the review of medical records, including gender, age, symptoms, risk factors of ONFH and septic arthritis.

In this study, the diagnosis of septic hip includes ESR > 30 mm/h, CRP > 10 mg/L, pus-like synovial fluid (Fig. 1), positive microbiological culture, the findings of septic arthritis on MRI scans (Fig. 2). MRI findings that were considered as positive for septic arthritis included an increase of joint effusion, presence of synovial thickening, alterations in signal intensity of bone marrow of both proximal femur and acetabulum and soft tissue around the hip joint with strong enhancement [13].

Fig. 1
figure 1

During the surgery, pus-like fluid gushed out from the hip joint

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Fig. 2
figure 2

A 67-year-old male patient suffered from ONFH accompanied with septic hip (case 6). A The initial radiograph revealing the collapse of femoral head and narrowing of joint space. B MRI shows a large amount of effusion and synovial thickening of the hip

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All patients underwent a standard two-stage arthroplasty (Fig. 3). The first stage includes removal of the femoral head, and aspiration of synovial fluid for pathogenic culture. At least three surrounding deep tissues were sent for histological analysis and a radical debridement was performed on the affected joint. An antibiotic-loaded articular bone cement spacer, containing 2 g of vancomycin and 0.5 g of gentamicin per 40 g bone cement (Refobacin® Bone Cement R, Zimmer Biomet), was then inserted. Patients received 2 weeks of intravenous antibiotics plus 4 weeks of oral antibiotics. Antibiotics were selected and used according to the drug susceptibility results of pathogen culture and the opinions of infectious disease specialists. Regular monitoring of inflammatory markers was conducted during antibiotic treatment. Afterwards, use of antibiotics was suspended for at least 6 weeks. Patients were regularly tested for clinical and inflammatory indicators, and if necessary, aspiration of synovial fluid was performed for culture. Reimplantation will not be considered feasible until the patient has no clinical signs of infection, the surgical wound has healed up, and the ESR and CRP are gradually decreasing. The second stage included removal of the cement spacer, aspiration of synovial fluid for pathogenic culture, sending periprosthetic tissues for histological analyses, debridement and irrigation once again, and then implant the prosthesis. Intravenous antibiotics were routinely administered postoperatively, and drug was discontinued when the intraoperative culture results turned negative. After discharge, patients were routinely followed up in outpatient clinics, and ESR, CRP and X-ray were performed according to each patient's condition. When patients need revision surgery for various reasons, it is considered a failure of the surgery.

Fig. 3
figure 3

Standard two-stage arthroplasty (case 6). A Radiograph after an antibiotic-loaded cement spacer inserted. B Radiograph after two-stage arthroplasty

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The classification schemes for ONFH of Ficat were evaluated twice, once by the specially trained surgeon and once by a blinded surgeon [14]. The intraclass correlation coefficient was measured to be > 0.8, indicating good reproducibility.

Results

Previous studies included a total of 34 patients with ONFH accompanied with septic hip (Table 1). In this study, a total of ten patients (six males and four females) were diagnosed with ONFH accompanied with septic hip. According to the Ficat staging criteria for ONFH, nine patients (90%) were in Ficat stage IV and one patient (10%) was in Ficat stage III. The average age was 67.5 years (55–76), and the average follow-up period was 43.5 months (22–91). None of the patients experienced any failure during the follow-up period. The risk factor of ONFH were alcohol-related (60%), steroid-related (20%) and idiopathic (20%). Nine patients (90%) have no risk factor of septic arthritis and one patient (10%) has nephrotic syndrome. All patients did not experience any fever symptoms before surgery, but all showed worsening symptoms of hip joint pain. There were three patients (30%) with an abnormal WBC count > 10 × 109/L, eight patients (80%) with ESR > 30 mm/L, and nine patients (90%) with CPR > 10 mg/L. All patients had elevated ESR and/or CPR. Nine patients (90%) had positive MRI findings, and seven patients (70%) had positive microbiological culture (Table 2).

Table 1 Previously reported 34 patients with ONFH accompanied with septic hip
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Table 2 Patients with ONFH accompanied with septic hip in this study
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Discussion

Septic hip usually occurs in children, while in adults it is more common in patients with autoimmune diseases [15, 16]. Patients with ONFH accompanied with septic hip are rare. The possible reason is that the necrotic tissue in the femoral head provides a favorable environment for bacterial proliferation, leading to the occurrence of infections. The clinical symptoms of patients with ONFH accompanied with septic hip are usually hidden. Such patients often have a history of alcoholism, systemic lupus erythematosus (SLE), steroid therapy, and varying degrees of immune function suppression [17]. There is also a lack of specific diagnostic indicators for diagnosis. Once such patients are misdiagnosed, they are prone to PJI after undergoing THA. Therefore, it is necessary to conduct various examinations to exclude septic hip in patients with ONFH after admission.

Patients with limited immune function have a higher risk of ONFH accompanied with septic hip. Previous studies reported a total of 34 patients with ONFH accompanied with septic hip, of which 12 patients (35.3%) had limited immune function or risk factors of septic arthritis, and 22 patients (64.7%) had normal immune function [11, 12, 17,18,19,20,21,22,23]. In our study, only 2 patients (20%) required steroid therapy due to nephrotic syndrome, while the remaining 8 patients (80%) had normal immune function. This study shows that patients without risk factors of septic arthritis and limited immune function, as well as those with immune deficiency diseases and receiving steroid therapy, are prone to ONFH accompanied with septic hip. The possible reason is that steroid therapy and other immunosuppressants weaken the body's immune function, increasing the risk of infection for patients [24]. In addition, when the body experiences infection or inflammation, alcohol can inhibit the function of polymorphoneutrophil and their ability to clear pathogens [25, 26].

WBC, ESR, and CPR are routine tests before total joint arthroplasty and are also one of the criteria for diagnosing PJI [27, 28]. Lee and Kim et al. [11, 12, 23] reported a total of 21 patients with ONFH accompanied with septic hip, all of whom had elevated ESR and/or CPR. ESR > 30 mm/h and CRP > 10 mg/L were used as one of the diagnostic criteria in this study. Nine patients (90%) met the criterion, and although one patient (10%) did not meet this criterion, ESR and CPR were abnormally increased. Only three patients (30%) had elevated WBC. In addition, from July 2015 to October 2021, we performed THA on 4 patients with significantly elevated ESR and CPR for ONFH (Table 3). All patients had normal WBC, negative MRI findings and microbiological culture. The average follow-up period was 61.5 months (19–90), and none of them had undergone revision surgery for any reason. This study shows that WBC has poor diagnostic ability for septic hip, while ESR and CPR show high specificity. Patients with normal ESR and CPR can rule out the possibility of septic hip, while patients with elevated ESR and CPR need further examination to exclude septic hip.

Table 3 Patients with elevated ESR and CPR for ONFH
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The first imaging modality of an infected joint should be a radiograph. Radiographic abnormalities, which include soft tissue swelling, joint space loss, periarticular osteopenia, and central or marginal osseous erosions, may be delayed following clinical onset of infection [29, 30]. In this study, nine patients (90%) were in Ficat stage IV and one patient (10%) was in Ficat stage III. Therefore, we propose a hypothesis that patients with ONFH of Ficat stage IV are more likely to be accompanied by septic hip. Other imaging modalities are more sensitive and specific than plain radiographs for detecting inflammation or effusions especially early in the disease process. MRI has high sensitivity for the diagnosis of musculoskeletal infection and also delineates with detail the extent of the osseous and soft tissue involvement [31]. Hopkins et al. [32] found that MRI with IV gadolinium had a sensitivity of 100% and specificity of 77%. The findings seen on MRI in the setting of septic arthritis include joint effusion, destruction of cartilage, and the presence of cellulitis in the soft tissues surrounding the joint in question [31]. Karchevsky et al. [13] reported that synovial enhancement, peri-synovial edema, and joint effusion had the best correlation with the presence of a septic joint. Galindo, Lee, and Kim et al. [11, 12, 18, 23] reported a total of 24 patients with ONFH accompanied with septic hip. Among them, 22 patients (91.7%) showed positive MRI findings, and 2 patients did not undergo MRI scan before surgery. In this study, 9 patients (90%) showed positive MRI findings. We believe that MRI is a valuable diagnostic tool in ONFH accompanied with septic hip. The information provided may be useful for patient management and preoperative planning.

Microbiological culture can not only detect the presence of infection but also provide information on drug sensitivity and drug resistance [33]. However, one particular problem is that surgeons may lack accessible synovial fluid, or a “dry tap,” when diagnostic aspiration is performed. Microbiological culture cannot be performed using common methods before surgery in these patients. Saline solution lavage and reaspiration for culture in patients with insufficient synovial fluid before surgery may be a sound practice [34]. However, the 2018 ICM recommended that clinicians should avoid the practice of saline lavage aspiration because it has a dilution effect on synovial fluid tests and causing artificially reduced sensitivity [35]. In this study, we did not perform synovial fluid aspiration on patients before surgery. All patients underwent intraoperative joint fluid microbiological culture, and 7 patients (70%) showed positive culture. Previous studies reported 20 patients, of which 14 patients (70%) were positive for bacterial culture. The low positive rate may be attributed to some patients having received antibiotic treatment before admission, delayed testing, and insufficient microbiological culture time.

Multiple studies have shown that two-stage arthroplasty is not only an effective method for treating PJI, but also a reliable solution for treating septic arthritis. In this study, we performed two-stage arthroplasty on 10 patients with ONFH accompanied with septic hip. During an average follow-up period of 43.5 months, all patients showed no evidence of recurrent infection and did not underwent revision surgery for any reason. In a retrospective study, Lee et al. [12] performed two-stage arthroplasty on 14 patients with ONFH accompanied with septic hip. During a follow-up period of 1–7 years, all patients showed no signs of infection. Diwanji et al. [36] performed two-stage arthroplasty on 9 patients with septic hip, with an average follow-up period of 42 months. It was found that Two-stage reconstruction using an antibiotic-loaded cement spacer was found to give satisfactory results for the treatment of hip infections with various etiologies. Additionally, ONFH accompanied with septic hip can also be treated by arthroscopic surgery. Kim et al. [23] described the technique and clinical outcome of minimally invasive arthroscopic resection arthroplasty for septic hip arthritis concomitant with ONFH. During the follow-up period, there was no recurrence of infection. One patient underwent THA at 18 months after surgery, but the postoperative condition of THA was not recorded. Lee et al. [11] performed arthroscopic surgery on 5 patients with ONFH accompanied with septic hip. During the follow-up period, there were no recurrent infections. Two patients underwent THA at 5 and 10 months postoperatively, respectively. One patient had no recurrent infections at 8 months after THA surgery, and another patient did not record the condition of THA. However, a coexistence of osteomyelitis with septic hip arthritis is regarded as a contraindication to arthroscopic treatment due to concerns of incomplete debridement of infected tissue and relapse of infection [37, 38]. In this study, patients with ONFH accompanied with septic hip showed satisfactory results after two-stage arthroplasty. However, there have been no research comparing the long-term effects of these two methods in treating ONFH accompanied with septic hip, and more research is needed to discuss in the future.

This study has some limitations. First, limited number of cases, which is related to the lower rate of ONFH accompanied with septic hip. Lee et al. [12] reported 1226 patients with ONFH, of which only 14 patients (1.1%) were accompanied with septic hip. Additionally, due to concerns about PJI, many surgeons did not perform THA on patients with elevated ESR and CRP, resulting in a lower detection rate for patients with ONFH accompanied with septic hip. Second, we could not compare the functional outcomes of both procedures because of a lack of the records regarding postoperative function scores. Finally, the MRI exams were not independently reviewed by at least two radiologists to reach a consensus on the diagnostic findings and there might be some variability in identified the extent of the infections.

Conclusion

When patients with ONFH experience worsening hip joint pain accompanied by unexplained elevated CRP and/or ESR, it should be suspected whether ONFH is accompanied with septic hip. In these cases, MRI scans should be performed to exclude the possibility of septic hip. Due to the low positive rate of microbiological culture, we suggest treating as ONFH accompanied with septic hip when ESR and CRP significantly increase and MRI indicates infection, even if microbiological culture is negative.

Abbreviations

ONFH:

Osteonecrosis of the femoral head

ESR:

Erythrocyte sedimentation rate

CRP:

C-reactive protein

MRI:

Magnetic resonance imaging

THA:

Total hip arthroplasty

PJI:

Periprosthetic joint infection

SLE:

Systemic lupus erythematosus

References

  1. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77(3):459–74. https://doi.org/10.2106/00004623-199503000-00018.

    Article  PubMed  CAS  Google Scholar 

  2. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am. 2006;88(5):1117–32. https://doi.org/10.2106/jbjs.E.01041.

    Article  PubMed  Google Scholar 

  3. Sodhi N, Acuna A, Etcheson J, Mohamed N, Davila I, Ehiorobo JO, et al. Management of osteonecrosis of the femoral head. Bone Joint J. 2020;102:122–8. https://doi.org/10.1302/0301-620x.102b7.Bjj-2019-1611.R1.

    Article  PubMed  Google Scholar 

  4. Kurtz SOK, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5. https://doi.org/10.2106/JBJS.F.00222.

    Article  PubMed  Google Scholar 

  5. Petis SMAM, Perry KI, Mabry TM, Hanssen AD, Berry DJ. Long-term results of a 2-stage exchange protocol for periprosthetic joint infection following total hip arthroplasty in 164 hips. J Bone Joint Surg Am. 2019;101(1):74–84. https://doi.org/10.2106/JBJS.17.01103.

    Article  PubMed  Google Scholar 

  6. Khan NPD, Ibrahim MS, Kayani B, Haddad FS. Outcomes of repeat two-stage exchange hip arthroplasty for prosthetic joint infection. Bone Joint J. 2019;101:110–5. https://doi.org/10.1302/0301-620X.101B6.

    Article  PubMed  Google Scholar 

  7. Fehring TKOS, Struble S, Fehring K, Griffin WL, Mason JB. Hip instability in 2-stage reimplantation without an articulating spacer. J Arthroplast. 2007;22:156–61. https://doi.org/10.1016/j.arth.2007.03.028.

    Article  Google Scholar 

  8. Cooper HJDVC. The two-stage standard in revision total hip replacemen. Bone Joint J. 2013;95:84–7. https://doi.org/10.1302/0301-620X.95B11.

    Article  PubMed  Google Scholar 

  9. Białecki JKM, Chaberek S, Bartosz P, Obrębski M, Marczyński W, Para M. Two-stage revision arthroplasty in the treatment of periprosthetic hip infections with severe bone loss: Results from 182 cases. Orthop Rev (Pavia). 2020;12(2):8545. https://doi.org/10.4081/or.2020.8545.

    Article  PubMed  Google Scholar 

  10. Chen SYHC, Chen CC, Chang YH, Hsieh PH. Two-stage revision arthroplasty for periprosthetic hip infection: mean follow-up of ten years. Biomed Res Int. 2015;2015:345475. https://doi.org/10.1155/2015/345475.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Lee YK, Lee YJ, Ha YC, Kim KC, Koo KH. Septic arthritis of the hip in patients with femoral head osteonecrosis. Arch Orthop Trauma Surg. 2011;131(11):1585–90. https://doi.org/10.1007/s00402-011-1334-1.

    Article  PubMed  Google Scholar 

  12. Lee YK, Won S, Yeom J, Park JW, Lim SM, Im JW, et al. Concomitant septic arthritis of the hip in patients with osteonecrosis of the femoral head. Surg Technol Int. 2019;35:402–5.

    PubMed  Google Scholar 

  13. Karchevsky M, Schweitzer ME, Morrison WB, Parellada JA. MRI findings of septic arthritis and associated osteomyelitis in adults. AJR Am J Roentgenol. 2004;182(1):119–22. https://doi.org/10.2214/ajr.182.1.1820119.

    Article  PubMed  Google Scholar 

  14. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br. 1985;67(1):3–9. https://doi.org/10.1302/0301-620x.67b1.3155745.

    Article  PubMed  CAS  Google Scholar 

  15. Mitchell M, Howard B, Haller J, Sartoris DJ, Resnick D. Septic arthritis. Radiol Clin North Am. 1988;26(6):1295–313.

    Article  PubMed  CAS  Google Scholar 

  16. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478–88. https://doi.org/10.1001/jama.297.13.1478.

    Article  PubMed  CAS  Google Scholar 

  17. Shiota K, Miki F, Kanayama Y, Kohno M, Ohe A, Takamatsu K, et al. Suppurative coxitis due to Salmonella typhimurium in systemic lupus erythematosus. Ann Rheumatic Dis. 1981;40(3):312–4. https://doi.org/10.1136/ard.40.3.312.

    Article  CAS  Google Scholar 

  18. Galindo M, Mateo I, Pablos JL. Multiple avascular necrosis of bone and polyarticular septic arthritis in patients with systemic lupus erythematosus. Rheumatol Int. 2005;25(1):72–6. https://doi.org/10.1007/s00296-004-0444-2.

    Article  PubMed  Google Scholar 

  19. Ostrum RF. Nocardia septic arthritis of the hip with associated avascular necrosis. A case report. Clin Orthopaed Rel Res. 1993;288:282–6.

    Article  Google Scholar 

  20. Nuovo MA, Sissons HA, Zuckerman JD. Case report 662: Bilateral avascular necrosis of femur, with supervening suppurative arthritis of right hip. Skelet Radiol. 1991;20(3):217–21. https://doi.org/10.1007/bf00241674.

    Article  CAS  Google Scholar 

  21. Phillips FM, Pottenger LA. Acute septic arthritis in chronic osteonecrosis of the hip. J Rheumatol. 1988;15(11):1713–6.

    PubMed  CAS  Google Scholar 

  22. Habermann ET, Friedenthal RB. Septic arthritis associated with avascular necrosis of the femoral head. Clin Orthop Relat Res. 1978;134:325–31.

    Google Scholar 

  23. Kim JT, Kim HY, Kim CH, Park JI, Aditya K, Kim HY, et al. Arthroscopic resection arthroplasty for septic hip with osteonecrosis of the femoral head in patients with multiple comorbidities: a report of two cases. J Orthopaed Sci. 2021;26(1):186–9. https://doi.org/10.1016/j.jos.2018.05.012.

    Article  Google Scholar 

  24. Füessl HS. Hip pain in long-term steroid therapy. Septic arthritis. MMW Fortschr Med. 1999;141(39):49–50.

    PubMed  Google Scholar 

  25. Zhang P, Bagby GJ, Happel KI, Raasch CE, Nelson S. Alcohol abuse, immunosuppression, and pulmonary infection. Curr Drug Abuse Rev. 2008;1(1):56–67. https://doi.org/10.2174/1874473710801010056.

    Article  PubMed  CAS  Google Scholar 

  26. Lister PD, Gentry MJ, Preheim LC. Ethanol impairs neutrophil chemotaxis in vitro but not adherence or recruitment to lungs of rats with experimental pneumococcal pneumonia. J Infect Dis. 1993;167(5):1131–7. https://doi.org/10.1093/infdis/167.5.1131.

    Article  PubMed  CAS  Google Scholar 

  27. Alijanipour PBH, Parvizi J. Diagnosis of periprosthetic joint infection: the threshold for serological markers. Clin Orthopaed Rel Res. 2013;471(10):3186–95. https://doi.org/10.1007/s11999-013-3070-z.

    Article  Google Scholar 

  28. Bauer TW BH, Creech JD, Deirmengian C, Eriksson H, Fillingham Y, Grigoryan G, Hickok N, Krenn V, Krenn V, Lazarinis S, Lidgren L, Lonner J, Odum S, Shah J, Shahi A, Shohat N, Tarabichi M, W-Dahl A, Wongworawat MD (2019) Hip and Knee Section, Diagnosis, Laboratory Tests: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019;34(2S):S351–S359. https://doi.org/10.1016/j.arth.2018.09.019

  29. Mohana-Borges AV, Chung CB, Resnick D. Monoarticular arthritis. Radiol Clin North Am. 2004;42(1):135–49. https://doi.org/10.1016/s0033-8389(03)00168-4.

    Article  PubMed  Google Scholar 

  30. Christian S, Kraas J, Conway WF. Musculoskeletal infections. Semin Roentgenol. 2007;42(2):92–101. https://doi.org/10.1053/j.ro.2006.08.011.

    Article  PubMed  Google Scholar 

  31. Zalavras CG, Rigopoulos N, Lee J, Learch T, Patzakis MJ. Magnetic resonance imaging findings in hematogenous osteomyelitis of the hip in adults. Clin Orthopaed Rel Res. 2009;467(7):1688–92. https://doi.org/10.1007/s11999-009-0763-4.

    Article  Google Scholar 

  32. Hopkins KL, Li KC, Bergman G. Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes. Skelet Radiol. 1995;24(5):325–30. https://doi.org/10.1007/bf00197059.

    Article  CAS  Google Scholar 

  33. Deirmengian C, Feeley S, Kazarian GS, Kardos K. Synovial fluid aspirates diluted with saline or blood reduce the sensitivity of traditional and contemporary synovial fluid biomarkers. Clin Orthopaed Rel Res. 2020;478(8):1805–13. https://doi.org/10.1097/corr.0000000000001188.

    Article  Google Scholar 

  34. Li R, Lu Q, Chai W, Hao LB, Lu SB, Chen JY. Saline solution lavage and reaspiration for culture with a blood culture system is a feasible method for diagnosing periprosthetic joint infection in patients with insufficient synovial fluid. J Bone Joint Surg Am. 2019;101(11):1004–9. https://doi.org/10.2106/jbjs.18.01052.

    Article  PubMed  Google Scholar 

  35. Abdel Karim M, Andrawis J, Bengoa F, Bracho C, Compagnoni R, Cross M, et al. Hip and knee section, diagnosis, algorithm: proceedings of international consensus on orthopedic infections. J Arthroplasty. 2019;34:S339-S350. https://doi.org/10.1016/j.arth.2018.09.018

  36. Diwanji SR, Kong IK, Park YH, Cho SG, Song EK, Yoon TR. Two-stage reconstruction of infected hip joints. J Arthroplast. 2008;23(5):656–61. https://doi.org/10.1016/j.arth.2007.06.007.

    Article  Google Scholar 

  37. Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. 1943. Clin Orthopaed Rel Res. 2008;466(2):258–63. https://doi.org/10.1007/s11999-007-0082-6.

    Article  CAS  Google Scholar 

  38. Givon U, Ganel A. Re: Treatment of early septic arthritis of the hip in children: comparison of results of open arthrotomy versus arthroscopic drainage. J Children’s Orthopaed. 2008;2(6):499. https://doi.org/10.1007/s11832-008-0138-5.

    Article  Google Scholar 

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Funding

This work was supported by the grants from the Shandong Provincial Natural Science Foundation, China [Grant No. ZR2021MH090] and supported by Qingdao Outstanding Health Professional Development Fund.

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  1. Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China

    MingYang Li, ZhenShuai Shao, HaoXiang Zhu & YongTao Zhang

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Contributions

ML: wrote the paper. YZ as designers of the study. ZS and HZ for acquisition, analysis and interpretation of data. ML and YZ as revisors of the study. All authors have read and approved the manuscript.

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Correspondence to YongTao Zhang.

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Li, M., Shao, Z., Zhu, H. et al. The diagnosis and treatment of septic hip with osteonecrosis of the femoral head. J Orthop Surg Res 19, 46 (2024). https://doi.org/10.1186/s13018-023-04518-6

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  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13018-023-04518-6

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X