Journal of Pediatric Orthopaedics - 2026-09-17 - Journal Article
International Delphi Consensus on the Diagnosis and Management of Septic Arthritis of the Hip in Prewalking Children.
Shah H, Belthur MV, Ranade A, Ganjwala D, Agarwal A, Monsell F, Carpenter C, Thacker MM, Malone J, Crawford H, Chand S, Sampath JS, Eastwood D, Wijayasinghe S, Sanghrajka A, Singh KA, Marangoz S, Khot A, Hamdy R, Bhaskar A, Gopinathan NR, Gahukamble A, Gupta P, Sheth B, Challawar N, Chandankere V, Tennakoon D, Fernandes JA, Horn A, Baar Z A, Rabbi Q, Shrestha A, Alam Q
Topics
Key Takeaway
An international Delphi panel of 32 pediatric orthopaedic surgeons from 12 countries reached consensus on 15 of 20 statements, establishing open anterior arthrotomy as the preferred approach and antibiotic duration ≤4 weeks for isolated septic hip arthritis in prewalking children.
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Summary
This modified Delphi study sought expert consensus on diagnosis and management of septic hip arthritis in prewalking children, using 20 statements evaluated by 32 fellowship-trained pediatric orthopaedic surgeons across two rounds with consensus defined as ≥70% agreement. Fifteen of 20 statements reached consensus, endorsing pseudoparalysis with pain on passive movement as the primary clinical sign, open anterior arthrotomy as the preferred surgical approach, antibiotic duration ≤4 weeks for isolated septic arthritis, and minimum 2-year follow-up. Five statements failed consensus, including the role of routine ultrasound, synovial fluid analysis thresholds, and postoperative care protocols.
Key Limitation
Five statements—including the role of routine ultrasound and synovial fluid WBC thresholds—failed to reach consensus, leaving the most operationally critical diagnostic decision points unresolved.
Original Abstract
BACKGROUND
Septic arthritis of the hip in infants and prewalking children is a surgical emergency that can lead to rapid joint destruction and long-term sequelae. Despite its urgency, diagnostic and management practices vary considerably, and high-quality comparative evidence remains limited. This study aimed to develop expert consensus on the key principles of diagnosis and management using a modified Delphi methodology.
METHODS
A working group of 3 pediatric orthopaedic surgeons developed 20 statements addressing clinical diagnosis, imaging, medical and surgical management, postoperative care, and follow-up. Forty-five fellowship-trained pediatric orthopaedic surgeons from 12 countries, including 15 from high-resource and 30 from low-resource countries, were invited to participate. Thirty-five completed round 1, and 32 completed round 2. Consensus was defined a priori as ≥70% agreement. Statements that did not reach consensus were revised and redistributed in round 2.
RESULTS
Eight statements reached consensus in round 1, including universal laboratory testing, avoidance of antibiotic-only treatment, preference for anterior arthrotomy, and early surgical decompression. Twelve statements were revised for round 2, of which 7 subsequently achieved consensus. The final consensus emphasized: (1) pseudoparalysis with pain on passive movement as the most important clinical sign; (2) selective but important use of MRI in cases of diagnostic uncertainty or suspected osteomyelitis; (3) open anterior arthrotomy as the preferred surgical approach; (4) immobilization only for unstable hips; (5) an antibiotic duration of ≤4 weeks for isolated septic arthritis; and (6) a minimum follow-up of 2 years. Five statements did not reach consensus.
CONCLUSION
This international Delphi study provides expert-derived recommendations for the diagnosis and management of septic arthritis of the hip in prewalking children. These consensus statements offer a practical framework for clinical decision-making and identify key areas requiring further research, including the role of routine ultrasound, synovial fluid analysis, and postoperative care.
LEVEL OF EVIDENCE
Level V (expert opinion/consensus statement).