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Investigating the prevalence of the concomitant osteomyelitis in pediatric hip septic arthritis: a systematic review and Meta-analysis

Journal of Orthopaedic Surgery and Research volume 20, Article number: 196 (2025) Cite this article

Abstract

Background

Paediatric hip septic arthritis is a critical condition that requires prompt surgical intervention. It may occur as an isolated issue or alongside concomitant osteomyelitis, which heightens the risk of secondary surgeries and can lead to conversion to Choi IV after the initial arthrotomy. Accurately assessing the prevalence of concomitant osteomyelitis in these patients is vital. However, existing literature reveals significant variability in prevalence estimates. This review aims to clarify the occurrence of concomitant osteomyelitis in paediatric hip septic arthritis.

Methods

This study was executed in alignment with PRISMA guidelines and has been registered with PROSPERO. A meticulous search was carried out across the PubMed, Embase, and Cochrane Library databases until September 2024 to identify relevant literature. The criteria for inclusion involved studies diagnosed with paediatric hip septic arthritis, aged 18 years or younger, with at least five documented cases. To derive pooled prevalence rates from the collected data, we utilized a random-effects meta-analysis approach. The quality of the selected studies was evaluated using the Joanna Briggs Institute’s assessment checklist, ensuring a comprehensive appraisal of methodological integrity. Additionally, to explore potential sources of variability among the studies, sensitivity analyses were performed via the leave-one-out method. Subgroup analyses were also conducted focusing on three significant factors: age, geographical region, and overall study quality.

Results

A total of 21 studies were incorporated into the final analysis, which included 684 paediatric cases of septic arthritis of the hip. The meta-analysis produced a pooled prevalence estimate of concomitant osteomyelitis in this population at 33.2% (95% CI: 27.3–39.8). Notably, significant heterogeneity was identified among the studies (I² = 59.414%; P < 0.001). Furthermore, statistically significant differences were observed based on continent (Europe, Asia, or America) (P = 0.008) and study quality (High or Fair) (P = 0.003).

Conclusion

This systematic review and meta-analysis identifies a pooled prevalence of concomitant osteomyelitis in paediatric hip septic arthritis at 31.8–34.5%, employing rigorous methodologies such as sensitivity analyses and stratified assessments that enhance the reliability of the findings despite limitations like small sample sizes and exclusion of non-English studies. These insights are essential for guiding future research and informing treatment strategies, ultimately supporting clinicians in making informed decisions to improve patient care in paediatric orthopedics.

Introduction

Paediatric hip septic arthritis is a critical condition marked by microbial invasion within the joint space, with an incidence of 5 to 12 cases per 100,000 children [1]. As an orthopedic emergency, it requires immediate and precise diagnosis alongside effective treatment to ensure optimal long-term outcomes and mitigate complications such as chondrolysis, osteonecrosis, and systemic sepsis, all of which may result in lasting disabilities [2, 3]. Therefore, medical consensus dictates that septic arthritis in paediatric patients should be surgically drained without delay. Ultrasound or fluoroscopy-guided hip aspiration is the preferred approach for confirming the diagnosis when there is suspicion of septic arthritis [4, 5]. Subsequently, performing a hip arthrotomy for debridement and lavage has become the established standard treatment for this condition [6, 7].

While paediatric hip septic arthritis can occur independently, it often coexists with osteomyelitis. Research conducted by Murphy et al. [8] indicates that the presence of concomitant osteomyelitis increases the risk of requiring secondary surgeries after the initial arthrotomy. Moreover, Agarwal [9] observed that concurrent femoral osteomyelitis correlates with progression to Choi IV classification post-arthrotomy in cases of paediatric hip septic arthritis. Understanding the prevalence of concomitant osteomyelitis in these patients is essential, as it equips both parents and orthopedic surgeons to make informed decisions regarding surgical procedures, ultimately reducing suffering and adverse outcomes.

However, the reported prevalence of concomitant osteomyelitis in paediatric hip septic arthritis shows significant variability across studies, ranging from 12–75% [10,11,12]. Currently, no systematic review or meta-analysis has provided a comprehensive estimate of this prevalence in the affected population. Evidence derived from such analyses could offer valuable insights into the epidemiology of this condition. This review aims to analyze existing literature regarding the prevalence of concomitant osteomyelitis in paediatric hip septic arthritis, employing both qualitative and quantitative methodologies.

Methods

Research design and method

This research adhered rigorously to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We employed a systematic approach encompassing literature search, eligibility assessment, quality evaluation of studies, data extraction, and results analysis, all framed by a predetermined protocol. Furthermore, our study protocol received registration with the International Prospective Register of Systematic Reviews (PROSPERO) before any data was extracted, thereby promoting transparency and methodological integrity (Registration number: CRD42024585002).

Data source and selection process

In September 2024, searches were performed within the PubMed, Embase, and Cochrane Library databases. Our search strategy incorporated a combination of Medical Subject Headings (MeSH) terms and keywords, specifically targeting the following phrases: “hip septic arthritis”, “hip infectious arthritis”, “hip bacterial arthritis”, “hip suppurative arthritis” as well as “osteomyelitis”. Additionally, we included variations pertaining to age, such as “child”, “infant”, “newborn” and “paediatric”. To enhance our search for relevant studies, we also examined the reference lists of the selected eligible articles, allowing us to identify further studies that met our inclusion criteria. This comprehensive approach ensured a thorough exploration of the literature surrounding paediatric hip septic arthritis.

Eligibility criteria and study selection

This comprehensive review included studies that met specific and rigorous criteria: (i) the studies comprised children diagnosed with pediatric hip septic arthritis (Fig. 1), aged 18 years or younger, with at least five documented cases; (ii) the studies explicitly reported the prevalence of concomitant osteomyelitis in these pediatric patients or provided sufficient data for its calculation; and (iii) the publication was in English. Various types of publications were excluded from our analysis, including systematic reviews, commentaries, case reports, and research involving non-human subjects. Furthermore, items such as letters to the editor, conference abstracts, books, editorials, and notes were also omitted.

Fig. 1
figure 1

A MRI demonstrating concomitant septic arthritis (right arrow demonstrates effusion) with pelvis osteomyelitis (left arrow) in a 10-year-old male [13]. B1/B2 A 4-year-old boy presented with a 3-day history of right hip pain. A coronal T2WI (B1) and enhanced T1WI (B2) indicated contrast enhancement of the surrounding soft tissue. He was diagnosed with SA and Streptococcus was isolated in a culture study [14]. T1WI, T1-weighted image; T2WI, T2-weighted image, SA, septic arthritis

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Methods for data extraction and quality assessment

Data extraction from the selected studies was performed independently by two authors, who collected relevant information including the names of the first author(s), year of publication, total sample size, cases, prevalence estimates, mean age, and country of origin.

All search results were systematically aggregated and assessed for eligibility by the same two authors. In cases where disagreements arose concerning study inclusion, a third author facilitated discussions during a collaborative meeting with the screening authors, promoting an open dialogue until a consensus was reached. The initial screening involved a meticulous review of abstracts corresponding to each result. After this preliminary evaluation and the removal of duplicate entries, studies identified as potentially relevant underwent an exhaustive full-text review to verify their eligibility for inclusion.

To assess the quality of the final studies selected, we employed the Joanna Briggs Institute Quality Assessment Tool, which allows for a systematic appraisal of individual research using a frequency scale that categorizes responses as “yes”, “no”, “not clear” or “not applicable”. The overall quality score for each study was calculated by summing all affirmative responses to ensure a comprehensive evaluation.

Data synthesis and analysis

Statistical analyses in this study were conducted using Comprehensive Meta-Analysis Software, version 3.0. Prevalence rates from the individual studies were synthesized utilizing a random-effects meta-analysis model to account for variability [15]. To evaluate heterogeneity among the studies, we applied the I² statistic, interpreting values according to established thresholds: high heterogeneity is indicated by values over 75%, moderate heterogeneity by 50%, and low heterogeneity by 25% [16]. Further exploration of potential heterogeneity sources was conducted through sensitivity analyses using the leave-one-out method, allowing for the assessment of individual study impacts on overall results. Additionally, subgroup analyses were carried out based on three key factors: age, continent, and study quality. The risk of publication bias was assessed through Egger’s regression tests and visual inspection of funnel plots. Throughout all statistical analyses, a P-value threshold of 0.05 was maintained to establish statistical significance, thus ensuring the robustness and reliability of our findings.

Results

Identification of relevant studies

The initial literature search yielded a total of 630 studies. After removing 146 duplicate records, we conducted title and abstract screening, resulting in the exclusion of 431 records: 297 were eliminated based solely on titles, while 134 were excluded after reviewing abstracts due to their failure to meet our stringent inclusion criteria. This rigorous screening process culminated in 53 publications advancing to the full-text review stage. Ultimately, 21 of these publications were deemed appropriate and met the qualifications for inclusion in our systematic review and meta-analysis (Fig. 2).

Fig. 2
figure 2

PRISMA flowchart of the review search

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Characteristics of the included studies

The fundamental attributes of the studies included in this systematic review and meta-analysis are detailed in Table 1. A total of 21 articles [8,9,10,11,12, 17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32] were incorporated into the final analysis, collectively encompassing 684 cases of paediatric hip septic arthritis. These studies spanned an extensive period from 1976 to 2023. Sample sizes within the included studies varied markedly, ranging from as few as 8 paediatric cases [29] to as many as 138 [8]. The age distribution of the participants also exhibited diversity, four studies [9, 11, 24, 28] reported a mean age of less than 4 years, while thirteen studies [8, 10, 17,18,19,20,21,22, 25,26,27, 29, 31] indicated a mean age of 4 years or older. Notably, four studies [12, 23, 30, 32] did not specify the mean age of their participants. In terms of geographical distribution, the studies were primarily conducted in the USA, with 10 studies [8, 12, 19, 22, 23, 26, 27, 30,31,32] originating from this country. Additionally, there were two studies each from Turkey [20, 29], Germany [17, 25], and China [10, 11], three studies from India [9, 21, 28], and one study each from the UK [18] and South Korea [24].

Quality of the included studies

Table 2 provides a comprehensive analysis of the quality and potential biases present in the studies included in our review. This study defines a sample size greater than 30 as an appropriate sample frame. Out of the total studies analyzed, 9 (42.9%) [8, 10, 12, 17,18,19, 23, 24, 32] employed an adequate sample frame, which enabled a reliable determination of the prevalence of concomitant osteomyelitis in paediatric hip septic arthritis. Furthermore, around 8 studies (38.1%) [8, 12, 17,18,19, 23, 24, 32] received positive evaluations regarding their response rates, indicating a robust engagement with participants and data collection. Using the Joanna Briggs Institute’s quality evaluation checklist, the articles selected for final analysis exhibited a mean quality score of 6.9, with individual scores ranging from 4 to 9. Among these, 8 studies (38.1%) [8, 12, 17,18,19, 23, 24, 32] were classified as high-quality, each achieving a score of 6.9 or above, demonstrating their methodological rigor. The remaining studies [9,10,11, 20,21,22, 25,26,27,28,29,30,31], which scored between 4 and 6.9, were categorized as fair quality, suggesting that while they met some criteria, there were notable limitations that could affect the reliability of their findings. Among the studies classified as having fair quality, several criteria were generally lacking, including an inappropriate sample frame for the target populations, inadequate sample sizes, and a lack of information regarding the response rate adequacy. These trends underscore the necessity for improved methodological rigor in future research to enhance the validity of findings.

Table 1 The characteristics of the included studies
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Table 2 Quality of the included studies
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The prevalence of concomitant osteomyelitis in paediatric hip septic arthritis (metaanalysis)

The pooled prevalence estimate of concomitant osteomyelitis in paediatric hip septic arthritis was 33.2% (95% CI: 27.3–39.8). Significant heterogeneity was observed across the studies included in this analysis, with I2 = 59.414% and P < 0.001 (Fig. 3).

Fig. 3
figure 3

The prevalence of concomitant osteomyelitis in paediatric hip septic arthritis: A random effects meta-analysis (I2 = 59.414%; P < 0.001; based on a random effects model)

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Sensitivity analysis

To investigate the possible sources of variability among the studies included in our analysis, we utilized a sensitivity analysis employing the leave-one-out technique. The results indicated that our main findings remained consistent and were not significantly influenced by any single study. By systematically omitting each study one at a time, the pooled prevalence estimate for concomitant osteomyelitis in paediatric hip septic arthritis fluctuated between 31.8% (95% CI: 26.2–37.8) and 34.5% (95% CI: 28.6–40.9). Furthermore, we performed a stratified analysis categorizing participants by four key variables: age, continent, study quality, and study time periods. This analysis indicated no statistically significant differences in the prevalence of concomitant osteomyelitis related to age (under 4 years versus 4 years and older) (P > 0.05) (Table 3). However, significant variations were observed based on continent (Europe, Asia, or America) (P = 0.008), study quality (High or Fair) (P = 0.003), and study time periods (1976–2010 or 2011–2023) (P = 0.001) (Table 3).

Table 3 Sensitivity analysis of included studies
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Publication bias

In the context of our systematic review and meta-analysis, we evaluated publication bias regarding the prevalence of septic arthritis of the hip with osteomyelitis in children. Based on the symmetry of the funnel plot and the regression test associated with its evaluation (Egger’s test: B = 0.86, SE = -1.12, P = 0.105) (Fig. 4), we found no indication of publication bias.

Fig. 4
figure 4

Funnel plot of the risk of publication bias for the prevalence of concomitant osteomyelitis in paediatric hip septic arthritis

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Discussion

Key findings

Our review encompassed 21 studies examining the prevalence of concomitant osteomyelitis in paediatric hip septic arthritis, resulting in a pooled prevalence estimate of 33.2%. Additionally, our qualitative and quantitative analyses indicated that scientific evidence on this prevalence varies by continent and study quality. Notably, significant differences were found related to continent (Europe, Asia, or America) (P = 0.008), study quality (High or Fair) (P = 0.003), and study time periods (1976–2010 or 2011–2023) (P = 0.001). This study can provide valuable insights for both parents and orthopedic surgeons, enabling informed decision-making regarding surgical options for children, thereby alleviating suffering and reducing negative outcomes.

Comparisons with the existing evidence

The prevalence of septic arthritis with osteomyelitis of the hip in children is estimated at 33.2% in this study. Subgroup analysis revealed incidence rates of 36.6% in the United States and 29.0% in Asia, compared to 29.4% from 1976 to 2010 and 35.2% from 2011 to 2023. These trends may be related to economic development and advancements in medical imaging, particularly MRI technology. Economic development and the widespread application of MRI have significantly enhanced early diagnosis of pediatric hip pyogenic arthritis with osteomyelitis [33]. MRI provides clearer, more detailed images of soft tissues, enabling physicians to accurately identify infections, inflammation, and associated lesions [34]. However, in developing regions lacking advanced imaging technology, reliance on traditional X-rays can delay diagnosis [28]. Furthermore, Garg et al. [35] noted that septic arthritis frequently coexists with adjacent infections, especially in the hip joint, with a prevalence of 44.47%. Their study found that 42.48% of patients exhibited periarticular infections on MRI, with osteomyelitis being the most commonly observed infection among the 209 patients (41.84%). Additionally, 32.5% of patients with septic arthritis required a second surgical procedure, compared to 61.11% of those with periarticular infections. These considerations underscore the urgent need for enhanced diagnostic strategies, particularly the implementation of MRI, to effectively mitigate adverse outcomes associated with these serious conditions.

Strengths and limitations

This study presents several notable strengths. First, the systematic review and meta-analysis aim to evaluate the prevalence of concomitant osteomyelitis in paediatric hip septic arthritis. By integrating existing literature, it provides a foundational perspective on this medical concern. Second, a stratified approach was utilized to assess prevalence rates by categorizing participants based on three essential variables: age, continent, study quality, and study time periods. This methodology allows for a more nuanced analysis across different patient demographics. Third, sensitivity analyses were performed to identify and mitigate potential biases, enhancing the reliability and validity of the findings. Collectively, these methodological advantages make a substantial contribution to the field of paediatric orthopedics, offering valuable insights for both clinicians and researchers.

However, several limitations of this systematic review and meta-analysis should be noted. First, the inclusion of all studies being retrospective may introduce sampling bias, and many studies included in the review had relatively small sample sizes, raising concerns about whether the reported prevalence of concomitant osteomyelitis truly reflects actual rates within the wider population. Second, to date, there has been no standardized method for diagnosis and treatment. The utilization of more sensitive diagnostic tests, such as polymerase chain reaction (PCR), and higher doses of antibiotics was not prevalent in earlier years. Additionally, prior antibiotic treatment before sample collection may result in false-negative microbiological diagnoses. Finally, our review was restricted to studies published in English, which may have led to the exclusion of pertinent research conducted in other languages, potentially introducing language bias into our findings.

The implications of the findings

This study has significant implications for both research and clinical practice. First, future research should prioritize larger sample sizes for pediatric hip septic arthritis to enhance our understanding of concomitant osteomyelitis and to establish the fundamental differences in treatment protocols between septic arthritis alone and those involving concomitant osteomyelitis. Furthermore, it is crucial for upcoming studies to investigate the various bacterial infections associated with this condition, as such insights could inform antibiotic usage, mitigate the risk of drug-resistant bacteria, and lead to shorter treatment durations. Lastly, additional research should explore the relationship between symptom duration and the incidence of concomitant osteomyelitis in this patient population, with the aim of reducing the likelihood of secondary surgeries.

Conclusion

This systematic review and meta-analysis identifies a pooled prevalence of concomitant osteomyelitis in paediatric hip septic arthritis at 31.8–34.5%, employing rigorous methodologies such as sensitivity analyses and stratified assessments that enhance the reliability of the findings despite limitations like small sample sizes and exclusion of non-English studies. These insights are essential for guiding future research and informing treatment strategies, ultimately supporting clinicians in making informed decisions to improve patient care in paediatric orthopedics.

Data availability

All data generated or analysed during this study are included in this article.

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Acknowledgements

We thank research office staff at Chengdu Women’s and Children’s Central Hospital.

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  1. Miao Xinling and Tang Qingsong contributed equally to this work as co-first authors.

Authors and Affiliations

  1. School of Nursing, Chengdu University, Chengdu, China

    Miao Xinling, Li Xiahui, Xu Yi & Tan Xin

  2. Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China

    Tang Qingsong, Ren Xiang, Zhao Kang & Hu Jie

  3. Affiliated Hospitial of Chengdu University, Chengdu, China

    Chen Xuelian & Xiong Jian

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Contributions

Miao Xinling and Tang Qingsong equally to this work as co-first authors. Miao XL conceptualized the study, performed the literature search, conducted analyses, and wrote and approved the final manuscript. Tang QS was involved in data extraction and also read and approved the final manuscript. Ren X, Zhao K, Hu J, Li XH, Xu Y, Tan X, Chen XL, and Xiong J participated in discussions, reached consensus, and approved the final manuscript. All authors have read and approved the final version of the manuscript.

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Correspondence to Li Xiahui.

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Xinling, M., Qingsong, T., Xiang, R. et al. Investigating the prevalence of the concomitant osteomyelitis in pediatric hip septic arthritis: a systematic review and Meta-analysis. J Orthop Surg Res 20, 196 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13018-025-05597-3

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Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X