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Transient Synovitis of the Hip

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Other Names

  • Transient Synovitis
  • Transitory Coxitis
  • Acute Transient Epiphysitis
  • Coxitis Fugax
  • Coxitis Serosa Seu Simplex
  • Phantom Hip Disease
  • Toxic Synovitis
  • Observation Hip

Background

  • This page describes Transient Synovitis (TS) of the Hip Joint, a benign, self-limited condition affecting children

History

  • First characterized by Lovett in 1892[1]

Epidemiology

  • Annual incidence estimated at about 0.2%[2]
    • Lifetime risk is roughly 3%
    • Risk of recurrence or relapse is estimated to be about 4%
  • Most commonly seen between ages 3 and 8[3]
    • In a Netherlands cohort, the mean age was 4.7[4]
    • Note there are case reports in adults
  • More common in males, with a a male:female ratio range from 1.7-2.8:1[5]
  • Bilateral involvement has been described, estimated incidence is 1-4% of cases[6]

Pathophysiology

  • Pathophysiology remains largely unknown but typically thought to be viral

Etiology

  • Viral Infection
    • Kastrissianakis et al found patients with TS more likely to have preceding viral symptoms of vomiting and diarrhea or upper respiratory infection[7]
    • Leibowitz et al found patients with TS have higher interferon concentrations and are more likely to be in an anti-viral state[8]
    • Direct links to specific viral candidates (parvovirus B-19 and human herpes simplex virus-6) have been unsuccessful
  • Other proposed etiologies
    • Trauma
    • Hypersensitivity/ Allergic Reaction
    • Bacterial Infection

Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • History
    • Typically acute onset of groin or thigh pain
    • Unwillingness to bear weight, +/- a limp
    • ROM limited
    • It's important to inquire about any preceding upper respiratory, gastrointestinal, genitourinary symptoms or recent trauma
  • Physical Exam: Physical Exam Hip
    • Resting position or position of comfort may be slight flexion, abduction and external rotation[9]
  • Special Tests

Evaluation

Kocher Criteria

  • Algorithm from Kocher et al for predicting probability of septic arthritis[10]
    • Fever (Temp > 38.5°C)
    • Inability to bear weight
    • ESR > 40 mm/h
    • WBC > 12 x 10^6 cells/L
    • This PPV based on the presence of 1, 2, 3 and 4 criteria is 3.0, 40.0, 93.1 and 99.6%, respectively
  • CRP > 1 mg/dl (C-reactive protein ) has also been subsequently added to this algorithm
    • Caird et al: presence of 3, 4 and 5 factors PPV found to be 83, 93 and 98%, respectively[11]
  • Other studies have failed to reproduce these findings[12]
    • In children, Fever (Temp > 38.5°C) followed by elevated CRP were found to be the most significant predictors[13]
    • Singhal et al found CRP > 20 mg/dl was the strongest independent risk factor for septic arthritis[14]

Radiographs

  • Plain Radiographs Hip
    • Typically normal
    • Exclude other causes of hip pain
  • May show
    • Widening of the medial joint space

Ultrasound

  • Rapidly able to evaluate joint space
    • Can reliably exclude/include the presence of an effusion[15]
    • It has been suggested that an absence of a joint effusion excludes septic arthritis
    • Note that Zamzam et al found several cases of false-negative US studies that delayed care in their patient population[16]

MRI

  • Helpful to distinguish TS from septic arthritis
    • MRI with IV contrast has a NPD of 88.9%[17]
  • Findings supporting septic arthritis
    • Signal intensity abnormalities in the bone marrow
    • Decreased perfusion at the femoral epiphysis on fat suppressed gadolinium-enhanced coronal T-weighted images[18]
  • Findings supporting TS
    • Contralateral joint effusion

Bone Scintography

  • Has been used and suggested
  • Limited applicability in the diagnosis of TS[19]

Arthrocentesis

  • If there is an effusion present, consider Hip Arthrocentesis under US guidance
  • Findings that support septic arthritis
    • WBC > 50 x10^9/L
    • Positive gram stain

Classification

  • Not applicable

Management

Prognosis

  • TS is a self limited condition that resolves spontaneously
    • Typically in 3-10 days without any specific treatment
  • In patients with previous diagnosis of TS, recurrence remains a risk
    • Uziel et al found recurrence risk was 69, 13 and 18% in years 1, 2 and 3 following the initial diagnosis[20]

Nonoperative

  • Observation
  • Rest
  • NSAIDS
    • Kermond et al in an RCT found Ibuprofen reduced duration of symptoms from 4.5 days to 2 days[21]
  • Hip Arthrocentesis
    • In addition to diagnostic value, fluid aspiration has a therapeutic/ palliative effect
    • Wingstrand et al noted effusion recurred in 1 day in 11/13 patients[9]

Operative

  • Indications
    • There are case reports for refractory cases[22]
  • Technique
    • Arthroscopic debridement

Rehab and Return to Play

Rehabilitation

  • No specific rehabilitation is typically required

Return to Play

  • When asymptomatic and able to run pain free

Complications

  • Legg-Calve-Perthes Disease
    • Incidence is up to 3% following an episode of TS[2], in general population it is 0.9/100,000 patients
    • Mukamel et al combined data from 10 studies and also found an increased risk[23]
    • Kallio et al was not able to reproduce these findings[24]

See Also


References

  1. Lovett RW, Morse JL. Transient or ephemeral form of hip-disease, with a report of cases. Boston Med Surg J 1892; 127:161–163.
  2. 2.0 2.1 Landin LA, Danielsson LG, Wattsga° rd C. Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes’ disease. J Bone Joint Surg Br 1987; 69:238–242.
  3. Baskett A, Hosking J, Aickin R. Hip radiography for the investigation of nontraumatic short duration hip pain presenting to a children’s emergency department. Pediatr Emerg Care 2009; 25:78–82.
  4. Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Acute non-traumatic hip pathology in children: incidence and presentation in family practice. Fam Pract 2010; 27:166–170.
  5. Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. J Bone Joint Surg Br 1999; 81:1029–1034.
  6. Ehrendorfer S, LeQuesne G, Penta M, Smith P, Cundy P. Bilateral synovitis in symptomatic unilateral transient synovitis of the hip: an ultrasonographic study in 56 children. Acta Orthop Scand 1996; 67:149–152.
  7. Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med 2010; 17:270–273.
  8. Leibowitz E, Levin S, Torten J, Meyer R. Interferon system in acute transient synovitis. Arch Dis Child 1985; 60:959–962.
  9. 9.0 9.1 Wingstrand H, Egund N, Carlin NO, Forsberg L, Gustafson T, Sunde´n G. Intracapsular pressure in transient synovitis of the hip. Acta Orthop Scand 1985; 56:204–210.
  10. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81:1662–1670.
  11. Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am 2006; 88:1251–1257.
  12. Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am 2004; 86-A:956–962
  13. Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. J Bone Joint Surg Br 2010; 92:1289–1293.
  14. Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br 2011; 93:1556–1561.
  15. Yabunaka K, Ohue M, Morimoto N, Kitano N, Shinohara K, Takamura M, et al. Sonographic measurement of transient synovitis in children: diagnostic value of joint effusion. Radiol Phys Technol 2012; 5:15–19.
  16. Zamzam MM. The role of ultrasound in differentiating septic arthritis from transient synovitis of the hip in children. J Pediatr Orthop B 2006; 15: 418–422.
  17. Kim EY, Kwack KS, Cho JH, Lee DH, Yoon SH. Usefulness of dynamic contrast-enhanced MRI in differentiating between septic arthritis and transient synovitis in the hip joint. Am J Roentgenol 2012; 198:428–433.
  18. Kwack KS, Cho JH, Lee JH, Cho JH, Oh KK, Kim SY. Septic arthritis versus transient synovitis of the hip: gadolinium enhanced MRI finding of decreased perfusion at the femoral epiphysis. Am J Roentgenol 2007; 189:437–445.
  19. Connolly LP, Connolly SA. Skeletal scintigraphy in the multimodal assessment of young children with acute skeletal symptoms. Clin Nucl Med 2003; 28:746–754.
  20. Uziel Y, Butbul-Aviel Y, Barash J, Padeh S, Mukamel M, Gorodnitski N, et al. Recurrent transient synovitis of the hip in childhood. Long term outcome among 39 patients. J Rheumatol 2006; 33:810–811.
  21. Kermond S, Fink M, Graham K, Carlin JB, Barnett P. A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Ann Emerg Med 2002; 40:294–299.
  22. Shetty VD, Shetty GM. Arthroscopic view of transient synovitis of the hip joint: a case report. Knee Surg Sports Traumatol Arthrosc 2009; 17: 1003–1005.
  23. Mukamel M, Litmanovitch M, Yosipovich Z, Grunebaum M, Varsano I. Legg–Calve–Perthes disease following transient synovitis. How often? Clin Pediatr (Phila) 1985; 24:629–631.
  24. Kallio P, Ryo¨ ppy S, Kunnamo I. Transient synovitis and Perthes’ disease. Is there an aetiological connection? J Bone Joint Surg Br 1986; 68:808–811.
Created by:
John Kiel on 23 September 2020 23:17:35
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Last edited:
5 October 2022 13:10:15
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