International Delphi Consensus on the Diagnosis and Management of Septic Arthritis of the Hip in Prewalking Children

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.

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.

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.

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 V (expert opinion/consensus statement).