Multifocal Osteoarticular Infections in Infants: A Case Report with Long-Term Follow-Up

Multifocal Osteoarticular Infections in Infants: A Case Report with Long-Term Follow-Up | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Multifocal Osteoarticular Infections in Infants: A Case Report with Long-Term Follow-Up Jie Hu, Xiaofang Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6380645/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Osteoarticular infections in infants represent acute and severe conditions that frequently involve multiple sites, which increases the likelihood of missed diagnosis. Damage to the growth plate or missed diagnosis of suppurative hip arthritis often portends catastrophic consequences. Case presentation: We present a rare case of multifocal osteoarticular infection in an infant under three months of age. The initial diagnosis and treatment concentrated solely on the infection site of the right femoral epiphysis and knee joint, while the left femur and hip joint were overlooked due to atypical clinical presentations. Interestingly, despite numerous risk factors indicating a poor prognosis, a favorable outcome was ultimately achieved after five years of follow-up. Conclusion: Infants are prone to multi-articular bone infections due to their special physiological mechanisms. It is necessary to conduct a careful physical or imaging examination to avoid missed diagnosis, and their prognosis may not conform to conventional experience. Multifocal Osteoarticular Infections growth plate damage suppurative hip arthritis infant case report Figures Figure 1 Figure 2 Background Suppurative osteoarthritis is uncommon in infants[ 1 ], the absence of evident signs and symptoms can complicate the diagnostic process and lead to missed diagnosis. Failure to recognize bone and joint infections at an early stage can impose significant social and economic burdens, potentially resulting in long-term sequelae related to limb dysfunction [ 2 – 4 ]. The prevalence of osteomyelitis accompanied by septic arthritis in infants and young children is notably high, ranging from 40.9–71%[ 1 , 5 , 6 ]. This occurrence is largely attributable to the open transphyseal blood vessels that remain viable until approximately 18 months of age, allowing for bidirectional bacterial dissemination through this conduitl[ 7 , 8 ]. Such dynamics exacerbate damage to the growth plate; even successful treatment of the osteoarticular infection may leave irreversible impairments in limb growth and development. The hip joint is recognized as an independent risk factor for sequelae following septic arthritis. Pediatric orthopedic surgeons agree that early arthrotomy (within four days post-infection) can significantly enhance prognosis[ 9 – 11 ]. Conversely, outcomes of delayed interventions are often unfavorable, and surgical reconstruction at later stages poses challenges, frequently resulting in unsatisfactory results[ 4 , 12 ]. We reported a rare case of multifocal osteoarticular infection with the above-mentioned risk factors. The suppurative left hip arthritis was missed due to atypical symptoms. However, after a long-term follow-up, this case unexpectedly achieved a favorable prognosis, an outcome that deviates from conventional experience. Case presentation A 2-month-and-10-day-old boy was admitted to the hospital due to pseudo-paralysis of the right leg lasting 10 days, accompanied by gradual swelling of the right knee joint, without accompanying febrile symptoms or other positive physical signs. Laboratory findings indicated a peripheral white blood cell count of 13.20 × 10^9/L, a serum CRP level of 126 mg/L, and an ESR of 140 mm/h. Preliminary X-ray examination revealed damage to the distal metaphysis and epiphysis of the right femur, with a significant periosteal reaction. A periosteal reaction was also noted on the left lateral femur, which was initially overlooked by the attending surgeon(Fig. 1 A). Under the guidance of ultrasound, purulent fluid was aspirated from the cavity of the right knee joint. The infant was diagnosed with osteomyelitis of the right femur and suppurative arthritis of the right knee joint. Emergency surgery was then performed. A 4cm lateral incision was made to simultaneously access the distal femur and knee joint on the right side, facilitating the removal of pus and necrotic tissue for culture and drug sensitivity testing. Holes were drilled at both the metaphysis and epiphysis to promote pus drainage, and irrigation and drainage tubes were placed within the joint cavity. Irrigation was ceased one week post-operation, and all tubes were removed two weeks after the procedure. Following surgery, ceftazidime was administered empirically for infection control(30mg/kg q8h), and a follow-up MRI was conducted on the second postoperative day to assess damage to the growth plate (Fig. 1 B). The pus culture confirmed an infection with Staphylococcus aureus. Given the favorable change in CRP levels, no alterations to the antibiotic regimen were made. The total course of antibiotic treatment was 4 weeks after the operation. In subsequent follow-up examinations, the clinician focused predominantly on the condition of the right knee joint. No physeal bridge was found in the growth plate at the distal end of the right femur, and the damaged epiphysis was also in the process of restoration (Fig. 1 C, Fig. 1 D). Additionally, no limb length discrepancies were detected in either lower limb. However, at the age of three years, re-examination revealed a flattened appearance of the ossification nucleus of the left femoral head (Fig. 1 E), and it was diagnosed as femoral head necrosis. According to the Choi classification[ 13 ], it was classified as Type I. Based on earlier examination results, we inferred that the patient had developed left-sided suppurative arthritis of the hip at the age of 2 months and 10 days. Unpredictably, at five years, X-ray imaging demonstrated ongoing repair of the epiphysis at the distal right femur and the left femoral head (Fig. 1 F). The range of motion in the left hip joint, including flexion, extension, abduction, adduction, external rotation, and internal rotation, was assessed as normal (Fig. 2 ). Discussion and Conclusion Infantile pyogenic arthritis commonly manifests with mild systemic symptoms during its early stages, which can be attributed to the unique characteristics of the infant immune system. The primary clinical features include pseudoparalysis of the affected limb and localized swelling[ 2 , 14 ]. In infants younger than three months, it is crucial to consider the potential for multi-joint involvement, as illustrated in this case, the absence of prominent left-sided signs in this patient prior to surgery resulted in missed diagnosis. Consequently, a comprehensive examination of all joints in small infants is essential to prevent overlooked diagnoses. When emergency MRI is not readily available, an ultrasound examination can serve as an effective alternative for screening high-risk joints, given its convenience and avoidance of sedation, which ultimately reduces the likelihood of missed diagnosis[ 15 , 16 ]. Damage to the growth plate generally results in the formation of bony bridges, leading to angular deformities or longitudinal growth disturbances. However, several studies have identified instances of growth plate damage without subsequent bony bridge formation[ 17 , 18 ]. This scenario is evident in the current case; despite sustaining a growth plate injury, no bony bridge formation or longitudinal growth disturbances were observed during follow-up. This phenomenon may relate to the location and extent of the growth plate injury. When the area of damage to the growth plate is less than 7% and located in the central region, traction effects from the surrounding intact growth plate can potentially disrupt any forming bony bridge at the damaged site, thereby allowing normal growth to resume[ 19 ]. Another potential influencing factor involves the presence of bone tissue on both sides of the damaged growth plate. If channels devoid of bone tissue exist on both sides of the injured growth plate, a bony bridge is unlikely to form rapidly; instead, fibrous tissue may substitute the bony bridge[ 17 , 20 ]. The hip joint is one of the most commonly affected sites in infantile pyogenic arthritis, accounting for approximately 32–62.1% [ 1 , 3 , 21 , 22 ]. Early diagnosis and surgical intervention yield relatively favorable outcomes, with 83.9% of cases achieving satisfactory clinical results and 51.6% demonstrating satisfactory imaging outcomes[ 9 ]. However, only 33.3% of cases with delayed treatment attain satisfactory clinical and imaging results[ 23 ], and prognosis worsens as patient age decreases. In Mortia's study, all four children under one month who underwent delayed surgery experienced sequelae[ 24 ]. In contrast, the patient in this case, who had left-sided suppurative hip arthritis, received effective antibiotic treatment without undergoing surgical intervention, and yet the function of the hip joint recovered adequately. The favorable clinical outcome in this case may be primarily attributable to the asynchronous progression of polyarticular infections involving the right knee and left hip joints. Notably, the left hip infection remained in its incipient phase upon hospital admission, allowing for immediate implementation of pathogen-directed antimicrobial therapy that achieved successful containment of the localized infectious process. Although the timely use of antibiotics is crucial in the treatment of purulent hip arthritis, for confirmed cases of suppurative arthritis, it does not rule out the necessity of arthrotomy. Some studies have mentioned that repeated joint aspiration under ultrasound guidance can serve as an alternative to arthrotomy[ 25 , 26 ]. However, we still maintain a cautious attitude towards this approach and more research is needed. Antibiotics are the cornerstone of the treatment of osteoarticular infections. It is very important to select appropriate antibiotics based on the age characteristics of the children and the local prevalence of microorganisms. Staphylococcus aureus is the most common in all age groups[ 27 ], but in infants younger than 3 months, the possibility of Streptococcus agalactiae infection needs to be considered[ 28 ]. Therefore, we initially chose third - generation cephalosporin antibiotics. Conclusion The symptoms of suppurative osteoarthritis in infants are not typical. It is necessary to be alert to the possibility of multiple osteoarticular infections. Early thorough physical or imaging examination to avoid missed diagnosis is crucial for preventing sequelae. Abbreviations CRP C-reactive protein ESR erythrocyte sedimentation rate MRI magnetic resonance imaging Declarations Availability of data and materials The data that support the findings of this case report are available from the corresponding author upon reasonable request. Acknowledgements Not applicable. Funding Not applicable. Author information Author and Affiliations: Jie Hu 1 , Xiao-fang Zhang 2 * 1 Department of Orthopedics,Chengdu Women’s and Children’s Central Hospital, 2 Department of Pediatric Neurology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610073, Sichuan Province, China, Contributions Jie Hu obtained the informed consent of the guardians and wrote this manuscript. Xiaofang Zhang participated in the collection of the pictures and edited the manuscript. All the authors have read and approved the final manuscript. Corresponding author Correspondence to Xiao-fang Zhang, Email: [email protected] . Ethics declarations Ethics approval and consent to participate This study was approved by Chengdu Women’s and Children’s Central Hospital Ethics Committee Board. Consent for publication Written informed consent for publication of all clinical details and radiographic images was obtained from the patient's mother, the legal guardian. Competing interests All authors assert that no conflict of interest exists in relation to this manuscript. References Mediamolle N, Mallet C, Aupiais C, Doit C, Ntika S, Vialle R, et al. Bone and joint infections in infants under three months of age. Acta Paediatr Oslo Nor 1992. 2019;108:933–9. Dessì A, Crisafulli M, Accossu S, Setzu V, Fanos V. Osteo-articular infections in newborns: diagnosis and treatment. J Chemother Florence Italy. 2008;20:542–50. Sreenivas T, Nataraj AR, Kumar A, Menon J. Neonatal septic arthritis in a tertiary care hospital: a descriptive study. Eur J Orthop Surg Traumatol Orthop Traumatol. 2016;26:477–81. Samora JB, Klingele K. Septic arthritis of the neonatal hip: acute management and late reconstruction. J Am Acad Orthop Surg. 2013;21:632–41. Liu Y, Zhao K, Liu Y, Sun Y-H, Li M-X, Yu M, et al. Bone and joint infection complicated with sepsis in neonates and infants under three months of age. J Pediatr (Rio J). 2024;100:156–62. Rubin LG, Shin J, Kaur I, Scheuerman O, Levy I, Long SS. Frequency of Multifocal Disease and Pyogenic Arthritis of the Hip in Infants with Osteoarticular Infection in Three Neonatal Intensive Care Units. J Pediatr. 2020;227:157–62. Urish KL, Cassat JE. Staphylococcus aureus Osteomyelitis: Bone, Bugs, and Surgery. Infect Immun. 2020;88:e00932-19. Agarwal A, Aggarwal AN. Bone and Joint Infections in Children: Septic Arthritis. Indian J Pediatr. 2016;83:825–33. Prognostic factors of septic arthritis of hip in infants and neonates: minimum 5-year follow-up - PubMed. https://pubmed.ncbi.nlm.nih.gov/25729527/. Accessed 21 Dec 2024. The Price for Delayed Diagnosis of Pediatric Septic Hip: Increased Cost and Poor Outcomes - PubMed. https://pubmed.ncbi.nlm.nih.gov/39193800/. Accessed 24 Dec 2024. Nunn TR, Cheung WY, Rollinson PD. A prospective study of pyogenic sepsis of the hip in childhood. J Bone Joint Surg Br. 2007;89:100–6. Choi IH, Shin YW, Chung CY, Cho T-J, Yoo WJ, Lee DY. Surgical treatment of the severe sequelae of infantile septic arthritis of the hip. Clin Orthop. 2005;:102–9. Choi IH, Pizzutillo PD, Bowen JR, Dragann R, Malhis T. Sequelae and reconstruction after septic arthritis of the hip in infants. J Bone Joint Surg Am. 1990;72:1150–65. Clinical characteristics of neonatal and infant osteomyelitis and septic arthritis: a multicenter retrospective study - PubMed. https://pubmed.ncbi.nlm.nih.gov/38642591/. Accessed 23 Dec 2024. Huang S-F, Teng Y, Hui-Qing Shi null, Chen W-J, Zhang X-H. Clinical and ultrasound features of 46 children with suppurative osteoarthritis: experience from two centers. J Orthop Surg. 2024;19:220. Valisena S, De Marco G, Cochard B, Di Laura Frattura G, Bazin L, Vazquez O, et al. Is the emergency MRI protocol for acute pediatric osteoarticular infection a luxury or an absolute priority? Front Pediatr. 2023;11:1328870. Saisu T, Kamegaya M, Watanabe A, Ochiai N, Takahashi K. Endoscopic surgery for chronic osteomyelitis extending across the physis. A report of two cases. J Bone Joint Surg Am. 2008;90:1744–50. Bogoch E, Thompson G, Salter RB. Foci of chronic circumscribed osteomyelitis (Brodie’s abscess) that traverse the epiphyseal plate. J Pediatr Orthop. 1984;4:162–9. Cochard B, Habre C, Pralong-Guanziroli N, Gavira N, Di Laura Frattura G, Di Marco G, et al. Transphyseal Hematogenous Osteomyelitis: An Epidemiological, Bacteriological, and Radiological Retrospective Cohort Analysis. Microorganisms. 2023;11:894. Abood AA, Rahbek O, Olesen ML, Christensen BB, Møller-Madsen B, Kold S. Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model. Strateg Trauma Limb Reconstr. 2021;16:8–13. Berberian G, Firpo V, Soto A, Lopez Mañan J, Torroija C, Castro G, et al. Osteoarthritis in the neonate: risk factors and outcome. Braz J Infect Dis Off Publ Braz Soc Infect Dis. 2010;14:413–8. Rubin LG, Shin J, Kaur I, Scheuerman O, Levy I, Long SS. Frequency of Multifocal Disease and Pyogenic Arthritis of the Hip in Infants with Osteoarticular Infection in Three Neonatal Intensive Care Units. J Pediatr. 2020;227:157–62. Li Y, Zhou Q, Liu Y, Chen W, Li J, Yuan Z, et al. Delayed treatment of septic arthritis in the neonate: A review of 52 cases. Medicine (Baltimore). 2016;95:e5682. Mortia M, Nakamura H, Kitano T. Comparison of clinical outcome after treatment of hip arthritis caused by MRSA with that caused by non-MRSA in infants. J Pediatr Orthop Part B. 2009;18:1–5. Givon U, Liberman B, Schindler A, Blankstein A, Ganel A. Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations. J Pediatr Orthop. 2004;24:266–70. Donders CM, Spaans AJ, Bessems JHJM, van Bergen CJA. A systematic review of the optimal drainage technique for septic hip arthritis in children. Hip Int J Clin Exp Res Hip Pathol Ther. 2022;32:685–93. Pääkkönen M, Peltola H. Simplifying the treatment of acute bacterial bone and joint infections in children. Expert Rev Anti Infect Ther. 2011;9:1125–31. Raabe VN, Shane AL. Group B Streptococcus (Streptococcus agalactiae). Microbiol Spectr. 2019;7. Additional Declarations No competing interests reported. Supplementary Files 414CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6380645","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":452019197,"identity":"5c116040-c26d-4aaf-8a79-9af2a84cd9a2","order_by":0,"name":"Jie Hu","email":"","orcid":"","institution":"Chengdu Women's and Children's Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Hu","suffix":""},{"id":452019198,"identity":"31554e79-b783-4e35-9589-81761788c773","order_by":1,"name":"Xiaofang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYBACfvbm4z8+/GCTsz/efIA4LZI9xxIkZ/bwGTOcOZZAnBaDGzkG0jxscokNQAaRLjuQY2DAw2OW2Nhz5uONNwx2croNBHQwNhwrSJCwSDNuZu/dbDmHIdnY7AABLcyMzRsOGPAck23jObtNmofhQOI2QlrYmBkMGxLY/jP2SOQ8I04LDxuLMcMBNjbFGRI5bMRpkeBhS2Ns7GEzBjrO2HKOARF+sb//+BjzH2BUGrA3P7zxpsJOjqAWNCuJjRokLaTqGAWjYBSMghEBAKDXQx51OH+pAAAAAElFTkSuQmCC","orcid":"","institution":"Chengdu Women's and Children's Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiaofang","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-04-05 07:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6380645/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6380645/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82356617,"identity":"a31d35f3-4dd3-4053-85f3-045fdbfb1e20","added_by":"auto","created_at":"2025-05-09 11:19:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3480518,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological Examination of Lower Limb Joints (A) Preoperative femur X-ray; (B) MRI of the right femur on the second postoperative day; (C) Femur X-ray one month postoperatively; (D) Knee X-ray six months postoperatively; (E) Femur X-ray three years postoperatively; (F) Femur X-ray five years postoperatively.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6380645/v1/847fd9c1b301140968c99562.png"},{"id":82354748,"identity":"87bbe076-11d3-4bb7-bfbf-a0131e292560","added_by":"auto","created_at":"2025-05-09 11:11:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":9097549,"visible":true,"origin":"","legend":"\u003cp\u003ePhysical examination of lower limb joints at age five in this patient\u003c/p\u003e\n\u003cp\u003e(A) Right hip and knee flexion; (B) Left hip and knee flexion;(C) Left hip abduction;(D)Left hip adduction;(E)Left hip patrick's test;(F) Left hip internal rotation;(G) Left hip external rotation\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6380645/v1/9710cf431aae2c595c595a5c.png"},{"id":101193840,"identity":"89b7fe4f-4bd2-4dcd-a147-6ef9b49a591a","added_by":"auto","created_at":"2026-01-27 07:43:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":14000941,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6380645/v1/3b3132c6-2c05-4f8d-8117-085a4ed14b0a.pdf"},{"id":82354735,"identity":"a0338303-814e-4fc8-9143-ce9aa79b989e","added_by":"auto","created_at":"2025-05-09 11:11:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":758903,"visible":true,"origin":"","legend":"","description":"","filename":"414CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6380645/v1/01137d95ec05c1eba3335e55.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eMultifocal Osteoarticular Infections in Infants: A Case Report with Long-Term Follow-Up\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eSuppurative osteoarthritis is uncommon in infants[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the absence of evident signs and symptoms can complicate the diagnostic process and lead to missed diagnosis. Failure to recognize bone and joint infections at an early stage can impose significant social and economic burdens, potentially resulting in long-term sequelae related to limb dysfunction [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of osteomyelitis accompanied by septic arthritis in infants and young children is notably high, ranging from 40.9\u0026ndash;71%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This occurrence is largely attributable to the open transphyseal blood vessels that remain viable until approximately 18 months of age, allowing for bidirectional bacterial dissemination through this conduitl[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Such dynamics exacerbate damage to the growth plate; even successful treatment of the osteoarticular infection may leave irreversible impairments in limb growth and development.\u003c/p\u003e \u003cp\u003eThe hip joint is recognized as an independent risk factor for sequelae following septic arthritis. Pediatric orthopedic surgeons agree that early arthrotomy (within four days post-infection) can significantly enhance prognosis[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Conversely, outcomes of delayed interventions are often unfavorable, and surgical reconstruction at later stages poses challenges, frequently resulting in unsatisfactory results[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe reported a rare case of multifocal osteoarticular infection with the above-mentioned risk factors. The suppurative left hip arthritis was missed due to atypical symptoms. However, after a long-term follow-up, this case unexpectedly achieved a favorable prognosis, an outcome that deviates from conventional experience.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 2-month-and-10-day-old boy was admitted to the hospital due to pseudo-paralysis of the right leg lasting 10 days, accompanied by gradual swelling of the right knee joint, without accompanying febrile symptoms or other positive physical signs. Laboratory findings indicated a peripheral white blood cell count of 13.20 × 10^9/L, a serum CRP level of 126 mg/L, and an ESR of 140 mm/h. Preliminary X-ray examination revealed damage to the distal metaphysis and epiphysis of the right femur, with a significant periosteal reaction. A periosteal reaction was also noted on the left lateral femur, which was initially overlooked by the attending surgeon(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Under the guidance of ultrasound, purulent fluid was aspirated from the cavity of the right knee joint. The infant was diagnosed with osteomyelitis of the right femur and suppurative arthritis of the right knee joint. Emergency surgery was then performed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA 4cm lateral incision was made to simultaneously access the distal femur and knee joint on the right side, facilitating the removal of pus and necrotic tissue for culture and drug sensitivity testing. Holes were drilled at both the metaphysis and epiphysis to promote pus drainage, and irrigation and drainage tubes were placed within the joint cavity. Irrigation was ceased one week post-operation, and all tubes were removed two weeks after the procedure. Following surgery, ceftazidime was administered empirically for infection control(30mg/kg q8h), and a follow-up MRI was conducted on the second postoperative day to assess damage to the growth plate (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The pus culture confirmed an infection with Staphylococcus aureus. Given the favorable change in CRP levels, no alterations to the antibiotic regimen were made. The total course of antibiotic treatment was 4 weeks after the operation.\u003c/p\u003e \u003cp\u003eIn subsequent follow-up examinations, the clinician focused predominantly on the condition of the right knee joint. No physeal bridge was found in the growth plate at the distal end of the right femur, and the damaged epiphysis was also in the process of restoration (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). Additionally, no limb length discrepancies were detected in either lower limb. However, at the age of three years, re-examination revealed a flattened appearance of the ossification nucleus of the left femoral head (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE), and it was diagnosed as femoral head necrosis. According to the Choi classification[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], it was classified as Type I. Based on earlier examination results, we inferred that the patient had developed left-sided suppurative arthritis of the hip at the age of 2 months and 10 days. Unpredictably, at five years, X-ray imaging demonstrated ongoing repair of the epiphysis at the distal right femur and the left femoral head (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF). The range of motion in the left hip joint, including flexion, extension, abduction, adduction, external rotation, and internal rotation, was assessed as normal (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion and Conclusion","content":"\u003cp\u003eInfantile pyogenic arthritis commonly manifests with mild systemic symptoms during its early stages, which can be attributed to the unique characteristics of the infant immune system. The primary clinical features include pseudoparalysis of the affected limb and localized swelling[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In infants younger than three months, it is crucial to consider the potential for multi-joint involvement, as illustrated in this case, the absence of prominent left-sided signs in this patient prior to surgery resulted in missed diagnosis. Consequently, a comprehensive examination of all joints in small infants is essential to prevent overlooked diagnoses. When emergency MRI is not readily available, an ultrasound examination can serve as an effective alternative for screening high-risk joints, given its convenience and avoidance of sedation, which ultimately reduces the likelihood of missed diagnosis[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDamage to the growth plate generally results in the formation of bony bridges, leading to angular deformities or longitudinal growth disturbances. However, several studies have identified instances of growth plate damage without subsequent bony bridge formation[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This scenario is evident in the current case; despite sustaining a growth plate injury, no bony bridge formation or longitudinal growth disturbances were observed during follow-up. This phenomenon may relate to the location and extent of the growth plate injury. When the area of damage to the growth plate is less than 7% and located in the central region, traction effects from the surrounding intact growth plate can potentially disrupt any forming bony bridge at the damaged site, thereby allowing normal growth to resume[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another potential influencing factor involves the presence of bone tissue on both sides of the damaged growth plate. If channels devoid of bone tissue exist on both sides of the injured growth plate, a bony bridge is unlikely to form rapidly; instead, fibrous tissue may substitute the bony bridge[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe hip joint is one of the most commonly affected sites in infantile pyogenic arthritis, accounting for approximately 32–62.1% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Early diagnosis and surgical intervention yield relatively favorable outcomes, with 83.9% of cases achieving satisfactory clinical results and 51.6% demonstrating satisfactory imaging outcomes[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, only 33.3% of cases with delayed treatment attain satisfactory clinical and imaging results[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and prognosis worsens as patient age decreases. In Mortia's study, all four children under one month who underwent delayed surgery experienced sequelae[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In contrast, the patient in this case, who had left-sided suppurative hip arthritis, received effective antibiotic treatment without undergoing surgical intervention, and yet the function of the hip joint recovered adequately. The favorable clinical outcome in this case may be primarily attributable to the asynchronous progression of polyarticular infections involving the right knee and left hip joints. Notably, the left hip infection remained in its incipient phase upon hospital admission, allowing for immediate implementation of pathogen-directed antimicrobial therapy that achieved successful containment of the localized infectious process. Although the timely use of antibiotics is crucial in the treatment of purulent hip arthritis, for confirmed cases of suppurative arthritis, it does not rule out the necessity of arthrotomy. Some studies have mentioned that repeated joint aspiration under ultrasound guidance can serve as an alternative to arthrotomy[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, we still maintain a cautious attitude towards this approach and more research is needed.\u003c/p\u003e\u003cp\u003eAntibiotics are the cornerstone of the treatment of osteoarticular infections. It is very important to select appropriate antibiotics based on the age characteristics of the children and the local prevalence of microorganisms. Staphylococcus aureus is the most common in all age groups[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], but in infants younger than 3 months, the possibility of Streptococcus agalactiae infection needs to be considered[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, we initially chose third - generation cephalosporin antibiotics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe symptoms of suppurative osteoarthritis in infants are not typical. It is necessary to be alert to the possibility of multiple osteoarticular infections. Early thorough physical or imaging examination to avoid missed diagnosis is crucial for preventing sequelae.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003eC-reactive protein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eESR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003eerythrocyte sedimentation rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 278px;\"\u003e\n \u003cp\u003emagnetic resonance imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this case report are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor and Affiliations: Jie Hu\u003csup\u003e1\u003c/sup\u003e, Xiao-fang Zhang\u003csup\u003e2\u003c/sup\u003e*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Orthopedics,Chengdu Women’s and Children’s Central Hospital, \u003csup\u003e2\u003c/sup\u003eDepartment of Pediatric Neurology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610073, Sichuan Province, China,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJie Hu obtained the informed consent of the guardians and wrote this manuscript. Xiaofang Zhang participated in the collection of the pictures and edited the manuscript. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to\u0026nbsp;\u003cstrong\u003eXiao-fang Zhang,\u0026nbsp;\u003c/strong\u003eEmail: [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by\u0026nbsp;Chengdu Women’s and Children’s Central Hospital Ethics Committee Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of all clinical details and radiographic images was obtained from the patient's mother, the legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors assert that no conflict of interest exists in relation to this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMediamolle N, Mallet C, Aupiais C, Doit C, Ntika S, Vialle R, et al. Bone and joint infections in infants under three months of age. Acta Paediatr Oslo Nor 1992. 2019;108:933\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eDess\u0026igrave; A, Crisafulli M, Accossu S, Setzu V, Fanos V. Osteo-articular infections in newborns: diagnosis and treatment. J Chemother Florence Italy. 2008;20:542\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eSreenivas T, Nataraj AR, Kumar A, Menon J. Neonatal septic arthritis in a tertiary care hospital: a descriptive study. Eur J Orthop Surg Traumatol Orthop Traumatol. 2016;26:477\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eSamora JB, Klingele K. Septic arthritis of the neonatal hip: acute management and late reconstruction. J Am Acad Orthop Surg. 2013;21:632\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eLiu Y, Zhao K, Liu Y, Sun Y-H, Li M-X, Yu M, et al. Bone and joint infection complicated with sepsis in neonates and infants under three months of age. J Pediatr (Rio J). 2024;100:156\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eRubin LG, Shin J, Kaur I, Scheuerman O, Levy I, Long SS. Frequency of Multifocal Disease and Pyogenic Arthritis of the Hip in Infants with Osteoarticular Infection in Three Neonatal Intensive Care Units. J Pediatr. 2020;227:157\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eUrish KL, Cassat JE. Staphylococcus aureus Osteomyelitis: Bone, Bugs, and Surgery. Infect Immun. 2020;88:e00932-19.\u003c/li\u003e\n\u003cli\u003eAgarwal A, Aggarwal AN. Bone and Joint Infections in Children: Septic Arthritis. Indian J Pediatr. 2016;83:825\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003ePrognostic factors of septic arthritis of hip in infants and neonates: minimum 5-year follow-up - PubMed. https://pubmed.ncbi.nlm.nih.gov/25729527/. Accessed 21 Dec 2024.\u003c/li\u003e\n\u003cli\u003eThe Price for Delayed Diagnosis of Pediatric Septic Hip: Increased Cost and Poor Outcomes - PubMed. https://pubmed.ncbi.nlm.nih.gov/39193800/. Accessed 24 Dec 2024.\u003c/li\u003e\n\u003cli\u003eNunn TR, Cheung WY, Rollinson PD. A prospective study of pyogenic sepsis of the hip in childhood. J Bone Joint Surg Br. 2007;89:100\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eChoi IH, Shin YW, Chung CY, Cho T-J, Yoo WJ, Lee DY. Surgical treatment of the severe sequelae of infantile septic arthritis of the hip. Clin Orthop. 2005;:102\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eChoi IH, Pizzutillo PD, Bowen JR, Dragann R, Malhis T. Sequelae and reconstruction after septic arthritis of the hip in infants. J Bone Joint Surg Am. 1990;72:1150\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eClinical characteristics of neonatal and infant osteomyelitis and septic arthritis: a multicenter retrospective study - PubMed. https://pubmed.ncbi.nlm.nih.gov/38642591/. Accessed 23 Dec 2024.\u003c/li\u003e\n\u003cli\u003eHuang S-F, Teng Y, Hui-Qing Shi null, Chen W-J, Zhang X-H. Clinical and ultrasound features of 46 children with suppurative osteoarthritis: experience from two centers. J Orthop Surg. 2024;19:220.\u003c/li\u003e\n\u003cli\u003eValisena S, De Marco G, Cochard B, Di Laura Frattura G, Bazin L, Vazquez O, et al. Is the emergency MRI protocol for acute pediatric osteoarticular infection a luxury or an absolute priority? Front Pediatr. 2023;11:1328870.\u003c/li\u003e\n\u003cli\u003eSaisu T, Kamegaya M, Watanabe A, Ochiai N, Takahashi K. Endoscopic surgery for chronic osteomyelitis extending across the physis. A report of two cases. J Bone Joint Surg Am. 2008;90:1744\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eBogoch E, Thompson G, Salter RB. Foci of chronic circumscribed osteomyelitis (Brodie\u0026rsquo;s abscess) that traverse the epiphyseal plate. J Pediatr Orthop. 1984;4:162\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eCochard B, Habre C, Pralong-Guanziroli N, Gavira N, Di Laura Frattura G, Di Marco G, et al. Transphyseal Hematogenous Osteomyelitis: An Epidemiological, Bacteriological, and Radiological Retrospective Cohort Analysis. Microorganisms. 2023;11:894.\u003c/li\u003e\n\u003cli\u003eAbood AA, Rahbek O, Olesen ML, Christensen BB, M\u0026oslash;ller-Madsen B, Kold S. Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model. Strateg Trauma Limb Reconstr. 2021;16:8\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eBerberian G, Firpo V, Soto A, Lopez Ma\u0026ntilde;an J, Torroija C, Castro G, et al. Osteoarthritis in the neonate: risk factors and outcome. Braz J Infect Dis Off Publ Braz Soc Infect Dis. 2010;14:413\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRubin LG, Shin J, Kaur I, Scheuerman O, Levy I, Long SS. Frequency of Multifocal Disease and Pyogenic Arthritis of the Hip in Infants with Osteoarticular Infection in Three Neonatal Intensive Care Units. J Pediatr. 2020;227:157\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eLi Y, Zhou Q, Liu Y, Chen W, Li J, Yuan Z, et al. Delayed treatment of septic arthritis in the neonate: A review of 52 cases. Medicine (Baltimore). 2016;95:e5682.\u003c/li\u003e\n\u003cli\u003eMortia M, Nakamura H, Kitano T. Comparison of clinical outcome after treatment of hip arthritis caused by MRSA with that caused by non-MRSA in infants. J Pediatr Orthop Part B. 2009;18:1\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eGivon U, Liberman B, Schindler A, Blankstein A, Ganel A. Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations. J Pediatr Orthop. 2004;24:266\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eDonders CM, Spaans AJ, Bessems JHJM, van Bergen CJA. A systematic review of the optimal drainage technique for septic hip arthritis in children. Hip Int J Clin Exp Res Hip Pathol Ther. 2022;32:685\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003eP\u0026auml;\u0026auml;kk\u0026ouml;nen M, Peltola H. Simplifying the treatment of acute bacterial bone and joint infections in children. Expert Rev Anti Infect Ther. 2011;9:1125\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eRaabe VN, Shane AL. Group B Streptococcus (Streptococcus agalactiae). Microbiol Spectr. 2019;7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multifocal Osteoarticular Infections, growth plate damage, suppurative hip arthritis, infant, case report","lastPublishedDoi":"10.21203/rs.3.rs-6380645/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6380645/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eOsteoarticular infections in infants represent acute and severe conditions that frequently involve multiple sites, which increases the likelihood of missed diagnosis. Damage to the growth plate or missed diagnosis of suppurative hip arthritis often portends catastrophic consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eWe present a rare case of multifocal osteoarticular infection in an infant under three months of age. The initial diagnosis and treatment concentrated solely on the infection site of the right femoral epiphysis and knee joint, while the left femur and hip joint were overlooked due to atypical clinical presentations. Interestingly, despite numerous risk factors indicating a poor prognosis, a favorable outcome was ultimately achieved after five years of follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eInfants are prone to multi-articular bone infections due to their special physiological mechanisms. It is necessary to conduct a careful physical or imaging examination to avoid missed diagnosis, and their prognosis may not conform to conventional experience.\u003c/p\u003e","manuscriptTitle":"Multifocal Osteoarticular Infections in Infants: A Case Report with Long-Term Follow-Up","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 11:10:59","doi":"10.21203/rs.3.rs-6380645/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8730debb-acb9-4084-a7de-e0b9d3ce4ab8","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T07:42:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 11:10:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6380645","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6380645","identity":"rs-6380645","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}