Age and C-reactive protein as modifiers of Kocher criteria in pediatric septic knee monoarthritis

Introduction: Although Kocher criteria can distinguish a septic hip from an aseptic cause, they may not apply to a septic knee. We aimed to identify predictors to discriminate septic and aseptic causes of acute knee monoarthritis in children who underwent arthrocentesis. Methods: We conducted a retrospective cohort study among children who underwent arthrocentesis for suspected septic arthritis of the knee. Collected data included demographic, clinical and laboratory characteristics. We performed univariate and multivariable analyses to identify predictors of the septic knee. We further investigated accuracy of different predictive models. Results: A total of 60 patients who underwent arthrocentesis for suspected knee septic arthritis were included in this study. Septic arthritis of the knee was confirmed in 32 (53%) patients. Age ≤ 5 years (OR 4.237, [95% CI 1.270–14.127], p = 0.019), WBC > 12,000 cells/mm³ (OR 5.059, [95% CI 1.424–17.970], p = 0.012), and CRP > 2 mg/dL (OR 3.180, [0.895–11.298], p = 0.074) were the most important predictors of a septic knee. Three-tier model comprising these three factors (AUC 0.766) and 4-tier model with addition of fever >38.5°C (AUC 0.776) performed better than Kocher criteria (AUC 0.677), modified Kocher criteria (AUC 0.699) and Full Model (adding age ≤ 5 years and CRP >2 mg/dL to Kocher criteria) (AUC 0.746). Full Model successfully ruled out septic arthritis if all 6 criteria were negative. Conclusion: Based on these findings, we propose an algorithm to identify low, intermediate and high-risk patients for knee septic arthritis. Our proposed two-step algorithm incorporating major (age, WBC, CRP) and minor (fever, ESR, non-weight bearing) criteria can serve as a simple decision-support tool to justify arthrocentesis in children with suspected knee septic arthritis.