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Bone and joint infections

– Bone and joint infections pose a formidable challenge to the

orthopaedic surgeon.
– The high success rate obtained with antibiotic therapy in most
bacterial diseases has not been obtained in bone and joint
infections because of the physiological and anatomical
characteristics of bone.
– The overall surgical site infection rate has been estimated by
CDC to be 2.8% in the United States.
– Although bacteremia is common—estimated to occur 25% of the
time after simple tooth brushings—other etiological factors
must be present for an infection to occur.
• The mere presence of bacteria in bone, whether from
bacteremia or from direct inoculation, is insufficient to
produce osteomyelitis.
• Osteomyelitis occurs when an adequate number of a
sufficiently virulent organism overcomes the host's
natural defenses (inflammatory and immune responses)
and establishes a focus of infection.
• The relative absence of phagocytic cells in the
metaphyses of bones in children may explain why acute
hematogenous osteomyelitis is more common in this
• The peculiarity of an abscess in bone is that it is contained within a firm
structure with little chance of tissue expansion.
• As infection progresses, purulent material works its way through the haversian
system and Volkmann canals and lifts the periosteum off the surface of bone.
• The combination of pus in the medullary cavity and in the subperiosteal
space causes necrosis of cortical bone.
– This necrotic cortical bone, known as a sequestrum, can continue to harbor bacteria
despite antibiotic treatment.
• Antibiotics and inflammatory cells cannot adequately access this avascular
area, resulting in failure of medical treatment of osteomyelitis.
• Recognizing these unique characteristics of bone infections, the best course is
• The orthopaedic surgeon should evaluate the risk of infection in each patient
by considering patient-dependent and surgeon-dependent factors
• Patient-Dependent Factors
• Nutritional Status
– A patient's nutritional status and immunological response are important.
– If a patient is malnourished or immunocompromised and cannot mount a
response to an infection, the effects of any treatment are diminished.
– Malnutrition adversely affects humoral and cell-mediated immunity, impairs
neutrophil chemotaxis, diminishes bacterial clearance, and depresses
neutrophil bactericidal function, the delivery of inflammatory cells to
infectious foci, and serum complement components.
– Basal energy requirements of a traumatized or infected patient increase
from 30% to 55% of normal.
– Fever of just 1°F above normal increases the body's metabolic rate 13%.
– Malnourishment was identified by an albumin level of less than 3.4 g/dL
or a total lymphocyte count of less than 1500 cells/mm3 and nutritional
support before elective surgery reccomended.
• Immunological Status
• To fight infection, the patient must mount inflammatory (white blood
cell count) and immune (antibody) responses that initially stop the
spread of infection and then, ideally, destroy the infecting
• The body's main defense mechanisms are
– Neutrophil response
– humoral immunity
– cell-mediated immunity
– reticuloendothelial cells.
• Abnormal neutrophils or humoral and cell-mediated immunities
have been implicated in infections caused by encapsulated bacteria
in infants and elderly patients, in the increased incidence of
Pseudomonas infections in heroin addicts, and in Salmonella and
Pneumococcus infections in patients with sickle cell anemia.
• Diabetes, alcoholism, hematological malignancy, and
cytotoxic therapy are common causes of neutrophil
• If the neutrophil count decreases to less than 55/mm3,
infections caused by Staphylococcus aureus, gram-
negative bacilli, Aspergillus organisms, and Candida
organisms become a major threat.
• Immunoglobulins and complement factors are two plasma proteins that play
crucial roles in humoral immunity.
• Patients with hypogammaglobulinemia or who have had a splenectomy are at
increased risk of infection caused by encapsulated bacteria, such as
Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria organisms.
• When a defect in a component of the complement cascade is present, S. aureus
and gram-negative bacillus infections are common.
• Septic arthritis caused by unusual organisms such as Mycoplasma pneumoniae
and Ureaplasma urealyticum has been reported and should be suspected in
patients with hypogammaglobulinemia and culture-negative septic arthritis.
• Primary cell-mediated deficiencies are rare, but
secondary cell-mediated deficiencies are common.
• Steroid therapy, malnutrition, lymphoma, systemic
lupus erythematosus, immunodeficiency in elderly
patients, and autoimmune deficiency syndrome all can
cause a secondary cell-mediated deficiency
• which predisposes the host to fungal and
mycobacterial infections, herpesvirus, and
Pneumocystis carinii
• Vaccinations also play a role in host response.
– Haemophilus influenzae type B vaccine that is given to
children has all but eliminated musculoskeletal infections
caused by H. influenzae
• Surgeon-Dependent Factors
• Skin Preparation
– Wound contamination exists anytime the skin barrier is broken,
but proper skin preparation decreases the contamination
caused by bacteria present on the skin.
– Skin barriers also may decrease skin contamination during
– The skin can never be disinfected completely but the number of
bacteria present can be reduced markedly before surgery.
– The skin and hair can be sterilized with alcohol, iodine,
hexachlorophene, or chlorhexidine, but it is almost impossible
to sterilize the hair follicles and sebaceous glands where
bacteria normally reside and reproduce.
– Skin preparations have a limited effect on sebaceous glands
and hair follicles because they do not penetrate an oily
Agent On Gram- On Gram- On Viruses On On Fungi
Positive Negative Mycobacteriu
Bacteria Bacteria m
Alcohol +++ +++ ++ +++ +++

Chlorhexidine +++ ++ ++ ++ ++

Iodophors +++ +++ ++ ++ ++

Triclosan ++ ++ ++ + −
• Disinfectants that penetrate the oily environment are
absorbed by the body and have potentially toxic side
• Hexachlorophene has better penetration, but also has
neurotoxic side effects.
• Hand washing is the most important procedure for
prevention of nosocomial infections.
• Studies suggest that hand scrubbing for 2 minutes is as
effective as traditional hand scrubbing for 5 minutes.
• The optimal duration of hand scrubbing has yet to be
• Hand rubbing with an aqueous alcohol solution that is
preceded by a 1-minute nonantiseptic hand washing for the
first case of the day was found to be just as effective in
prevention of surgical site infections as traditional hand
• Hair removal at the operative site is not recommended
unless done in the operating room.
• Shaving the operative site the night before surgery can
cause local trauma that produces a favorable
environment for bacterial reproduction.
• Glove perforation has been reported to occur in 48% of
• Most frequently, the perforation occurs on the index
finger or thumb of the nondominant hand.
• At a minimum, surgical gloves should be changed every
2 hours.
• Operating Room Environment
– Airborne bacteria are another source of wound
contamination in the operating room.
– These bacteria usually are gram-positive and originate
almost exclusively from humans in the operating room
– Conventional operating room air may contain 10 to 15
bacteria per cubic foot.
– Airborne bacterial concentrations in the operating room
may be reduced by at least 80% with laminar-airflow
systems and even more with personnel-isolator systems.
• Wound contamination rates have been reported to be reduced by
80% with the use of these systems.
• Prophylactic Antibiotic Therapy
– Many studies have shown the effectiveness of prophylactic
antibiotics in reducing infection rates after orthopaedic
– During the first 24 hours, infection depends on the number
of bacteria present.
– During the first 2 hours, the host defense mechanism
works to decrease the overall number of bacteria.
– During the next 4 hours, the number of bacteria remains
fairly constant, with the bacteria that are multiplying and
the bacteria that are being killed by the host defenses
being about equal.
– These first 6 hours are called the “golden period,” after
which the bacteria multiply exponentially.
– Antibiotics decrease bacterial growth geometrically and
delay the reproduction of the bacteria.
– The administration of prophylactic antibiotics expands the
• A prophylactic antibiotic should be safe, bactericidal, and
effective against the most common organisms causing
infections in orthopaedic surgery.
• Because the patient's skin remains the major source of
orthopaedic infection, prophylactic antibiotics should be
directed against the organism most commonly found on
the skin, which is S. aureus, although the frequency of
Staphylococcus epidermidis is increasing.
• This increase in S. epidermidis is important because this
organism has antibiotic resistance and often gives
erroneous sensitivity data.
• Escherichia coli and Proteus organisms also should be
covered by antibiotic prophylaxis.
• In the United States, first-generation cephalosporins
have been favored for many reasons.
• They are relatively nontoxic, inexpensive, and
effective against most potential pathogens in
orthopaedic surgery. Cephalosporins are more
effective against S. epidermidis than are
semisynthetic penicillins.
• Clindamycin can be given if a patient has a history of
anaphylaxis to penicillin.
• Routine use of vancomycin for prophylaxis should be
• A prophylactic antibiotic should be safe, bactericidal, and
effective against the most common organisms causing
infections in orthopaedic surgery.
• Because the patient's skin remains the major source of
orthopaedic infection, prophylactic antibiotics should be
directed against the organism most commonly found on the
skin, which is S. aureus, although the frequency of
Staphylococcus epidermidis is increasing.
• This increase in S. epidermidis is important because this
organism has antibiotic resistance and often gives
erroneous sensitivity data.
• Escherichia coli and Proteus organisms also should be
covered by antibiotic prophylaxis.
• In the United States, first-generation cephalosporins
have been favored for many reasons.
• They are relatively nontoxic, inexpensive, and
effective against most potential pathogens in
orthopaedic surgery.
• Cephalosporins are more effective against S.
epidermidis than are semisynthetic penicillins.
• Clindamycin can be given if a patient has a history
of anaphylaxis to penicillin.
• Routine use of vancomycin for prophylaxis should
be avoided
• Ideally, antibiotic therapy should begin immediately
before surgery (≤2 hours before incision and ideally 30
minutes before skin incision).
• A maximal dose of antibiotic should be given and can
be repeated every 4 hours intraoperatively or whenever
the blood loss exceeds 1000 to 1500 mL.
• Little is gained by extending antibiotic coverage over
72 hours, and the possibility of side effects, such as
thrombophlebitis, allergic reactions, superinfections, or
drug fever, is increased.
• Barie suggested that prophylactic antibiotics should
not be extended past 24 hours even if drains and
catheters are still in place.
• Namias et al. found that antibiotic coverage for
longer than 4 days led to increased bacteremia and
intravenous line infections in patients in intensive
care units.
• Evidence now shows that 24 hours of antibiotic
administration is just as beneficial as 48 to 72 hours.
• Antibiotic irrigation has not found a definite role in
orthopaedic surgery but in vitro test showed benefit.
• When a topical antibiotic is used, it should have
– a wide spectrum of antibacterial activity,
– the ability to remain in contact with normal tissues without
causing significant local irritation,
– low systemic absorption and toxicity,
– low allergenicity,
– minimal potential to induce bacterial resistance,
– availability in a topical preparation that can be easily
suspended in a physiological solution.
• Triple-antibiotic solution (neomycin, polymyxin, and
bacitracin) is most commonly used for wound
irrigation in orthopedics.
• The importance of irrigation and débridement in the
treatment of open fractures has been well
• The principles of elimination of devitalized tissue and
dead space, evacuation of hematomas, and soft-
tissue coverage also can be applied to “clean”
orthopaedic cases.
– The diagnosis of infection may be obvious or obscure.
– Signs and symptoms vary with the rate and extent of bone and
joint involvement.
– The classic triad is fever, swelling, and tenderness or pain.
– Pain probably is the most common symptom.
– Fever is not always a consistent finding.
– Infection also may be as indolent as a progressive backache or
a decrease in or loss of function of an extremity.
– No single test is able to serve as a definitive indicator of the
presence of musculoskeletal infection
• Laboratory Studies
– A complete blood count, including differential and
erythrocyte sedimentation rate (ESR) and C-reactive
protein, should be obtained .
– The white blood cell count is an unreliable indicator of
infection and often is normal even when infection is
– The differential shows increases in neutrophils in acute
– The ESR becomes elevated when infection is present, but
this does not occur exclusively in the presence of
• The ESR also is unreliable in neonates, patients with sickle
cell disease, patients taking steroids, and patients whose
symptoms have been present for less than 48 hours.
• Peak elevation of the ESR occurs at 3 to 5 days after infection
and returns to normal approximately 3 weeks after treatment
is begun.
• C-reactive protein, synthesized by the liver in response to
infection, is a better way to follow the response of infection
to treatment.
• C-reactive protein increases within 6 hours of infection,
reaches a peak elevation 2 days after infection, and returns to
normal within 1 week after adequate treatment has begun.
• Material obtained from aspiration of joint fluid can be sent to
the laboratory for a cell count and differential to distinguish
acute septic arthritis from other causes of arthritis.
• In septic arthritis, the cell count usually is greater than 80,000,
with more than 75% of the cells being neutrophils.
• A Gram stain also should be obtained: in about a third of
bone and joint aspirates positive.
• Intraoperative frozen section also should be obtained in cases
in which infection is suspected.
– A white blood cell count greater than 10 per high-power field is
considered indicative of infection, whereas a count less than 5
per high-power field all but excludes infection
Synovial Fluid Analysis

Disease Leukocytes Neutrophils (%)

Normal <200 <25

Traumatic <5000 <25

Toxic synovitis 5000-15,000 <25

Acute rheumatic fever 10,000-15,000 50

Juvenile rheumatoid arthritis 15,000-80,000 75

Septic arthritis >80,000 >75

• Imaging Studies
• Radiographic studies are helpful, but are not as
useful in the diagnosis of acute bone and joint
infections as they are in following responses to
• Plain radiographs show soft-tissue swelling, joint
space narrowing or widening, and bone destruction.
swelling and loss of normal fat planes around the
involved bone or joint should be used.
• Bone destruction is not apparent on radiographs until
an infection has been present for 10 to 21 days.
– In addition, 30% to 50% of the bone matrix must be lost to
show a lytic lesion on radiographs .
– 5% of plain radiographs were initially abnormal in bone
and joint infections
– fewer than 30% were abnormal at 1 week
– 90% were abnormal at 3 to 4 weeks.
• If initial radiographs are normal in the evaluation of
bone and joint infections, other imaging methods that
show soft-tissue
Culture Studies
• Although blood tests, radiographs, and clinical signs
all give presumptive evidence of an infection, they do
not suffice for an actual bacteriological diagnosis that
would allow development of a treatment plan including
correct antibiotic selection.
• The timing and selection of the culture are crucial.
• Most orthopaedic infections are deep-seated, and
adequate culture specimens are difficult to obtain.
• Despite this, every effort should be made to obtain a culture
specimen before antibiotic therapy is begun.
• Cultures of superficial wounds or sinus tracts should not be
relied on because they have been shown to be unreliable
indicators of deep infection and usually are polymicrobial.
• Swab cultures of a sinus tract give misleading results unless
S. aureus coagulase is the predominant isolate, or unless a
single species is isolated in pure culture.
• The preferred specimen in most bacterial and yeast
infections is aspirated fluid (joint or purulent fluid).
• A deep wound biopsy or a curetted specimen after
cleaning the wound is acceptable.
• In certain bacterial and fungal infections, tissue
biopsy from the edge of the wound is preferable.
• Aerobic and anaerobic swabs are more commonly
used, but aspirated fluid or tissue biopsy is
• use of blood culture vials
intraoperatively for placement of
aspirated fluid is more sensitive than
swab cultures or tissue biopsy.
• Tissue specimens should be placed in
small carbon dioxide–filled containers
to reduce exposure to air.
• Rapid diagnostic procedures that may
aid in initial decision making are
qualitative tests only.
 A Gram stain determines if gram-
• Often, antibiotic therapy is begun before a definitive
culture result is obtained, and the selection of an
antibiotic is based on the most probable causative
bacteria, which varies considerably depending on age
and epidemiological factors.
• S. aureus is most frequently isolated in infectious
• After this, N. gonorrhoeae is more common in adults
younger than 30 years
• H. influenzae type B is more common in children
younger than 2 years.
• These three bacteria, along with various Streptococcus
species, constitute most known isolates in joint
• In contrast, prosthetic joint infections most often are
caused by skin flora, such as S. epidermidis and other
coagulase-negative Staphylococcus and gram-
negative bacilli that are transient skin colonizers.
• The etiological agent for osteomyelitis also depends on
age, epidemiological factors, and whether the
osteomyelitis is primary or secondary.
• S. aureus is the most frequent isolate in osteomyelitis,
but Salmonella organisms have an increased incidence
in patients with sickle cell anemia or neonatal
• Postsurgical osteomyelitis also has a predominance of
skin flora and hospital flora.
– This is where an individual hospital statistical survey of
infections would be beneficial.
• Treatment of an orthopaedic infection may require antimicrobial
and surgical treatment.
• Antibiotic treatment alone may be sufficient, but several principles
should be followed.
– The organism should be accurately identified
– antimicrobial susceptibility determined.
– The correct antibiotic, preferably bactericidal, should be chosen
based on the MIC and SBC.
– The antibiotic must be delivered to the organism in sufficient
concentration to destroy it.
• Surgery may go hand in hand with antibiotic treatment.
• Surgery can accomplish in 1 hour what the body and
antibiotic treatment may require days or weeks to do.
• Débridement reduces the inoculum and removes
necrotic and avascular bone, bacteria, and harmful
bacterial products.
• After 48 hours, the sensitivity should have been
reported, and a correct antibiotic can be chosen.
• If an abscess has formed, surgery is indicated
• Surgery is not always necessary:
– Essential when pus is found on aspiration
– when radiographic changes of osteomyelitis are seen, indicating
pus, necrotic material, and chronic inflammation.
– If these are not present, a trial of antibiotic treatment is
appropriate only after culture material has been obtained.
– If the patient does not respond to antibiotic treatment in 36 to
48 hours, the wrong antibiotic has been chosen, or an abscess
• In the early 1900s, about 20% of patients with
osteomyelitis died, and patients who survived had
significant morbidity.
• Currently, morbidity and mortality from osteomyelitis are
relatively low because of modern treatment methods,
including the use of antibiotics and aggressive surgical
• Nevertheless, osteomyelitis is still difficult to treat
• The key to successful management is early diagnosis
and appropriate surgical and antimicrobial treatment.
• Osteomyelitis is defined as an inflammation of the
bone caused by an infecting organism.
• The infection may be limited to a single portion of the
bone or may involve numerous regions, such as the
marrow, cortex, periosteum, and the surrounding soft
• The infection generally is due to a single organism,
but polymicrobial infections can occur, especially in
the diabetic foot
• Classification of osteomyelitis is based on numerous
– duration
– mechanism of infection
– type of host response to the infection.
• Duration: acute, subacute, or chronic, depending on the
duration of symptoms.
– The time limits defining these classes are arbitrary.
• Mechanism of infection: can be exogenous or
– Exogenous osteomyelitis is caused by open fractures,
surgery (iatrogenic), or contiguous spread from infected
local tissue.
– The hematogenous form results from bacteremia.
• Host response to the disease:
– pyogenic or
– nonpyogenic
– Acute hematogenous osteomyelitis is the most common type of
bone infection and usually is seen in children.
– Acute hematogenous osteomyelitis is more common in males
in all age groups affected.
– It is caused by a bacteremia, which is a common occurrence in
• The causes of bacteremia are many.
–Bacteriological seeding of bone generally is
associated with other factors such as
• localized trauma,
• chronic illness,
• malnutrition, or
• an inadequate immune system.
–In many cases, the exact cause of the disease
cannot be identified
• In children, the infection generally involves the
metaphyses of rapidly growing long bones
– Arteriole Loop / Venous Lakes
– The metaphysis has relatively fewer phagocytic cells than the
physis or diaphysis
• The age distribution of acute hematogenous osteomyelitis
in children is bimodal, generally affecting children
younger than 2 years and children 8 to 12 years old.
• The effects of osteomyelitis in children vary with age
based on differences in blood supply and the
anatomical structure of the bone
I)In children younger than 2 years
• Some blood vessels cross the physis and may allow the
spread of infection into the epiphysis
– infants are susceptible to limb shortening or angular
deformity if the physis or epiphysis is damaged from the
– physis acts as a barrier that prevents the direct spread of a
metaphyseal abscess into the epiphysis..
• A resulting abscess breaks through the thin metaphyseal
cortex, forming a subperiosteal abscess.
• The diaphysis rarely is involved, and extensive
sequestration occurs infrequently except in the most
severe cases
II)In children older than 2 years
– Physis effectively acts as a barrier to the spread of a metaphyseal
– Because the metaphyseal cortex in older children is thicker,
the diaphysis is at greater risk in these patients.
– Spreads into the diaphysis,endosteal blood supply &With a
concurrent subperiosteal abscess ,periosteal blood supply is
• extensive sequestration and chronic osteomyelitis if not properly
III)After the physes are closed
– Acute hematogenous osteomyelitis is much less common.
– Hematogenous seeding of bone in adults usually is seen in a
compromised host.
– Although it can occur anywhere and in any part of the bone,
generally the vertebral bodies are affected.
– In these patients, abscesses spread slowly, and large sequestra
rarely form.
– If localized destruction of cortical bone occurs, pathological
fracture can result
Spread of infection to a contiguous

Spread of infection to a contiguous joint also is affected by the
patient's age.
I)In children younger than 2 years
– common blood supply of the metaphysis and epiphysis crosses
the physis
• can allow spread of a metaphyseal abscess into the epiphysis
and eventually into the joint.
– The hip joint is the most commonly affected in young patients
– however, the physes of the proximal humerus, radial neck, and distal
fibula also are intraarticular, and infection in these areas can lead to septic
arthritis as well.
– In severe infection, epiphyseal separation can occur in children younger
than 2 years.
• II)In older children
– this common circulation is no longer present, and septic arthritis
is rare.
III)After the physes are closed
– infection can extend directly from the metaphysis into the
epiphysis and involve the joint.
– Septic arthritis resulting from acute hematogenous
osteomyelitis generally is seen only in infants and adults.
Epiphyseal separation caused by infection in young
• Staphylococcus aureus is the most common infecting
organism found in older children and adults with
• Gram-negative bacteria have been found to cause an
increasing number of vertebral body infections in adults.
• Pseudomonas is the most common infecting organism
found in intravenous drug abusers with osteomyelitis.
• Fungal osteomyelitis is seen increasingly in chronically
ill patients receiving long-term intravenous therapy or
parenteral nutrition.
• Salmonella osteomyelitis has long been associated with
SS or SC hemoglobinopathies.
– This infection tends to be diaphyseal rather than metaphyseal
• In infants with acute hematogenous osteomyelitis, S.
aureus is still a frequent isolate, but group B
streptococcus and gram-negative coliforms also are
commonly found.
• S. aureus or gram-negative organisms are the usual
cause of orthopaedic infections found in premature infants
undergoing treatment in the neonatal intensive care unit;
more than 40% have multifocal involvement.
• Group B streptococcus is the most likely infecting
organism found in otherwise healthy infants 2 to 4
weeks old.
• Haemophilus influenzae infections occur primarily in
children 6 months to 4 years old.
Evaluation of Acute Hematogenous Osteomyelitis

• History and physical examination

• Laboratory tests: white blood cell count, erythrocyte
sedimentation rate, C-reactive protein
• Plain radiographs
• Technetium-99m bone scan ± MRI
• Aspiration for suspected abscess
• The white blood cell count often is normal, but the
erythrocyte sedimentation rate and C-reactive
protein level usually are elevated.
• The C-reactive protein is a measurement of the acute
phase response and is especially useful in
monitoring the course of treatment of acute
osteomyelitis because it normalizes much sooner
than the erythrocyte sedimentation rate.
• Standard radiographs generally are negative, but
may show soft-tissue swelling.
• Skeletal changes, such as periosteal reaction or bony
destruction, generally are not seen on plain films until
10 to 12 days into the infection.
• Technetium-99m bone scans can confirm the
diagnosis 24 to 48 hours after onset in 90% to 95% of
• Gallium scans and indium-111–labeled leukocyte scans
also can aid in diagnosis when used in conjunction
with technetium scanning.
• MRI can show early inflammatory changes in bone
marrow and soft tissue.
• Radiograph showing bony
• Bone scan showing increased uptake in area of
• The causative organism can be identified in
approximately 50% of patients through blood
• Bone aspiration usually gives an accurate
bacteriological diagnosis and should be
performed with a 16-gauge or 18-gauge needle
in the area of maximal swelling and tenderness,
usually the long bone metaphysis.
• The subperiosteal space should be aspirated first by
inserting the needle to the level of the outer cortex, If no
purulent material or fluid is encountered, the needle is
placed through the cortex to obtain a marrow aspirate.
• Patients with suspected osteomyelitis of the hip or
vertebra should have CT- or ultrasound-assisted
• The sample is sent to the laboratory for Gram stain,
culture, and sensitivities.
• In 1983, Nade proposed five principles for the treatment
of acute hematogenous osteomyelitis:
1) an appropriate antibiotic is effective before pus formation
2) antibiotics do not sterilize avascular tissues or abscesses, and such areas
require surgical removal
3) if such removal is effective, antibiotics should prevent their
reformation, and primary wound closure should be safe
4) Surgery should not damage further already ischemic bone and soft
5) antibiotics should be continued after surgery.
• The two main indications for surgery in acute
hematogenous osteomyelitis are
– (1) the presence of an abscess requiring drainage and
– (2) failure of the patient to improve despite appropriate
intravenous antibiotic treatment.
• The objective of surgery is to
– drain any abscess cavity
– remove all nonviable or necrotic tissue.
• When a subperiosteal abscess is found in an infant,
several small holes should be drilled through the
cortex into the medullary canal.
– If intramedullary pus is found, a small window of bone is
– The skin is closed loosely over drains, and the limb is splinted.
• The limb is protected for several weeks to prevent
pathological fracture.
• Intravenous antibiotics should be continued
• The duration of antibiotic therapy is controversial;
however, the current trend is toward a shorter course of
intravenous antibiotics, followed by oral antibiotics
and monitoring of serum antibiotic levels.
Drainage of Acute Hematogenous
• Use a tourniquet whenever possible.
• Make an incision 5 to 7.5 cm long over the affected part
• Incise the periosteum longitudinally; it may be elevated
from bone by a subperiosteal abscess, and if so, the
compressed pus will escape.
• If no abscess is found, gently elevate the periosteum 1.5
cm on each side.
• Try to strip as little periosteum as possible; the more
periosteum that is stripped, the more an already
compromised blood supply to bone is damaged
• Drill several holes 4 mm in diameter through the cortex
into the medullary canal, regardless of whether a
subperiosteal abscess is present.
• If pus escapes through these holes, use a drill to outline a
cortical window 1.3 × 2.5 cm, and remove the cortex
with an osteotome.
• Evacuate the intramedullary pus, and gently remove
any necrotic tissue.
• Irrigate the cavity with at least 3 L of saline with a
pulsatile lavage system.
• Antibiotics may be placed in the irrigation solution.
• Close the skin loosely over drains, but do not close the
wound if this produces excessive tension on the skin.
– A long leg posterior plaster splint is applied with the foot in a
neutral position, the ankle at 90 degrees, and the knee at 20
degrees of flexion.
– When the wound has healed, the splint is removed, and
protected weight bearing with crutches is begun.
– The patient is placed on antibiotics based on culture
– Generally, a 6-week course of intravenous antibiotics is given.
– Orthopaedic and infectious disease follow-up is continued for at
least 1 year.
subacute hematogenous
• subacute hematogenous osteomyelitis has a more insidious
onset and lacks the severity of symptoms, which makes the
diagnosis of this disorder difficult.
• The indolent course of subacute osteomyelitis is thought to
be the result of
– Increased host resistance
– decreased bacterial virulence
– the administration of antibiotics before the onset of symptoms.
• Inflammation to persist in bone without producing significant
signs or symptoms
• Systemic signs and symptoms are minimal.
• Temperature is only mildly elevated if at all.
• Mild-to-moderate pain is one of the only consistent signs
suggesting the diagnosis.
• White blood cell counts generally are normal.
• The erythrocyte sedimentation rate is elevated in only 50%
of patients
• blood cultures usually are negative.
• Even with an adequate bone aspirate or biopsy specimen, a
pathogen is identified only 60% of the time.
• S. aureus and Staphylococcus epidermidis are the
predominant organisms identified in subacute
• Histologically, subacute osteomyelitis is characterized by a
large amount of granulation tissue, chronic
inflammatory cells, and new bone formation.
• Subacute osteomyelitis is observed as a cavitary or
neoplastic-like lesion.
• Cavitary lesions usually occur in the metaphysis and/or
– Radiographs show a radiolucent area surrounded by a thin rim
of reactive bone formation.
• Neoplastic-like subacute osteomyelitis is most often
seen in the diaphysis of long bones or in atypical
locations such as the clavicle.
– Radiographs show periosteal elevation and new bone
Gledhill and modified by Roberts radiographic classification of subacute
hematogenous osteomyelitis
Typ Gledhill Classification Robert et al Classification Differential
e Diagnosis
I Solitary localized zone of radiolucency Ia—Punched-out radiolucency Langerhans' cell
surrounded by reactive new bone Ib—Punched-out radiolucent lesion histiocytosis
formation with sclerotic margin Brodie abscess

II Metaphyseal radiolucencies with cortical — Eosinophilic granuloma;

osteogenic sarcoma
III Cortical hyperostosis in diaphysis; no Localized cortical and periosteal Osteoid osteoma
onion skinning reaction
IV Subperiosteal new bone and onion skin Onion skin periosteal reaction Ewing sarcoma
V — Central radiolucency in epiphysis Chondroblastoma

VI — Destructive process involving Tuberculosis;

vertebral body osteogenic sarcoma
• Ross and Cole recommended biopsy and curettage followed
by treatment with appropriate antibiotics for all lesions that
seem to be aggressive.
• For lesions that seem to be a simple abscess in the
epiphysis or metaphysis, biopsy is not recommended.
– These lesions, which are characteristic of subacute
hematogenous osteomyelitis, should be treated with
intravenous antibiotics for 48 hours followed by a 6-week
course of oral antibiotics.
• Ross and Cole had an 87% success rate with this
treatment regimen.
• Hamdy et al. reviewed 44 patients with subacute
osteomyelitis and found no difference in outcome after
conservative and surgical treatment for benign-
appearing lesions.
• They suggested open biopsy and curettage only for
aggressive-appearing lesions or for lesions that do not
respond to antibiotic treatment alone
• Brodie Abscess
– A Brodie abscess is a localized form of subacute osteomyelitis
that occurs most often in the long bones of the lower extremities
of young adults.
– Before physeal closure, the metaphysis is most often affected.
– In adults, the metaphyseal-epiphyseal area is involved.
– Intermittent pain of long duration is the presenting complaint, along
with local tenderness over the affected area.
• On plain radiographs, a Brodie abscess generally
appears as a lytic lesion with a rim of sclerotic bone,
but it can have a markedly varied appearance.
• Careful evaluation of plain films is mandatory because a
Brodie abscess can be easily mistaken for a variety of
• Organisms of low virulence are believed to cause the
• S. aureus is cultured in 50% of patients
• In 20%, the culture is negative.
– This condition often requires an open biopsy with curettage to
make the diagnosis.
• The wound should be closed loosely over a drain
Brodie abscess in right distal tibial epiphysis of 3-year-old child.
Chronic Hematogenous Osteomyelitis
• Patients with chronic hematogenous osteomyelitis typically
have had symptoms for several weeks to several months.
• Systemic symptoms may subside, but one or more foci in
the bone may contain purulent material, infected
granulation tissue, or a sequestrum .
• Intermittent acute exacerbations may occur for years and
often respond to rest and antibiotics.
• The hallmark of chronic osteomyelitis is infected dead
bone within a compromised soft-tissue envelope.
• The infected foci within the bone are surrounded by
sclerotic, relatively avascular bone covered by a
thickened periosteum and scarred muscle and
subcutaneous tissue.
– This avascular envelope of scar tissue leaves systemic
antibiotics essentially ineffective.
• Sequestra often are present.
• A sinus tract to the skin may occur.
• This tract decompresses purulent drainage from the
osteomyelitis but also is a portal for secondary seeding of
the bone.
• In less developed countries, chronic hematogenous
osteomyelitis in children is relatively common and typically
follows a delay in treatment.
• In industrialized countries, the condition is uncommon in
children and most often occurs in adults, either secondary
to open fracture or by direct extension from foot ulcer in
patients with diabetes mellitus.
• Typical radiographic findings include areas of
radiolucency that indicate bone destruction and
radiodense sequestra surrounded by a radiolucent area
of fibrous tissue.
• Secondary infections are common, and sinus track
cultures usually do not correlate with cultures
obtained at bone biopsy.
• Cierny and Mader developed a classification
– based on physiological and anatomical criteria
– to determine the stage of infection.
• Anatomical Type
• Type I [medullary] lesion, is characterized by endosteal
• Type II [superficial] osteomyelitis is limited to the surface
of the bone
– Cortical surface infected because of coverage defect.
• Type III [localized] infection involving a stable, well-
demarcated lesion characterized by full-thickness
cortical sequestration and cavitation.
– In this type, complete débridement of the area would not lead
to instability.
• Type IV [diffuse] osteomyelitic lesion that creates
mechanical instability, either at presentation or after
appropriate treatment
– Features of I, II, and III plus mechanical instability before or
after débridement
• Physiological Class
– A host- [Normal] Immunocompetent with good local
– B host- [Compromised] Local (L) or systemic (S)
factors that compromise immunity or healing
– C host- [Prohibitive] Minimal disability, prohibitive
morbidity anticipated, or poor prognosis for cure.
• the results of treatment are potentially more
damaging than the presenting condition.
• Diagnosis
• The diagnosis of chronic osteomyelitis is based on
clinical, laboratory, and imaging studies.
• The “gold standard” is to obtain a biopsy specimen for
histological and microbiological evaluation of the infected
• Physical examination should focus on the integrity of the
skin and soft tissue, determine areas of tenderness,
assess bone stability, and evaluate the neurovascular
status of the limb.
• Laboratory studies generally are nonspecific and give no
indication of the severity of the infection.
• Erythrocyte sedimentation rate and C-reactive protein are
elevated in most patients, but the white blood cell count is
elevated in only 35%.
• Multiple imaging studies are available to evaluate chronic
osteomyelitis; however, no technique can absolutely
confirm or exclude the presence of osteomyelitis.
• Plain radiographs :-Signs of cortical destruction and
periosteal reaction strongly suggest the diagnosis of
• Plain tomography is not as readily available as it was
previously; however, if it can be obtained, it is extremely useful
in the detection of sequestra.
• Sinography can be performed if a sinus track is present and
can be a valuable adjunct to surgical planning
• Isotopic bone scanning is more useful in acute osteomyelitis
than in the chronic form because the former typically has
negative plain films.
• Technetium-99m bone scans, which show increased uptake in
areas of increased blood flow or osteoblastic activity, tend
to lack specificity
• The “gold standard” in the diagnosis of osteomyelitis is a
biopsy with culture and sensitivity.
• A biopsy is not only useful in establishing a diagnosis, but
also is helpful in determining the proper antibiotic regimen.
• Typically, staphylococcal species are identified, especially
in posttraumatic infections.
• Anaerobes and gram-negative bacilli are commonly
• Treatment
– Chronic osteomyelitis generally cannot be eradicated without
surgical treatment.
– Antibiotics alone rarely can eradicate the infection for numerous
Bacteria are able to:
– adhere to orthopaedic implants and bone matrix through various
– hide intracellularly.
– form a slimy coat that protects them from phagocytic cells and
• Surgery for chronic osteomyelitis consists of
– Sequestrectomy
– resection of scarred and infected bone and soft tissue.
• The goal of surgery is eradication of the infection by
achieving a viable and vascular environment.
• Radical débridement may be required to achieve this goal.
• Inadequate débridement may be one reason for a high
recurrence rate in chronic osteomyelitis
Sequestrectomy and Curettage for Chronic

• Sequestrectomy and curettage require more time to perform

and result in considerably more blood loss than an
inexperienced surgeon would anticipate.
• Consequently, appropriate preparation should be made
before surgery.
• Sinus tracks can be injected with methylene blue 24
hours before surgery to make them easier to locate and
• Expose the infected area of bone, and excise all sinus
tracks completely.
• Incise the indurated periosteum, and elevate it 1.3 to 2.5 cm
on each side.
• Use a drill to outline a cortical window at the appropriate
site, and remove it with an osteotome.
• Remove all sequestra, purulent material, and scarred and
necrotic tissue.
• If sclerotic bone seals off a cavity within the medullary
canal, open it into the canal in both directions to allow
blood vessels to grow into the cavity.
– A high-speed burr helps to locate the demarcation between
healthy and ischemic bone
• After removing all suspicious matter, carefully excise the
overhanging edges of bone, and avoid leaving a cavity
or dead space.
• If a cavity cannot be filled by the surrounding soft tissue,
a local muscle flap or a free tissue transfer can be used
to obliterate the dead space.
• If there is a nonunion present with any bony
instability, the bone must be stabilized,
preferably with an Ilizarov-type external
• If possible, close the skin loosely over
drains, and ensure that no excessive skin
tension is present.
• If closure is impossible, pack the wound
open loosely or apply an antibiotic bead
pouch, and plan for delayed closure or skin
grafting at a later time.
• Appropriate antibiotics should be used
• The Ilizarov fixator is a circular frame which surrounds
your limb and is attached via high tensioned wires or
thicker pins called half pins.
• Wires are inserted through your soft tissues and bone and
are attached and tensioned on each side to the rings.
• Half pins are stainless steel pins attached to one side of
the frame and are used when higher strength fixation is
• Each frame is individually designed for each patient and
depends on the aim of treatment e.g. limb deformity
correction, lengthening, fracture healing or joint fusion.
• The limb is splinted until the wound has healed, and then it is
protected to prevent pathological fracture.
• Antibiotic treatment is continued for a prolonged period
and should be monitored by an infectious disease
• Bony and soft-tissue defects must be filled to reduce the
chance of continued infection and loss of function.
– Several techniques have been described for the management of
such defects and have proved successful when properly
performed, but they require meticulous surgical technique.
• The methods described to eliminate this dead space are
– bone grafting with primary or secondary closure
– use of antibiotic polymethyl methacrylate (PMMA) beads as a
temporary filler of the dead space before reconstruction
– local muscle flaps and skin grafting with or without bone
– microvascular transfer of muscle, myocutaneous, osseous, and
osteocutaneous flaps
– the use of bone transport (Ilizarov technique).
• Sclerosing osteomyelitis is a chronic form of disease in which the
bone is thickened and distended, but abscesses and sequestra are
• The disease affects children and young adults.
• Its cause is unknown, but it is thought to be an infection caused by a
low-grade, possibly anaerobic bacterium.
• Patients report intermittent pain of moderate intensity and usually of
long duration.
• Swelling and tenderness over the affected bone may be found.
• Radiographs show an expanded bone with generalized sclerosis.
• Biopsy specimens
show only chronic,

• Because the involucrum is sometimes insufficient, the shaft of a long

bone may fracture during the acute or subacute stage of
osteomyelitis before immobilization has been started.
• Later, as a result of becoming dense and brittle, the bone also may
• Whatever the cause of the fracture, all operations necessary to
combat the infection should be carried out thoroughly, and bone
fragments are then realigned and immobilized as with any other
• Plates and medullary nails have been used to fix infected fractures,
but they should be avoided if possible.
• External fixation or cast immobilization usually is preferred.
• Chronic recurrent multifocal osteomyelitis is an inflammatory bone
disease characterized by an insidious onset of mild-to-moderate
pain with signs of inflammation over the affected parts, which tend to
• The disease most often affects the metaphysis of long bones,
especially the tibia, femur, and clavicle
• Radiographically, the bony lesions are predominantly lytic and
bilaterally symmetrical. Varying degrees of sclerosis may be
• No effective treatment for chronic recurrent multifocal osteomyelitis
has been found, and if the results of cultures are negative, antibiotic
treatment is not indicated.
• Nonsteroidal antiinflammatory medication may help relieve pain

• Puncture wounds to the foot frequently occur in children.

• The association of Pseudomonas osteomyelitis with
puncture wounds to the foot is well documented in the
literature; however, it is relatively rare considering the total
number of such wounds seen by physicians.
• Pain is experienced initially from the puncture wound, but this
usually diminishes.
• In cases of osteomyelitis, pain and swelling increase 2 to 4
days after the injury.
• Treatment consists of surgical drainage,
curettage when indicated, and appropriate
antibiotic treatment.
• Jacobs et al. suggested that 7 days of
intravenous antibiotics after surgical
débridement is adequate, although other
authors recommended a longer antibiotic
• Anaerobic bacteria are recognized increasingly as an
important cause of osteomyelitis
• Anaerobic soft-tissue infections usually start in injured or
ischemic tissue.
• Frequently, a putrid discharge and gas production are present, and
extensive tissue necrosis tends to burrow through
subcutaneous and fascial planes.
• Anaerobic infections have been frequently associated with
diabetic gangrene.
• Treatment is by surgical drainage and resection of the necrotic
tissue, combined with the use of appropriate antibiotics as
determined by culture and sensitivity studies
Distal Third of the Femur
• Chronic osteomyelitis of the distal third of the femur is
difficult to treat.
• Because the periosteum may become completely separated
posteriorly by a subperiosteal abscess, this part of the
bone may lose most of its blood supply, and sinuses often
• A mass of scar tissue forms that interferes with
revascularization of the bone; the scar tissue is relatively
inaccessible surgically because of the proximity of large
vessels and nerves.
Make a lateral longitudinal incision on
the distal third of the thigh, beginning 5 cm
proximal to the joint line of the knee, and
extend it proximally for 10 cm.
Incise the iliotibial band, retract the
vastus lateralis muscle anteriorly, and
expose the femur.
Avoid opening the knee joint in the distal
end of the incision.
 Confine the operation to the lateral and
posterolateral surfaces of the bone, or the
suprapatellar bursa may be opened, and the knee
joint could become contaminated.
 Use a drill to outline a cortical window on the
posterolateral surface of the bone, and remove
the window with an osteotome.
 Enter the medullary canal proximal to the
metaphysis, and place the window so that pus
drains posteriorly.
 Remove only necrotic and infected matter.
 Close the wound loosely over rubber drains, which
exit through separate incisions and permit direct
posterolateral drainage.
• The limb is splinted with the knee straight
until the wound has healed, and it is
protected during ambulation to prevent
pathological fracture.

Amputation is performed infrequently for osteomyelitis.
• The prevalence of malignancy arising from chronic osteomyelitis has
been reported to be 0.2% to 1.6% of cases.
– Most of these are squamous cell carcinoma arising from a sinus track, but
reticulum cell carcinoma, fibrosarcoma, and other malignancies have been
– Amputation is the most reliable means of treating cases of osteomyelitis
associated with malignant change.
• Arterial insufficiency, major nerve paralysis, or joint contractures
and stiffness that make a limb nonfunctional are indications for
septic arthritis
• Acute septic arthritis results from bacterial invasion of
a joint space, which can occur through
 Hematogenous spread
 direct inoculation from trauma or surgery
 contiguous spread from an adjacent site of
osteomyelitis or cellulitis.
• Despite in-depth research into the pathophysiology
and treatment of acute septic arthritis, the morbidity
and mortality are still significant, especially in
patients at the extremes of age.
• The bacterial strain and the individual's immune
system determine whether a septic joint or a less
severe infection develops.
• Even with currently available antibiotics and treatment
regimens, serious complications may result.
• Delay in diagnosis and failure to begin treatment
promptly are the most common reasons for late
complications of infection.
• Acute septic arthritis can occur at any age, but
young children and elderly adults are most
susceptible, especially if they have an already
abnormal joint from previous trauma or from
conditions such as hemophilia, osteoarthritis,
or rheumatoid arthritis.
• Immune compromise for any reason and
diseases such as cancer, diabetes,
alcoholism, cirrhosis, and uremia increase the
risk for infection
• Typical symptoms of septic arthritis include acute
onset of swelling and pain in the affected joint
accompanied by malaise and fever (temperature of
• Children with the condition frequently limp, stop
walking, or refuse to move the upper extremity
• Patients hold the affected joint in a comfortable
position that accommodates maximum distention,
and attempts to move the joint cause intense pain and
• Typical postures of involved joints include the hip held
in flexion, abduction, and external rotation; the
knee in 20° to 40° flexion; the ankle in 10° to 20°
• Septic arthritis occurs most frequently in
adults; however, the most serious sequelae
from infection occur in children, especially
if a hip joint is involved, and treatment has
been delayed.
• Age-dependent anatomical variables may be
responsible for the serious complications in
children, such as destruction of the
epiphysis and associated osteonecrosis
from increased intracapsular pressure and
septic effusion
• The lower extremity weight bearing joints are
• Acute septic arthritis can be difficult to
diagnose in neonates because the
inflammatory response is blunted, and signs
such as fever, swelling, erythema, and pain
may be minimal or lacking.
• The only finding in a neonate may be
infection at another site (e.g., the umbilical
catheter), irritability, failure to thrive,
asymmetry of limb position, or displeasure
at being handled
Organisms Found in Common Clinical Settings of Infectious

Clinical Factor Organism

Patient Age

Neonate Staphylococcus aureus

<2 y Haemophilus influenzae, S. aureus

>2 y S. aureus

Young adults (healthy, sexually active) Neisseria gonorrhoeae

Elderly adults S. aureus (50%), streptococci, gram-

negative bacilli
Structural Abnormalities

Aspiration or injection S. aureus

Trauma Gram-negative bacilli, anaerobes, S.

Early infection S. epidermidis

Late infection Gram-positive cocci, anaerobes

Medical Conditions

Injecting drug use Atypical gram-negative bacilli (e.g.,

Pseudomonas species)
Rheumatoid arthritis S. aureus

Systemic lupus erythematosus, sickle Salmonella species

cell anemia
Hemophilia S. aureus (50%), streptococci, gram-
negative bacilli
Immunosuppression S. aureus, Mycobacterium species,
• S. aureus is the leading cause in all ages followed by
group A streptococcus and Enterobacter
• Neisseria gonorrhoeae causes approximately 75% of
septic arthritis cases in healthy, sexually active young
adults, although a septic joint develops in less than
3% of patients infected with N. gonorrhoeae.
• In the first few days of infection, radiographs
usually are normal; however, they may be
helpful in that they may show
soft-tissue swelling
displacement of the fat pad
joint space widening from localized edema.
As the infection progresses, joint space
narrowing from the destruction of cartilage may
become evident.
• Radiographs may be used to monitor the response to
treatment and to detect inadequately treated stages of
the disease, such as generalized joint destruction,
osteomyelitis, osteoarthritis, joint fusion, or bone
• Ultrasonography, in contrast to radiographs, can be
used to detect even small collections of fluid deep
in the joints.
• Non–echo-free effusions from clotted hemorrhagic
collections are characteristic of a septic joint.
• Ultrasonography can be used to guide initial joint
aspiration and drainage and to monitor the status of
intraarticular compartments, joint capsules, bone
surface, or adjacent soft tissues.
• It is noninvasive, inexpensive, and easy to use, but is
heavily operator-dependent.
• CT, MRI, and bone scans also may be obtained to
diagnose septic arthritis; however, these tests are not
• Hematogenous infection of a joint begins with a
systemic bacteremia that ultimately invades the
synovial cartilaginous junction from the
intravascular space and spreads throughout the
synovium and synovial fluid.
• Why joints are affected and other vulnerable organs
are not is unclear; however
 collagen receptors found on Staphylococcus
aureus (the most common nongonococcal infecting
cause of hematogenous septic arthritis) may play a
 the lack of a limiting basement membrane in the
capillaries of synovium may allow intravascular
synovial fibroblasts inhibit
phagocytosis of bacteria.
• Soon after the synovium has been
infected, it becomes hyperemic and
infiltrated with polymorphonuclear
leukocytes that rapidly increase over the
next several days.
• Histologically, the appearance changes
from acute to chronic inflammation with
an increase in mononuclear leukocytes
and lymphocytes, which become the
predominant inflammatory cells by 3
• Destruction of the articular cartilage, which
results from degradation of ground substance, is
apparent 4 to 6 days after infection.
• Depletion of ground substance begins
approximately 2 days after inoculation and is
caused by activation of enzymes from the
acute inflammatory response, production of
toxins and enzymes by bacteria, and
stimulation of T lymphocytes during the
delayed immune response.
• Complete destruction of articular cartilage
occurs at approximately 4 weeks. Joint
dislocation or subluxation and osteomyelitis also
may occur.
• Nade suggests three essential principles in
the management of acute septic arthritis:
• (1) The joint must be adequately drained
• (2) antibiotics must be given to diminish the
systemic effects of sepsis
• (3) the joint must be rested in a stable
• If a joint is suspected of being infected,
aspiration with a large-bore needle should
be done before antibiotic therapy is
• Careful skin preparation before aspiration is
mandatory, and the fluid obtained should be
sent for immediate Gram staining, culture,
cell counts, and crystal analysis
• Although the orthopaedic literature reports
a low rate (18% to 48%) for culture-
negative septic arthritis, Lyon and Evanich
found that 70% of children who had
clinical findings of septic arthritis had
negative synovial fluid cultures.
• They recommended aggressive treatment
in children regardless of whether a
causative organism is identified.
• Initial antibiotic treatment is empirically
based on the patient's age and risk factors
Likely Antibacterial
Subgroup Pathogens Selection Daily Dosage Doses/Day
Neonates Staphylococcus Nafcillin and 100 mg/kg 4
aureus cefotaxime or
Enterobacteriac 150 mg/kg 3
Group B 7.5 mg/kg 3
Children <5 y S. aureus Nafcillin or 150 mg/kg 4
Haemophilus 150 mg/kg 3
influenzae type

Children ≥5 y S. aureus Nafcillin 150 mg/kg 4

Adolescents and Neisseria Ceftriaxone or cefotaxime 1-2 g 1
adults with possible gonorrhoeae
S. aureus 3-6 g 3

Adults unlikely to have S. aureus Nafcillin and cefotaxime or 6-12 g 6

STD gentamicin
Streptococci 3-6 g 3

Enterobacteriaceae 5 mg/kg 3

Adults with joint Staphylococcus Vancomycin and ceftazidime 2 g 2

prosthesis or infection epidermidis or aztreonam or ciprofloxacin
after procedure or or gentamicin
S. aureus 3-6 g 3

Streptococci 3-6 g 3

Gram-negative 800 mg 2
bacilli including
Pseudomonas 5 mg/kg 3
Antibacterial Therapy of Bacterial Arthritis after Culture and Susceptibility Results

Primary Suitable Orally

Organism Antibacterial Alternative Administered “Equivalent”
MSSA Nafcillin Cefazolin, Dicloxacillin, cephalexin,
clindamycin, clindamycin
MRSA Vancomycin Teicoplanin Co-trimoxazole (trimethoprim
sulfamethoxazole) ± rifampicin
(rifampin), ciprofloxacin ±
rifampicin, fusidic acid
Streptococcus Benzylpenicillin Cefazolin, Phenoxymethylpenicillin
pyogenes (penicillin G) cefotaxime, (penicillin V), cephalexin,
clindamycin cefuroxime axetil, cefixime,
Neisseria Ceftriaxone Cefotaxime Amoxicillin-clavulanic acid,
gonorrhoeae cefuroxime axetil, cefixime
Haemophilus influenzae
β-lactamase– Ampicillin Cefotaxime Amoxicillin, co-
negative trimoxazole,
cefaclor, cefuroxime
axetil, cefixime

β-lactamase– Cefotaxime Co-trimoxazole Co-trimoxazole,

positive cefaclor, cefuroxime
axetil, cefixime,

Enterobacteriaceae As per susceptibility

of isolate
Pseudomonas Piperacillin, Ceftazidime or Ciprofloxacin
aeruginosa mezlocillin, or aztreonam + an
ticarcillin + an aminoglycoside
• A controversy continues about the advantages of
open surgical drainage, arthroscopic
drainage, and multiple aspirations.
• Excellent results have been reported with all
three methods.
• Except for gonococcal arthritis, which usually
can be treated effectively with antibiotics,
drainage should be performed for all other
infectious arthritis.
• Adjuvant therapies, such as synovectomy,
salicylate administration, and constant
passive motion, although theoretically helpful,
have not been shown to influence the results.
• We believe that if the diagnosis is made early and the
involved joint is superficial, such as the elbow or ankle,
aspiration should be performed and repeated if necessary.
• Appropriate antibiotics should be administered, and the joint
should be splinted in a position of function.
• The patient should be observed for a decrease in pain,
swelling, and temperature and for improved joint
• Infections caused by less virulent organisms usually
respond promptly to treatment.
• If the response is not favorable and repeat aspiration does
not show a decrease in the synovial leukocyte count
within 24 to 48 hours, open surgical drainage is
• If purulent material is deeply situated in a joint, such as the
shoulder or hip, open surgical drainage should be done.
• As the infection resolves, therapy to restore normal joint
function is begun, including functional splinting initially
to prevent deformity, isometric muscle strengthening,
and active range-of-motion exercises.