Prevention and Management of Acute Musculoskeletal Infections
Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
Copyright ©2001 Lippincott Williams & Wilkins
> Table of Contents > 3 – Prevention and Management of Acute Musculoskeletal Infections
3
Prevention and Management of Acute Musculoskeletal Infections
Prevention of infection is the key to successful orthopaedic surgery.
Meticulous attention to aseptic technique in the operating room, proper
skin preparation and surgical scrub, the use of modern gown and mask
techniques, planning the operation to shorten the time the tissues are
exposed to air, laminar flow air, and prophylactic antibiotics (1,2,3,4)
are all important in the prevention of infection. None, however, is as
critical as meticulous debridement of wounds and the careful handling
of tissues to prevent cell death (4). When
infection does occur following an operation or from hematogenous
origin, early diagnosis and prompt effective treatment can prevent
disastrous complications.
Meticulous attention to aseptic technique in the operating room, proper
skin preparation and surgical scrub, the use of modern gown and mask
techniques, planning the operation to shorten the time the tissues are
exposed to air, laminar flow air, and prophylactic antibiotics (1,2,3,4)
are all important in the prevention of infection. None, however, is as
critical as meticulous debridement of wounds and the careful handling
of tissues to prevent cell death (4). When
infection does occur following an operation or from hematogenous
origin, early diagnosis and prompt effective treatment can prevent
disastrous complications.
I. Prevention
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Elective surgery. Refer to Chap. 1, III, and Chap. 10, I, for techniques described for the prevention of operative and posttraumatic infections.
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Early diagnosis
-
Whenever a patient’s postoperative or
postinjury status does not follow the normal or expected course, the
surgeon should be alert to the possibility of infection. A respiratory problem
such as mild atelectasis may be a cause for persistent postoperative
temperature elevation (this is especially common in patients who
smoke), but such a potential diagnosis should not lull the surgeon into
complacency. Wound infection may be the cause, or the two could be
concurrent. Large hematomas can themselves be the cause of low-grade
fever, but hematomas also represent the best culture media for bacteria
and hence should be avoided or evacuated if present. Always obtain a
culture of any evacuated hematoma. -
When there is concern regarding a wound infection, inspect the wound and document the findings
at least daily, using sterile technique. Inspect the wound for
swelling, erythema, and serous or bloody drainage. Culture any
drainage. Tense skin, erythema, and abnormal tenderness or swelling
frequently are signs of low-grade inflammation and infection. -
If the patient does not respond promptly to treatment or if the wound remains indurated, then aspiration should be carried out using aseptic technique with a large needle inserted into the wound area but away from the suture line.
-
A low-grade fever in patients who have
had antibiotics is not uncommon. In such instances, the temperature
rarely exceeds 37.8°C (100°F) and may show a mild afternoon elevation.
The patient frequently feels lethargic and has mild anorexia. If the low-grade inflammatory process
involves a joint, the patient complains of pain to passive motion of
the joint, which should alert the surgeon to the possibility of a
septic joint. -
Be alert to the possibility of infection. Establish the diagnosis through cultures
whenever possible, and treat the infection aggressively. If in doubt,
the best course is generally to return the patient to the operating
room and open the wound, irrigate and debride it to remove hematoma and
necrotic wound tissue, and reclose the wound using the most “tissue
friendly” suture technique (see Chap. 10). Consultation with another experienced surgeon can be helpful.
-
-
Treatment.
Once the diagnosis of a musculoskeletal infection has been established,
treatment proceeds as for acute osteomyelitis or septic arthritis. The
principles of
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treatment
include removal of all dead tissue and any hematoma along with
appropriate antibiotic therapy. The wound is nearly always left open
for secondary closure except when the infection involves a joint. If
the wound is closed, a suction drain is mandatory.
II. Bone and Joint Infections
-
Bones and joints represent special
problems for the host defense mechanisms. Normal bone has an excellent
blood supply, although there is slowing of the circulation in the
metaphyseal region in children. Once pus forms under pressure, the vascular supply to bone is lost
because of its rigid structure, resulting in areas of infected,
devitalized bone. Septic emboli in bone or vascular thrombosis can
cause additional devascularization. Ligaments and tendons are
relatively avascular structures and do not handle infection well.
Joints, with their avascular cartilage and menisci, pose a particular
problem. Local phagocytic function can be deficient, and it is often
difficult to ensure adequate delivery of humeral factors (antibodies,
opsonins, complement). In addition to the direct destructive effect of
cell breakdown on cartilage, the pus under pressure interferes with
cartilage nutrition and blood supply to the periarticular structures.
At particular risk is the epiphyseal blood supply, and avascular
neurosis may be the result. Antibiotics can inhibit or cure an
infection only when they can reach the infecting organism in
bacteriostatic or bactericidal concentrations. Infections producing
pressure in a bone or joint as well as in relatively avascular tissues
can impede or prevent antibiotics from reaching the primary site of
infection. -
An acute infection of bone (hematogenous osteomyelitis),
in its earliest phase, is a medical disease and can often be cured by
prompt, appropriate antibiotic therapy. However, the time between
initial infection and bone infarct is often short. If effective
treatment is delayed and devascularization of the involved tissues
results, then surgical treatment is a necessary adjunct to the
antibiotic therapy. Even under the best of circumstances, late
treatment (perhaps as early as 48 hours after the infection starts) may
result in the loss of or abnormal function of the joint. Thus,
appropriate antibiotic therapy must be initiated as early as possible.
Appropriate therapy requires knowledge of the etiologic agent and its
sensitivities. Every effort should be made to obtain a bacterial
culture and determine sensitivity. Once the culture specimen is
obtained, it is important to institute antibiotic therapy based on a
probable diagnosis using the most effective broad-spectrum antibiotics. -
Diagnosis
-
The earliest symptom or sign that may help differentiate a bone or joint infection is usually pain or localized tenderness in the periarticular region.
In the infant, refusal to move or use an extremity may be noted first.
The cardinal signs of infection redness, heat, and swelling may appear
later than the pain and tenderness, or not at all. When examining a
child with a fever of unknown origin, note any pain or alteration of
the normal range of motions of a joint and carefully palpate all
metaphyseal areas to determine local tenderness. Roentgenograms are of
little value in making the early diagnosis, although careful comparison
with the opposite side may show abnormal soft-tissue shadows.
Roentgenographic evidence of bone or joint destruction is seen during
the chronic phase of the disease. Osteomyelitis should always be
included in the differential diagnosis for a patient with the
radiographic appearance of a bone tumor (5). Radioisotopic bone scanning, especially indium imaging, is helpful in early localization of bone infection (6). Many authorities have advocated the use of magnetic resonance imaging in the diagnosis of osteomyelitis (7,8,9,10),
but clinical context is of paramount importance in the evaluation of
any abnormal findings. Erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP) serum levels are useful in laboratory
evaluations (11,12,13,14). -
Identification of the infecting organism
is essential. In the early stages of the disease, particularly if there
is a spiking temperature, blood cultures can often yield the organism.
If acute metaphyseal tenderness is present, then the organism can
frequently be obtained by inserting a needle into the site of maximum
tenderness. A serrated biopsy needle is useful if subperiosteal pus is
not
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encountered.
If a joint is involved, then the effusion should be aspirated before
joint lavage. Processing the aspirates should include the following:-
Immediate Gram stain.
-
Inoculation of culture broth for aerobic and anaerobic cultures.
-
White blood cell count.
If thick, purulent material is encountered, then dilution in broth
occasionally enhances the growth of organisms by decreasing the
concentration of leukocytes and humeral antibacterial factors. This is
done routinely in the microbiology laboratory with fluid aspirates. -
Determination of the character of the
hyaluronic precipitate, the presence of fibrin clots, and any disparity
between the glucose in the aspirate and blood glucose may prove helpful, but the Gram stain, culture, and cell count are most valuable (see Chap. 3).
-
-
-
Differential
diagnosis. Care must be taken to differentiate soft-tissue infection,
or cellulitis, from an infection occurring in a bone or joint.
This is a particularly important precaution when the infection overlies
a joint because any aspiration of a reactive sterile effusion by
passing a needle through the soft-tissue infection may create a
pyarthrosis. Tenderness and swelling from unrecognized trauma over a
bone, particularly with some periosteal reaction, can present a
confusing picture, but the absence of fever and systemic signs is
helpful. Nonbacterial inflammatory arthritis, including viral and toxic
synovitis and rheumatoid arthritis, must be included in a differential
diagnosis, but until proved otherwise, think first of septic arthritis.
Spontaneous hemorrhages in patients with hemophilia and fractures in
paraplegic patients, particularly patients with meningomyelocele, are
special situations that can confuse the picture. -
Bacterial considerations (1,4,12)
-
In acute hematogenous osteomyelitis, Staphylococcus aureus
is the most common etiologic agent in all age groups. In recent years,
an increasing number of isolated strains have been found to be
methicillin resistant. In infants younger than 1 month, a diversity of
other bacteria must also be considered. Group B streptococci and
gram-negative organisms such as Escherichia coli, Proteus species, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Salmonella
species are all suspect. In infants with a complicated medical history,
particularly those who have had prolonged indwelling venous catheters,
extensive surgery, or intensive prior antibiotic therapy,
coagulase-negative staphylococci and rarely anaerobic organisms such as
Bacteroides fragilis and fungal agents such as Candida albicans (hard to diagnose) must also be considered. -
In septic arthritis and osteomyelitis among infants younger than 1 month, S. aureus is the predominant etiologic agent. After the neonatal period and up to 4 years of age, Haemophilus influenzae is also a major cause of septic arthritis. In later childhood, the etiologic agents are the same as for adults, with S. aureus predominating. Neisseria gonorrhoeae
must be seriously considered, particularly among adolescents with
single (especially the knee joint) or multiple joint findings. If there
has been a preceding infection or if there is a concurrent infection in
another organ system, one may suspect that the etiologic agent is the
same as that from the initiating focus. But, because this is not always
the case, direct culture from the bone or joint infection is advised.
-
-
Special considerations
-
Infections of the intervertebral discs, or acute discitis, may be encountered in children without antecedent infection or surgery (15).
When organisms have been recovered, they have usually been
staphylococcal. Infants may merely refuse to stand or walk, whereas
older youngsters complain of pain in the back or lower extremity. The
infection usually is low grade, particularly among children younger
than 5 years of age. Roentgenograms reveal that the involved disc
narrows rapidly over the first 2 to 3 weeks. A bone scan shows
increased activity in the adjacent vertebrae. Although the process
often appears self-limited, the symptoms and course of the disease can
be improved by plaster immobilization and antistaphylococcal
antibiotics. The difficulty in
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obtaining
a bacterial diagnosis, even with needle biopsy, combined with the
benign course of this condition, has led many clinicians to ignore
efforts at establishing a bacterial diagnosis. The condition must,
however, be differentiated from vertebral osteomyelitis with secondary
disc destruction; in the latter condition, it is essential to obtain
the bacterial diagnosis as an integral part of treatment of what can be
a severe disease. The same precaution applies to disc infections
following laminectomy. In these cases, an infection should be suspected
when a postsurgical patient complains of increasing back pain starting
1 to 2 weeks postoperatively. -
Patients with hemolytic disorders, particularly those with sickle cell disease, are prone to the development of a subacute form of osteomyelitis. Salmonella infections are frequent, but other types of bacterial osteomyelitis are not uncommon (4).
Because the diagnosis is usually made late, treatment is difficult and
may require extensive surgical debridement and prolonged antibiotic
therapy. -
Another special problem is presented by the patient who sustains a puncture wound
in the sole of the foot. Despite initial cleansing and occasional
debridement, cellulitis, arthritis, or osteomyelitis involving the foot
develops in many patients (11). This occurrence is most commonly caused by P. aeruginosa. Early surgical debridement of the infected, including the plantar fascia, combined with preoperative and postoperative anti-P. aeruginosa
antibiotics, has been the most effective method of management. For a
serious infection, treatment is 5 days of antibiotic therapy with an
aminoglycoside (e.g., tobramycin) or an antipseudomonal beta-lactam
(e.g., ceftazidime) administered parenterally. Recently, ciprofloxacin
has been used in gram-negative bone and joint infections (1);
it must not be used in prepubertal children, however. Appropriate
sensitivities guide antibiotic selection. Duration of therapy is
empirical and may be guided by the clinical appearance and the CRP or
ESR (11,15).
Aminoglycoside doses need to be adjusted according to peak and trough
serum levels and monitoring must include weekly Serum Creatinine (Cr)
measurements and regular audiologist evaluation. Patients with human
immunodeficiency virus or acquired immunodeficiency syndrome can have
septic joints, which frequently may be missed because of the relatively
weak immune response to the infectious agent. Joint aspiration should
be performed in this setting (16). -
Lyme arthritis. Lyme arthritis, the most common vectorborne infection in the United States, is caused by the spirochete Borrelia burgdorferi, which is transmitted to humans primarily via the Ixodes scapularis tick from its natural hosts, deer and white-footed mice (17).
Arthritis, the most common form of late Lyme disease (other forms being
encephalopathy and polyneuropathy), can occur weeks to months after the
original infection. Approximately 60% of untreated primary disease will
develop arthritis (18). Clinical presentation
includes fever and joint effusion, which may be confused with acute
septic arthritis, especially in children (19).
Treatment with oral antibiotics such as doxycycline for 4 weeks or the
parenteral agent ceftriaxone for 2 weeks usually results in lasting
cure. However a small percentage of patients experience ongoing
symptoms despite antibiotic therapy. Possible reasons include
persistent infection, residual joint damage, or a chronic autoimmune
synovitis (20).
-
-
Requirements and characteristics of appropriate antibiotic treatment (1,4,21)
-
For initial treatment of bone or joint infection, choose a bactericidal antibiotic
effective against the suspected organism and a route of administration
that ensures delivery of therapeutic levels to the infected site. The
intravenous (IV) route is generally preferred for initial treatment
[although some agents such as gentamicin and tobramycin are effective
given intramuscularly (IM)]. Recent studies (1)
have indicated that oral antibiotics appear in therapeutic
concentrations in bones and joints and, if given properly, can
substitute for parenteral therapy in children. Most authorities,
however, prefer the IV route. -
The duration of parenteral treatment is 3 to 4 weeks for septic arthritis and 4 to 6 weeks for osteomyelitis (the longer duration for infections caused by S. aureus). In adults with selected organisms, the treatment may be completed using
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oral quinolones after the initial pain, swelling, and fever have
resolved with IV antibiotics. Quinolone antibiotics (ciprofloxacin,
gatifloxacin, levofloxacin, moxifloxacin) have allowed oral therapy
against a broad spectrum of bacteria including Pseudomonas (1). In treating children
with osteomyelitis, treatment may be initiated with an IV agent such as
nafcillin (Nafcil or Unipen), and the 4- to 6-week treatment course may
be completed with oral dicloxacillin (Dynapen) or trimethoprim (Bactrim
or Septra). For all ages the dosage of
antibiotics (oral or parenteral) is at the upper therapeutic level.
When appropriate, adequate bactericidal drug levels for both oral as
well as parenteral agents should be documented. Providing parenteral
antibiotics through home health care teams greatly reduces the cost of
treatment. The differentiation between a mild, well-localized infection
and a localized bone tumor can sometimes require a surgical biopsy (5). The CRP or ESR is also a helpful guideline to determine the duration of treatment (11). A summary of antimicrobial agents commonly used in acute bone and joint infections is presented in Table 3-1. These agents are known to enter bone and joint sites readily when given in adequate doses. -
In an acute infection in which the organism is not immediately identified, the choice of therapy
is determined by the organisms most commonly expected in the various
age groups, along with the other factors previously listed. General
guidelines are presented in Table 3-2. -
A local instillation or continuous irrigation with an antibiotic solution is almost never indicated. Systemic antibiotics, properly administered, achieve adequate levels in viable tissues (1,4). In many posttraumatic conditions, delivery of local antibiotics in methyl methacrylate beads is worthwhile (21).
This treatment is indicated especially when a delayed bone graft or
soft-tissue muscle flap is planned. Some favorable reports have been
published about an implantable pump with a reservoir for antibiotic
(generally amikacin). -
Continue antibiotics until the infection has been eliminated. A normal or declining ESR or CRP is one of the most helpful laboratory tests to indicate control of infection.
-
-
Adjunctive treatment. Most orthopaedists believe that the healing process is aided by immobilizing
the infected area. There is disagreement over casting or splinting.
Undoubtedly, however, patients are more comfortable when the infected
area is immobilized. If damage to the bone is significant, cast
immobilization may be important to prevent a pathologic fracture. If
damage to articular cartilage is suspected, motion of the involved
joint is recommended after a brief 1- to 2-day period of immobilization. -
Surgical intervention.
Appropriate antibiotic treatment instituted within the first 48 hours
of acute osteomyelitis or septic arthritis is usually satisfactory.
However, early diagnosis is rarely the case. If treatment is initiated over 48 hours after onset, it is important to determine whether medical treatment alone is adequate.
Err on the side of more aggressive operative drainage. If the patient
has been on an appropriate antibiotic for more than 24 hours without
significant resolution of pain and temperature, then surgical
intervention is indicated.-
In a bone infection,
metaphyseal or subperiosteal abscesses must be drained. If metaphyseal
point tenderness is present, and there is doubt whether this represents
significant metaphyseal or subperiosteal pus, then it is safer to err
on the side of a small surgical exploration or aspiration with a biopsy
needle. If pus is encountered, then open surgical drainage is indicated. -
Joints
-
In joint infections, satisfactory evacuation of pus can be achieved by needle aspiration.
When the joint is easily visible and palpable, such as with the knee
joint, repeated needle aspiration is usually adequate to keep the joint
decompressed. Aspiration should be done with a 16- to 18-gauge needle.
Irrigation of the joint to ensure removal of as much cellular debris as
possible is helpful (12). The hip joint presents special problems (12).
The blood supply to the femoral head is intraarticular; hence, any
increase in pressure can deprive the entire femoral head of its
circulation. Because hip
P.44P.45P.46P.47
joint
effusions are not readily palpable, it is difficult to be certain that
repeated aspirations decompress the joint. For this reason, most
authorities believe that immediate surgical drainage of a septic hip is
indicated, and some believe that the shoulder should be treated
similarly. The possible exception is in gonococcal arthritis (22).
The hip joint can be drained anteriorly between muscle planes or
posteriorly with a muscle-splitting incision. The capsule and synovium
are opened and drains are inserted.TABLE 3-2 Tentative Selection of Therapy When Organisms Are Not Immediately IdentifiedSituation Organisms suspected Suggested antibiotic choice Newborn (1 mo) Staphylococcus aureus Nafcillin plus gentamicin or tobramycin Osteomyelitis Streptococci Gram-negative bacteria including Escherichia coli, Klebsiella pneumoniae, Proteus group, Pseudomonas aeruginosa Septic arthritis S. aureus 1 mo–4 yr Osteomyelitis S. aureus Second-generation cephalosporin to cover H. influenzae Septic arthritis Haemophilus influenzae
S. aureus
StreptococciSecond-generation cephalosporin to cover H. influenzae 4 yr–12 yr Osteomyelitis
Septic arthritisS. aureus First- or second-generation cephalosporin 12 yr–adult Osteomyelitis S. aureus A cephalosporin (first- or second-generation agent) or nafcillin Septic arthritis S. aureus A cephalosporin or nafcillin (ceftriaxone if gonococcus is strongly suspected) Special considerations Chronic hemolytic disorders Osteoarthritis S. aureus A cephalosporin (second-generation if salmonella is suspected) or nafcillin until sensitivity results are available Septic arthritis Pneumococci
Salmonella groupaInfections following puncture wounds of the foot Pseudomonas aeruginosa Ceftazidime actually achieves better drug levels than aminoglycosides (gentamicin or tobramycin) Infections following trauma or surgery S. aureus
Streptococci
Gram-negative organismsA first- or second-generation cephalosporin (or nafcillin) plus gentamicin or tobramycin aInfections caused by Salmonella
should be documented first by culture and sensitivity testing before
empirical treatment with agents such as ampicillin (or chloramphenicol)
is initiated.
From Hansen ST Jr, Ray CG. Antibiotics in orthopaedics. In: Kagan BM, ed. Antimicrobial therapy, 3rd ed. Philadelphia, PA: WB Saunders, 1980, with permission. -
At times, the fibrin entering the joint
as a transudate forms clots and isolates segments of the joint from
decompression. Hypertrophy of synovium and adhesions may also affect
the ability of the surgeon to decompress the joint adequately. Under
these circumstances, it is advisable to debride the joint arthroscopically or with an open procedure. Joints amenable to arthroscopic lavage are the knee, shoulder, and ankle.
-
-
-
Chronic osteomyelitis
presents a different problem from acute infection. Acute infection in
the earliest phase is primarily a medical disease, with surgical
techniques used as an adjunct. In chronic infection, the primary
problem is surgical removal of all dead
and poorly vascularized tissue. If this removal is properly done under
appropriate antibiotic therapy, it is possible to eradicate most sites
of chronic osteomyelitis. The operation must be carefully planned
because it often involves significant removal of bone and surrounding
tissues. In the case of chronic joint infections, it may mean complete
resection of the joint with the creation of a pseudarthrosis or an
arthrodesis. Rotational muscle flaps or free-tissue transfer may be
required to cover areas of viable but poorly covered bone. Intravenous
and oral antibiotics serve as valuable adjuncts. Patient quality of
life can be profoundly impacted by chronic osteomyelitis (23); treatment leading to resolution of the infection does improve this impact. -
Gas gangrene
-
Gas gangrene can be a fatal process. Prevention
can be achieved by thorough debridement and removal of all devitalized
tissue, delayed wound closure when in doubt, and antibiotic treatment
as recommended previously. -
Clostridium perfringens infections carry a 65% overall mortality rate, which increases to 75% in infants and elderly patients. The diagnosis
should be suspected when the patient is pale, weak, perspiring, and
more tachycardiac than the degree of fever warrants. The patient
frequently complains of severe pain. Mental confusion and gas in the
tissues are late signs, as are the characteristic mousy odor, jaundice,
oliguria, and shock. -
Other gas-producing species in addition to C. perfringens (ten isolated toxins), include E. coli, Enterobacter aerogenes, anaerobic streptococci, B. fragilis, and K. pneumoniae. Antitoxin does not appear to help much because it is neutralized as rapidly as it reaches muscle. Treatment consists of debridement and high doses of antibiotics. Penicillin is usually the best for the C. perfringens
group; it should be given in amounts of 20 to 50 million units/day.
Clindamycin or metronidazole are good alternative antibiotics in
patients who are allergic to penicillin. Some clostridia are resistant
to clindamycin, making it necessary to check sensitivities carefully.
Hyperbaric oxygen is only an adjunct to surgery. Its use allows the
surgeon to save more tissue than might otherwise be possible, and it
does lower the mortality rate slightly.Although exceedingly uncommon, group A streptococcal
myonecrosis can have a similar course and results in death in a high
percentage of cases. It must be treated with aggressive surgical
debridement or amputation in addition to appropriate antibiotic
therapy. Toxic shock syndrome has also been noted in orthopaedic
patients and is caused by unique staphylococcal strains with unusual
phage types. Toxic shock syndrome is also a surgical condition, but it
carries a more favorable prognosis. Necrotizing fasciitis can be caused
by several bacterial types (most commonly group A streptococcus) and
often requires debridement combined with appropriate antibiotic
therapy. Infectious disease consultation is indicated for each of these
infectious conditions.
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III. Summary
-
Infections in the musculoskeletal system
present special problems for treatment with antibiotics alone.
Cartilage is avascular, tendon and ligaments are relatively
hypovascular, and bone is vulnerable to situations that render it
avascular. Because antibiotics can be effective only if they are
delivered to the site of infection, every effort must be made to
preserve a normal blood supply and normal joint fluid dynamics. The essentials of treatment are as follows:-
Prompt diagnosis, with identification of the bacteria through culture and with sensitivity for determining the appropriate antibiotic
-
Rapid initial treatment with the most effective bactericidal antibiotic
-
Constant evaluation to assess the need for surgical drainage of pus or removal of devitalized tissue
-
Antibiotic therapy
by a route that ensures adequate blood levels and administration until
the signs of infection, as manifested usually by a decreasing ESR,
resolve completely -
Judicious use of immobilization and traction to improve patient comfort and provide the best possible environment for primary healing
-
-
The greatest benefit of antibiotics in musculoskeletal infection is in preventing
the mortality and morbidity that result from chronic osteomyelitis and
joint destruction from pyarthrosis. Even chronic infection can be
controlled and a satisfactory functional result obtained in most
patients by the use of surgery and appropriate antibiotics.
References
1. Greenberg RN, Kennedy DJ, Reilly PM, et al. Treatment of bone, joint, and soft-tissue infections with oral ciprofloxacin. Antimicrob Agents Chemother 1987;31:151–155.
2. Hendershot EF. Fluoroquinolones. Infect Dis Clin North Am 1995;9:715–730.
3. Henry
SL, Galloway KP. Local antibacterial therapy for the management of
orthopaedic infections: pharmacokinetic considerations. Clin Pharmacokinet 1995;29:36–45.
SL, Galloway KP. Local antibacterial therapy for the management of
orthopaedic infections: pharmacokinetic considerations. Clin Pharmacokinet 1995;29:36–45.
4. Mader JT, Landon GC, Calhoun J. Antimicrobial treatment of osteomyelitis. Clin Orthop 1993;295:87–95.
5. Cottias P, Tomeno B, Anract P, et al. Subacute osteomyelitis presenting as a bone tumor: a review of 21 cases. Int Orthop 1997;21:243–248.
6. Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR Am J Roentgenol 1992;158:9–18.
7. Boutin RD, Brossman J, Sartoris DJ, et al. Update on imaging of orthopedic infections. Orthop Clin North Am 1998;29:41–66.
8. Tang JS, Gold RH, Bassett LW, et al. Musculoskeletal infection of the extremities: evaluation with MR imaging. Radiology 1988;166:205–209.
9. Tehranzadeh J, Wang F, Mesgarazadeh M. Magnetic resonance imaging of osteomyelitis. Crit Rev Diagn Imaging 1992;33:495–534.
10. Unger E, Moldofsky P, Gatenby R, et al. Diagnosis of osteomyelitis by MR imaging. AJR Am J Roentgenol 1988;150:605–610.
11. Crosby LA, Powell DA. The potential value of the sedimentation rate in monitoring treatment outcome in puncture wound-related Pseudomonas osteomyelitis. Clin Orthop 1984;188:168–172.
12. Dagan R. Management of acute hematogenous osteomyelitis and septic arthritis in the pediatric patient. Pediatr Infect Dis J 1993;12:88–92.
13. Frederiksen B, Chritiansen P, Knudsen FU. Acute osteomyelitis and septic arthritis in the neonate, risk factors and outcome. Eur J Pediatr 1993;152:577–580.
14. Unkila-Kallio
L, Kallio MJ, Eskola J, et al. Serum C-reactive protein, erythrocyte
sedimentation rate and white blood cell count in acute hematogenous
osteomyelitis of children. Pediatrics 1994;93:59–62.
L, Kallio MJ, Eskola J, et al. Serum C-reactive protein, erythrocyte
sedimentation rate and white blood cell count in acute hematogenous
osteomyelitis of children. Pediatrics 1994;93:59–62.
15. Cushing AH. Diskitis in children. Clin Infect Dis 1995;17:1–6.
16. Malin JK, Patel NJ. Arthropathy and HIV infection: a muddle of mimicry. Postgrad Med 1993;93:143–150.
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17. Spiro ED, Gerber MA. Lyme disease. Clin Infect Dis 2000;31:533–542.
18. Steere AC. Lyme disease. N Engl J Med 2001;345:115–125.
19. Willis AA, Widmann RF, Flynn JM, et al. Lyme arthritis presenting as acute septic arthritis in children. J Pediatr Orthop 2003;23:11418.
20. Weinstein A, Britchkov M. Lyme arthritis and post-Lyme disease syndrome. Curr Opin Rheumatol 2002;14:383–387.
21. Ostermann PA, Seligson D, Henry SL. Local antibiotic therapy for severe open fractures: a review of 1085 consecutive cases. J Bone Joint Surg (Br) 1995;77:93–97.
22. Scopelitis E, Martinez-Osuna P. Gonococcal arthritis. Rheum Dis Clin North Am 1993;19:363–377.
23. Lerner
RK, Esterhai JL Jr, Polomano RC, et al. Quality of life assessment of
patients with posttraumatic fracture nonunion, chronic refractory
osteomyelitis and lower extremity amputation. Clin Orthop 1993;295:28–36.
RK, Esterhai JL Jr, Polomano RC, et al. Quality of life assessment of
patients with posttraumatic fracture nonunion, chronic refractory
osteomyelitis and lower extremity amputation. Clin Orthop 1993;295:28–36.
Selected Historical Readings
Burnett JW, Gustilo RB, Williams DN, et al. Prophylactic antibiotics in hip fractures. J Bone Joint Surg (Am) 1980;62:457–462.
Clawson DK, Davis FJ, Hansen ST Jr. Treatment of chronic osteomyelitis with emphasis on closed suction-irrigation technique. Clin Orthop 1973;96:88–97.
Ha’eri GB, Wiley AM. The efficacy of standard surgical face masks: an investigation using “tracer particles.” Clin Orthop 1980;148:160–162.
Hamilton HW, Booth AD, Lone FJ, et al. Penetration of gown material by organisms from the surgical team. Clin Orthop 1979;141:237–246.
Lunseth PA, Heiple KG. Prognosis in septic arthritis of the hip in children. Clin Orthop 1979;129:81–85.
Monson TP, Nelson CL. Microbiology for orthopaedic surgeons: selected aspects. Clin Orthop 1984;190:14–22.
Patzakis MJ, Harvey P Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg (Am) 1974;56:532–541.
Perry
CR, Ritterbusch JK, Rice SH, et al. Antibiotics delivered by an
implantable drug pump: a new application for treating osteomyelitis. Am J Med 1986;80(6B):222–227.
CR, Ritterbusch JK, Rice SH, et al. Antibiotics delivered by an
implantable drug pump: a new application for treating osteomyelitis. Am J Med 1986;80(6B):222–227.
Peterson AF, Rosenberg A, Alatary SD. Comparative evaluations of surgical scrub preparations. Surg Gynecol Obstet 1978;146:63–65.
Schurman DJ, Hirshman HP, Nagel DA. Antibiotic penetration of synovial fluid in infected and normal knee joints. Clin Orthop 1978;136:304–310.