Simplifying the Treatment of Acute Bacterial Bone and Joint Infections in Children

Markus Pääkkönen; Heikki Peltola

Disclosures

Expert Rev Anti Infect Ther. 2011;9(12):1125-1131. 

In This Article

Surgery

Fulfilling the wisdom 'ubi pus, ibi evacua' (where pus, there evacuate), surgery has been deemed pivotal in OM, SA and OM+SA. Trepanation of bone is often performed in OM,[30] and routine arthrotomy is recommended at least in hip and shoulder arthritis, because of the fear of hyperpressure and cartilage destruction in these tightly encapsulated joints.[1,31] Interestingly, this view has been based solely on retrospective analyses, and no prospective study has demonstrated its validity.[5–8] As intra-articular pressure is regulated by the position of the joint during aspiration,[32,33] some new thinking is warranted also in this respect regarding SA.

In a prospective, randomized study on 61 shoulder arthritides, mostly caused by Salmonella spp., arthrotomy showed no advantage over aspiration,[5] when antibiotics were given orally for 6 weeks. A cohort from Israel showed favorable results with repeated ultrasound-guided aspirations in septic hip arthritis.[6] In our own retrospective analysis there were 62 septic hips of which no more than 12 (21%) underwent arthrotomy.[7] However, most children were older than 2 years, the median age was 7 years and the history of disease was 1–5 days – all factors which might have lowered the need for arthrotomy. Neonates and children presenting late in disease likely warrant a different approach. Aspirations or needle-joint lavages performed blindly without ultrasonographic or fluoroscopic control will be more likely to fail or give a negative result.[6] Also, refraining from initial arthrotomy requires the patient to be kept under continuous observation and a 24-h immediate access to operating theater is required should complications develop.[7]

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