Pediatric Septic Arthritis

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5 Orthopedic Infections

Fig. 5.5 Abscess perforates the metaphyseal cortex and spreads to the subperiosteal space and joint

Fig. 5.6 Sequestered fragments of dead bone and periosteal new bone, or involucrum, may be seen on radiographs

Diagnosis andTreatment

Patients present with rapid onset of pain from one to several days in duration limiting the involved extremity’s range of motion and weight-bearing. Older patients may be able to assist inlocaliza-

tion of the pain, although the clinician must be capable of identifying potential sites of referred pain (knee pain for hip osteomyelitis). Children are usually irritable and febrile and often give a history of generalized malaise. Uncovering a potential site of a concomitant infection, such as a recent upper respiratory or ear infection, may provide the clinician with an etiology for hematogenous spread. Physical examination is extremely important, with localized swelling and tenderness often characterizing the physical exam.

Laboratory results are extremely important in diagnosing and treating osteomyelitis; however, they do not replace a complete history and physical examination. A complete blood count with differential, C-reactive protein (CRP) and an erythrocyte sedimentation rate (ESR) are imperative. Adjuvant tests such as serum procalcitonin and interleukin-6 have been shown to provide some utility in pediatric osteomyelitis. While leukocytosis and neutrophilia are typically present, it must be emphasized that not all patients suffering from osteomyelitis present with a classic clinical history, physical ndings, and basic laboratory values. Thus, the inammatory markers convey particular utility in diagnosis. CRP, a direct measure of an inammatory process, peaks within 48 h, and with appropriate therapy may normalize within 1 week. In comparison, ESR, an indirect measure of inammation, peaks within 3–5 days and normalizes within several weeks after successful therapy. Thus, CRP has become a useful adjuvant in diagnosis as well as monitoring clinical progression. Of important consideration, diagnosis in neonates may be especially problematic because of the immaturity of their immune system, which may not be able to mount an identiable host response.

In the acute setting, initial radiographs may be negative, except for soft tissue swelling, because the characteristic changes of osteomyelitis require 10–14days to be appreciated. Historically, bone scans served as a valuable tool to identify areas of accelerated bone growth; however, magnetic resonance imaging (MRI) with contrast has supplanted all imaging modalities in diagnosis of bone infections. Within the rst few days, MRI

R. A. Cowley et al.

may demonstrate bone marrow edema as hypointense T1 signal or hyperintense T2 signal (Image

5.1). As the disease progresses, peripheral rim-

enhancement may be visible indicating abscess formation.

Bone aspiration is the best means of clinically identifying the presence of a bone infection as well as any organisms associated with it. A largebore stylet needle (18- or 16-gauge spinal needle) should be used to prevent plugging of soft tissue, bone, or thickened purulent material in the tip. Both subperiosteal and intramedullary sites must be aspirated. In addition, using a second needle, one should consider aspirating the adjacent joint if clinically indicated. Local anesthesia is given, with the needle being easily punched through the soft metaphyseal cortex. If purulent material is obtained, the uid is sent for immediate Gram stain and culture. The presence of pus necessitates that the patient undergo an operative

irrigation and debridement. However, antibiotics should be started immediately following aspiration with these initial cultures, serving to direct later modications to organism-specic antibiotic coverage.

The initial antibiotic choice is often based upon the broad-spectrum approach. In patients who are not allergic to penicillin, a beta- lactamase resistant penicillin derivative should be chosen. Good initial choices include oxacillin or nafcillin, with penicillin-allergic patients often being treated with cefazolin. The optimal length of therapy is still under debate, with a regimen of 3weeks of IV antibiotics, followed by 3weeks of oral therapy, often being acceptable. An infectious disease consultation is necessary to help guide antibiotic therapy choice and duration.

In the event that purulent material is not aspirated, sterile saline should be injected, aspirated, and sent for culture in the hopes of identifying an organism. Bacteriostatic saline should not be used as this may inhibit bacterial growth. In cases in which no frank purulent material is aspirated, surgery is usually not indicated, as there is no pus to decompress or necrotic bone to debride. In this setting, the administration of antibiotics is the mainstay of treatment.

Chronic infections are uncommon in children, as patients usually present early in the course of the disease. However, if this scenario occurs, these patients almost invariably require surgical intervention to debride sequestrated tissues. Complications are high in this setting from both the disease process and the surgical procedure, including pathologic fracture and physeal arrest.

Image 5.1 T1 image marrow changes associated acute osteomyelitis of proximal humerus with notable concerning glenohumeral joint effusion. (Courtesy of Dr. Ryan Murray)

Pediatric Septic Arthritis

Acute septic arthritis may develop from hematogenous sources or, more commonly, from extension of an adjacent foci of osteomyelitis into the joint. Susceptible joints are those in which the metaphysis is intra-articular: hip, shoulder, elbow, and ankle (NOT the knee) (Fig.5.7).

Although relatively uncommon, septic arthritis can rapidly destroy articular surfaces

5 Orthopedic Infections

Fig. 5.7 Schematic representation of the immature hip. Metaphyseal osteomyelitis spreads by direct extension into the hip joint

Table 5.1 Common pathogens and recommended treatment for septic arthritis

Initial antibiotic

Age group Probable organisms Neonate GBS, S. aureus,

Gram-negative

coliforms Infants and children (4weeks to 4years)

Children (>4years) Adolescent N. gonorrhoeae

S. aureus, H. inuenzae,

GBS, GAS, Kingella,

Eikenella,

Cardiobacterium,

Actinobacilus

S. aureus Oxacillin or

choice Penicillin,

oxacillin, and gentamicin Cefuroxime

cefazolin

via robust enzymatic response of neutrophils and matrix metalloproteinases within 8 h. Concurrently, increased joint pressure leads to osteonecrosis; therefore, septic arthritis must be definitively excluded at symptom onset.

Depending upon the age of the patient, different organisms prevail as likely pathogens (Table5.1).

Diagnosis andTreatment

Pediatric septic arthritis patients tend to be more toxic than acute osteomyelitis with higher temperatures, more pain, and notably elevated inammatory markers. Understandably, these children are extremely reluctant to move the involved extremity or infected joint. With increased uid in the affected joint, patients tend to position their joints to maximize joint capsule space. For example, the hip, this is usually exion abduction and external rotation. For the knee, this tends to be roughly 30degrees of exion. Radiographs may demonstrate a joint effusion and associated soft tissue swelling.

As mentioned previously, the window for treatment for septic arthritis is 8h before irreversible damage to the cartilage via enzymatic reactions of the inammatory cells occurs. Thus, a septic joint is considered a surgical emergency.

Given low cost and wide-spread availability, ultrasound has become the mainstay for evaluation. In particular for hips, bilateral imaging is recommended for comparison and because contralateral disease has been described. MRI is an

R. A. Cowley et al.

option, but center-dependent based upon availability. Septic arthritis, again in particular in the hips, may mimic transient synovitis.

Transient synovitis is a post-viral sequela that creates joint pain in pediatric patients that is improved with anti-inammatories. The Kocher criteria provide clinicians a specic and sensitive algorithm to aid in differentiating between the hip transient synovitis and septic arthritis of the hip. The updated Kocher criteria (Table5.2):

1. Temperature >38.5°C

2. CRP >2 (mg/dL)

3. ESR >40mm/h

4. WBC >12,000 cells/μL

5. Refusal to bear weight

Some have extrapolated this algorithm from the hip to other joints. However, regardless of clinical suspicion, a joint aspiration is mandatory for diagnosis. Ultrasound or uoroscopy may be used to aid in retrieval of uid especially in less accessible joints such as the hip. An arthrogram for the hip may be added as well to conrm appropriate location. Usually, a form of sedation is required for children as they simply will not tolerate the aspiration. The uid should be analyzed for gram stain, culture, cell count with differential, and for the presence of crystals. In the majority of cases the joint aspiration will demonstrate a WBC count greater than 50,000; this may often exceed 100,000in severe cases. The white blood cell population is usually composed of polymorphonuclear leukocytes, comprising as much as 90–95% of the cells in fulminant cases. On occasion, circumstances may require the clinician to inform the laboratory of the possible organism as special techniques may be necessary. For lyme endemic

Table 5.2 Number of positive Kocher criteria nds correlated with percent probability of hip septic arthritis

Number of factors % Probability of septic arthritis 0 17 1 36 2 62 3 83 4 93 5 98

areas, serologies should be sent. As Haemophilus inuenzae is difcult to culture, the specimen must be incubated in a CO2 environment. Because the percentage of organism retrieval has been reported by some series to be between 70% and 85%, blood cultures should also be obtained. Additional clues to possible infection include an elevated protein or a decreased glucose level in the joint aspirate.

If a septic arthritis is highly suspected, the initial aspiration can be performed in the operating room under general anesthesia, to be followed by immediate open debridement and irrigation upon conrmation of the presence of pus or organisms. However, having a diagnosis prior to the operation is prudent to avoid unnecessary consumption of hospital resources.

The goals of an irrigation and debridement are decompression of all purulent material, irrigation of both bacteria and host lysozymes from the joint, and debridement of nonviable tissues.

Reexamination of the joint is necessary following surgery or aspiration to be assured a purulent material has not reaccumulated.

Intravenous antibiotics are initiated immediately following acquisition of joint uid. Again, antibiotic choice is based upon the suspected pathogens with the assistance of an infectious disease consultation. Compared to treatment of osteomyelitis, the antibiotic course for septic arthritis is usually shorter (4 weeks), with 2 weeks of IV antibiotics followed by an additional 2weeks of oral therapy.

Adult Osteomyelitis

For adult osteomyelitis, the management involves determining the level of infection and consideration of several patient variables to create an appropriate treatment plan:

1. Physiology of patient (a) Malnutrition, immune deciency, malig-

nancy, diabetes, chronic lymphedema, venous stasis, major vessel disease, extensive scarring, other

2. Anatomic site

3. Psychosocial factors

5 Orthopedic Infections

In conjunction with an infectious disease consultation, the goal of treatment should be determined: suppressive or curative.

The Cierny–Mader classication of Osteomyelitis assists surgeons in determining the prognosis of available treatment modalities through anatomic location and host factors: (Fig.5.8).

Location

Stage I: Medullary Stage II: Supercial Stage III: Localized Stage IV: Diffuse

Host

Type A: Normal Type BL: Locally compromised Type BS: Systemically compromised Type C: Treatment is worse to patient than

infection

Fig. 5.8 The Cierny classication of chronic osteomyelitis: type I, medullary; type II, supercial; type III, localized full thickness; type IV, diffuse

Stage I medullary osteomyelitis is completely endosteal and does not require bone stabilization following debridement. Stage II supercial osteomyelitis only involves the outer cortex and again, which does not require bone reconstruction following local excision of infected material. Stage III localized osteomyelitis combines types I and II, therefore requires full thickness cortical resection to effectively debride the bone. Although this does not confer segmental instability, eventual bone grafting techniques may need to be employed to reestablish continuity. Stage IV osteomyelitis results in wide-spread cortical and endosteal infection, with segmental resection being required to eradicate the infection. Diffuse osteomyelitis is mechanically unstable both before and after debridement; thus, stabilization and eventual bone reconstruction is required.

R. A. Cowley et al.

Surgical treatment of osteomyelitis involves

three main facets:

1. Extensive debridement

2. Vascular soft tissue coverage

3. Bone stabilization

An aggressive debridement of nonviable tissues to healthy bleeding tissue is crucial to achieving successful eradication of osteomyelitis by preventing residual bacteria from persistently reinfecting the bone.

Multiple cultures of all debrided material should be obtained before the initiation of antibiotic therapy to aid in guiding cultures specic antibiotic selection. Often the patient may require several debridements until the wound is considered to be clean prior to addressing soft tissue coverage. Basic soft tissue ap coverage options include:

1. Simple skin graft

2. Local transpositional muscle graft

3. Vascularized free ap

Muscle transposition and free aps provide a fresh bed of vascularized tissue to assist in bone healing and antibiotic delivery.

Finally, bone stability must be considered. This step remains last as placing a graft into an incompletely resolved infection provides a nutrient rich environment for infection to proliferate. Cancellous and cortical autografts may be used. The Masquelet technique (MT) and the Ilizarov bone transport (IBT) technique are the two prominent methods that address signicant segmental bony defects.

MT is a two-stage procedure. In the rst stage, anti-microbial cement is placed in the defect. This cement is left for 6–8weeks to permit the formation of a self-induced periosteal membrane. Once this membrane is formed, the second stage is performed to remove the cement and place cancellous bone graft.

IBT is technically demanding and requires a longer treatment duration. IBT consists of application of a small pin (Ilizarov) or half-pin external xator with gradual distraction. After a

latency period of approximately 7–10days, distraction begins at a rate of 0.75–1mm per day. As distraction is carried out, the soft tissues regenerate along with the bone to cover the newly generated tissue.

The comparison of these two techniques have generated a large volume of research with comparable results.

Adult Septic Arthritis

As with children, septic arthritis in adults can develop from hematogenous sources, direct inoculation, contiguous soft tissue infection, or periarticular osteomyelitis. Several patient factors predispose patients such as IV drug abuse, immunosuppressants, systemic corticosteroid use, and pre-existing arthritis. Similar to children, Staphylococcus aureus is the most common pathogen isolated from infected adult joints (44%). Neisseria gonorrhoeae is another common adult pathogen, with a reported incidence of 11%. The joints most commonly involved are the knee (40–50%), hip (20–25%), and shoulder and ankle (10–15%). In IV drug abusers, the sternoclavicular, sacroiliac, and manubriosternal joints are common sites, with Pseudomonas aeruginosa often being isolated.

Presentation and diagnosis do not differ greatly between adults and children. Adult patients present with pain, swelling, and a decreased range of motion of the affected joint. Evaluation involves routine laboratory tests (CBC, CRP, ESR), blood cultures, and joint aspirations. The appearance of the synovial uid (straw, cloudy, or purulent) as well as the WBC count, the percentage of polymorphonuclear cells, and cultures can assist in the diagnosis. In adults, crystal analysis is even more critical as crystal-induced arthropathy can appear quite similar to a septic arthritis (Table5.3).

Treatment of an adult with a septic arthritis requires aggressive irrigation and debridement utilizing either arthroscopic techniques or an open arthrotomy. Infectious disease consultation is often obtained to determine antibiotic choice, route of administration, and duration.

5 Orthopedic Infections

Table 5.3 Synovial uid

Examination Normal Noninammatory Inammatory Septic Appearance Transparent Transparent Opaque translucent Opaque, cloudy,

purulent Viscosity High High Low Variable WBC/mm PMN (%) <25% <25% >50% >75% Culture – – – Often positive Associated conditions

Esterhai JL, Gelb I: Adult septic arthritis. Orthop Clin North Am 18:503–514, 1991; reprinted with permission

<200 <200 5000–75,000 >50,000

– Degenerative joint

disease Trauma Neuropathic PVNS SLE Acute rheumatic fever

Rheumatoid arthritis Crystalline-induced arthritis Seronegative arthritis SLE Acute Rheumatic fever

Bacterial infection

Compromised

immunity

Open Fractures

An open fracture involves exposure of fractured bone to the outside environment. This exposure increases the risk of bone contamination from foreign debris and inoculation with bacteria. Concomitantly, open fractures are often associated with severe soft tissue damage, devascularization, and devitalization of bone fragments facilitating an even more favorable environment for bacterial growth.

While many grading systems have been created, perhaps the most widely used classication of open fractures comes from Gustilo–Anderson. This classication considers energy, wound size, soft tissues damage, level of contamination, fracture comminution, periosteal stripping, skin coverage, and presence of neurovascular injury. From the classication system, an antibiotic has been developed providing utility in initial management (Table5.4).

While the Gustilo-Anderson system affords ease of applicability, particularly size of wound, the zone of injury may be much larger than the wound. Thus, this system can be misleading in its categorization.

The most critical aspect of care for open fracture occurs in the emergency department. Time to antibiotics has been shown to be vital in preventing catastrophic infections. A tetanus booster is commonly given as well.

Formerly, open fractures were taken for operative debridement within 6h of injury as the status

of the patient permitted. The standard of care has shifted based on several landmark studies demonstrating no difference in outcomes between debridement with 6 and 24h. Open fractures are still considered operative emergencies and need to be taken to the operating room as soon as the patient is considered medically stable enough to tolerate surgery but now within 24h.

After ensuring administration of antibiotics, gentle wound irrigation and application of a sterile dressing should be performed. Depending on the fracture, a reduction and splint immobilization may be indicated just as with any closed injury. Cultures in the emergency department are frequently contaminated providing minimal, if any, therapeutic value and are thus not recommended. The general principles regarding antibiotic therapy is that rst-generation cephalosporins are given regardless of grade. For Gustilo type III, the addition of an aminoglycoside has been traditionally recommended; however, controversy regarding this addition is present. For any farm injuries or those associated with bowel contamination, the addition of an aminoglycoside and penicillin are recommended.

In the operative suite, assessment of the extent of injury and aggressive debridement should be undertaken in the operating room in an emergent manner. As with any debridement, the removal of any devitalized tissues is critical to prevent proliferation of bacterial growth. As mentioned previously, the zone of injury is often greater than the wound. Determining this zone of injuries

Table 5.4 Gustilo-Anderson classication

I II IIIA IIIB IIIC Energy Low Moderate High High High Wound size <1cm 1–10cm Usually

>10cm Soft tissue damage Minimal Moderate Extensive Extensive Extensive Contamination Clean Moderate Extensive Extensive Extensive Fracture comminution Periosteal stripping No No Yes Yes Yes Skin coverage Local Local Local Free or rotational

Neurovascular injury None None None None Vascular injury requiring

Minimal Moderate Severe Severe Severe

Usually >10cm Usually >10cm

Free or rotational ap

ap

repair

R. A. Cowley et al.

allows for a more comprehensive debridement. Often this determination can be challenging during the index procedure; thus, many advocate for a second look procedure 48–72h prior to wound closure especially for higher energy injuries. If a wound is not closed primarily during the index procedure, wound vacuums are applied and remain until eventual closure providing three critical benets: decreasing wound tension, removal of uid accumulation, and protection from the outside environment.

Presence of Morel Lavellée lesion, a closed shearing injury separating the fascia and subcutaneous skin, requires special attention. These shearing lesions create a deep space that provides an unwanted hospitable environment for bacterial proliferation. A surgical drain to compression may be placed to close down this dead space and minimize risk of infection.

Fracture stabilization is a pertinent facet of the operative intervention. While disagreement exists on the manner, a general consensus is that there needs to be some form of stabilization for soft tissue healing, early mobility, and pain control. For grossly contaminated wounds, temporizing measures may be employed including splinting or external xation. External xation can represent a denitive treatment; however, intramedullary nailing or plate/screw xation are commonly employed for denitive xation once the site is sufciently debrided.

A delayed primary closure may be all that is required in grade I and grade II fractures, whereas skin grafting or soft tissue transfers may be nec-

essary for grade III fractures. Options for soft tissue coverage should be individualized for the patient and the degree of injury. For more complex soft tissue defects, a plastic surgeon consultation may be recommended.

Nutritional status plays a vital role in wound healing especially considering the increased metabolic demand of polytraumatized patients. Systemic parameters that have been shown to impede soft tissue healing include a serum albumin less than 3.5mg/dL, prealbumin <16mg/dL, transferrin <212 mg/dL, or a total lymphocyte count less than 1500 cells/mL. For those with diabetes, tight glycemic control is pertinent to reduce the risk of infection. As such, nutritional resuscitation and blood glucose management become vital in the perioperative setting.

If an infection such as wound dehiscence, abscess formation or osteomyelitis develops following an open fracture, then the same principles of debridement apply with one important exception—the retention of implants for xation of the fracture. In patients who present with an infection surrounding an intramedullary nail or plate, the wound should be aggressively debrided and the implant maintained if fracture stability is being achieved. Loose implants should be removed and either replaced or substituted by another implant type (i.e., an external xator replacing a loose plate and screws). Intravenous antibiotics should be administered and directed toward isolated organisms for at least 6weeks. Once a fracture has healed, the implant can be removed and further debridement performed as

5 Orthopedic Infections

necessary. This approach reduces the complexity of treatment from an infected nonunion to an infected united bone with a better prognosis for successful healing and eradication of the infection.

Prosthetic Joint Infections (PJI)

The presence of a foreign substrate such as an arthroplasty can provide bacteria with an excellent site for binding and colonization. Unfortunately, the diagnosis of a PJI remains challenging. The onset of symptoms in relation to the time of surgery plays a role in the diagnosis. Acute infections are dened within 3–6weeks of surgery and chronic infections are considered greater than 3–6weeks.

Obvious ndings like wound dehiscence, drainage, erythema, and effusions with systemic symptoms (fevers, chills, malaise) immediately warrant work up and likely intervention. However, some may present with indolent subclinical symptoms that could easily be overlooked; thus, a high level of clinical suspicion is required.

Plain lms are the main imaging modalities utilized for PJI for comparison to prior lms. Profound bone resorption surrounding implants may also be suggestive of infection; however, similar changes can be seen with aseptic loosening without an associated infection (Image 5.2).

Laboratory values, although often abnormal, are also not specic for infection. Bone scans using technetium 99m and indium-111 help detect inammation and leukocytes, respectively, with great sensitivity (99%), however, suboptimal specicity; thus, these scans are uncommonly used. Similarly, positron emission tomography (PET) scans have been described to identify areas of high metabolic activity with a high sensitivity and specicity; however, due to cost restrictions and availability, PET scans are not frequently utilized.

Obtaining basic laboratory values are standard of care including a CBC as well as inammatory markers. The WBC count is rarely elevated except in a fulminant infection. The inamma-

Image 5.2 Anterior posterior plain radiograph demonstrating a hinge total knee replacement with distal femur cerclage and notable bony resorption associated with prosthetic joint infection. (Courtesy of Dr. Kenneth Vaz)

tory markers, ESR and CRP, are generally elevated. While not commonly utilized, serum interleukin-6 (IL-6) has been shown to have the highest correlation with periprosthetic joint infection with a sensitivity of 100% and specicity of 95%.

An aspiration still remains the best single test to identify a subclinical infection, with a sensitivity of 90%, specicity of 80%, and an accuracy of 78%. For more conned joints such as the hip, uoroscopy or ultrasound should be used to conrm needle localization within the joint. These samples should be sent for the same tests as native septic joints (cell count, culture, gram stain, crystal). Traditionally, a chronic PJI is suspected if there are greater than 3000 WBCs/μL. Higher thresholds for acute PJIs remain controversial. Other synovial tests may be sent as well, which provide particular diagnostic value in the culture negative specimens including synovial CRP.The

100

R. A. Cowley et al.

addition of alpha-defensin immunoassay, a peptide release by neutrophils, may aid clinicians as this is 100% sensitive and 98% specic for PJI.Another benet for alpha- defensin is the sensitivity is not affected by previous antibiotic administration. Similar to urinalysis, leukocyte esterase colorimetric strips may be performed on the synovial samples to demonstrate neutrophil activity. With recent awareness of more fastidious organisms such as Cutibacterium acnes (formerly Propionibacterium acnes), some centers have begun to hold specimens for 3–4weeks to allow for their possible identication. With the advent of next generation sequencing, uncovering a microbial source through this polymerase chain reaction (PCR) test and other nucleic acid amplication tests (NAATs) may be feasible for previous culture negative samples. Implementing this technique into the standard workup has yet to manifest as cost and availability remain a few of the barriers.

In 2011, the Musculoskeletal Infection Society (MSIS) and Infectious Disease Society developed criteria in hopes of standardizing and improving diagnostic accuracy. Subsequently, this criteria was updated in 2018 by Dr. Jared Parvizi to address the limitations of the initial algorithm. This criteria is divided into major and minor criteria boosting a 98% sensitivity and 99.5% specicity for diagnosis of PJI.

tion. For those unt for surgery, chronic suppressive antibiotic therapy may be the only option. While this option may provide symptomatic relief, success of complete eradication is limited; thus, this therapy typically is reserved for palliative patients. For acute infections, some propose the biolm has not been developed; therefore, an aggressive debridement and polyethylene liner exchange with component retention may be sufcient. Some surgeons argue a one-stage complete component exchange and debridement can be a suitable option in appropriate patients who are otherwise healthy and are infected by low-virulent organisms. However, currently, the gold standard treatment remains a two-stage revision arthroplasty. The rst stage entails complete removal of all components with placement of an antibiotic spacer. The second reimplantation stage occurs in delayed fashion with >6weeks intervals demonstrating greater overall success. In all circumstances, an infectious disease consultation is recommended as these patients require extended antibiotic regimens. Salvage options are available including resection arthroplasty, arthrodesis, and amputation. These options should be matched with appropriate candidates based upon their issue and preference.

Summary andConclusions

Major Criteria: (PJI if 1 major criteria exists)

1. Sinus tract communicating with the prosthesis

2. Pathogen isolated by culture from 2 separate

tissue or uid samples

Minor Criteria (PJI ≥6, inconclusive 5–2, no infection 1–0)

1. Elevated synovial WBC (>3000 cells/μL) or

Leukocyte Esterase—3 points

2. Positive synovial alpha-defensin—3 points

3. Elevated synovial PMN (>80%)—2 points

4. Elevated synovial CRP (>6.9mg/L)—1 point

While the 2018 MSIS criteria has aided in standardizing care, the inconclusive zone forces the surgeon to utilize their own clinical judgment.

Treatment of PJI should account for the patient’s ability to tolerate surgery and chronicity of infec-

The prompt diagnosis of a musculoskeletal infection is the most vital aspect in the appropriate management of these conditions. Though the diagnosis may at times prove difcult due to a variety of mitigating circumstances, the prudent use of laboratory data, imaging studies and sound clinical acumen should minimize delay or missed diagnosis. Acute treatment of an infection is substantially more straightforward than management of chronic musculoskeletal infections and their unfortunate sequelae.

Pediatric Septic Arthritis

Adult Osteomyelitis

Adult Septic Arthritis

Open Fractures

Prosthetic Joint Infections (PJI)

Further Reading