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performed, but arthrocentesis or arthroscopy, depending on the local expertise, may be effective in a number of cases of SA. Both these procedures are minimally invasive compared to arthrotomy. Some orthopaedic surgeons prefer arthrotomy to closed needle aspiration because more complete pus removal can be achieved. However, few small studies, one prospective and the others retrospective, have shown some evidence that arthrocentesis may be an © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 23 appropriate approach for SA therapy in children, even when shoulder and hip are involved (133–137). · Arthrotomy should may be considered in some SA involving the hip or shoulder (especially if experience with arthrocentesis is lacking) in young children (3-6 months) (8), longer duration of symptoms at presentation (5-7 days), and with more virulent pathogens (MRSA or PVL+) since the rate of developing complications and sequelae may be higher (34,83,131,140–142). Some studies have associated SA of the hip with higher developping of sequelae (8,143) and, therefore, some authors suggest arthrotomy when this join is involved (143). · In some institutions, many episodes of SA such as those in the knee and ankle, and hip SA without risk factors (134,137), are managed by repeated closed needle aspirations and lavage in older children – consider surgery if more than 2-3 interventions have to be performed (136,137). If closed needle aspiration is selected, it should be performed with a sterile procedure (144). Benefits include avoidance of surgery but it may require general anesthesia in young children · Arthroscopy has been associated with shorter lengths of hospital stay, and may provide improved visualization of the joint space for prognostic purposes (139,145,146) · Generally, even after arthrotomy, there is no need for immobilisation except for pain control or upon risk of fracture, although some orthopaedic surgeons recommend this, especially after hip SA to avoid a potential luxation of the joint. · There is little evidence to leave a drain in place routinely. If considered due to the extent of infection or difficulty in debridement, drains should be inserted for as short a period as possible. Notes – In general, inflammation in the follow-up does not per se mean infection. Repetitive surgical interventions should be discussed by an interdisciplinary approach. 7.6 Physical therapy Rehabilitation is a very important part in the management of BJI, and especially so in SA and after surgery. Although injury to the area involved should be avoided, prompt mobilisation is crucial for the prevention of complications such as rigidity. · Depending on the site and severity of the OM, some type of support and/or protection device, such as a soft removable cast, boot case, and instructions to avoid weight bearing for some period, may help prevent the development of a pathologic fracture. · Non-weight bearing is considered essential in the early management for pain control for the short and longer term - though clearly for some toddlers it is harder to enforce; back slabs/splints may be used to make this easier. · Supportive devices (i.e., corsets) in case of spondylodiscitis may be recommended. · BJI management is often a multidisciplinary approach with orthopaedics or paediatric orthopaedics (in larger centres) and adjunctive therapy should be discussed on a case-bycase basis with them. 7.7 Follow-up & outcome, complications/sequelae Early diagnosis and appropriate treatment are associated with excellent outcome and successful prevention of chronic inflammation and development of sequestra and fistulae (24). Common sequelae are: limping, dismetry, chronic pain, rigidity and chronic inflammation in the absence of an infectious agent. © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 24 · Experienced orthopaedic surgeons should follow children for a variable duration of time depending on the severity of the infection, age, and the area affected. · After hospitalisation, follow up by orthopaedics and paediatricians with musculoskeletal experience (and especially infants, hips and physis involvement) is recommended at about 2 weeks, 4-6 weeks, 3 months, and 12 months after discharge. · Consider longer follow-up in children with involvement of the pelvis, the spinal column and hip, or if the physis is affected. Infants and younger children may be followed longer, as well. · Pain-free normal activity is an important end point prior to discharge from follow up. · Check-up should include: clinical investigation, CRP, US – radiography only when indicated. · Provide NSAID or analgesia as needed. The identification of Salmonella (147), MRSA or PVL+ bacteria may be related with higer rate of complications and/or sequelae. Recent studies show that morbidity associated with MRSA BJIs in children may be significantly higher than that caused by MSSA, and this reflects on type and duration of therapy (131,140,141). Other studies, however, did not see this difference (56,96). PVL positive (PVL +) S. aureus (MSSA or MRSA) may also be associated with higher morbidity in paediatric BJI (34,56,96,142,148). Some authors claim that MRSA virulence may be related to PVL (or other toxin) production since PVL is more commonly found in MRSA than in MSSA (96,107,142).
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