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Prosthetic joint infection (PJI) diagnosis includes several classes of verification. Among them, only a few have a stronger independent value, namely intraarticular purulence and communicating fistulas. Other diagnostic methods require careful test combinations, analysis, and interpretation. Molecular based techniques using the polymerase chain reaction (PCR) seem to be a promising PJI diagnostic modality due to its excellent sensitivity, specificity, positive predictive value, and speed. Most of the recent reviewers are in agreement that molecular diagnosis has enough potential for future application in orthopaedics even if there are only a few heterogeneous studies fully supporting this concept. Conversely, at least one study has been published with significantly worse results (sensitivity and specificity less than 0.75). The lack of supporting evidence in the published studies may be closely related to varying PCR laboratory procedures, inappropriate reference standards, and other methodological shortcomings among research centers. It is not yet justifiable to firmly include molecular methods into the present PJI diagnostic schemes. The orthopaedic community must await the results of well-organized ongoing studies before considering inclusion of molecular diagnostics as a PJI diagnostic method. The aim of this paper was to make a survey of current PJI molecular diagnostic techniques in orthopaedics.

Cefotaxime powder was diluted with sterile water to a concentration of 100 mg/mL. The volume of solution was adjusted for each experimental horse to provide a total dose of 15, 20, and 25 mg/kg and was administered by infusion through a jugular vein catheter over a 10-min period. All three doses were administered to each of the six experimental horses at three different times. Cefotaxime concentrations in plasma and synovial fluid samples were measured by high-performance liquid chromatography (HPLC). Standard compartmental analysis techniques and the WinSAAM modeling program were used to determine standard pharmacokinetic parameters for cefotaxime. The plasma and synovial fluid data from the five horses administered the 25 mg/kg dose was analyzed. Plasma cefotaxime concentrations appeared to be linearly related to dose infused and declined in parallel, suggesting linear drug kinetics. Moreover, cefotaxime concentrations declined monotonically suggesting that its disposition kinetics could essentially be described by a one-compartment model rather than the fact that sampling occurred after the infusion was discontinued. Maximum concentration of cefotaxime in plasma occurred immediately after cessation of the infusion. Minimum inhibitory concentrations were determined for Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, common isolates from septic arthritis in horses. Based on our pharmacokinetic data, a regimen of 25 mg/kg administered i.v. every 6 h appears appropriate for susceptible joint infections in adult horses.

Radiographic diagnosis plays an important role in bone and joint infection management but the techniques used do not all present the same interest. Conventional radiography may not be informative during the first weeks and ultrasonography is especially useful to show accumulation of intra articular fluid or edematous soft-tissue. Computed tomography, magnetic resonance imaging, bone scintigraphy are the best exams for this diagnosis. According to the type of infection (septic arthritis, osteomyelitis, spondylodiskitis, diabetic foot, prosthetic joint infection), and to anatomical localization, the examination is chosen depending on its sensitivity and its specificity for bone and joint infection management.

Gram-positive organisms, particularly staphylococci and streptococci, are responsible for the majority of bone and joint infections. Treatment of these infections can be difficult, usually involving a prolonged course of antibiotics, often with surgical intervention. The selection of antibiotics depends on sensitivity profile, patient tolerance and long-term goals, e.g. cure or suppression, but there are few randomized controlled trials in patients comparing efficacy of different antibiotics. Different degrees of bone penetration and clinical outcome for specific antibiotics, e.g. the beta-lactams, clindamycin and quinolones, have been described, although the methodology in these studies is not standardized and findings cannot always be applied directly to patients. The effect of attaining minimum serum bactericidal concentrations in patients has also been studied but this is no longer routinely recommended in clinical practice. Comparative clinical trials are few but have demonstrated efficacy of oral fluoroquinolones in combination with either rifampicin or fusidic acid for selected Gram-positive infections. In the past decade, increasingly resistant organisms, e.g. methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci have been recognized as causes of orthopaedic infection. Individual case reports describe successful treatment using the newer antibiotics, e.g. linezolid and quinupristin/dalfopristin, but results of clinical trials are awaited.

The superior soft tissue contrast and multiplanar capability of MR imaging has contributed to earlier diagnosis and implementation of effective treatment for a variety of arthropathies and infectious conditions of the elbow, wrist, and hand. Because of overlapping clinical signs and symptoms, MR imaging plays an important role in delineating the features and staging of each of these conditions. This article discusses the seropositive and seronegative inflammatory arthropathies, with emphasis on early detection and surveillance, as well as gout, synovial osteochondromatosis, pigmented villonodular synovitis, tenosynovitis, and de Quervain's tenosynovitis. Certain noninflammatory arthritides and infectious conditions are also reviewed.

By the use of 16S rRNA gene sequence analysis we identified 28 of 31 Corynebacterium spp. isolated from bone and joint infections, including species never before isolated in such infections. Phenotypic analysis led to the correct identification of 8 of 31. 16S rRNA gene sequence analysis appears to be a good technique for identification of clinical strains of Corynebacterium spp.

Our case concerns a 32-year old Cameroonian male presenting with tuberculous sacroiliitis. Diagnosis was made on the basis of a positive abscess needle aspirate. Tuberculous sacroiliitis is rare and generally an isolated phenomenon. Its insidious presentation leads to delayed diagnosis. The affection is often overlooked due to lack of awareness of the clinicians, the usually good condition of the patient and minimal signs of sacroiliac joint infection. Haematological data are frequently non contributory. High risk groups include developing countries immigrants, immunodepressed patients and low socioeconomic status. Accurate diagnosis is based on percutaneous synovial fluid or abscess aspirate bacteriology. CT-scan and NMR are the most helpful radiological examinations.

Soft tissue infection may be acute or chronic and may be introduced by the haematogenous route, or by inoculation, including surgical infection, or spread from other areas. The spectrum of infecting organism differs in primary infection, in immunodeficiency or when foreign bodies, including prostheses, are present. Bacterial infections are usually more rapid than those due to fungi or atypical organisms. Inflammation usually begins as cellulitis, proceeding through necrosis to cavitation and abscess formation, sometimes complicated by haemorrhage. Imaging, apart from MRI in selected cases, is rarely helpful in the early stages, but early diagnosis of pyomyositis and necrotizing fasciitis is mandatory. When infection is established, US, CT and MRI all have individual value in diagnosis, including biopsy, and in directing therapy, including percutaneous or surgical drainage or debridement. Both MRI and CT are best suited to monitoring progress. Septic arthritis presents as rapidly progressive, destructive arthritis, and early diagnosis is essential to prevent long-term morbidity. Ultrasound offers the best method of detecting early joint effusion and synovial thickening, but aspiration is usually required for diagnosis. In more advanced stages CT is valuable for revealing destructive changes, and MRI for documenting intra-articular changes and detecting inflammation in surrounding bone.

Prosthetic joint infections (PJIs) occur in approximately 1.5%-2.5% of all primary hip or knee arthroplasties. The mortality rate attributed to PJIs may be as high as 2.5%. Substantial morbidity is associated with a loss of mobility, although this is temporary. The costs associated with a single episode of PJI are approximately $50,000 per episode, exclusive of lost wages. Risk factors that increase the occurrence of PJI include revision arthroplasty, time in the operating room, postoperative surgical site infection, and malignancy. Pain is the most consistent symptom. Staphylococcus species are the most common organisms isolated from PJI sites. Two-stage revision is superior to single-stage revision or to debridement with prosthesis retention. Long-term antibiotic suppression and/or arthrodesis are useful for patients too frail to undergo extensive surgery. Using an optimal approach, recurrent infection occurs in <10% of previously infected joints.

Objective: Sternoclavicular joint infections are rare, and their management is controversial. We reviewed our experience with the surgical management of this condition., Methods: From August 1988 to August 2001, 26 patients (16 men and 10 women) were treated surgically for infected sternoclavicular joints. The median age was 56 years (range, 20-77 years). Patients who had a recent previous median sternotomy were excluded., Results: All patients were symptomatic. Pain was present in 21 patients, swelling in 14 patients, fever in 11 patients, and erythema in 9 patients. Associated conditions included recent or ongoing infections in other areas in 12 patients (pneumonia in 4 patients, multiple joint infections in 2 patients, and other in 6 patients) and an indwelling central venous catheter in 1 patient. Five patients had a history of trauma in the region of the joint. Four patients had prior joint incision and drainage. Unilateral sternoclavicular joint resection was done in 18 patients, bilateral resection in 2 patients, and incision and drainage with debridement in 6 patients. Wound culture results were positive in 24 patients, and the most common organism isolated was Staphylococcus aureus (n = 17). Eleven patients had transposition of the ipsilateral pectoralis major muscle to obliterate residual space and to reconstruct the chest wall. Two (7.7%) patients had complications, and 1 died (operative mortality, 3.8%). Follow-up was complete in all 25 operative survivors and ranged from 2 months to 10 years (median, 25 months). Twenty-one patients are alive without symptoms, infection, or limitations in range of motion. Four patients have died as a result of causes unrelated to their joint infections., Conclusions: Symptomatic sternoclavicular joint infections often require surgical intervention. Surgical resection combined with muscle transposition provides effective long-term outcome.

Bone and joint infections are significant causes of morbidity, mortality and healthcare costs. The cost of treatment for such infections is driven primarily by the length of hospital stay. Many of these infections will require treatment with prolonged periods of parenteral antibiotic therapy. Clinicians and healthcare managers are being attracted increasingly by administering treatment in the ambulatory setting as this offers clinical, economic and quality of life advantages from both the hospital's and patient's perspective. Our retrospective audit of managing 55 treatment episodes of bone and joint infections with teicoplanin delivered in the outpatient or home setting revealed that the mean cost of care per episode of infection was less with treatment in the ambulatory setting ( pound 1749.15) compared with the in-patient setting ( pound 11 400) or compared with the hypothetical situation of treatment with oral linezolid in the home setting ( pound 2546). Teicoplanin therapeutic drug monitoring appears to be valuable in establishing optimal serum levels, which appear to correlate with good clinical outcomes. The potential for alternative day or thrice weekly dosing with teicoplanin may offer further cost advantages whilst maintaining equivalent clinical effectiveness.

Under field circumstances amyloid arthropathy was nerve recorded in white layers, while experimentally their brown counterparts were found to be more susceptible to the induction of amyloid arthropathy, although articular amyloid was found in a few white leghorns. In the present manuscript the first field case of amyloid arthropathy in white layers associated with Mycoplasma synoviae is reported. In the same house where the white birds were housed, brown layers were present. The condition was much more severe in the latter chickens. The different susceptibility between both breeds is discussed in view of previously performed research.

A case of cellulitis was observed in Japanese quail (Coturnix coturnix japonica) reared for commercial meat production. This condition in Japanese quail has not been reported in the literature. This incident was the first, and to date only, occurrence of cellulitis in this processing plant. The cellulitis lesions were localized to the subcutis overlying the breast and inner thigh. Carcasses of processed birds and live birds from the affected farm were presented to the Poultry Diagnostic and Research Center, University of Georgia. Escherichia coli was cultured from the lesion. The affected live birds displayed lameness and had osteomyelitis. Pasteurella multocida serotype 3,4 was cultured from the liver and bone marrow of affected birds. Approximately 4.61% of the processed carcasses from the flock were condemned because of cellulitis. This represented a 10fold increase from the typical condemnation rate. Further investigation revealed birds were placed in higher than normal density; therefore, we theorize that the concurrent pasteurellosis and increased placement density resulted in the cellulitis condition.

Chronic meningococcaemia is a rare disorder. A patient was admitted to hospital with intermittent fever and arthralgia of a migratory nature for 1 week. Maculopapular lesions were present. His temperature was 38.5 degrees C. Physical examination revealed a patient without any signs of severe illness. Blood cultures grew Neisseria meningitides.

Skeletal infections in injection drug users have an insidious onset, present with indolent symptoms, and often occur in unusual locations. Unless physicians are familiar with the disease entities unique to the injection drug user, the diagnosis is frequently delayed. Systemic signs of infection are often lacking. The organisms causing the infection represent a wide spectrum; hence, empiric therapy is not generally recommended. Plain-film radiographs are of little help for early diagnosis. Imaging studies, especially radionucleotide studies and CT or MR imaging scans, can help localize the site of infection. For etiologic diagnosis of these infections, bone biopsy or needle aspiration of the involved bone or joint is required. The choice of antibiotic agent should be based on culture results and the antimicrobial susceptibility of the causative organism. Treatment may also involve surgical drainage or débridement of affected structures. Failure to manage acute bone and joint infection aggressively inevitably leads to chronic, often incurable, infection. Successful therapy requires a team approach including the internist and consultants from orthopedic surgery, infectious diseases, and substance abuse counselors.

Thirty-three cases of acute hematogenous bone or joint infection in children were randomly treated with short-term (7 days for joint infection, 10 days for bone infection) or long-term (14 days and 21 days, respectively) intravenous antibiotics after surgical drainage. The treatment outcome was measured through a detailed scoring system that included the ability to eradicate infection, the functional status of the limb, and the radiographic appearance of the bone and joint. The results were similar in both groups, showing the added benefit of a shorter hospital stay for children with blood-borne musculoskeletal infection. The use of this scoring system in choosing the route of antibiotic administration is recommended.

We analyzed the bacterial contamination rate of femoral head allografts from living donors and determined the true bacterial load with cultures from the grafts in their entirety in a specially prepared medium. During 4 years we took swab cultures from 2,679 grafts of which 2,414 (90%) were negative. In a period of 12 months, grafts rejected for reasons other than infectious disease were cultured in their entirety to determine the true bacterial load. Of the 106 grafts included, 15 were contaminated. Microorganisms were isolated from 10 of the 91 initially swab culture-negative grafts (9%) and from only 5 of the 15 swab culture-positive grafts, most of which were normal skin contaminants. Swab culture negative grafts apparently may still be contaminated. It seems wise to subject all femoral head allografts from living donors to antibacterial processing.

Fungal prosthetic joint infection (PJI) is rare, with Candida species being the most frequently reported pathogen in the medical literature. The risk of relapse following delayed reimplantation arthroplasty for candidal PJI is unknown. We describe 4 new cases and summarize 6 previously reported cases of candidal PJI treated with delayed reimplantation arthroplasty. Ninety percent of the patients received antifungal therapy. Eight patients received amphotericin B either alone or in combination with other antifungals. One patient received fluconazole alone. The median duration of time from resection arthroplasty to reimplantation for total hip and total knee arthroplasties was 8.6 and 2.3 months, respectively. Eight patients did not have relapse of candidal PJI following delayed reimplantation arthroplasty after a median duration of follow-up of 50.7 months (range, 2--73 months). Candidal PJI can be successfully treated with delayed reimplantation arthroplasty after receipt appropriate antifungal therapy.

Although symmetrical polyarticular amyloidosis has been described extensively in brown layers, spontaneous unilateral amyloid arthropathy has not been described previously in chickens. Birds from nine flocks of broiler parent stock (PS) had unilateral lameness associated with severe swelling of the left hock joint and the caudal aspect of the metatarsus. Gross pathology was restricted to the left hock joint and the left digital flexor tendons in almost all cases, suggesting an association with administration of Marek's disease vaccine. Amyloid deposits were found in 83% (25/30) of affected joints by histological examination of Congo red stained sections. Systemic amyloidosis, involving mainly the liver and spleen, was found in 59% (10/17) of birds. Enterococcus faecalis was isolated from joints in 77% (23/30) of cases and Staphylococcus aureus was isolated from the joint in one case (1/30). Thirty-five E. faecalis isolates from joints, tendons and blood samples from birds in five affected PS flocks were compared using pulsed-field gel electrophoresis (PFGE) to separate genomic fragments after digestion with SmaI. All but one isolate had identical or closely related restriction endonuclease digestion (RED) patterns that were very similar to a known arthropathic and amyloidogenic E. faecalis isolate. A further 30 E. faecalis isolates from seven grandparent stock (GPS) flocks and two isolates from two unaffected PS flocks of the same genetic background were analysed by PFGE. Among these isolates, 11 originating from four GPS flocks had RED patterns identical to or closely related to the reference amyloid-inducing strain. Moreover, one E. faecalis isolate from amyloidotic joints of brown layers housed in California, USA was included in the analysis and appeared to be identical to the reference strain. This study showed that the E. faecalis isolates involved in these outbreaks of unilateral amyloid arthropathy in broiler breeders belonged to the same clone as that responsible for outbreaks in brown layers.

One-day-old brown layer chicks were exposed to an aerosol of an arthropathic and amyloidogenic Enterococcus faecalis strain alone or after being subjected to treatment with formaldehyde gas (100-200 ppm). Four-day-old chicks were also treated with the same aerosol but after treatment with a Newcastle disease vaccine virus (NDVV) aerosol or intramuscular injection with methylprednisolon at day 1. The same E. faecalis strain was inoculated intramuscularly in day-old chicks as positive control. Bacteremia with time showed that 24 hr after the aerosol the day-old exposed chicks had the highest rate of positive blood cultures (70%-80%). Lower numbers of bacteremic birds at this point in time were found in the chicks treated with E. faecalis aerosol at day 4 (3/10 in the methylprednisolon-treated group and 0/10 in the NDVV-treated group) and the E. faecalis intramuscular-injected group at day 1 (2/10). Formaldehyde gas treatment did not favor the occurrence of bacteremia. NDVV aerosol exposure or injection with corticosteroids did not favor the occurrence of bacteremia 24 hr after E. faecalis aerosol exposure at day 4 either, although 66 days after aerosol, one bird (1/14) treated with NDVV showed bacteremia. A few bacteremic birds were found 10 days after aerosol in the NDVV- and methylprednisolon-treated groups, whereas at 14 days after aerosol, one bacteremic bird was seen in the group subjected to E. faecalis aerosol at day 1, indicating the occurrence of chronic bacteremia. In contrast to the E. faecalis intramuscular-inoculated birds, no joint pathology was seen in the aerosol-exposed groups in spite of the occurrence of chronic bacteremia.

DNA-DNA hybridization experiments and comparative 165 rDNA sequence analysis revealed that six isolates from purulent joint and lung infections in calves, from a lung lesion in a sheep, and from a joint infection of a pig represented a novel species belonging to the genus Globicatella. Whole-cell protein electrophoresis and biochemical activity testing revealed that the isolates formed a homogeneous group differing from Globicatella sanguinis, the only species of this genus described to date. These animal isolates were classified as Globicatella sulfidifaciens sp. nov. with LMG 188441 (= CCUG 44365T), isolated from the lung of a calf, as the type strain. A detailed description of its phenotypic characteristics is presented. Hydrogen sulphide production was found to be a very useful diagnostic feature.

Enterococcus faecalis-related amyloid arthropathy was diagnosed in a sample of birds from a flock of brown layer parent chickens aged 57 weeks. E. faecalis was isolated from amyloidotic knee joints and from blood samples from lame birds. From this flock a smaller one was kept for production purposes to study the vertical transmission of arthropathic and amyloidogenic E. faecalis. Three batches of non-soiled and thoroughly disinfected eggs, to prevent egg-shell contamination, were collected for 6 weeks and submitted for incubation every 2 weeks. No joint pathology was found in the offspring chicks (n = 458) monitored for joint disease until 16 or 21 weeks of age. Fresh and candled eggs (infertiles and dead embryos) obtained at day 18 of the incubation period had negative results at bacteriological examination of the yolk sac, except one non-hatched egg (late embryonal death in shell) from which E. faecalis was isolated. Genotyping by pulsed-field gel electrophoresis (PFGE) of all E. faecalis isolates obtained from blood and joints (except one) of the parent birds and of the non-hatched egg after Sma I digestion showed that all isolates were genetically closely related or identical to a known arthropathic and amyloidogenic E. faecalis strain. In this study, vertical transmission of E. faecalis, although it may occur on a small scale as shown by PFGE, did not seem to play a significant role. Conversely, the chronicity of the condition and the development of an immune response may have affected the efficiency of its transmission.

Dactylitis is an important feature of inflammatory arthritis and unusual complication of osteoarticular brucellosis. We report a case of dactylitis of the index finger in a female patient with brucellosis.

Adult chronic hip pain can be difficult to attribute to a specific cause, both clinically and radiographically. Yet, there are often subtle radiographic signs that point to traumatic, infectious, arthritic, neoplastic, congenital, or other causes. Stress fractures appear as a lucent line surrounded by sclerosis or as subtle lucency or sclerosis. Subtle femoral neck angulation, trabecular angulation, or a subcapital impaction line indicates an insufficiency fracture. Apophyseal avulsion fractures appear as a thin, crescentic, ossific opacity when viewed in tangent and as a subtle, disk-shaped opacity when viewed en face. Effusion, cartilage loss, and cortical bone destruction are diagnostic of a septic hip. Transient osteoporosis manifests as osteoporosis and effusion. The earliest finding of avascular necrosis is relative sclerosis in the femoral head. Subtle osteophytes or erosive change is indicative of arthropathy. Osteoarthritis can manifest as early cyst formation, small osteophytes, or buttressing of the femoral neck or calcar. Rheumatoid arthritis may manifest as classic osteopenia, uniform cartilage loss, and erosive change. A disturbance of the trabecular pattern might suggest an early permeative pattern due to a tumor. Knowledge of common causes of chronic hip pain will allow the radiologist to seek out these radiographic findings.

Ankylosing enthesopathy (ANKENT) is a naturally occurring joint disease in mice with numerous parallels to human ankylosing spondylitis (AS). Similarities between AS and ANKENT include not only affected tissue (joint entheses) but also association of the disease with genetic background, including MHC genes, gender, and age. Young males with the C57Bl/10 background have been described to suffer from ANKENT and, among H-2 congenic strains, high frequency of afflicted joints has been recorded in B10.BR (H-2(k)) males. Interestingly, the incidence of ANKENT is higher in conventional (CV) males that in their specific-pathogen-free (SPF) counterparts. The latter finding suggests that microbes could play a role as an ANKENT-triggering agent. To further examine this hypothesis we have established a germ-free (GF) colony of B10.BR mice and observed ANKENT incidence in both GF males and their conventionalized (ex-GF) male littermates; 20% of ex-GF males developed ANKENT before 1 year of age. In contrast, no joint disease was observed under GF conditions (p < 0.0001). Our results show that live microflora is required in ANKENT pathogenesis.

A multidisciplinary panel of Belgian specialists describes the overall therapeutic approach for bone and joint infections. Classification, general methods of investigation, therapeutic options, special circumstances, the role of aminoglycosides and of glycopeptides are described. The possibility of home treatment is discussed, as well as some pharmaco-economic insights.

Background: There is evidence to suggest that Crohn disease is caused by an immunologic response to an unknown intestinal luminal antigen, probably of bacterial origin. The reported demonstration of yersinia antigen in the synovial fluid of patients with yersinosis therefore prompted a search for bacterial antigens in the synovial fluid of patients with Crohn arthropathy., Methods: Antisera were raised in rabbits to synovial fluids obtained from seven patients with Crohn arthropathy and from seven 'control' subjects with other forms of arthropathy. These antisera were used to probe sonicates of the bacteria cultured from the gastric juice of patients with gastric Crohn disease., Results: The antisera made from the Crohn synovial fluids, but none of those made from the controls, reacted uniquely with antigens in sonicates of strains of two species of viridans streptococci (Streptococcus parasanguis and an atypical S. oralis) isolated from four of the five patients with gastric Crohn disease., Conclusions: These findings suggest that the arthropathy of Crohn disease and, possibly, the intestinal disease itself may involve an immunologically mediated inflammatory response to these antigens.

A MAJOR PROBLEM: Two-thirds of all amputations involve infection. Infection is favored by dysfunction of the antibacterial defense systems due to high blood glucose and vascular disorders., Diagnosis: General signs of infection are usually not found. A careful exploration is required to rule out or confirm osteitis in order to guide surgery and plan the antibiotic regimen. A history of chronic and/or recurrent ulceration or direct signs at inspection may be suggestive of osteitis. Radiographic signs are late and nonspecific. Scintigraphy scans are difficult to interpret. Magnetic resonance imaging can be quite helpful in difficult cases., Bacteriological Proof: Staphylococcus aureus and to a lesser extent streptococci account for almost all of the superficial infections in the diabetic foot. In case of deep ulceration, it is important to obtain deep specimens at surgical cleansing as more superficial samples are easily contaminated. Nevertheless, if Staphylococcus aureus is isolated from pus coming from a deep zone fistulizing to the skin, it is likely the causal agent since 80% of all bone infections involve S. aureus. Other germs besides staphylococci and streptococci include enterobacteria (40%), enterococci (26%) and pseudomonas (7%). Several germs are involved in about 70% of cases with a probable synergetic effect between the different bacterial colonies within the infected tissues.

Multidisciplinary Care: A multidisciplinary approach is essential. General measures include immobilization of the focus, controlling blood glucose, anticoagulation, and anti-tetanus vaccination. Topical application of growth factors is currently under evaluation., Antibiotic Therapy: The antibiotics chosen should diffuse well into bone tissue. Combinations with synergetic or additive effects against Staphylococcus aureus are best. Treatment duration depends on the depth of the ulceration. Two weeks is generally advised for superficial ulcers. For deep ulcers, treatment duration depends on the presence or not of osteitis and the quality of surgical debridement. In case of osteitis, after amputation with a healthy margin, antibiotics can generally be discontinued 2 weeks after surgery. Six weeks are required if the amputation margins do not lie in healthy zones. Finally, if no surgery is attempted, the antibiotic regimen should be continued for 3 months, or even longer, with a risk of failure greater than 50%. The best criterion for successful treatment is the absence of late recurrence., Surgery: Surgery is an indispensable element in the overall treatment of deep infections and/or osteitis. The operation should be performed as early as possible to improve prognosis. Well-conducted early surgical debridement can prevent the infection from spreading and avoid the need for much more mutilating "salvage" procedures. Vascular surgery can help maintain sufficient blood supply for wound healing and antibacterial defense. Plastic surgery can be very helpful., Prevention: A certain number of simple measures help reduce the risk of diabetic foot ulcers. However, many patients, and practitioners, are insufficiently aware of their effectiveness. Prevention and treatment can best be accomplished by a multidisciplinary approach calling upon the endocrinologist and the vascular and orthopedic surgery teams. A carefully planned rehabilitation program using adapted soles, orthesis, orthopedic shoes or prostheses as needed can considerably reduce the frequency of recurrence. The risk of recurrence in a patient wearing adapted footwear is only 26% at 5 years compared with 83% in other cases.

A 31-year-old woman who is an intravenous drug abuser developed sternoclavicular joint infection with mediastinal and subcutaneous tissue abscesses that communicated through an erosion in the manubrium caused by osteomyelitis. Air entrapment from a subsequent apical pneumothorax formed a localized anterior "pneumothoracocele." We referred to this condition as "pneumothorax necessitans," and we suggest including it in the differential diagnosis of anterior chest wall masses.

To assess the epidemiological and clinical features of osteoarticular symptoms during tetanus infection, we carried out a retrospective study in infectious Diseases Ward of the University Teaching Hospital in Dakar (Senegal). Over a period of 7 years (1990-1996), 1, 199 cases of tetanus of more than 1 month of age were diagnosed. Among those who survived (n = 948), 18 cases of osteo-articular manifestations were observed (1.8%): 15 presented with vertebral fracture located within the thoracical part T4-T8 (83.3%) while 3 patients had para-articular osteoma in the elbows (16.7%). These complications occurred on stage II (89%) and stage III (11%) of Mollaret's classification of tetanus infection. Males were more represented than females (sex-ratio = 5) and the median age was 13 years (range = 6-45 years). The mean hospitalisation duration was significantly higher for patients with para-articular osteoma (6 weeks) than for those with vertebral fracture (3 weeks). No major functional impairment was noticed during hospitalisation and patients required only physiotherapy and clinical and radiological surveillance. Although not frequent and of some little functional consequence, osteoarticular complications of tetanus, should invite to improve the antitetanic immunization strategies in developing countries.

DIFFICULT ASSESSMENT: Bone and joint infections are difficult to treat. Therapeutic success depends greatly on the diffusion of antibiotics into bone tissue. Few studies have been devoted to this subject and the variable nature of those reported hinders interpretation. Bone biopsies are generally obtained during orthopedic procedures. Antibiotic administration routes vary although intravenous infusion predominates. Agar gel diffusion is generally used for antibiotic assays but methodology varies depending of the study. The most recent reports use high-performance liquid chromatography. DIFFUSION STUDIES: The different studies examining antibiotic diffusion in bone tissue describe three classes: good diffusion (greater than 30%), moderate diffusion (between 15% and 30%), and low diffusion (less than 15%). Antibiotics in the good diffusion class include fluoroquinolones, teicoplanin, macrolides, rifampicin and trimethoprime. Antibiotics with moderate bone diffusion are ureidopenicillins, second and third generation cephalosporins, aminoglycosides, clindamycin, fosfomycin and vancomycin. Those with low bone diffusion are aminopenicillins, penicillin M and first generation cephalosporins. No data is available on the bone diffusion of pristinamycin. DATA INTERPRETATION: The clinical impact of these classifications must be interpreted with precaution when considering bone and joint infections as they were established on the basis of pharmacokinetic studies and not clinical trials. They would however appear to be useful in guiding antibiotic prophylaxis for orthopedic surgery in protocols with administration conditions and concentration goals similar to the experimental conditions. PRACTICAL ATTITUDES: These laboratory results could be used in clinical practice by comparing the MIC50 of the germs regularly encountered in bone infections (staphylococci, streptococci including enterococci, Gram negative bacilli including P. aeruginosa and H. influenzae) with concentrations obtained in the different studies, i.e. by calculating the inhibitor coefficient (IQ) of each antibiotic for each susceptible germ. This gives a classification by efficacy (excellent IQ > 10, good 1 < IQ < 10, poor IQ < 1) useful for guiding antibiotic choice in the difficult situation of bone and joint infection.

One of the most important prognostic factors in patients with musculoskeletal infections is the delay in establishing therapy. Early diagnosis of septic arthritis requires analysis of joint fluid. Ultrasonography (US) is a rapid, portable, sensitive technique for confirming the presence of joint effusions. The study can be easily repeated for follow-up of lesions. US allows real-time guidance of fluid aspiration and can reduce the risk of contaminating other anatomic compartments, especially in the hands, wrists, and feet. Radiography provides complementary information and should be performed in conjunction with US. US is the imaging modality of choice for diagnosis of superficial abscesses. Dynamic compression with the US probe and color Doppler imaging can facilitate detection of superficial abscesses. US may help in the early diagnosis of osteomyelitis by demonstrating subperiosteal or juxtacortical fluid collections and by providing guidance for aspiration of these collections. Evaluation of osseous involvement requires additional imaging; a US examination with normal results does not allow exclusion of bone infection. US is not degraded by metallic artifact and may be useful in cases of osteomyelitis complicating metallic fixation in an extremity. After initial radiography, US can play an important role in the management of musculoskeletal infections.

Alternaria is a fungus that is usually saprophytic but occasionally causes skin infections. Involvement of other structures is exceedingly rare. We report two cases in which a joint was also affected. The possible precipitating role of intraarticular glucocorticoid therapy is discussed. Both patients achieved a full recovery after itraconazole therapy, given for 12 and seven months, respectively.

Septic sacroiliitis is an uncommon condition that is often diagnosed late. Two cases in the immediate postpartal period are reported. Magnetic resonance imaging contributed decisively to the early diagnosis.

Peptostreptococcus micros is a commensal of the oral cavity and the genitourinary tract that rarely causes serious infections. A case of a destructive knee joint infection with rapid progress caused by P. micros is presented. The significance of the microbiological findings was initially not acknowledged, which contributed to a nonsuccessful clinical outcome.

A case of hematogenous spread of an actinomycotic granule to the left hip joint is presented. This occurred in a 62-year-old woman under immunosuppressive treatment for Wegener's disease. It was a chance finding on routine synovium biopsy during a total hip replacement. Treatment consisted of 1 g ampicillin I.M. a day for six weeks. The postoperative course was uneventful.