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Hello, everyone and welcome to our event today. It's great to have you join us. Um Today we're gonna be, well, I'm not gonna be as you already know today Monza is gonna be talking about pediatric bone and joint infection. Um as always popped questions in the chat on the right hand side at the end of the tour augments or we will answer those questions. Um Your feedback form will come to you in an hour's time in your inbox directly to the inbox that you registered with and then you're gonna pop, you're gonna fill that out and your attendance certificate will be on your medal account after you've completed that. I will also f uh pass on that feedback to MSA and maybe he might decide to give us another teaching session in the New Year. Alright, everyone. Enjoy your session. Thank you, MS. Thank you. Right. Uh It's good afternoon here in the UK. So, uh hi, everyone. I hope that you can hear me clearly and you can see the slides and I assume so. So, uh shall we start? Two? Yes, please. All right. So, uh today's topic is a very common topic. In trauma and orthopedics, especially in pediatric trauma orthopedics. So the most common urgent or I would say emergency, uh high yield topics in Children, orthopedics is bone and joint infection and naming the Osteomyelitis and septic arthritis. So my background is I, I'm from Sudan, worked in Sudan for some time and then worked in Saudi Arabia for some time and now in the UK. Uh so I kind of have a global idea of what sort of infections and common causative organisms uh a bit from here and a bit from there. So uh let's start. So our agenda will cover Osteomyelitis and septic arthritis and they are more or less uh in the same in terms of the age group in Children, bones and joints affected and a gender will cover the age, the incidence, ology, pathophysiology, how they present what sort of laboratory investigations they need to order and what are the perfect imaging modalities to uh choose from treatment strategy and some sort of special groups who have um weird presentations. So by definition, osteitis and inflammation of bone caused by a biogenic organism. And most often the result is a hematogen has spread from uh a nearby um infection and then seeding on that bone or joint. And the most common age group is about six years old, seven years old and always more affected than girls. And I don't know why that um uh selection, but this is what we generally see. And it's more common in the first day of the life due to the massive blood supply that Children have and their immune system is still developing. So, uh the disease is changing and there is a change in the v of organisms. It could be related to background community. Uh Where do you live? Where do you stay? Nutritional status? There's also a seasonal variation uh climate lifestyle. And there is also some risk factors such as poor body, immune response, diabetes. Um And if you have some sort of uh debilitating disease such as let's say, um renal failure, so you get more exposed to very, very low various organisms. So, osteomyelitis most commonly uh um uh seen with staph aureus in all age groups, either you're an infant child or an adult. So, staph aureus is are the big, the big, the top of the list. And then sadly, Staph aureus has M RSA, which is a penicillin resistant staph aureus. And these are more aggressive in terms of that infection and they are more resistant to antibiotics. Uh And then there is a Staph which has APV N locus and this is, is a locus where it is very um uh powerful in terms of fighting antibiotics, they have more resistance. Uh And then secondly, uh strip B is a more common organism in units. And then we kind of see um quite increase in king king, which is a low grade infection usually happens in kids who are less than four years old. Um We usually not easily pick those up in cultures that we take. And sometimes we need to run a more extensive uh PCR test to pick these up. And unfortunately, it started to increase gradually over the past uh 75 years and lots of literature about KK infection. And we have to put this on our mind because it has a very low grade infection. And usually the presentation is not as bad as the normal septic or osteomyelitis type picture. So he haemophilus and from one Z was quite uh known initially. But now because of the advent of the vaccination against that, then it is almost vanishing uh within the, within the microbiology and the causes of Osteomyelitis or septic arthritis. Uh salmonella is quite uh close to sickle cell anemia patients. So if you have a sickle cell patient, staph aureus is still on the top of your list, but uh salmonella and sickle cell patients are quite close. So where is the common site? We usually see them in the femur uh tibia humerus and sometimes in the pelvis. And the presentation is quite a bit tricky with the pelvic osteomyelitis and obviously spine where you can have vertebral osteomyelitis or discitis. So, moving on to what is the pathophysiology. So it could be a direct uh inoculation where you have like a direct impact from a needle stick injury or you can get it from a thorn, usually kids playing in play areas, they get uh directly injured and then you can have a hematogenous spread, Children with upper respiratory tract infection, urine tract infection, um or an infection everywhere in the body, then the seeds in the bloodstream and it goes and settles down in the joint or in the bone and then you can have a local invasion from a nearby infection. Um And then what we see quite common is having a trauma. So a trauma builds up some hematoma and then this sees into the nearby infection and causes the uh start of the inflammatory process and then infection in the bone of the joint. So uh what is very specific for Children is um uh they do have a growth plate which blocks the end of the arteries and this will cause more and more stages of the blood supply at the end of the metaphysis. Uh So the blood running all the way up to the metaphysis is quite sluggish in the flow. So it doesn't flow very quickly. So, if there is a bacteria, this gives it a very good time to seed in and sitting down there and plus the ph is uh low and oxygen tension is low. So it's a very good medium for bacteria really. And then they settle there and they, they start to increase in number and size and uh they make their way through the uh Aversan canal and the vol canal in the bone. And eventually uh they start to uh break down through the endothelium. The bacteria passes outside, they adhere to the collagen, especially collagen one. And then the BP increases within the bone. And because the bone is a tight compartment, it cannot withstand this high build up of infection, then it will either cause uh a breakthrough, the cortex and build up of pus. And then you have subperiosteal collection which we call an abscess. Or at this point of time, if you reflect this on the clinical presentation, when the periosteum is the most sensory part, the build up of this pressure will cause pain. This is why when the patient presents to you in the hospital and then if this is treated at a certain time, uh which is quite critical, patients will get relieved and fine. If not, then you go to the next step, which is the bone gets necrotic and and and dies. And this is called uh sequester. Uh So this picture quite delineates what we have been talking through. And you can see the build up of the pus of the proximal metastasis of the bone and then it has to find a place to go and leak through. So it could go either break through the cortex of the bone and then collect in the subperiosteal area or it can go to the adjacent joint. And we know some joints are quite included in the capsule or the proximal part of the bone and thus allows the infection to seed into the joint and cause septic arthritis plus the ongoing osteomyelitis. So, joints which are well incorporated within the capsule are the hip, shoulder, distal ankle, proximal humerus. But because the knee capsule quite is a bit short, um in terms of covering the proximal metastasis, then not always Osteomyelitis, seeds into the uh joint and in the knee and then quite differently in kids. Uh the growth plate at the age of um 18 months, uh over 18 months, it is impermeable to spread. Under 18 month, infection can cross the growth plate. So uh I can see from this picture how things develop. So when you are quite young, there is no growth plate and then the blood supply goes all the way from metastasis to the phys to the epiphysis. But as the Children grow, then you have the phys uh and the growth zone start to appear and then the end arterioles of the uh blood supply start to close off and curl around the end of the metaphysis. So if you have a child who is under 18 months, they can easily see from bone to joint because the Pfizer is not well developed. Uh So what happens next? The infection persists and what you can see in the X ray uh is some lytic lesions. So the lytic lesions because the infection is eating the bone and then uh a lytic lesion happens in the bone which you can see in an X ray. So osteoblasts are, and then the osteoclasts start to be activated and they release the uh factors and these factors start to enhance an inflammatory response. And then the bone fights and uh the, the the what you can see is a li lesion in the X ray. And this is as a result of the Osteomyelitis which has been happening for a while. So if you see this in an x-ray, so probably just at least uh two weeks history. So now you have to have a diagnostic model and usually we say history and examination the most important. And then if you think about it, you have to order some bloods and further imaging, then rediscuss. Uh uh your case with a colleague, we usually say it's an MDT approach. So the clinical picture for Osteomyelitis is a little bit different from septic arthritis. So the patients usually present with pain and a limp. And because it might be that it, it is about three or four days after they have the pain fevers start to develop and they become more lethargic, more apathetic anoxic and not eating well, not feeding well. And then because Children have lots of, you know, flu like symptoms, which happens every now and then. Uh and if the joint or the bone is not quite swollen and it's just about pain and and temperature, the presentation to the hospital might be a bit delayed and this will be he dealt with initially as either a tract infection or he's febrile because he has some flu like symptoms and they will give him some um course of painkillers or antibiotics. And then this delays the presentation a little bit to the hospital. Uh This is quite also commonly seen and then they come to the hospital with a limp, swollen leg, swollen knee or any other part of the body, which has been uh affected. Uh So the blood work that you need to order. If you think that this is an infection uh are usually straight for uh a full blood count, you want to check the white cell count. They usually raised with uh high neutrophil count and polymorph. Uh We usually order ES R and C RP and these are like inflammatory acute phase response. Um uh proteins and the CRP quite get elevated very quickly within 4 to 6 hours and the response very quickly if the infection has been dealt with uh over the course of 4 to 8 hours, the ASR takes about 24 to 36 hours to get elevated. So if you have, if you have a high esr, so this infection has been going for a day or maybe two. Um And then obviously, you need to know what is the cause of this bone and joint infection. So you take a blood culture to see if there is a bacteremia and if there is bacteremia and you have uh a bone and joint infection, then this patient needs to uh deal with very quickly with uh IV antibiotics. The blood culture unfortunately takes about five days to have a formal final uh um results. So we will talk about this through when we chat about treatment that, that you have to start antibiotics according to your local hospital guidelines. Or where, what do you think is the uh common organism? And quite recently, there is um a huge use of uh procalcitonin C and it's still under testing and uh validation. But again, it's a acute phase uh response protein which gets very elevated, very quickly for bacterial infections precisely. So it can be very sensitive and specific for bacterial infections. Uh So that's procalcitonin C. Uh this is a very common uh graph uh which is classic for uh the response of C RP and E SR. And you quite nicely see that CRP uh raises very quickly in the 1st 4 to 6 hours in response to any infection especially, they are very sensitive and specific for uh septic arthritis and osteitis. They are uh CRP is also used to titrate treatments. So there is a very good response um with the C RP dropping down, then you can say, ok, the patient is responding very well. And am I considering switching this patient for my antibiotics or antibiotics? So it helps in knowing the infection and helps in uh tailoring uh antibiotic therapy as well. Uh So blood cultures, so not all blood cultures are positive. So you can get uh culture negatives and about 76% of the time. Uh uh it is culture positive. So you still have about 40% which cultures can be negative, but you still have an infection and this also is affected by the use of antibiotics. So the patient comes a bit late who has been using antibiotics for some time and then you do the blood pressures and they are negative. Uh uh then this might be the reason but bear in mind. Not all culture, negative means that there is no infection. And uh if you are uh in a situation where you can do a direct aspiration from a subperiosteal abscess in a tibia or, or a an ankle joint. These are possible because it is quite subcutaneous. You can see the infection, you can see the swelling and it's quite, quite at the time. Then you can go in and do a pus aspiration uh straight away. And this is like a diagnostic tool that you have pus uh in the tibia. This is osteons and then you can decide that the patient needs. Uh sometimes this is not seen because a patient present early. It can be just an infection with the picture of inflammation and swelling. And um uh you can't outrightly go and do an aspiration. So it could be done operatively. So it should be an operative drainage. You go in, put the patient with general aesthetic. And after obviously doing uh some radiological pictures, you know where the site and then uh you go in and do your drainage and obviously send the pus aspirate for uh cultures and sensitivity. And again, there is a battery yield if you send the culture in a blood culture bottom, so it heals more, it gives you more growth uh in an enriched medium. And again, we we say about 30 to 50% there is a chance that the culture is negative. But now with the advent of PR which is poly just reaction, the PCR has more uh yield. It gives you more uh spectrum of an uh bacterias that you can see and especially with bacterias that take maybe sometimes you need to culture them for about two weeks or three weeks to get the results. This PCR is uh very, quite quickly gives you an idea of what in the source of bacteria or microorganism that might be the cause of this. So it's very highly sensitive. So uh x-ray wise, so if you do an x-ray for a patient who you suspect is uh having osteomyelitis in the 1st 48 hours, you might not see anything. And because there will be no periosteal reaction, there will be no lipid lesions, there will be no periostal abscess for the patient presented early. So you still have your suspicions, but you do the x-ray i in Children to be always very um a good idea to x-ray the other side to have a comparative x-ray. So you can know what is normal, what is abnormal, especially in Children, you might see some soft tissue swelling within 48 hours. But again, uh it might not be very uh specific. And as you know, the pathophysiology, the pers of reaction takes about maybe a week. Sometimes it might be up to 10 days. It depends on what sort of bacteria is causing the infection. And obviously, by two weeks, we're quite sure that osteolysis happens if it is not treated. And then when you do the X ray, then you can clearly see uh the findings of lysis in the bone. And then you can say yes, this is osteitis has been going there for at least about 10 days, two weeks because we can now try to see the osteolytic lesions. So if the patient comes very early and x-ray is normal and you still suspect this might be osteitis, then the next step would be an MRI scan. So it's uh one of the gold standard diagnostic tools that you can use to uh diagnose uh osteitis and the sensitivities about 83 to 100% and quite specific from 75 to 100%. And its positive predictive value is as good as using a technique and bone scan. So the technique, bone scan is very good in the 1st 48 hours because they will be um good uptake and that don't affect it. But usually patients don't come as early as 48 hours. They come three days later or four days or maybe five days later. Then your MRI scan is the best tool to use. The tricky situation in Children is not all Children are quite compliant to sit on the MRI scanner for about 45 minutes or one hour. So there's a challenge about putting the patient under a general anesthetic to do the MRI scan without having any artifact or movement. And um this might be a little bit tricky in someone who's four year old or three year old because you have to arrange an MRI scan and general anesthetic. But this would be one of the best diagnostic tools and it's very good again in deep seated infections such as spinal or pelvis. And now we quite see a lot of Pelvic osteomyelitis and usually we have more or less a similar presentation but not as classic as Osteomyelitis and tibial or femur. So the MRI S kinda helps you to say that this is infection or this is trauma or this is tumor or this might be just post surgical uh inflammation or reaction. Now, uh if we've reached the point that we have said that this is osteitis, now, we need to treat it. Now, the treatment could be either antibiotic therapy or a surgical debridement. So the mainstay of treatment for osteitis is antibiotic therapy. And antibiotics really depends on where you work because antibiotics are tailored according to the most common organism you have at your area of practice. So, in the UK, here, the most common as we have discussed is Staph aureus. And we empirically start antibiotics uh with um flucloxacillin in patients who are above your five year olds and those who are under fives or, or four get cefTRIAXone. So you have to formulate your own hospital policy uh to know which is the most common variant in uh microorganism. And then you can say that our empiric antibiotic is going to be this or this. And then you get your cultures back either from the blood or from your aspirate and then you know, what sort of bacteria is it causing this infection? And then you can provide a culture specific antibiotic. Uh So the usual statement is six weeks total of antibiotics for osteomyelitis. And now because um there is a good a follow up, a good response. Uh There is a change towards early oral switch, which is uh was not there before they used to give IV antibiotics for maybe two weeks, three weeks, uh sometimes up to six weeks. Uh But now because now the, the, the antibiotics improved a lot and the penetration to the bone is a lot better and sometimes because the patients are uh brought up early then the infection is well controlled. So there is a massive change towards early order, which maybe in day four, if the patient is responding very well, and the blood markers are trending down. So uh we usually repeat uh blood markers every 48 to 72 hours just to make sure that the antibiotic is working nicely. And uh the blood markers are trending down and they are trending down and the patient is uh clinically improving. Started to walk around. No temperatures, swelling has gone down. And there's a very good response to antibiotic therapy. Uh And then you can decide what will be the best or to switch from your current IV antibiotics. And in Children again, it's a little bit tricky with oral switch. Some of them are not great with taking oral antibiotics. So you might want to keep the boy or the girl in the hospital for at least 24 hours to make sure that they are taking the antibiotics really. Uh uh Well, and it's not causing any side effects. And uh if they are fine within 24 hours and parents are happy, then you can discharge the patient with oral antibiotics. But again, the total period for osteitis IV and oral is uh usually six weeks. So, uh why surgery? So a surgeon is uh preserve patients who don't respond very well to antibiotic therapy and they're still febrile, still spiking temperatures, still not well, getting more and more sick and lethargic. Um you might try switching the antibiotics or adding, adding another sort of antibiotics. But again, if they're not responding very well, and probably there is a proper abscess collecting and the antibiotics are doing very well. In terms of penetrating to the abscess, then you have to consider doing a surgical debridement. Uh and this means putting the patient to sleep, making an incision around where you think the abscess is and debriding this. And in addition to this, you might want to drill the bone as well to decrease the pressure and to allow any pus inside to be washed out and come through these drill holes. And sometimes there is an associated septic arthritis. So it might be that osteomyelitis have caused uh con committed septic arthritis in the nearby joints which you need to surgically and form and tain and wash out. So, uh these are the main reasons why you intervene surgically and uh Osteomyelitis because now the mainstay of treatment is IV antibiotics. Unless there is a proper abscess that needs drainage. In the advent that this osteomyelitis surpassed the acute phase, it becomes chronic and you might need to uh do some sort of surgical and formal debridement for the chronic sequestered bone to take it off. So, a quick uh chat about septic arthritis. So, septic arthritis is infection of the uh joint and this is an orthopedic emergency. So the joint gets um filled up with pus. And if it's not treated in timely fashion. This has very d bad and deleterious effects. And then again, the most common organism according to age group is uh staph aureus and streptococcus. And uh on as you go towards the more older group and adolescents and others, you start to see gram negatives uh from several different reasons. And for septic arthritis, you need to straight away, you know, the clinical presentation and formulate your COCA criteria, which is patient present with inability to wear, bear because the joint isn't affected. And then you can't put weight and the white cell count is 12,000 or more. E sr is 40 temperature is 35 38.5 or more. And the modified CO criteria has CRP in it. And ACR P is usually raised and you can say if you have about four of these, the chance of having Sertic arthritis is about 97 95%. And again, the diagnostic model is very important with history. Patient usually have fever. Uh there might be a history of trauma. Uh They're usually limping and an examination, they have the joint is not moving at all or what we call it a pseudoparalysis. If uh it's a proper infected joint and you do some blood works again for blood count. ESR and CRP, they're usually high and, and then from a just general observation, patients with osteomyelitis uh yeah, the CRP is more higher compared to patients with septic arthritis. So again, uh joint fluid analysis, if the child is big enough and cooperative, you might say, OK, I will try and do this on the bedside, um with some sedation, but this is not usually standard of care. It's better to do it under a general aesthetic in a theater. Uh set up um sterile condition because you're obviously introducing a needle into the joint and you need a very nice decent um, clean um aspirate. So you can send to the lab uh and you can send the fluid analysis to uh the lab and ask them to do a culture uh of that, the gram stain, which might take uh a couple of hours and then you have an answer straight away. And if the grams says, OK, you have um Tokai or you have uh uh um positive um organism, then you can uh decide what sort of antibiotic therapy you want to give. And the joint fluid analysis also can be sent for a white cell count. And generally, if I have a white cell count between more than 30,000 or 50,000, this is more leaning towards uh septic arthritis, you can also send them for uh proteins, crystals. Uh But if you are suspecting septic arthritis, the answer you want back from the lab is what is the white cell count number? And what is the ent? And again, we say not all infections have a positive uh G AM and there is some uh fluid analysis that you send to the lab and you have a culture negative and uh moving forward, you can ask for imaging such as ultrasound scan and MRI scan. So if the child comes with um limp and you think this is a inflammation or infection in the joint, you can ask for an ultrasound scan and the ultrasound scan showed fluid in the joint. Sometimes the scanners are quite good and they tell you that there is some debris or sign of thickening. This is more uh like a pus or it could be just a reactive fluid. So you you match and add all things up together with the uh clinical picture that you have got. And you might also uh ask for an MRI scan if you think this is a, a mixed match picture between osteitis and septic. Uh an MRI scan is a very good and um diagnostic tool to help you to know which is which. So if you think septic arthritis, um and from the clinical examination, I think you can confidently say if this is a septic joint or not, when you start thinking about doing surgery, you don't need to delay a septic arthritis patient to get extra imaging. If you think this is a septic joint and especially in Children, we see it quite common in hips and knees and from a clinical examination, we can, I would say with good confidence, say that this is a septic joint. And if you just do an ultrasound scan and show that there is fluid in the joint, you will be much more leaned to taking the patient to a um a surgical hip washout or a knee washout depending on where the joint is. And we quite outside advise that not to start antibiotics before obtaining samples from the fluid in the joint because this helps you to get a better idea of what is the causative organism. But again, if your patient is very sick and mm hemodynamically unstable because of this infection, you can start antibiotics. Meanwhile, taking the patient to uh get him operated on and because of the advent of PCR, there is high chance that you know what sort of antibiotics uh to give according to the micro organism that we can yield up from the PCR. Um and then you can change antibiotics according to the cultures. The total duration is about three weeks uh for septic arthritis, not as six weeks for osteitis. And again, early oral switch is um indicated depending on what is the clinical situation of the patient. And if the inflammatory markers are trending down. So the differential diagnosis for a septic arthritis is uh is a differential diagnosis for a limping child. So, not all limping child with uh painful joint are septic. You can have Perthes disease, uh which is uh decreased blood supply to the hip joint and they start limping and uh trauma would be another reason, soft tissue infection around the joint will cause the child to limp and tumors. And in the child uh population, we do have juvenile rheumatoid arthritis, which if uh uh it is a bad one, they can more or less be very uh quite a similar picture to septic arthritis. And at the bottom, you have trans sinusitis, which is very, very common in Children where you just have an inflammatory response as a result of infection and the prescribed infection. And they are very quiet presenters to uh A&E department and they have a very similar picture to septic arthritis. But their inflammatory markers are very normal or low. They don't have high temperatures and they usually respond very nicely to uh a dose of uh non infl non inflamma. Um nonsteroidal antiinflammatory such as brofen or maybe paracetamol and within 24 48 hours, they, you can see that they are improving quite nicely. Uh Now, septic arthritis is an orthopedic emergency because if left alone, then you might have complete joint destruction. So you need to act quickly. If you notice that this patient might be a septic patient due to a joint infection. Your next thought process is taking this patient to have a form of surgical debridement and wash out because the effects are really bad with contracts stiffness. They have cross disturbance because they are still growing Children and their piss is not get closed. So they will end up having some leg gland discrepancy or joint deformities. And obviously, osteonecrosis, which has decreased blood supply to the uh affect the joint and uh they end up with uh uh that uh joint. So, uh my closing remarks will be uh there is no single investigation including joint aspiration to be 100% sufficiently reliable to diagnose pediatric bone and joint infections. So, it's a collective picture. You have to put the whole picture together and then make a safe decision. And then moving to early or switch in day four and shorter durations of antibiotics is seemed to be safe as long as the patient is uh stable and improving and the blood markers are improving. And again, there is no clear and concise antibiotic guidelines. Uh So every hospital where we work with should have their own antibiotic guidelines which uh we should follow. And then again, you have to have a multidisciplinary team approach where you have to have some input from your infectious disease team about what is the best antibiotics and duration. And then obviously your lab and sometimes you need input from physical therapy if you operated on that patient to get them up and about and back quickly and just uh to not like King is an increasing uh microorganism and the cause of uh Children, bone and joint infection. And it can be identified using PCR. Um And it also depends on where you practice really and what is the most common organism. Uh Procalcitonin C is a new marker for bone and joint infection in Children and adults. And I think it would be uh one of the inflammatory markers that we will be using every uh now and then in patients with bone and joint infections. All right. So this comes uh to the end of my presentation and now I'm happy to take uh any further questions. Perfect. If everyone, if you have any questions, please pop them uh in the chat on the right. Perfect. There we go. As you all know, I am not medical, I cannot ask questions. It's just not gonna happen. Um So please pop your questions in and we have lots of people saying hello, which is great. Yeah, I can see that. So any questions anybody um will it be possible to send us the recorded video? I think that's for you. Yeah, it's for me. So if we will add this as catch up. So um yes, in probably the middle of next week, you can access it on the same link as we are on now. You'll be able to access it as long as that's OK. That yeah, that's great. I just assumed you'd let us. Yeah. Absolutely. Great. Great. Uh Oh, thank you. I'm thank you. Thank you. Oh, thanks, Lina. Ah There we go. You've got some questions now. OK. Emanuel says, what is the best first line antibiotic for septic arthritis? Right? Again, so it depends on where you work. So we think the most common organism is Staph aureus. But again, it depends on where you work. So, Staph aureus, the best modality of antibiotic is um amoxicillin. So it's usually flucloxacillin. Uh but it depends on the age. So, if the patient is less than five, we usually use Fior, which is usually cefTRIAXone. But if the patient is more than five, we usually go for flucloxacillin. But again, you have to check with your local microbiology team. And if you work in an area where you don't have one, then you have to uh make this decision by saying, OK, this probably is tough for your so strep or whatever and then you can decide what sort of antibiotics. Now, following surgical intervention for osteomyelitis, do we still do antibiotics for six weeks? Yes. So the answer is yes. Even if you do a form of surgical debridement, you still have to give antibiotics because uh although you need surgery to decompress and take the pus out there will still be some infection left behind. So you still need to do the whole six weeks. Can you see clinically if it is Osteomyelitis or septic arthritis? Uh yes, you can but sometimes sticky with proximal femur osteomyelitis or proximal tibial osteo. So if you have a proximal femur osteomyelitis and a patient has a limb fever, it might be a little bit tricky to know which is which. But uh you can, if you have access to ultrasound scan, you ask your radiology department to do a scan and your joint has no fluid, then this is more likely to be approximal femur oritis. But again, MRI scan is the best gold standard uh to gi to give you an answer to this question. From a clinical point of view, the joint is usually in a pseudoparallel ster where it is not moving. There is more range of movement in osteomyelitis compared to septic arthritis, osteomyelitis, patients are usually I think more sick and feverish compared to septic arthritis patient. It depends really on the course of and duration of the uh clinical presentation. Um And obviously, with time and experience, you can say, which is which uh just to not recently, I had a patient who had was limping feverish, uh was having antibiotics. One week three, bein was not bad. Um He was a little bit tender in his proximal femur. So we did an ultrasound scan, both hips, both knees, there was no fluid. So we requested an MRI scan, hips, knees and j bone were all normal. So his infection was in the muscles around the pelvis. So he was having myositis. So sometimes it becomes really difficult to say clinically. Is this septic or osteitis? Mhm. Any other question? Uh does glucocorticoids have roles in septic arthritis management? And I don't think so. So I don't think uh septic arthritis is treated with glucocorticoids uh if you have a septic arthritis patient, you have to take him to theater to wash the joint from infection and then give antibiotics. What is the basis of four day intravenous antibiotics? I've always thought it to be for two weeks. So Charles asked the question about four day intravenous antibiotics. So it is not four days. Again, I would say it is early oral switch. There is no asset day. So I would say four days as an example. But now there is a trend towards changing from giving IV antibiotics for a long time because the patient needs to stay in the hospital. But with the good antibiotics that we have, which have good penetration into the bone, you can easily switch the patient from IV antibiotics at the 4567, whatever you think is appropriate to continue on oral antibiotics at home for the amount of time. If it's septic arthritis, it will be three weeks total IV. And oral. If it is osteitis, the total should be six weeks. So it's early oral switch, it's not day four. Uh And aga is asking before cultures come in. Do you begin antibiotics? Treatment with strong antibiotics such as a later degeneration Kosor or are they not used in Children? So I've again, I've mentioned this before. So if you are in a situation, if this is septic arthritis, you have to take the patient to get his joint washed and cleaned and then you can start antibiotics after taking the sample and the antibiotics you start. Depends on your common practice. Where do you work? So when I practice in the UK, the common organism, staff for, yes. When I take the aspiration, it start flucloxacillin and then wait for the final con. Ok. If this is Osteomyelitis in early stages, the treatment is antibiotics. So you don't need to take the patient to theater and the antibiotics you, we choose depends on the age group. So if he's more than five, we will give flucloxacillin. If it is less than five, we give sins and kallosin, namely cefTRIAXone. So preferably you have to take the blood culture out first before starting antibiotics. If your patient is really, really sick and you don't have capacity to do blood cultures or you don't have time, you can start antibiotics. Uh straight away, depending on what you think is your most causative organism in your practice. Uh If you is asking, is there a room for antibiotic infiltration following sequestration and irrigation for osteitis? Yes, there is a room for chronic osteomyelitis, not the acute ones. So if you have an acute osteitis, you can drill it, wash it, clean it and continue IV therapy. But if you reach the point of chronic osteo, you're doing debridement for the bone, for a necrotic bone, you can use antibiotic beads. So some companies manufacture antibiotic beads where you can put them into the bone and they have very good local infiltration and illusion for a period of about say two weeks, but eventually they drop down over the course of six weeks. Um Is there uh for knee joint septic arthritis in Children, what do you prefer? Arthroscopic washout or arthrotomy? Uh Good question. Thank you. So, in a very young child who is, I know this is a septic arthritis unusual in the knee joint and this is definitely gonna be arthroscopic two portals worse the joint and that's it. But if you think there is more than just a washout, you need to do more because the infection has been going for some time. Um I think a formal washout will be better uh make a small incision. You can go in and debride nicely. Uh Some people are more expert than me using a scope. So they are very happy to do an arthroscopic washout and debridement and shaving. It depends on what you have at the end. The results are the same and you just do whatever is uh good in your hands that you can do. So both are having good results. So it it's not necessarily arthroscopic arthrotomy, but for someone who is very young and I'm not, I'm definite that this is just gonna be a, just a washout. I do it arthroscopic uh saying following resolution of osteolysis, how long does it take for X ray findings to resolve? Good question. Thank you. So it might take up to six months to one year. So every time the patient comes to your clinic, uh you do an X ray findings are still there. It might take up to six months to one year and if it stays there, but the patient is still asymptomatic, jumping and running around. Um You don't need to worry, you just keep an eye on it. Uh Sometimes it forms something called blood abscess, which is a cold abscess in the bone. If the patient is symptomatic and the markers are going up and down, we might need to do a revision debridement. But this might not be acute, might be within six months to one year. But yes, the X ray findings might resolve but it might take up to six months to one year. John is asking what is the best pain medication for osteomyelitis and septic arthritis? Mm. So uh you can get whatever you think is possible to keep the patient not in pain. So I would say for a septic arthritis, the best painkiller would be take the patient to theater and wash the joint and then give paracetamol ibuprofen morphine. It depends on what you have. Um for Osteomyelitis, obviously, when the antibiotics start working, uh the pain will go down. But again, you can give up to um that morphine if the patient is in pain. And to be honest with the patient who is in back pain, this means the antibiotic therapy is not working and you might need to either switch it, change it or add something or take the patient to do um uh decompression of the puss and washing. Uh Thank you very much, please. Is there a role for limb embolization, postarthrotomy? Uh Excellent question. So if you do an arthrotomy for a hip joint in a very young child who is, let's say six months, one year old, there is a risk that the hip might dislocate a little bit. So I would say immobilizing on a hip spiker or just a simple brace is very protective for the hip joint for the knee. This is not an issue. You can just put some bandage on it. There is no need to immobilize the knee joint. So I'm gonna dislocate in Children. It might be a little bit uncomfortable. You might put uh a brace but you want the joint to be moving. So I would just say bandages enough for a knee or an ankle or a shoulder. But for a hip joint, we have seen lots of cases dislocate or migraine after doing a formal big out. So the say immobilization for the hip is safe maybe for like maybe one week, two weeks. Uh and then you can take it off follow an arthroscopic washout. Is there room for drain insertion? If so, how long do we leave the drain? So I would say if you're 100% confident that this is not gonna cause any trouble. You can, you, you, you might not want to put a drain but you think this is a late infection. The pus is a lot, very inflamed sinus joint. You can put a drain and there is no rule for when or how long you can leave it as long as it is draining. But you have to take it as early as possible. If it is not draining, there is no cut off limit as in 10 mil 20 mill 30 mil. Uh there is no rule really. If it's training, then you have to leave it. If it's training and non stopping, you might consider taking the patient back to theater for a washout again, any role of antibiotic irrigation in septic arthritis. Um uh So if it's a straightforward septic arthritis in Children, you take the patient to say that a wash out. There is no role to infiltrate with antibiotics. There is no evidence but restless, but there is no evidence. I when will amputation be indicated in osteitis or septic arthritis. So, uh in osteolysis, usually the chronic ones will have very bad chronic nonhealing, discharging sinus. I would say amputation is the last resort ever. I wouldn't think about it initially unless this patient has a very, very, very bad infection where the sinuses are a lot and it's p and discharging a lot and you've done your level best to do a debridement. You've taken all the dead bone, you've put lots of local antibiotics. You tried to give antibiotic therapy for a long time, but this infection is not stopping. Then you can have a discussion with the patient and the team about what is the best and amputation might be um an answer. Uh I have seen such cases where I have practiced back initially in Sudan where the infection comes very late. The bone is badly destructed and there is no hope. Then you might consider amputation, but it is final, final, final, last result ever. So, in cases of antibiotic resistance, what alternative antibiotics may be considered for treating septic arthritis? So again, uh it depends on the microbiology advice and it depends on what cultures you have, what sort of m bacteria really. So um very unlikely you have resistance from uh antibiotics after you wash out the joint. Uh And if you do have resistance, the antibiotics are not working after you do a formal wash out. I would think about this patient is not uh a normal patient. I would say he might have an underlying disease, maybe diabetic, maybe he's having an im immune, a very bad immune response with immunodeficiency type disease because most Children who wash their joint, they have very good response and there is no resistance to antibiotics. But I would personally liaise with my colleagues who are the expert to join the infectious disease team. Uh Otto is the safest antibiotic in septic arthritis and toddlers. Uh So again, toddlers are usually the new workers, they are less than five. And again, here in my practice, we usually give cefTRIAXone, which is a Fondos sporine, which is aganist stephos. Uh because this is the most causative organism and it's a safe and most of the antibiotics now are quite safe. Uh that we use. Uh Is it always necessary to drill cortex while draining suberosis? There's a risk of spreading infection intrascar. So there is, it's not always necessary if uh usually, if you find the port where the pus broke through, you can use this to cur t the bone and clean the pus. Uh But if you think the, the infection is spreading a little bit down, you might thrill it. And I think it's not gonna cause problem of seeing or spreading the infection. Uh To the contrary, it might help to stop spreading the infection because you o obviously break the cortex for the infection to come out rather than keeping it in. So I would say it's not always necessary. But if you do an MRI scan and you think there is more infection down compared to the pus, which is a little bit higher up, you might want to do a little bit down as well. Uh What is your opinion regarding putting it in for one or two days following knee joint washout? Uh Very controversial topic, you can leave, you can, you can put a drain if you think uh there is more to drain. It's not harm. It's not an issue. I would say you're not, um, unsafe as a surgeon. Uh If you don't put a drain, you might think about, ok, I want to decrease the risk of infection. So why I'm putting a drain again, good approach. So I won't say there is a yes or no answer for this. Uh And again, if you think there is some massive infection there, I was put to drain for one or two days, there is no harm. Uh And as long as the drain is working, there is what coming then? Um, obviously it was a good practice and you can take the drain out whenever I did drain. Stop draining. Well, that was some questions, wasn't it? Yeah, that's very nice. Yeah, it's keeping it interactive. Yeah, I told you, I told you our mental education love to ask questions and we love it. It keeps your speakers on your toes. Yeah. Exactly. Ok. Oh, dear. You can't just present here. You gotta actually really think about it. I think this is the best part of the. So I think that's it for our questions. Um Thank you very much for coming along and speaking. Thank you very much to our delegates for joining us today. Like I said, your uh feedback form will be in your inbox in about a minute's time. Probably uh complete that and then your attendance certificate will be on your meal. Account. I'll get this uploaded uh for next week and then um you can catch it all again if you like. And hopefully Monday will come along and chat with us again next year. Hopefully. Yeah, absolutely. So for now, one there and I will say goodbye. So thank you very much. Everyone take care.