Copyright 983 by The Journal Pseudomonas Joint BY DON B. W. Front MD.I’, of A. were rarely indicated except synovial Orthopaedic Surgery. in patients with infection joint. Cook was an cently. infection medical aeruginosa uncommonly In 1960, reported Forkner was able of a bone or joint problem until re- to compile only one case reports in a review of the literature period of seventy-one years. Although this widely distributed in nature and is often found tinal were tract rarely of humans, documented cally debilitated In a later additional and incidence increasing, and septic arthritis who were not chroni- or hospitalized, review, cases teomyelitis osteomyelitis in patients or who Grieco found of Pseudomonas added five of drug abuse and reports thirty- covering a organism is in the intes- had had reports of arthritis more. In the same surgery. fifty-eight and Osperiod the and its medical complications was of sepsis, bacterial endocarditis, and thrombophlebitis after intravenous drug abuse appeared more frequently. In the 1970’s the first reports of drug abuse began to appear and by 1982 fifteen such artides had been published, documenting a total of sixty-eight patients i.2.7.:it4.is2::, This report describes our experience with an additional thirty-five patients in whom Pseudomonas bone or joint infection developed after intravenous From January a history teomyelitis and with thopaedic patients, graphic t to July of drug abuse septic arthritis 1979, and were forty-one hematogenous treated by patients the osOr- . Although Read thopaedic Methods Service of Cook County Hospital In six of these even though there were both clinical and radiosigns of bone and joint infection, no organism was isolated. ... 1976 and at the Surgeons, West Division Harrison VOL. 65-A, they Annual Meeting Atlanta, of Orthopaedic Street, Chicago, NO. 6, JULY responded 1983 to intravenous of The Georgia, Surgery, Illinois RICHARD Counts L. PEARSON, M.D.1, ILLINOIS Hospital, otic therapy these In the remaining Chicago six patients thirty-five were deleted patients, from the series. Pseudoinonas was isolated from thirty-nine bone and joint sites (Table I). Thirty of these patients were male and five were female. All patients except one were black. Their ages ranged from seventeen to forty-eight years. It must be aeruginosa emphasized that, due to the special nature of these patients, any long-term follow-up was virtually impossible to obtain. In fact, after the initial pain of the infection had subsided, most patients could be persuaded only with great to remain in the hospital the intravenous antibiotic follow-up appointments was these patients after treatment one and patient was gainfully fictitious addresses common (Talwin) patients) for the entire length of treatment. Failure to keep the rule. Attempting to locate was extremely difficult: only employed, and assumed names were commonplace. The most drugs used were and tripelenamine or heroin (twelve a combination (Pyribenzamine) patients). used both the pentazocine-tripelenamine heroin. Three patients had multiple There appeared to be no correlation of pentazocine (twenty-three Two patients had combination and areas of involvement. between the incidence of infection and the frequency of drug abuse. Some patients admitted to abuse of a drug on only one occasion, while others had been chronic abusers for as long as fourteen drugs years. Some patients repeatedly for several months or even a year denied using the prior to the onset of their symptoms. Unlike most patients with acute septic arthritis or hematogenous osteomyelitis, these patients were not severely toxic at the time of presentation. The temperature grees Celsius on admission (mean, 37.7 ranged degrees). from 36.5 The mean to 38.7 desedimenta- tion rate was forty-nine millimeters per hour and the mean white blood-cell count was 8,900. No patient had a sedimentation rate of less than thirty millimeters per hour drug abuse. Material and Abusers CHICAGO, difficulty Psetulo,nonas incorporated M.D.t, M.D.1’, period. Early diagnosis was based on a history of drug abuse and demonstration of the site of infection by a technetium bone scan. Most patients responded to long-term therapy with intravenous aminoglycoside and carbenicillin. Extensive early surgical procedures of a large Surgt-rv. Bone LORENZ, PANKOVICH, of Pseudomonas in thirty-five intraover a four-year Thirty-nine sites bone and joint infection drug abusers were treated venous M. Division ABSTRACT: aeruginosa Joint in Drug MARK ARSEN the and aeruginosa Infection MISKEW, AND of Bone American Academy 1 1, 1980. Cook County Hospital, 60612. antibiof Or- February 1825 (Westergren) 12,000 when or a white Pseudomonas was grown on culture. from one day to more Radiographs infection were five of the blood-cell count was the only The than duration one year. of the suspected made for all patients thirty-five patients of more organism of symptoms than that ranged site of the bone or joint on admission, but only had radiographic changes compatible with infection at that time. The thirty patients in whom the initial radiographs were negative than had a scan with technetium pyrophosphate, and all scans were positive. The shortest length of time between admission 829 830 D. B. W. MISKEW, M. A. LORENZ, R. L. TABLE Location of Findings -- Infection Case Radiography on: Bone PEARSON, AND A. M. I Length Antibiotic Scan Culture PANKOVICH Other Therapy Treatment of Follow-up Result ( Wks.) - + + G - + + T and C External spine - + + T and C Brace Lumbar spine - + + T and C Brace Lumbar spine - + + T and C Pantaloon 6 Lumbar spine - + + T and C 1 Cervical spine 2 Thoracic spine 3 Lumbar 4 5 Fusion C3-C6, halo cast brace cast 64 Fused, 28 Fused asymptomatic 12 Asymptomatic 6 Asymptomatic T9-T10, 11 Asymptomatic Brace 8 Asymptomatic 7 Lumbar spine - + + T and C Brace 4 Asymptomatic 8 Lumbar spine - + + T and C Brace 7 Asymptomatic 9 Lumbar spine - + + T and C Brace 4 Asymptomatic 0 Lumbar spine - + + T and C Brace 5 Asymptomatic 11 Lumbar spine, - + + T and C Brace, 4, St Asymptomatic bed restt asymptomatic ischiurn 12 Lumbar spine - + + T and C Brace 9 Asymptomatic 13 Lumbar spine - + + T and C Brace 3 Asymptomatic 14 Sacro-iliac joint - + + T and C Bed rest 9 Asymptomatic I5 Sacro-iliac joint - + + T and C Bed rest 7 Asymptomatic 16 Sacro-iliac joint - + + T and C Bed rest 4 Asymptomatic 17 Sacro-iliac joint - + + T and C Bed rest 4 Asymptomatic 18 Sacro-iliac joint + + T and C Bed rest 4 Asymptomatic 19 Sacro-iliac joint - + T and C Bed rest, 20 Sacro-iliac joint - + + T and C Bed rest 21 Sternoclavicularjoint (bilat.), ischium - + + T and C Sling, 22 23 Sternoclavicularjoint - + 24 Symphysis pubis - 25 Symphysis pubis - 26 lschium 27 bed + T and C Sling + T and C Bed rest + + T and C Bed + + T and C Bed - + + T and C Ischium - + + T and 28 Ischium - + + 29 Shoulder + 30 Knee 3 1 32 Asymptomatic 5, 4* Asymptomatic Asymptomatic Asymptomatic rest 4 Asymptomatic rest 24 Asymptomatic Bed rest 5 Asymptomatic C Bed rest 3 Asymptomatic T and C Bed rest 4 Asymptomatic + T and C Debridement 52 Asymptomatic + + T and C Debridement 60 Infection range resolved of motion but restricted Knee + + T and C D#{233}bridement 108 Infection range resolved of motion but restricted Knee + + T and C Debridement 100 Infection range resolved of motion but restricted + + T and C D#{233}bridement + + T and C + + T and C Hip 34 Tihiofibular 35 Tibia pubis + joint (bilat.) . G = gentamicin, . Refers to the : Negative Refers and infection on aspiration to the and a positive symptoms for intection bone only T and from the onset graphic change weeks. specimens patients C in the but positive After and at the time The appropriate. the joints ischium, and appearance and the of involvement A combination Asymptomatic 56 D#{233}bridement Draining sinuses bilat. respectively. in the ischium, had had radio- of radiolongest was was were obtained from needle biopsy, or Only then was antibiotic therapy initiated, combined with rest in the form of immobilization when Asymptomatic 4 of fusion. prove to be as reliable as shortest amount of time to the days, 8 carbenicillin. in in a patient who In our experience, not the area for culture by aspiration, spine sternoclavicular scan was one day. of symptoms was fourteen and tobramycin = lumbar in the graphic examination did technetium bone-scanning. ing Asymptomatic 3 33 eight rest 5 5 4 Symphysis § fusion identified, all thirty-five open biopsy. and respectively. gentamicin (240 milligrams per day) and carbenicillin (sixteen grams per day) was administered intravenously in staggered doses over a four to six-week period. Antibiotic therapy alone, however, did not resolve the infection in one patient with an infected hip and in three patients with an infected knee. In them, synovectomy and d#{233}bridement of the joint was required. After synovectomy these four patients improved to follow-up. rapidly, it was or splint- of tobramycin or but they were subsequently lost Results The thirteen patients THE who JOURNAL had osteomyelitis OF BONE AND JOINT of SURGERY the PSEUDOMONIIS axial skeleton four weeks AERUGINOSI4 BONE responded to a regimen of bed rest in addition to intravenous antibiotic AND for two to therapy. d#{233}bridement and but was volving asymptomatic the ischium, clavicular joint and bed rest up. The only fusion of the when last the symphysis responded well sacro-iliac a patient who had osteomyelitis was verified by a bone scan. aeruginosa therapy regimen at last knowledge which but bone scan and Biopsy speciPseudotnonas on culture. In spite of four weeks of antibiotic and open d#{233}bridement of the tibiae, chronic drain- ing sinuses and active after treatment. There were five of large received infection were Pseudomonas synovial joints the described still present one year infections aeruginosa in this regimen that d#{233}bridement aeruginosa was grown procedure in spite for six to thirteen 831 ABUSERS in these four joints of the patient days. having been Between series. All of these patients of antibiotic therapy. The 197 1 to 1977, dealt with bones and sixty-eight sites of patients), fourteen Pseudornonas joint sion lost The joints cases in drug abusers were reported, involvement were the sternoclavicular cervical tients). was initially to a medical with treated service. involvement of the by needle aspiration After cultures were shoulder reports on admisfound to be ment was then performed, rapidly improved at last follow-up, seven days after admission. His after d#{233}bridement and irrigathirteen months after the initial admission, he was asymptomatic motion in the shoulder. There were three patients and with had a full involvement range of of the the 1,2.7,914.1822#{149} and the In our series there was no evidence and carbenicillin nephrotoxicity failures began it has to use tobramycin a much lower rotoxicity than not unexpected. think found. gentamicin, the diagnosis In our vere nous symptoms The technetium and toxicity Staphylococcus bone scan is most d#{233}bridement of the affected was restricted - in all three One patient VOL. 65-A, NO. 6, JULY 1983 absence of side than patients with infection of bones aureus knees. motion because we effects is we the and treatment of hematogenous Pseudomonas infection in bones and joints in drug abusers. experience, most of these individuals have less se- ramycin or gentamicin six weeks. Only when (Case 30) had I 5 degrees of extension and 78 degrees of flexion, the second (Case 3 1) had -5 degrees of extension and 95 degrees of flexion, and the third (Case 32) had -5 degrees of extension and 45 degrees of flexion. no evidence exclusively early in the series and incidence of ototoxicity and neph- of the three patients however, the range of but Because of the number of patients in our series, that we can come to some conclusions regarding aeruginosa or treatment. Our was no clinical symptoms. nitrogen levels of the amino- In retrospect, antibiotic had signs none or pain; of treat- of ototoxicity combination, was site of infection before changes graphs. It is our opinion that At follow-up infection of A total of most common lumbar spine (twenty-six joints (eight patients), the failure (Table I, Case 35), and only a few ment have been reported in the literature. knee joint in our series. One was treated with multiple aspirations for six days and the other two were treated by open biopsy and in-and-out irrigation for eleven and thirteen days in addition to the antibiotic therapy. In spite of this treatment, all three patients continued to have symptoms of ongoing infection in the knee. Open d#{233}bridement and synovectomy was then performed on all three knees. After d#{233}bridement all three patients responded to the usual regimen. of residual in the literainfections three days to eighteen months after the onset of symptoms. Radiographic changes were often late in appearing, but bone scans were reported to be positive. Most of the patients responded satisfactorily to the use of appropriate antibiotic therapy. In our series there was only one known of positive for Pseudoinonas aeruginosa the patient was given antibiotic therapy with tobramycin and carbenicillin. Despite the antibiotic therapy he continued to have an elevated temperature and his pain increased. Open d#{233}bridecondition tion, and de- spine (seven patients), and the hip joint (five paDiagnosis was frequently delayed, ranging from glycoside to follow-up. one patient had on antibiotics aeruginosa patient with involvement of the hip joint had open d#{233}- nephrotoxicity secondary to the antibiotic bridement on the day of admission and inflow and outflow patients did not have audiograms, but there tubes were inserted. He became asymptomatic after five evidence of hearing impairment or vestibular days of antibiotic therapy and was completely asymptoLevels of serum creatinine and blood urea were determined frequently during the use matic on discharge eight weeks after admission. He was then that or synovectomy , Pseudornonas on culture at the time of the second Discussion ture followwas in of the right tibia, He refused treatment, eight months later he again had a positive radiographic changes involving both tibiae. mens of the lesions in both tibiae grew DRUG joint, antibiotic alone and were asymptomatic failure of treatment to our IN It is of interest seen. All infections inpubis, or the sternoto the INFECTION layed Six of the seven patients with infection of the sacro-iliac joint responded to four weeks of rest and intravenous tobramycin and carbenicillin. One patient did not respond and required JOINT helpful hematogeand joints. in localizing the are visible on plain radioin most patients a definite bacteriological diagnosis can be easily established by closed biopsy or minor open-biopsy methods. The biopsy should be carried out as early as possible and before antibiotic treatment is begun. In patients with involvement of the spine, pelvis, and smaller synovial joints, the treatment of choice is immobilization and intravenous toband carbenicillin therapy for four to this fails do we recommend open site. ience, however, synovectomy we do recommend (in addition to Pseudoinonas aeruginosa joints. On the basis open antibiotic infections of our exper- d#{233}bridement and therapy) for of large synovial 832 D. Although was the of necessity nosis three B. length W. MISKEW, of limited, follow-up we found for such infections patients with a knee M. was joint A. LORENZ, in these . non did not develop. ankylosls . developed In two . in the patients the over-all prog- relatively infection favorable. obtained The a pain- patients - adjacent with a disc PEARSON, AND the only patients known in this patients. A. M. were failure bilateral tibial draw conclusions necrosis, infec- vertebral L. but that less but limited range of motion. Severe cartilage such as may be seen in neglected Staphylococcus tions4’, R. PANKOVICH asymptomatic when of treatment involvement. concerning particularly was However, long-term unreliable and last in the seen. Our patient with it is difficult to results of therapy transient population of infecNOTE: . bodles, The authors are indebted to Carol Lorenz br her help in the preparation of this man- ascript. References I. 2. AMINE, BRYAN, A. R. C., VINCENT: Intravenous 3. 4. 5. CHERUBIN, CURTISS, 797-806, CURTISS, Drug and SALAZAR, J. L.: FRANKS, LAWRENCE; Abuser. Surg. Neurol., C. E.: The Medical P. H ., June JR., 1963. and KLEIN, Sequelae LEROY: Pseudomonas and TORRES, I: 142-144, of Narcotic Destruction Lumbar HERNANDO: Diskitis. Illinois Pseudomonas Med. J., Aeruginosa 151: 110-112, 1977. Cervical Diskitis with Chondro-osteomyelitis in an 1973. Addiction. of Articular Ann. Cartilage Intern. Med., in Septic 67: 23-33, Arthritis. 1967. I. In Vitro Studies. J. Bone and Joint Surg. , 45-A: P. H., JR., and KLEIN, LEROY: Destruction of Articular Cartilage in Septic Arthritis. II. In Vivo Studies. J. Bone and Joint Surg., 1965. C. E., JR.: Pseudomonas Aeruginosa Infections. Modern Medical Monographs, pp. 50-59. New York, Grune and Stratton, 1960. GIFFORD, D. B.; PATZAKIS, MICHAEL; IVLER, DANIEL; and SWEZEY, R. L.: Septic Arthritis Due to Pseudomonas in Heroin Addicts. J. Bone and Joint Surg., 57-A: 631-635, July 1975. 8. GRIECO, M. H.: Pseudomonas Arthritis and Osteomyelitis. J. Bone and Joint Surg., 54-A: 1693-1704, Dec. 1972. 9. HOLZMAN, R. S., and BISHKO, FREDERIC: Osteomyelitis in Heroin Addicts. Ann. Intern. Med., 75: 693-696, 1971. 10. JABBARI, BAHMAN, and PIERCE, J. F.: Spinal Cord Compression due to Pseudomonas in a Heroin Addict. Case Report. Neurology, 27: 10341037, 1977. 11. KAPLAN, S. S.: Pseudomonas Disc Space Infection in an Occasional Heroin User. Arizona Med., 31: 916-919, 1974. 12. KEYS, T. F.: Sternal-Costal Infection with Pseudomonas: A Complication of Drug Abuse. Western J. Med., 120: 72-73, 1974. 13. KID0, DANIEL; BRYAN, DAVID; and HALPERN, M.: Hematogeneous Osteomyelitis in Drug Addicts. Am. J. Roentgenol., 118: 356-363, 1973. 14. LEWIS, ROGER; GORBACH, SHERWOOD; and ALTNER, PETER: Spinal Pseudomonas Chondro-Osteomyelitis in Heroin Users. New England J. Med. , 286: 1303, 1972. 15. LOURIA, D. B.; HENSLE, TERRY: and ROSE, JOHN: The Major Medical Complications of Heroin Addiction. Ann. Intern. Med., 67: 1-22, 1967. 16. MISKEW, D. B.: BLOCK, R. A.: and WITT, P. F.: Aspiration oflnfected Sacro-Iliac Joints. J. Bone and JointSurg., 61-A: 1071-1072, Oct. 1979. 17. NEU, H. C.: Tobramycin: An Overview. J. Infect. Dis., 134 (Supplement): S3-Sl9, 1976. 18. SALAHUDDIN, N. I.; MADHAVEN, I. FISHER, E. J.; Cox, FRANK; QUINN, E. L.; and EYLER, W. R.: Pseudomonas Osteomyelitis. Radiologic Features. Radiology, 109: 41-47, 1973. 19. SELBY, R. C., and PILLAY, K. V.: Osteomyelitis and Disc Infection Secondary to Pseudomonas Aeruginosa in Heroin Addiction. J. Neurosurg., 37: 463-466, 1972. 20. SEQUEIRIA, WINSTON; JONES, EDITH; SIEGEL, M. E.; LORENZ, MARK; and KALLICK, CHARLES: Pyogenic Infections ofthe Pubis Symphysis. Ann. Intern. Med. , 96: 604-606, 1982. 21. TINDEL, J. R., and CROWDER, J. G.: Septic Arthritis Due to Pseudomonas aeruginosa. J. Am. Med. Assn., 218: 559-561, 1971. 22. ZUCKER, MICHAEL; WILLIAMS, J. P.: and BIRNBAUM, W. S., JR.: Osteomyelitis ofthe Vertebral Column in Heroin Users. Maryland State Med. J. , 23: 77-79, Oct. 1974. 23. WIESSEMAN, G. J.: WooD, V. E.; and KROLL, L. L.: Pseudomonas Vertebral Osteomyelitis in Heroin Addicts. J. Bone and Joint Surg., 55-A: 1416-1424, Oct. 1973. 47-A: 1595-1604, Dec. 6. 7. FORKNER, ThE JOURNAL OF BONE AND JOINT SURGERY
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