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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.
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