Urgent Care for Bone & Joint Infections

Understanding Bone & Joint Infections in the Indian Context

Bone and joint infections—osteomyelitis, septic arthritis, prosthetic joint infections—are orthopaedic emergencies requiring urgent surgical drainage and prolonged antibiotics. At Ajuda Hospitals, our 24/7 infection service combines orthopaedic surgeons, infectious disease specialists, and microbiologists to deliver rapid diagnosis, culture-guided therapy, and limb-salvage procedures for complex cases.

Key infection types:

• Septic Arthritis: Bacterial infection within joint space. Destroys articular cartilage within 24-48 hours if untreated—urgent washout <6-12 hours preserves joint function.
• Acute Osteomyelitis: Bone marrow infection, usually hematogenous (bloodstream seeding) in children or diabetics, direct inoculation in trauma/surgery. Early treatment cures 90%; chronic osteomyelitis develops if delayed.
• Chronic Osteomyelitis: Persistent bone infection with sequestrum (dead bone), draining sinuses. Requires radical debridement, dead space management, prolonged antibiotics. Cure rates 70-80%.
• Prosthetic Joint Infection (PJI): Bacteria form biofilm on implant surfaces—antibiotics alone fail. Early infections salvaged with washout; late infections need 2-stage revision.

Risk factors common in India: diabetes (30% prevalence in urban Hyderabad), malnutrition, HIV/TB co-infection, open fractures from road accidents, barefoot farming (soil-contaminated puncture wounds). Our protocols account for regional organism patterns—high MRSA rates, tuberculous osteomyelitis, tropical fungal infections.

When to Consult Our Infection Specialists

Red Flags (septic arthritis highly likely):

• Kocher Criteria (pediatric hip): Fever >38.5°C, non-weight-bearing, ESR >40 mm/hr, WBC >12,000/µL. All 4 present = 99% probability septic arthritis. Immediate MRI and joint aspiration.
• Systemic Sepsis: Hypotension, confusion, organ dysfunction—life-threatening. ICU resuscitation + emergency drainage within 6 hours.

Our Diagnostic Approach

Emergency Clinical Assessment

History:

• Onset (acute <2 weeks vs chronic >6 weeks), prior trauma, surgery, injection, dental procedure
• Risk factors: Diabetes, IV drug use, immunosuppression, dialysis, prosthetic joint, prior joint disease
• Systemic symptoms: Fever, chills, night sweats, weight loss (chronic infection, TB)

Physical Examination:

• Septic Arthritis: Effusion, warmth, erythema, exquisite tenderness, restricted range of motion (any motion painful). Hip held in flexion-abduction-external rotation (position of maximum capsular volume).
• Osteomyelitis: Localized bone tenderness, overlying soft tissue swelling, draining sinus (pathognomonic for chronic osteomyelitis), sinus tract probing to bone (positive probe-to-bone test = 87% osteomyelitis in diabetic foot).
• Prosthetic Joint Infection: Joint warmth, sinus tract, implant loosening (pain with weight-bearing), late periprosthetic fracture (bone resorption from chronic infection).

Laboratory & Microbiological Workup

Inflammatory Markers (trend guides treatment response):

• WBC: Elevated in acute infection; often normal in chronic
• ESR: Elevated (>40 mm/hr) in osteomyelitis, septic arthritis; remains elevated weeks (slow to normalize)
• CRP: More sensitive, rises/falls faster than ESR—serial CRP values monitor treatment response
• Procalcitonin: Distinguishes bacterial (elevated) vs non-infectious inflammation; guides antibiotic duration

Blood Cultures (before antibiotics if stable):

• Positive in 50-70% septic arthritis, 30-50% osteomyelitis
• Two sets from separate sites; hold 48-72 hours for slow growers (Propionibacterium, Cutibacterium)

Joint Aspiration (Gold Standard for Septic Arthritis):

• Synovial Fluid Analysis: WBC >50,000/µL with >90% PMNs = septic arthritis until proven otherwise. WBC 25,000-50,000 = indeterminate (crystalline arthropathy vs low-virulence infection). Gram stain positive in 50%; culture positive in 75-90%.
• Prosthetic Joint Aspiration: WBC >3,000/µL (lower threshold than native joint) or >80% PMNs suggests PJI. Alpha-defensin immunoassay 97% sensitive/specific.

Tissue/Bone Biopsy (Chronic Osteomyelitis):

• Send 3-5 samples (deep tissue, bone) for aerobic, anaerobic, fungal, TB culture
• Avoid superficial wound swabs (colonizers not causative organism)
• Histopathology confirms infection (acute/chronic inflammation, organisms on Gram/PAS stain)

MALDI-TOF Mass Spectrometry: Identifies bacteria from culture plates within 30 minutes (vs 48-72 hours traditional biochemical methods). Allows early antibiotic switch from empiric to targeted therapy.

Imaging Studies

X-rays (Baseline; Monitors Healing):

• Osteomyelitis changes visible 10-14 days post-infection: Periosteal reaction, lytic lesions, sequestrum (dense dead bone), involucrum (new bone shell around sequestrum)
• Prosthetic loosening: Radiolucent lines >2mm progressive over serial X-rays
• Diabetic foot: Gas in soft tissues (necrotizing fasciitis), joint destruction, Charcot changes

MRI (Gold Standard for Osteomyelitis):

• Marrow edema (T1 hypointense, T2/STIR hyperintense) = early infection before bone destruction visible on X-ray
• Abscess (rim-enhancing fluid collection), sinus tracts, soft tissue involvement guide surgical planning
• Sensitivity 90%, specificity 80% for osteomyelitis
• Contraindicated if prosthetic joint (metal artifact)—use CT or nuclear imaging

CT Scan:

• Excellent bony detail: Sequestrum, cortical destruction, involucrum
• Guides biopsy needle placement, surgical approach for deep infections (spine, pelvis)
• 3D reconstruction for complex cases

Nuclear Imaging (If MRI Contraindicated or Unclear):

• Bone Scan (Tc-99m MDP): Sensitive (>90%) but not specific—positive in fracture, tumor, arthritis
• Leukocyte Scan (In-111 WBC): Specific for infection vs sterile inflammation. Combined with bone marrow scan increases accuracy.
• PET-CT (FDG): High glucose uptake in infection and inflammation. Used for prosthetic infection, spinal infection, chronic osteomyelitis recurrence.

Surgical Planning & Multidisciplinary Consultation

Source Control Decision:

• Emergent drainage (<6-12 hrs): Septic arthritis, acute osteomyelitis with abscess
• Urgent (24-48 hrs): Diabetic foot with systemic sepsis
• Elective staged: Chronic osteomyelitis with sinus tract (optimize medically first)

Infectious Disease Consultation:

• Culture-guided antibiotic selection, dosing for bone penetration (high-dose beta-lactams, fluoroquinolones, linezolid)
• Duration: 4-6 weeks IV for osteomyelitis, consider oral step-down after 2 weeks if clinical improvement
• Biofilm-active agents for PJI: Rifampin (must combine with second agent to prevent resistance)

Vascular Surgery (Diabetic Foot Osteomyelitis):

• Assess perfusion (ABI, toe pressures, angiogram). Revascularization (angioplasty, bypass) if ischemic—antibiotics fail if tissue perfusion inadequate.

Treatment Pathways

Our infection protocols follow Infectious Diseases Society of America (IDSA) and Musculoskeletal Infection Society (MSIS) guidelines:

Septic Arthritis – Emergency Arthroscopic Washout

Timing: <6-12 hours from diagnosis (golden window). Each hour delay increases cartilage damage.

Procedure:

1. Arthroscopic portals (knee, shoulder, ankle) or open arthrotomy (hip—arthroscopic access difficult)
2. Synovial biopsy (culture, histopathology)
3. High-volume lavage: 6-9 liters normal saline via arthroscopic pump
4. Debride fibrinous debris, necrotic synovium
5. Suction drain left in situ for 24-48 hours
6. No antibiotics in irrigation fluid (dilutes antibiotic levels; systemic IV more effective)

Post-operative:

• IV antibiotics immediately after cultures obtained (don't wait for results if clinically unstable)
• Empiric coverage: Vancomycin (MRSA) + ceftriaxone (Strep, Gram-neg) until cultures finalize
• Early mobilization (Day 1-2): Prevents stiffness; infection doesn't contraindicate physiotherapy
• Repeat washout if no clinical improvement 48-72 hours (persistent fever, pain, elevated WBC/CRP)

Antibiotic Duration:

• 2 weeks IV, then 2-4 weeks oral if good response (total 4-6 weeks)
• Longer if S. aureus (6 weeks), gram-negative (4-6 weeks), immunocompromised (6-8 weeks)

Outcomes: 95% cure if treated within 24 hours. Permanent cartilage loss and secondary arthritis if delayed >48 hours.

Acute Hematogenous Osteomyelitis

Most Common: Children (metaphyseal blood flow), diabetics, IV drug users, hemodialysis patients.

Organisms: S. aureus (70-80%), Strep, Salmonella (sickle cell disease), K. kingae (children <5 years).

Surgical Indications:

• Subperiosteal or intramedullary abscess on MRI
• No clinical response to IV antibiotics 48-72 hours
• Chronic (>2 weeks) with sequestrum formation

Procedure:

1. Drill/window cortex to access medullary canal
2. Curette necrotic bone, pus
3. High-pressure pulse lavage
4. Culture deep bone samples (not superficial wound swabs)
5. Pack dead space with antibiotic-impregnated PMMA beads (gentamicin, vancomycin) or resorbable calcium sulfate beads
6. Negative pressure wound therapy (VAC) if soft tissue defect
7. Delayed closure or skin graft after 5-7 days

Antibiotic Course: 4-6 weeks IV (can transition to high-dose oral after 2 weeks if stable). Fluoroquinolones (ciprofloxacin, levofloxacin) or linezolid achieve excellent bone levels.

Outcomes: 90% cure in acute osteomyelitis. Chronic osteomyelitis develops in 10% if inadequate source control or antibiotic-resistant organism.

Chronic Osteomyelitis – Two-Stage Reconstruction

Papineau Technique / Masquelet Induced Membrane:

Stage 1 (Debridement + Spacer):

1. Radical debridement: Remove all sequestrum, sclerotic/avascular bone until bleeding bone edges (Papineau principle: "Leave nothing dead")
2. Excise sinus tracts entirely
3. Insert antibiotic-impregnated PMMA spacer (vancomycin 2-4g + tobramycin 3.6g per 40g cement) to maintain dead space and deliver high-dose local antibiotics
4. 6-week IV antibiotics

Stage 2 (Reconstruction, 6-8 Weeks Later):

1. Remove spacer—induces "Masquelet membrane" (vascularized pseudocapsule with osteogenic potential)
2. Fill defect with cancellous autograft (iliac crest) or vascularized fibula flap if defect >6 cm
3. External fixator or intramedullary nail for stability
4. Monitor union over 6-12 months

Alternative – Limb Reconstruction System (LRS):

• Single-stage debridement, bone transport with Ilizarov/Taylor Spatial Frame
• 1mm/day distraction osteogenesis regenerates new bone to fill defect
• Avoids need for bone graft harvest; excellent infection control
• 1 month in frame per 1 cm transported

Outcomes: 70-80% infection cure and bone union. Recurrence 15-25%. Amputation if recurrent infection after multiple failed surgeries, patient preference, or life-threatening sepsis.

Prosthetic Joint Infection (PJI) – DAIR vs 2-Stage Revision

DAIR (Debridement, Antibiotics, Implant Retention):

Indications:

• Early infection (<4 weeks post-op) OR acute hematogenous (<3 weeks symptoms) in well-fixed implant
• Susceptible organism (not methicillin-resistant, not fungal)
• Healthy host (no immunosuppression)

Procedure:

1. Open arthrotomy; complete synovectomy (remove all inflamed tissue—biofilm reservoir)
2. High-volume lavage (6-9 liters)
3. Exchange modular components (polyethylene liner, femoral head)—remove biofilm-coated surfaces
4. Retain well-fixed metal components
5. Closure over drains

Post-operative Antibiotics:

• Rifampin 600mg daily (biofilm penetration) PLUS second agent (fluoroquinolone, doxycycline, linezolid)
• Duration: 6-12 weeks (longer for S. aureus)

Success Rate: 55-75%. Failure risk higher with MRSA, late presentation, compromised host.

Two-Stage Revision (Gold Standard for Chronic PJI):

Stage 1 (Explantation):

1. Remove all components (femoral stem, acetabular cup, cement, screws)
2. Radical debridement of infected bone, cement, membrane
3. Insert antibiotic-loaded cement spacer (articulating or static) to maintain soft tissue tension and deliver high-dose local antibiotics
4. 6-8 weeks IV antibiotics

Antibiotic Holiday: 2-4 weeks off antibiotics before reimplantation. Repeat aspiration—if WBC <3,000/µL and CRP normalized, proceed to Stage 2.

Stage 2 (Reimplantation):

1. Remove spacer; send tissue cultures (confirm infection eradication)
2. Insert new revision implants (often larger stems with diaphyseal fixation, augments for bone loss)
3. Continuation antibiotics based on intra-op cultures

Success Rate: 85-95% infection cure at 5 years. Higher bone loss and functional impairment than primary joint replacement but avoids chronic infection and amputation.

Diabetic Foot Osteomyelitis

Medical vs Surgical Decision:

• Non-operative: Small bone involvement (<2 cm²), no abscess, adequate perfusion (ABI >0.7), compliant patient. Prolonged antibiotics (6-12 weeks) + offloading. Cure 60-70%.
• Surgical: Large bone destruction, soft tissue abscess, ischemia requiring revascularization, systemic sepsis. Debridement or amputation. Faster healing but loss of anatomy.

Limb Salvage Procedure:

1. Aggressive debridement infected bone (forefoot ray amputation, metatarsal head resection)
2. Soft tissue coverage: Local flaps, negative pressure therapy, skin graft
3. Offloading: Total contact cast, custom orthotic, Charcot restraint orthotic walker (CROW)
4. Revascularization if ischemic (angioplasty, bypass)
5. Tight glucose control (HbA1c <7%), smoking cessation, nutrition optimization

Partial Amputation (Toe, Ray, Transmetatarsal):

• Preserves ambulation; prosthetic not required
• Heals faster than limb salvage (8-12 weeks vs 4-6 months)
• Indicated if non-salvageable: Necrotizing infection, unreconstructable bone loss, non-compliant patient

Below-Knee Amputation (BKA):

• Last resort: Life-threatening sepsis unresponsive to limited debridement, or non-healing despite multiple salvage attempts
• Prosthetic allows ambulation; quality of life acceptable if patient motivated

Outcomes: Limb salvage success 60-70% if adequate perfusion. Recurrent ulceration/infection common—lifelong diabetic foot care and podiatry follow-up essential.

Technology & Innovation

MALDI-TOF Mass Spectrometry

Rapid Organism Identification: Laser ionizes bacterial colonies; time-of-flight mass spectrometry generates protein "fingerprint" matched against database. Result in 30 minutes.

Benefits:

• Earlier targeted antibiotic therapy (Day 1 vs Day 3-5 with biochemical methods)
• Detects slow-growing organisms (Propionibacterium acnes—common in shoulder PJI)
• Reduces unnecessary broad-spectrum antibiotic use (antibiotic stewardship)

Sonication of Explanted Implants

Biofilm Disruption: Removed implants placed in sonication fluid; ultrasonic waves disrupt biofilm. Fluid cultured—increases organism detection 30% vs tissue cultures alone.

Critical for PJI: Sensitivity 78% vs 61% for tissue culture. Changes management in 15% of cases (negative tissue cultures but positive sonicate = continue antibiotics).

Antibiotic-Eluting Scaffolds

Local Antibiotic Delivery: High concentrations at infection site (100-1000x serum levels) without systemic toxicity.

Options:

• PMMA Beads (Gentamicin, Vancomycin): Non-resorbable; require removal. Elution lasts 2-4 weeks.
• Calcium Sulfate Beads: Resorbable; replaced by bone over 6-12 weeks. Lower elution but no second surgery.
• Bioglass/Synthetic Bone Grafts: Osteoconductive + antibiotic delivery. Ideal for dead space management.

Outcomes: Reduces re-infection rate from 25-30% to 10-15% when combined with IV antibiotics.

Preventing Complications

Early Recognition Saves Limbs

Septic Arthritis: Each hour delay increases cartilage damage. Any hot, swollen joint with fever = ER visit immediately. Joint aspiration rules in/out infection within 1 hour (Gram stain, cell count).

Post-operative Wound Drainage: Not all drainage is infection—seroma, hematoma, superficial infection vs deep infection. If >5 days post-op, persistent pain, fever, elevated CRP—return to OR for washout. Early washout (DAIR) salvages 70% of prosthetic joints; delayed (>3 weeks) requires 2-stage revision.

Diabetic Foot Red Flags: Exposed bone in ulcer base (probe-to-bone test positive), foul odor (anaerobic infection), crepitus (gas gangrene), systemic toxicity—urgent surgical evaluation. Delay risks limb loss or death from sepsis.

Antibiotic Stewardship

Avoid Empiric Long-Term Antibiotics Without Culture: Drives resistance (MRSA, VRE, MDR Gram-negatives). Always obtain cultures before starting antibiotics if hemodynamically stable.

Appropriate Duration: Neither too short (inadequate source control) nor excessively long (Clostridioides difficile colitis, line infections). Typical: 4-6 weeks total for osteomyelitis, 2-4 weeks septic arthritis. Longer if immunocompromised or resistant organism.

Oral Step-Down: High-dose fluoroquinolones (ciprofloxacin 750mg twice daily), linezolid (600mg twice daily) achieve bone levels equivalent to IV. Transition after 2 weeks IV if stable—reduces PICC line complications (thrombosis, line infection), allows outpatient treatment.

Why Ajuda for Bone & Joint Infections?

Take the First Step

Bone and joint infections are orthopaedic emergencies—hours matter for septic arthritis, days for acute osteomyelitis. If you have severe joint pain with fever, wound drainage at surgery site, or diabetic foot with exposed bone, call our ER immediately at 9010550550 for urgent evaluation.

For prosthetic joint pain, chronic bone infection, or second opinions on amputation decisions, schedule a consultation with our infection specialists. Early intervention prevents irreversible cartilage damage, limb loss, and life-threatening sepsis.

Trust Ajuda's 24/7 infection service for expert bone and joint infection management.