This new blood test for infection is based on the phenomenon of leukergy in which white cells agglomerate in the peripheral blood of patients with inflammatory diseases. It was used in 26 patients with proven bone or joint infection and was positive in 25. The leukergy test was more accurate than the ESR, white cell count or blood culture. The percentage of cells agglomerated correlated with the clinical severity of the infection and the test detected reactivation of the septic process better than the other haematological tests. It is a rapid and inexpensive method which is useful in the diagnosis and management of bone and joint infections.

1. Continued follow-up of the 113 children with acute osteomyelitis previously reported and a study of a further thirty-eight proven cases has not changed our opinion that the correct management is rest and effective antibiotics. Operation should be undertaken only if pus is detectable clinically.

2. Bacteriological evidence shows that the flora causing this disease are less sensitive to benzylpenicillin than ten years ago and that a proportion are also likely to become resistant to methicillin and cloxacillin.

3. The most effective antibiotic combination used was fusidic acid and erythromycin. This lowered the failure rate to 10·5 per cent in thirty-eight proven cases. Two of the four failures were in haemophilus infections. No staphylococcal infection of a long bone became chronic, and all lesions were healed within three months of onset.

4. The duration of treatment (twenty-one days) and the method of splintage (removable plaster slabs) remained the same as in the previous series.

5. Careful watch must be kept on the incidence of haemophilus infections. If it rises, increasing the erythromycin or adding ampicillin may be necessary.

6. Use of the newer aqueous suspension of fusidic acid may lower the incidence of troublesome vomiting (12 per cent in this series).

7. Only 7 per cent of staphylococcus aureus infections in this hospital, and 17 per cent of such infections in our thirty-eight cases were sensitive to benzylpenicillin. It is thought that this drug has outlived its usefulness in osteomyelitis.

8. It is recommended that, on diagnosis, fusidic acid aqueous suspension 5 millilitres should be given three times a day to children aged one to five, and 10 millilitres twice a day for children aged six to twelve, with erythromycin stearate 30 milligrams per kilogram of body weight each day in divided doses.

1. In the treatment of chronic osteomyelitis the most troublesome factor is the infected bone cavity. This is seldom obliterated spontaneously by bone regeneration. The number of procedures designed to fill the cavity, since the beginning of the century, show how much it troubles the surgeon.

2. The use of bone grafts in the treatment of chronic osteomyelitis has been studied. One hundred and twenty cases are reviewed (the largest series in the literature), the follow-up being between two and ten years. The most common lesion was a bone cavity, with or without a sequestrum.

3. Treatment must include the removal of infected soft tissues as well as sclerosed bone, and must be done under appropriate antibiotic control. The value of cancellous bone grafts in filling infected cavities in the metaphysio-epiphysial regions is especially emphasised.

4. The results were gratifying, only four relapses occurring in 120 cases.

1. A primary subacute type of staphylococcal osteomyelitis has been described. It is the commonest form of osteomyelitis seen in East Africa, and the incidence appears to be increasing in Great Britain.

2. A review of the literature indicates that this is not a new disease but that in the past there has been some confusion in terminology.

3. The causative organism is a coagulase positive staphylococcus, but in a few instances a coagulase negative one has been isolated. The staphylococcus is thought to be of reduced virulence and in East Africa it is likely that the population has acquired an increased resistance to the staphylococcus.

4. Two radiologically distinct groups are recognised, depending on whether a bone abscess is present or not. In the first group there are two types of localised abscesses: the familiar Brodie's lesion and the less well recognised large bone abscess that occurs in the metaphysis of a long bone. While the pathology of the two types is similar, the radiological features are quite distinct. The lesions in the second group are characterised by extensive diaphysial changes, with or without metaphysial involvement, and an obvious abscess cannot usually be demonstrated.

5. The main clinical features are the long history, often weeks or months, before diagnosis; insignificant or absent general reaction to the infection and minimum physical signs.

6. Vertebral body osteomyelitis in adults is included because it generally presents as a subacute infection; the difficulties in distinguishing it from a tuberculous infection are outlined.

7. The most useful diagnostic aids are the staphylococcal antibody titres (especially in vertebral infections) and the erythrocyte sedimentation rate. A limited surgical exposure is usually required if the causative organism is to be isolated and empirical antibiotic therapy is to be avoided. The total and differential white blood count are so often normal in these patients that they are considered to be of no diagnostic value.

8. Curettage and local antibiotics together will cure the localised bone abscess. Other lesions may be effectively treated by systemic antibiotics alone, but in the later stages removal of sequestra and infected granulation tissue may be necessary. In this instance it is essential to make a planned incision and to cut a window in the bone large enough to expose the whole of the lesion; primary suture of the wound is advocated.

We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer.

Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a ^99mTc-MDP bone scan. If the latter was positive, an ¹¹¹In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination.

Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. ^99mTc-MDP bone scans with the appropriate ¹¹¹In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot.

1. The dominant role of pathogenic staphylococci in surgical infections has been confirmed by positive isolations in 89·9 per cent of a wide variety of lesions in a hospital infective unit. Of 150 staphylococci isolated, 147 were sensitive to fusidic acid, two were slightly sensitive and only one was resistant.

2. Fusidic acid was administered as sodium fusidate to 100 patients with staphylococcal infections (including seventy-two with chronic post-traumatic osteomyelitis). Sterile swabs were achieved in seventy-seven of these patients and in the remaining twenty-three a change of flora was detected.

3. Bone samples were taken at operation from twenty-nine patients with chronic osteomyelitis who had been treated for at least five days with fusidic acid. Depending on dosage, the mean fusidic acid concentrations were 7·3 and 9·8 micrograms per gram. Corresponding levels in non-inflammatory bone samples from thirty-one patients were, depending on the duration of treatment, 12·3, 2l·3 and 25·4 micrograms per gram. The fusidic acid levels in cancellous bone were almost twice as high as those in compact bone.

4. The relevance of these findings to the use of fusidic acid therapy as an adjunct to surgical management of chronic osteomyelitis is discussed.

1. The treatment of twenty-nine consecutive patients suffering from chronic osteomyelitis is reviewed. With the advent of an antibiotic, Fucidin, which has the ability to penetrate in significant amounts into tissues carrying a poor blood supply, a more limited surgical procedure has become possible.

2. A successful outcome, as judged by primary healing, was achieved in 86 per cent of patients treated with a combination of surgery and Fucidin with penicillin. This compares favourably with the results achieved in a previous series in which more radical surgery was undertaken.

3. Although Fucidin has advanced the treatment of chronic osteomyelitis, it is still essential to use surgery as well.

4. Fucidin caused no toxic effects despite an average total dose of seventy to eighty grammes. Resistance of the staphylococcus developed in vitro in one patient, without affecting a satisfactory clinical outcome.

A case of salmonella osteitis of the spine is described. It is thought to be the first case reported due to the serotype Salnionella muenchen.

1. The three age types of acute haematogenous osteomyelitis are conditioned in their respective clinical features by the differing nature of their vascular bone pattern.

2. In the infant the condition causes severe and often permanent epiphysial damage and joint infection, a large involucrum but only transient damage to the shaft and metaphysis.

3. In the child the condition is responsible for extensive cortical damage with involucrum formation, but, except for some stimulation of growth, permanent damage to the growth cartilage and to joints is exceptional. Chronicity of the disease is rare if treatment has been effective.

4. In the adult acute osteomyelitis of the long bones is rare. It causes very frequent joint infection; the cortex is absorbed instead of sequestrating. The whole of the bone is invaded and frequently leaves chronic infection in the bone marrow.

5. The vascular characteristics of the bones in each age group and their relation to the onset of infection are described.

6. Some general directives for management based on these facts are suggested.

1. The clinical findings and results in seventeen patients under two years of age, suffering from acute osteomyelitis, have been studied and compared with forty-eight similar cases treated without penicillin.

2. The results in the penicillin-treated group were not greatly superior to those in the control group and did not justify the high hopes that have been entertained for penicillin as a certain cure for osteomyelitis.

1. Forty-five cases of acute osteomyelitis have been reviewed with the object of determining the causes of relapse. The importance of an early diagnosis and prompt treatment is stressed, and the question of when to stop antibiotic drugs is discussed.

2. The provisional diagnosis was anterior poliomyelitis in seventeen out of forty-five patients; acute osteomyelitis was diagnosed in twelve only. The criteria for making an early diagnosis are discussed, including the value and limitation of blood culture.

3. The place of operation is discussed and certain conclusions are set out.

Aims. There is a lack of biomaterial-based carriers for the local delivery of rifampicin (RIF), one of the cornerstone second defence antibiotics for bone infections. RIF is also known for causing rapid development of antibiotic resistance when given as monotherapy. This in vitro study evaluated a clinically used biphasic calcium sulphate/hydroxyapatite (CaS/HA) biomaterial as a carrier for dual delivery of RIF with vancomycin (VAN) or gentamicin (GEN). Methods. The CaS/HA composites containing RIF/GEN/VAN, either alone or in combination, were first prepared and their injectability, setting time, and antibiotic elution profiles were assessed. Using a continuous disk diffusion assay, the antibacterial behaviour of the material was tested on both planktonic and biofilm-embedded forms of standard and clinical strains of Staphylococcus aureus for 28 days. Development of bacterial resistance to RIF was determined by exposing the biofilm-embedded bacteria continuously to released fractions of antibiotics from CaS/HA-antibiotic composites. Results. Following the addition of RIF to CaS/HA-VAN/GEN, adequate injectability and setting of the CaS/HA composites were noted. Sustained release of RIF above the minimum inhibitory concentrations of S. aureus was observed until study endpoint (day 35). Only combinations of CaS/HA-VAN/GEN + RIF exhibited antibacterial and antibiofilm effects yielding no viable bacteria at study endpoint. The S. aureus strains developed resistance to RIF when biofilms were subjected to CaS/HA-RIF alone but not with CaS/HA-VAN/GEN + RIF. Conclusion. Our in vitro results indicate that biphasic CaS/HA loaded with VAN or GEN could be used as a carrier for RIF for local delivery in clinically demanding bone infections. Cite this article: Bone Joint Res 2022;11(11):787–802

Primary subacute haematogenous osteomyelitis (PSHO) of the small bones of the foot is a rare and infrequently considered cause of a limp in children. We describe 11 patients with PSHO, of whom nine were under three years of age, who had a limp with few symptoms. The talus was involved in 36%. Bone scans were positive in all patients and led to localisation of the lesion in two. The radiological features included soft-tissue swelling, an osteolytic lesion in the talus and the calcaneus and a sclerotic appearance of the cuboid and the navicular bones. All patients except one were cured with antibiotics.

1. Fifteen patients who had had osteomyelitis of the lower femur or upper tibia during infancy have been studied. The cases of four patients showing particular features of the disease are presented in detail and the remainder are summarised.

2. It is suggested that damage to the epiphysis may be due to an abscess, or to ischaemia following occlusion of the blood supply. In the latter instance the prognosis may be better.

3. In the early stages the radiographic appearances may be deceptive, suggesting that damage to the epiphysis is irreparable.

4. Significant recovery of the epiphysis may occur in some patients after a delay of several years. This, together with the often good function which is preserved at the joint, should deter the surgeon from early destructive operation on the limb.

5. Deformity, which was present to some extent in all cases, appeared early and was not well controlled by conservative treatment. Operations were performed in twelve patients.

6. Shortening of the limb occurred in all patients and in some it was severe.

1. In chronic osteomyelitis grafting a cavity with split skin is a reliable method of treatment. The skin cover so obtained is durable.

2. The method may be used with good prospects of success even when the cavity is large and there is extensive disease of bone.

3. Operation is indicated for the relief of pain, to close a sinus or sinuses, to obtain healing of an ulcer or to prevent recurrent episodes of acute infection.

4. The technique of operation employed in eleven cases is described and illustrative case reports are given.

A series of ten infants is reported, seven of whom showed evidence of osteomyelitis of the upper end of the femur; the remaining three did not, but presented with an acute subluxation of the hip in a febrile illness. Four sequelae among the seven more severe cases were: 1) destruction of the capital epiphysis with dislocation at the hip; 2) destruction of the capital epiphysis, the femoral neck remaining in the acetabulum; 3) destruction of the epiphysial plate with the femoral head, remaining in the acetabulum, connected to the femoral neck by a fibrous union; 4) recovery with coxa magna but no other deformity.

The streptococcus plays a greater part in this osteomyelitis of infancy than in osteomyelitis of older children, but various other organisms were identified. The organism should be sought by blood culture as well as from the local lesion.

Aspiration of the hip, treatment of the hip in abduction and the use of the appropriate antibiotic are recommended. If there is marked swelling and induration, freer release of the pus is strongly advised.

Controlled abduction osteotomy plays a useful part in stabilising the femoral neck in the acetabulum or in stabilising the femoral neck beneath the capital epiphysis, but may usefully be preceded by an arthrograph because late ossification of a detached head sometimes occurs.

1. Vascular anatomical studies of the spine are described and the possibility of spread of infection from pelvis to spine through the paravertebral venous plexus is discussed.

2. Though a venous route does exist, our studies do not support the supposition that infection is likely to spread by this route; nor is there any clear clinical, pathological or anatomical evidence that such spread occurs.

3. Nineteen cases of pyogenic osteomyelitis of the spine are recorded, six of which followed urinary infections. The condition is compared with osteomyelitis as it occurs in the other bones of adults.