Book Review

Infections in Bones and Joints

N Engl J Med 1995; 332:615-616March 2, 1995

Article

Infections in Bones and Joints
By Carl Norden, William J. Gillespie, and Sydney Nade. 438 pp., illustrated. Boston, Blackwell Scientific, 1994. $85. ISBN: 0-86542-273-7

Drs. Norden, Gillespie, and Nade have written what may be the definitive treatise on bone and joint infections. They classify bone and joint infections in the same three groups proposed by Waldvogel et al. in their review of osteomyelitis (Osteomyelitis: Clinical Features, Therapeutic Considerations and Unusual Aspects. By F.A. Waldvogel, G. Medoff, and M.N. Swartz. Springfield, Ill.: Charles C Thomas, 1971): hematogenous osteomyelitis, direct infections resulting from traumatic inoculation of bacteria or from local spread of infection from a contiguous source, and infections in patients with diabetes who have neuropathic and vascular complications. In all three types of bone and joint infection, optimal management depends on early diagnosis, appropriate antibiotic therapy, and the use of surgical débridement, including the removal of prosthetic devices, when indicated. A subtle balance between medical and surgical therapy is necessary if a satisfactory outcome is to be achieved. Failure to reach this goal will often result in severe deformity, advancing infection, or amputation. Since such a large percentage of bone and joint infections occur in young patients, complications have a particularly important effect on the quality of life. The sections of the book focus on the clinical presentations of these infections, the most effective diagnostic tests, and finally, the therapeutic options.

The section on pathogenesis reviews the history of the disease and discusses in vitro experiments that support tenable models of the genesis and progress of infections and the development of complications. This section will be useful for anyone who has to lecture on bone and joint infections in pathophysiology courses. It also provides justification for some of the diagnostic and therapeutic strategies that the subsequent two sections describe.

The section on diagnosis and management contains a particularly useful, balanced description of the indications for radiologic procedures. It also deals with when medical and surgical treatments should be used. The training of the authors (an infectious-disease expert and two surgeons) provides the basis for a well-balanced approach to therapy. It is obvious that the authors agree in principle about how bone and joint infections should be treated. The spirit of agreement and cooperation reflected in this section of the book should serve as a model for the combined medical and surgical treatment that so many patients with such infections require.

The third section describes a large number of clinical syndromes. It is a valuable source of information on specific, sometimes esoteric presentations. I was puzzled by the lack of reference to fluconazole and itraconozole as alternatives to amphotericin B in the treatment of fungal infections of bones and joints, but this is a relatively minor point.

I enjoyed reading this book. Because it was written by only three authors, it has an even style without the repetitions that characterize medical textbooks with large numbers of authors. Of course, I have a special interest in infections of this type; others may find the book less satisfying to read in its entirety, but it will certainly be useful as a source of lecture material and of assistance in dealing with specific patients with complex problems in this area. The price of $85 is high for a book that may not be used very frequently, but there are many useful x-ray images illustrating the clinical syndromes described in the text. I would definitely recommend the book for purchase by all medical school libraries and also by medical and orthopedic department libraries.

Gerald Medoff, M.D.
Washington University School of Medicine, St. Louis, MO 63110