Investigating the Correlations Among Clinical, Laboratory, and Imaging Findings in Pediatric Patients with Osteomyelitis and Septic Arthritis: A 12- Year Retrospective Study

Investigating the Correlations Among Clinical, Laboratory, and Imaging Findings in Pediatric Patients with Osteomyelitis and Septic Arthritis: A 12- Year Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Investigating the Correlations Among Clinical, Laboratory, and Imaging Findings in Pediatric Patients with Osteomyelitis and Septic Arthritis: A 12- Year Retrospective Study Amirali Barkhordarioon, Mahdieh Mousavi Torshizi, Ghazal Shariatpanahi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5395455/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Dec, 2025 Read the published version in BMC Pediatrics → Version 1 posted 11 You are reading this latest preprint version Abstract Background : Septic arthritis (SA) and Osteomyelitis (OM) are critical pediatric emergencies that can lead to severe complications, including mortality. The study aimed to investigate the relationships between risk factors and clinical, laboratory, and imaging findings in these diseases. Methods : A retrospective study was conducted on 65 pediatric patients (46 diagnosed with SA and 19 with OM). Relevant demographic data, clinical, laboratory and imaging findings were analyzed. Results : 45 (69.2%) patients were male. The mean age was 5.4 years for SA and 4.8 years for OM. The mean duration of hospitalization was 8.1 days for SA and 15.32 days for OM. Eight patients (12.3%) experienced comorbidity, leading to longer hospitalization. The most affected joints were the knee, hip, and ankle, whereas the most affected bones were the femur, tibia, and humerus. The main clinical symptoms and signs of OM included pain, tenderness, and fever, whereas those of SA included pain, limited mobility, and tenderness. Leukocytosis was observed in 57.9% of OM patients and 50% of SA patients. Erythrocyte Sedimentation Rate (ESR) elevation was found in 52.6% of OM patients and 54.3% of SA patients. Elevated C-Reactive Protein (CRP) was present in 68.4% of OM and 80.4% of SA patients. Blood cultures were positive in 23.1% of OM patients and synovial fluid cultures in 23.5% of SA patients, with Staphylococcus aureus being the most common organism isolated (75%). There was a correlation between hospitalization duration for SA patients and abnormal ultrasound or X-ray findings. Conclusions : SA and OM were predominantly observed in boys aged 2–12 years. Comorbidities and immunosuppressive medications were associated with increased disease severity. Fever was recorded in less than 80% of the patients. The ESR emerged as the only parameter significantly associated with culture results, highlighting its importance in assessing infection severity and patient follow-up. The relationship between ultrasound findings and SA severity can guide clinical management. These findings identified MRI as the gold standard for diagnosing OM. The low culture positivity rates underscore the need for timely empirical treatment initiation, even in the absence of positive culture results. Children Osteomyelitis Septic arthritis ESR Imaging Treatment Figures Figure 1 Figure 2 Introduction Osteomyelitis (OM) and Septic Arthritis (SA) are critical pediatric emergencies requiring immediate attention and intervention ( 1 , 2 ). They present significant diagnostic and therapeutic challenges, with the potential for long-term consequences such as dysfunction, length discrepancies, asymmetry, and chronic pain ( 3 – 6 ). The occurrence of OM and SA ranges from 4–13 and 2–6 cases per 100,000 children, respectively, with higher prevalence in males ( 7 – 12 ). Acute Hematogenous Osteomyelitis (AHO), the most common form of OM, typically affects the metaphysis of long bones such as the femur, tibia, and humerus and requires prolonged antimicrobial therapy, and sometimes surgical intervention ( 3 , 8 , 11 , 13 ). SA typically affects the hip and knee joints through monoarticular involvement ( 1 , 7 , 10 , 14 , 15 ). The child's SA prognosis is determined by several factors, such as age and treatment delay ( 2 , 7 , 8 , 16 ). Infants under 18 months display unique anatomical features, such as metaphyseal-epiphyseal blood vessels, which are closely linked to the propagation of infections between bone and joint spaces and thereby make the clinical picture more complicated and the management approach more difficult ( 3 , 12 , 15 , 17 ). Classic AHO symptoms (fever, pain, and reduced mobility) appear in only about half of the cases, necessitating high clinical suspicion ( 9 , 18 ). Staphylococcus aureus is the main causal agent of osteoarticular infections. Nonetheless, consideration should be given to other organisms in certain patient populations, such as Group B Streptococcus in infants and Kingella kingae in young children ( 3 , 7 , 9 , 15 ). The rising prevalence of Methicillin-resistant staphylococcus aureus (MRSA) complicates management and often leads to severe systemic manifestations ( 3 , 7 , 9 , 15 , 19 ). Although plain radiography is usually the first imaging technique used, its effectiveness is limited in the early stage of infection ( 9 , 19 , 20 ). MRI provides high sensitivity and specificity but is not widely used because of its high cost, limited availability, and sedation requirements ( 9 , 15 , 20 ). Treatment strategies are primarily oriented toward empirical antibiotics based on local epidemiology, age, and clinical presentation ( 8 , 12 ). The heterogeneity in antibiotic resistance patterns across various geographical areas is a serious issue for the standardization of treatment ( 12 , 19 ). Previous research has shown a high resistance rate of Staphylococcus aureus strains to many commonly used antibiotics, such as cloxacillin, which necessitates the monitoring and prudent use of antibiotics ( 7 ). Further orthopedic review of the condition to identify the possibility of surgical intervention, such as aspiration or debridement, is also one of the important components of the treatment plan ( 12 ). This study aims to evaluate the epidemiological patterns, risk factors, microbiological profiles, and clinical characteristics of pediatric patients diagnosed with SA and OM. By analyzing demographic data, laboratory results, imaging findings, and treatment outcomes over 12 years, we seek to enhance our comprehension of the manifestation of these infections, their microbial etiologies, and the determinants affecting patient outcomes to enable early diagnosis and refine treatment techniques. Methods This study employs a retrospective cross-sectional design to examine pediatric cases of SA and OM. The research was conducted at Bahrami Children's Hospital, Tehran, Iran from April 2011 to March 2023. Patients were included on the basis of the following criteria: 1- Discharge diagnosis of OM or SA, identified by ICD-10; 2- The presence of clinical symptoms, including pain, swelling and redness, fever, limping, reduced mobility, or other abnormal physical examination findings, is consistent with the diagnosis; 3- At least one of the following: Identification or culture of a microbial pathogen from joint fluid, blood, or bone biopsy, Presence of pus during arthrocentesis despite negative culture results, and Laboratory or radiographic evidence suggesting osteomyelitis or septic arthritis. Final diagnosis confirmed by a pediatric infectious disease specialist or pediatric rheumatologist. The Kocher criteria are utilized for acute SA of hip. Radiography is used as a supplementary diagnostic technique in unclear cases. Patients with OM must fulfill a minimum of two requirements: 1- Clinical and laboratory findings included bone pain or tenderness, localized warmth, redness and swelling, reduced use of the affected limb, limping, fever, leukocytosis, and elevated inflammatory markers; 2- Purulent components in aspiration of the affected bone; 3- Positive blood culture or bone biopsy results indicative of osteomyelitis; 4- Positive imaging findings such as periosteal elevation or disruption, soft tissue swelling, and disruption of normal bone architecture. Patients who had significantly incomplete medical records, previous history of open fracture, bone surgery, or nosocomial infection, or definitive diagnosis other than OM or SA excluded from the study. Data were extracted from hospital records in the Bahrami Hospital database. A researcher-designed checklist was used to obtain the following variables: demographic data, medical history, clinical presentation, laboratory findings, radiographic evidences based on written reports by experienced radiologists, treatment details, and follow-up reports after discharge. The sample size is determined using the standard formula and P (expected prevalence) = 16% based on the study by Spyridakis et al ( 2 ). This calculation yields a minimum sample size of 52 patients. For statistical analysis, data are presented as the mean or median ± standard deviation or interquartile range (SD) for quantitative variables and were summarized by frequency (percentage) for categorical variables. The collected data were entered into SPSS software version 26 for analysis. In the inferential statistics section, appropriate statistical tests will be used to analyze the relationships between variables, with a p-value less than 0.05 considered statistically significant. Results This retrospective study involved 65 patients at Bahrami Hospital from 2011 to 2023 and reported 46 cases (70.8%) of SA and 19 cases (29.2%) of OM. The study population comprised 45 male patients (69.2%) and 20 female patients (30.8%). The mean age of patients with SA was greater than OM. Eight patients (12.3%) were hospitalized due to symptom recurrence. The mean duration of hospitalization for patients with SA was 8.13 days, whereas for patients with OM, it was 15.32 days (Table 1 ). The average duration of hospitalization for patients with comorbidities was significantly longer than that for those without (18.4 days vs. 9.1 days; p: 0.004). Eighteen patients (27.7%) had recently used antibiotics following the onset of symptoms. Cefixime (38.9%), amoxicillin (16.7%), and penicillin (16.7%) were the most commonly used antibiotics. Four patients (6.1%) had a history of corticosteroid use or other immunosuppressive drugs (cyclosporine, methotrexate). Additionally, two patients (3%) were using antiepileptic drugs (phenytoin and phenobarbital). In total, 10 patients (15.4%) reported a recent history of trauma to the affected limb (bone, joint). The mean time from symptom onset to hospitalization for patients with SA was 7.1 days, and that for patients with OM was 9.8 days. Table 1 Demographic distribution of patients with SA and OM Characteristic Septic Arthritis (n = 46) Osteomyelitis (n = 19) Age (years) Mean ± SD 5.4 ± 4.3 4.8 ± 3.8 Newborn (0–28 days) 0 (0%) 0 (0%) Infant (29 days − 1 year) 5 (10.9%) 4 (21.1%) Toddler (1–3 years) 9 (19.6%) 7 (36.8%) Preschooler (3–5 years) 16 (34.8%) 1 (5.3%) School age (6–12 years) 16 (34.8%) 7 (36.8) Gender, n (%) Male 33 (71.7%) 12 (63.2%) Female 13 (28.3%) 7 (36.8%) Residence, n (%) Urban 42 (91.3%) 18 (94.7%) Rural 4 (8.7%) 1 (5.3%) Infection type, n (%) Primary 42 (91.3%) 15 (78.9%) Recurrent 4 (8.7%) 4 (21.1%) Duration of hospitalization (days) Mean ± SD 8.1 ± 6.7 15.3 ± 10.6 Underlying Disease, n (%) None 12 (63.2%) 21 (45.7%) Nonspecific viral symptoms 5 (26.3%) 19 (41.3%) Aplastic Anemia 0 (0%) 1 (2.2%) Achondroplasia 1 (5.3%) 0 (0%) Hepatitis B 0 (0%) 1 (2.2%) Serum sickness 0 (0%) 1 (2.2%) ALL 0 (0%) 1 (2.2%) CP 0 (0%) 1 (2.2%) Epilepsy 1 (5.3%) 0 (0%) ESRD 0 (0%) 1 (2.2%) 73.9% of patients with SA had monoarticular involvement, whereas the remaining 26.1% had oligoarticular (two-joint) involvement. The most commonly affected joints were the knee (43.1%), hip (32.8%), and ankle (12.1%) (Fig. 1 ). Among the OM patients, except for two patients (10.5%) with simultaneous infection of two bones, the remaining patients (89.5%) had single bone involvement. The most frequently infected bones were the femur (33.3%), tibia (23.7%), and humerus (19%) (Fig. 2 ). The most common clinical signs and symptoms in OM patients were pain or discomfort (100%), tenderness (89.5%), and fever (78.9%). For SA patients, the most common clinical signs and symptoms were pain or discomfort (100%), reduced range of motion (84.8%), and tenderness (78.3%) (Table 2 ). The mean temperature recorded upon admission was 38.0°C (95% CI: 37.7–38.3) for patients with SA and 38.6°C (95% CI: 38.2–39.0) for those with OM (Table 2 ). Table 2 Frequency of Clinical Signs, Laboratory Parameters in Patients with OM and SA Clinical Signs and Symptoms Septic Arthritis (n = 46) Osteomyelitis (n = 19) Fever 29 (63.0%) 15 (78.9%) Pain 46 (100.0%) 19 (100.0%) Local signs 30 (65.2%) 13 (68.4%) Tenderness 36 (78.3%) 17 (89.5%) Decreased ROM 1 39 (84.8%) 14 (73.7%) Limping 32 (76.2%) 12 (80.0%) Inability to bear weight 26 (61.9%) 6 (40.0%) WBC (×10³ cells/µL) Elevated (%) 50.0% 57.9% Mean ± SD 12.0 ± 5.5 13.5 ± 4.4 NLR 2 Elevated (%) 63.0% 57.9% Mean ± SD 3.4 ± 3.1 2.9 ± 1.6 ESR 3 (mm/h) Elevated (%) 54.3% 52.6% Mean ± SD 46.3 ± 31.9 47.0 ± 31.1 CRP 4 (mg/L) Elevated (%) 80.4% 68.4% Mean ± SD 48.2 ± 34.8 50.9 ± 34.1 Hemoglobin (g/dL) 11.0 ± 1.3 11.0 ± 1.5 Platelet (×10³/µL) 353.9 ± 178.1 456.2 ± 192.8 Urea (mg/dL) 24.5 ± 20.8 22.3 ± 8.1 Creatinine (mg/dL) 0.6 ± 0.6 0.5 ± 0.1 Note: Values are presented as Number (%) and Mean ± SD. 1 ROM: range of motion 2 NLR: Neutrophil-to-Lymphocyte Ratio 3 ESR: Erythrocyte Sedimentation Rate 4 CRP: C-Reactive Protein In OM patients, leukocytosis (WCC > 12000) was present in 57.9% of cases, 52.6% had an ESR > 40, and 68.4% had elevated CRP levels (qualitative values of 1 + or higher and quantitative values of 20 or higher). Blood culture was positive in 23.1% of OM patients, and bone culture was positive in 20% of the patients whose culture reports were available in their hospital records. In patients with positive blood cultures, the most common identified organism was Staphylococcus aureus (75%). In OM patients with positive blood cultures, although the occurrence of clinical symptoms and increases in the WCC, NLR, and inflammatory markers were more severe and frequent than those in culture-negative patients, statistical analysis revealed that only the increase in the ESR was significantly and nonrandomly associated with positive blood cultures (p: 0.045) (Table 2 ). In SA patients, leukocytosis was present in 50% of cases, 54.3% had an elevated ESR, and 80.4% had elevated CRP levels (Table 2 ). Among SA patients with available culture results, positive blood cultures and positive synovial fluid cultures were found in 13.3% and 23.5% of cases, respectively. In patients with positive synovial fluid cultures, Staphylococcus aureus (75%) was the most commonly identified organism. Similar to osteomyelitis patients, only the ESR showed a significant and nonrandom increase in association with positive cultures (p: 0.007) (Table 3 ). Table 3 Distribution of Clinical Symptoms and Laboratory Parameters Based on Blood/Synovial Culture Results Clinical Signs and Symptoms Osteomyelitis Septic Arthritis Positive Blood Culture (n = 4) Negative Blood Culture (n = 9) p-value Positive Synovial Fluid Culture (n = 4) Negative Synovial Fluid Culture (n = 13) p-value Fever 4 (100%) 7 (77.8%) 0.305 3 (75%) 12 (92.3%) 0.347 Local signs 3 (75%) 6 (66.7%) 0.764 4 (100%) 9 (69.2%) 0.205 Tenderness 4 (100%) 7 (77.8%) 0.305 4 (100%) 10 (76.9%) 0.305 Decreased ROM 1 3 (75%) 6 (66.7%) 0.764 4 (100%) 12 (92.3%) 0.567 WBC (×10³ cells/µL) 12.9 11.7 0.445 14.5 11.2 0.211 NLR 2 4.2 2.7 0.141 2.6 2.2 0.600 ESR 3 (mm/h) 67.5 32.8 0.045 92.2 45.6 0.007 CRP 4 (mg/L) 78.2 49.0 0.115 60.5 57.5 0.881 Note: Values are presented as Number (%) and Mean ± SD. 1 ROM: range of motion 2 NLR: Neutrophil-to-Lymphocyte Ratio 3 ESR: Erythrocyte Sedimentation Rate 4 CRP: C-Reactive Protein In the ultrasound examination of 35 patients with SA, 26 patients (74.3%) had joint effusion, 10 patients (28.6%) had increased synovial thickness or joint capsule swelling, and 8 patients (22.8%) had normal ultrasound findings or no findings suggestive of SA. Among the 46 patients with SA included in this study, 18 patients underwent plain radiography of the affected limb, with 11 patients (61.1%) reported as normal and 7 patients (38.9%) showing soft tissue swelling accompanied by decreased bone density. The mean hospitalization duration for SA patients with abnormal ultrasound or X-ray findings was longer than that for those with normal imaging results (9.3 days vs. 3.8 days; p: 0.005). The most common findings in plain radiographs of 11 OM patients were the formation of osteolytic foci (54.5%) and soft tissue edema (36.4%). Three patients (27.3%) had normal radiographs. MRI reports of 8 OM patients revealed increased signal intensity in the affected bone, the most important diagnostic finding, in 7 patients (87.5%). Periosteal reactions (50%) and the presence of abscesses or collections (37.5%) were other reported findings in these patients. According to hospital records, 11 out of 19 OM patients underwent bone scans, all of which (100%) reported increased uptake of contrast material by the affected bone as a diagnostic finding. The most common antibiotic regimens used for patients were ceftriaxone + cloxacillin (27.3%), cloxacillin (22.7%), and ceftriaxone + clindamycin (15.9%) (Table 4 ). Table 4 Antibiotic Regimens Used in Patient Treatment Antibiotic Treatment Number (%) Ceftriaxone + Cloxacillin 12 (27.3%) Cloxacillin 10 (22.7%) Ceftriaxone + Clindamycin 7 (15.9%) Ceftazidime + Vancomycin 3 (6.8%) Ceftriaxone + Cefotaxime + Clindamycin 2 (4.5%) Ceftriaxone + Vancomycin 2 (4.5%) Clindamycin 2 (4.5%) Cefotaxime + Clindamycin 1 (2.3%) Cefotaxime + Cloxacillin 1 (2.3%) Cefotaxime 1 (2.3%) Ceftriaxone + Cloxacillin + Vancomycin 1 (2.3%) Cloxacillin + Amikacin 1 (2.3%) Meropenem + Linezolide 1 (2.3%) Discussion The present study aimed to investigate the demographic, clinical, laboratory, and imaging characteristics of patients with SA and OM at Bahrami Children's Hospital in Tehran. The findings reveal significant similarities and discrepancies with prior research. The prevalence of SA (70.8%) exceeded that of OM (29.2%), which aligns with the findings of previous studies indicating that SA is more prevalent in children. However, some studies have reported that the prevalence of OM is similar to or even greater than that of SA ( 9 , 10 , 17 , 21 ). These discrepancies may stem from variations in diagnostic criteria, study populations, and access to healthcare services. Both diseases were more prevalent in male children, which is consistent with the epidemiological patterns reported in most studies. This sex difference may result from differences in physical activity, exposure to trauma, or hormonal factors, which warrant further investigation ( 1 , 4 , 6 , 8 ). The mean age was greater in patients with SA than OM. Similar to several studies, the 2–14 year age group was the most common age group for patients ( 6 , 11 , 17 ). The mean time from symptom onset to hospital admission was high in both groups. According to previous studies, treatment outcomes are significantly better in patients who present within one week of symptom onset than in those who present later. Our findings indicate that the presence of underlying diseases and the use of immunosuppressive medications lead to increased disease severity, prolonged treatment courses, and extended hospital stays for patients with SA and OM. A history of trauma (15.4%) and symptoms similar to viral respiratory or gastrointestinal infections prior to limb involvement (36.9%) highlight the importance of obtaining a detailed medical history and considering OM and SA as two important differential diagnoses in these patients ( 1 , 6 ). In this study, similar to previous studies, the knee, hip, and ankle were the joints most commonly affected in patients with SA, whereas the femur, tibia, and humerus were the bones most commonly affected in patients with OM. This similarity in the distribution pattern of joint and bone involvement in patients from this region with the global pattern is noteworthy ( 1 , 8 , 10 , 14 ). Although pain was the most common symptom in both diseases, other symptoms exhibited different patterns ( 8 ). In patients with OM, tenderness and fever were more common, whereas in patients with SA, a reduced range of motion was more prominent. These differences can assist physicians in the initial and differential diagnosis of these two diseases. Fever was observed in fewer than 80% of the patients with both diseases, which contrasts with the findings of several previous studies reporting fever as the most common symptom or present in more than 80% of patients ( 1 , 4 ). This difference may be attributed to prior antibiotic use (27.7%) or delayed presentation. Elevated WBC counts and inflammatory marker levels showed different patterns in both diseases. In patients with OM, the mean of WBC was greater, whereas in patients with SA, elevated CRP was observed in more patients ( 1 , 13 ). These findings can improve the diagnosis and follow-up of patients. A previous study in Singapore indicated that the incidence of sequelae in SA patients with positive fluid cultures was greater than that in culture-negative patients ( 4 ). Additionally, Chen et al. reported that the rates of surgical intervention and complications are higher in culture-positive patients than in culture-negative patients ( 15 ). Notably, in our study, the ESR was the only parameter significantly associated with positive cultures in both diseases (p < 0.05). This highlights the importance of the ESR in assessing infection severity in the absence of culture results or in infections with atypical strains that may yield negative results in standard culture media, making it valuable for patient follow-up and treatment decision-making. Staphylococcus aureus was the most common pathogen in both diseases, which is consistent with the global pattern and emphasizes the importance of appropriate antibiotic coverage for this pathogen ( 2 , 3 , 7 , 10 , 14 , 21 ). The positive culture rate in this study was relatively low, similar to some comparable studies but contrary to other studies ( 7 , 14 ). This finding underscores the importance of prompt empirical treatment initiation, even in the absence of positive culture results. This low rate could be due to prior antibiotic use or delayed sampling. However, in the study by Lansell et al., no significant associations were found between blood, bone, and joint fluid culture results in patients with OM and SA and prior antibiotic use ( 11 ). Statistical analysis indicated that the presence of involvement in ultrasound or X-ray findings is directly related to the severity and activity of the disease, which can guide treatment plans. Conversely, although the detection rate of OM via X-ray findings of the affected limb was higher than that reported in Fan's study, both studies indicated that this modality lacks sufficient sensitivity in diagnosing OM ( 19 ). In patients with OM, MRI demonstrated high sensitivity which is consistent with previous studies that introduced MRI as the gold standard for diagnosing OM ( 3 , 6 , 9 , 13 ). All patients received intravenous antibiotic treatment during their hospital stay. The combination of ceftriaxone and cloxacillin (26.1%) was the most common antibiotic regimen used in this hospital, providing adequate coverage for common pathogens, especially Staphylococcus aureus . However, there is a need for periodic reviews of antibiotic resistance patterns in each region. The results of several clinical trials have shown that in patients with uncomplicated OM and SA, a short course of intravenous antibiotics followed by oral antibiotics is safe and effective. Evaluating the effectiveness of this treatment protocol in future studies is recommended ( 16 ). Among patients diagnosed with OM, two patients with special conditions were noteworthy. Both patients, without prior underlying disease or suspicious family history and presenting with common manifestations of fever, pain, weight-bearing intolerance, and leukocytosis, were initially treated with antibiotics under the probable diagnosis of AHO. Following clinical improvement, the patients were discharged. However, subsequent follow-up revealed symptom recurrence and multifocal involvement. After infection, neoplasm, and systemic diseases were ruled out through bone biopsy, the patients were diagnosed with chronic recurrent multifocal osteomyelitis (CRMO), also known as chronic nonbacterial osteomyelitis (CNO). CRMO is characterized by subacute or chronic inflammation with gradual onset of pain, swelling, and tenderness in bones, usually symmetrically and multifocally, particularly in the clavicle. The diagnosis is made through a bone biopsy, ruling out infectious and neoplastic issues ( 20 , 22 ). These two patients were subsequently treated with methotrexate and, following symptom resolution and the absence of recurrence or complications, discontinued treatment approximately two years prior. This study has several limitations. Its retrospective nature may have led to the loss of some data. Additionally, conducting the study in a single medical center may limit the generalizability of the results. For future studies, it is suggested that antibiotic resistance patterns, long-term treatment outcomes, and disease complications be investigated. In conclusion, this study demonstrated that SA and OM, despite their similarities, have significant differences in terms of clinical manifestations and paraclinical findings. Attention to these differences can contribute to faster and more accurate diagnoses and, consequently, more effective treatment of these diseases. Furthermore, the importance of the ESR in assessing infection severity and its association with positive cultures is a finding that can be useful in clinical decision-making. Abbreviations SA Septic Arthritis OM Osteomyelitis AHO Acute Hematogenous Osteomyelitis ESR Erythrocyte Sedimentation Rate CRP C-Reactive Protein NLR Neutrophil-to-Lymphocyte Ratio ROM Range of Motion MRI Magnetic Resonance Imaging MRSA Methicillin-Resistant Staphylococcus Aureus CRMO Chronic Recurrent Multifocal Osteomyelitis Declarations Acknowledgements The authors would like to thank the participating children and their parents, for providing consent, without which the study would not have been possible. Author contributions Mahdieh Mousavi (M.M.) and Amirali Barkhordarioon (A.B.) conceptualized and designed the study. A.B. and Ghazal Shariatpanahi (G.S.) contributed to the acquisition, analysis, and interpretation of data. A.B. wrote the initial draft. M.M., G.S. and Yousef Mojtahedi (Y.M.) reviewed the draft. All authors reviewed the final draft of the study and approved it for publication. All authors agree to be personally accountable for the submitted literature. Funding No funding or sponsorship was received for this study. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate This study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1401.657). Informed consent was obtained from legal guardians of the subjects enrolled in the study for study participation. This study was performed in accordance with the Declaration of Helsinki. Clinical trial number is not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Khalesi M, Ghodsi A, Hamedi AK. Clinical and Laboratory Symptoms of Septic Arthritis among Children Hospitalized in Imam Reza Hospital of Mashhad, Iran. International Journal of Pediatrics. 2020;8(10):12205-11. Spyridakis E, Gerber JS, Schriver E, Grundmeier RW, Porsch EA, St. Geme III JW, et al. Clinical features and outcomes of children with culture-negative septic arthritis. Journal of the Pediatric Infectious Diseases Society. 2019;8(3):228-34. Thakolkaran N, Shetty AK. Acute hematogenous osteomyelitis in children. Ochsner Journal. 2019;19(2):116-22. Jeyanthi JC, Yi KM, Allen Jr JC, Gera SK, Mahadev A. Epidemiology and outcome of septic arthritis in childhood: a 16-year experience and review of literature. Singapore medical journal. 2022;63(5):256. Panjavi B, Kalantar SH. Assessment of a new test in diagnosing pediatric septic arthritis. Journal of Orthopedic and Spine Trauma. 2018:38-9. McNeil JC. Acute hematogenous osteomyelitis in children: clinical presentation and management. Infection and drug resistance. 2020:4459-73. Kalantari N, Taherikalani M, Parvaneh N, Mamishi S. Etiology and antimicrobial susceptibility of bacerial septic arthritis and osteomyelitis. Iranian Journal of Public Health. 2007;36(3):27-32. Popescu B, Tevanov I, Carp M, Ulici A. Acute hematogenous osteomyelitis in pediatric patients: epidemiology and risk factors of a poor outcome. Journal of International Medical Research. 2020;48(4):0300060520910889. Dodwell ER. Osteomyelitis and septic arthritis in children: current concepts. Current opinion in pediatrics. 2013;25(1):58-63. Montgomery NI, Epps HR. Pediatric septic arthritis. Orthopedic Clinics. 2017;48(2):209-16. Lansell A, Vasili Y, Suchdev PS, Figueroa J, Kirpalani A. Impact of antibiotic pretreatment on cultures in children with osteomyelitis and septic arthritis: a retrospective review. BMC pediatrics. 2021;21:1-7. Le Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatrics & child health. 2018;23(5):336-43. Nadau E, Joseph C, Haraux E, Deroussen F, Gouron R, Klein C. Clinical features and outcomes in children with bone and joint infections of the ankle or foot. Archives de Pédiatrie. 2020;27(8):464-8. Cohen E, Katz T, Rahamim E, Bulkowstein S, Weisel Y, Leibovitz R, et al. Septic arthritis in children: updated epidemiologic, microbiologic, clinical and therapeutic correlations. Pediatrics & Neonatology. 2020;61(3):325-30. Chen J-A, Lin H-C, Wei H-M, Hsu Y-L, Lai H-C, Low YY, et al. Clinical characteristics and outcomes of culture-negative versus culture-positive osteomyelitis in children treated at a tertiary hospital in central Taiwan. Journal of Microbiology, Immunology and Infection. 2021;54(6):1061-9. Castellazzi L, Mantero M, Esposito S. Update on the management of pediatric acute osteomyelitis and septic arthritis. International journal of molecular sciences. 2016;17(6):855. Walter N, Bärtl S, Alt V, Rupp M. The epidemiology of osteomyelitis in children. Children. 2021;8(11):1000. Shet NS, Iyer RS, Chan SS, Baldwin K, Chandra T, Chen J, et al. ACR Appropriateness Criteria® osteomyelitis or septic arthritis-child (excluding axial skeleton). Journal of the American College of Radiology. 2022;19(5):S121-S36. Fan J, Guo Y, Li J, He L, Zhou J. Comparison of clinical effect of CT diagnosis and X-ray Plain film diagnosis in children with Acute Osteomyelitis during emergency treatment. Food Science and Technology. 2021;41(suppl 2):494-8. Jeor JDS, Thomas KB, Thacker PG, Hull NC. Multifocal subacute osteomyelitis in adjacent bones in the ankle without septic joint. Radiology Case Reports. 2020;15(10):1927-30. Gigante A, Coppa V, Marinelli M, Giampaolini N, Falcioni D, Specchia N. Acute osteomyelitis and septic arthritis in children: a systematic review of systematic reviews. European Review for Medical & Pharmacological Sciences. 2019;23. Ma L, Liu H, Tang H, Zhang Z, Zou L, Yu H, et al. Clinical characteristics and outcomes of chronic nonbacterial osteomyelitis in children: a multicenter case series. Pediatric Rheumatology. 2022;20:1-11. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Dec, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 16 Jan, 2025 Reviews received at journal 09 Dec, 2024 Reviews received at journal 22 Nov, 2024 Reviewers agreed at journal 18 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviewers agreed at journal 12 Nov, 2024 Reviewers invited by journal 12 Nov, 2024 Editor invited by journal 12 Nov, 2024 Editor assigned by journal 11 Nov, 2024 Submission checks completed at journal 11 Nov, 2024 First submitted to journal 05 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5395455","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":381618785,"identity":"171c9452-cc65-4b60-9258-a4ce43fc1bf5","order_by":0,"name":"Amirali Barkhordarioon","email":"","orcid":"","institution":"Tehran University of Medical Sciences (TUMS)","correspondingAuthor":false,"prefix":"","firstName":"Amirali","middleName":"","lastName":"Barkhordarioon","suffix":""},{"id":381618786,"identity":"94621e76-c5f9-4936-adee-cb4333ac4737","order_by":1,"name":"Mahdieh Mousavi Torshizi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYPACCR559v6PDxgYDhCvRcaw54CxASlaGGwYbiSYSRClRbe9x/jDzzYLHsaeA2nVPDV35PgZmB8+uoFHi9mZM2aSvW0SPOzsDcdu8xx7ZizZwGZsnINPy40cMwaeMxJAWw623eZhO5y44QAPmzQBLcYf/wC1MNxIZivm+UecFgNpngqQljQ2Zt42YrScOVYmLQPUYthzhllybt9hY8lmQn453rz54xuDOnt59h7GD2++HZbjZ29++BifFhTAxAMimYlVDgKMP0hRPQpGwSgYBSMGAADJnUwnPspZKwAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Pediatric Rheumatology, Bahrami Children’s Hospital, Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mahdieh","middleName":"Mousavi","lastName":"Torshizi","suffix":""},{"id":381618788,"identity":"cedd10b9-907b-4a66-9610-709410204d2a","order_by":2,"name":"Ghazal Shariatpanahi","email":"","orcid":"","institution":"Department of Pediatric Infectious Diseases, Bahrami Children’s Hospital, Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ghazal","middleName":"","lastName":"Shariatpanahi","suffix":""},{"id":381618792,"identity":"c8d86aa1-d5f3-460f-86bc-3727ae746ee8","order_by":3,"name":"Sayed Yousef Mojtahedi","email":"","orcid":"","institution":"Department of Pediatric Nephrology, Bahrami Children’s Hospital, Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sayed","middleName":"Yousef","lastName":"Mojtahedi","suffix":""}],"badges":[],"createdAt":"2024-11-05 12:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5395455/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5395455/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-025-06347-4","type":"published","date":"2025-12-09T15:56:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71544350,"identity":"d84b2bca-f892-4453-abd7-de126be0be93","added_by":"auto","created_at":"2024-12-16 14:58:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11536,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Joint Involvement in Patients with SA.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5395455/v1/961c8dbd9d2b2ff1c96e1dca.png"},{"id":71544360,"identity":"5f70ba26-19e1-4e91-818c-4a9216e7936c","added_by":"auto","created_at":"2024-12-16 14:58:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":14439,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Bone Involvement in Patients with OM.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5395455/v1/3b140696c899698ee1f86db2.png"},{"id":98243585,"identity":"b62d7347-5891-41e2-a11f-b948e0d6acf0","added_by":"auto","created_at":"2025-12-15 16:09:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":872846,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5395455/v1/6c592914-8901-4b7b-8cc5-4a2adf6487a4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigating the Correlations Among Clinical, Laboratory, and Imaging Findings in Pediatric Patients with Osteomyelitis and Septic Arthritis: A 12- Year Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteomyelitis (OM) and Septic Arthritis (SA) are critical pediatric emergencies requiring immediate attention and intervention (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). They present significant diagnostic and therapeutic challenges, with the potential for long-term consequences such as dysfunction, length discrepancies, asymmetry, and chronic pain (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The occurrence of OM and SA ranges from 4\u0026ndash;13 and 2\u0026ndash;6 cases per 100,000 children, respectively, with higher prevalence in males (\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Acute Hematogenous Osteomyelitis (AHO), the most common form of OM, typically affects the metaphysis of long bones such as the femur, tibia, and humerus and requires prolonged antimicrobial therapy, and sometimes surgical intervention (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). SA typically affects the hip and knee joints through monoarticular involvement (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The child's SA prognosis is determined by several factors, such as age and treatment delay (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Infants under 18 months display unique anatomical features, such as metaphyseal-epiphyseal blood vessels, which are closely linked to the propagation of infections between bone and joint spaces and thereby make the clinical picture more complicated and the management approach more difficult (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Classic AHO symptoms (fever, pain, and reduced mobility) appear in only about half of the cases, necessitating high clinical suspicion (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is the main causal agent of osteoarticular infections. Nonetheless, consideration should be given to other organisms in certain patient populations, such as Group B Streptococcus in infants and Kingella kingae in young children (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The rising prevalence of \u003cem\u003eMethicillin-resistant staphylococcus aureus\u003c/em\u003e (MRSA) complicates management and often leads to severe systemic manifestations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Although plain radiography is usually the first imaging technique used, its effectiveness is limited in the early stage of infection (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). MRI provides high sensitivity and specificity but is not widely used because of its high cost, limited availability, and sedation requirements (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Treatment strategies are primarily oriented toward empirical antibiotics based on local epidemiology, age, and clinical presentation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The heterogeneity in antibiotic resistance patterns across various geographical areas is a serious issue for the standardization of treatment (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Previous research has shown a high resistance rate of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e strains to many commonly used antibiotics, such as cloxacillin, which necessitates the monitoring and prudent use of antibiotics (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Further orthopedic review of the condition to identify the possibility of surgical intervention, such as aspiration or debridement, is also one of the important components of the treatment plan (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to evaluate the epidemiological patterns, risk factors, microbiological profiles, and clinical characteristics of pediatric patients diagnosed with SA and OM. By analyzing demographic data, laboratory results, imaging findings, and treatment outcomes over 12 years, we seek to enhance our comprehension of the manifestation of these infections, their microbial etiologies, and the determinants affecting patient outcomes to enable early diagnosis and refine treatment techniques.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employs a retrospective cross-sectional design to examine pediatric cases of SA and OM. The research was conducted at Bahrami Children's Hospital, Tehran, Iran from April 2011 to March 2023. Patients were included on the basis of the following criteria: 1- Discharge diagnosis of OM or SA, identified by ICD-10; 2- The presence of clinical symptoms, including pain, swelling and redness, fever, limping, reduced mobility, or other abnormal physical examination findings, is consistent with the diagnosis; 3- At least one of the following: Identification or culture of a microbial pathogen from joint fluid, blood, or bone biopsy, Presence of pus during arthrocentesis despite negative culture results, and Laboratory or radiographic evidence suggesting osteomyelitis or septic arthritis. Final diagnosis confirmed by a pediatric infectious disease specialist or pediatric rheumatologist. The Kocher criteria are utilized for acute SA of hip. Radiography is used as a supplementary diagnostic technique in unclear cases. Patients with OM must fulfill a minimum of two requirements: 1- Clinical and laboratory findings included bone pain or tenderness, localized warmth, redness and swelling, reduced use of the affected limb, limping, fever, leukocytosis, and elevated inflammatory markers; 2- Purulent components in aspiration of the affected bone; 3- Positive blood culture or bone biopsy results indicative of osteomyelitis; 4- Positive imaging findings such as periosteal elevation or disruption, soft tissue swelling, and disruption of normal bone architecture. Patients who had significantly incomplete medical records, previous history of open fracture, bone surgery, or nosocomial infection, or definitive diagnosis other than OM or SA excluded from the study. Data were extracted from hospital records in the Bahrami Hospital database. A researcher-designed checklist was used to obtain the following variables: demographic data, medical history, clinical presentation, laboratory findings, radiographic evidences based on written reports by experienced radiologists, treatment details, and follow-up reports after discharge. The sample size is determined using the standard formula and P (expected prevalence)\u0026thinsp;=\u0026thinsp;16% based on the study by Spyridakis et al (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This calculation yields a minimum sample size of 52 patients. For statistical analysis, data are presented as the mean or median\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or interquartile range (SD) for quantitative variables and were summarized by frequency (percentage) for categorical variables. The collected data were entered into SPSS software version 26 for analysis. In the inferential statistics section, appropriate statistical tests will be used to analyze the relationships between variables, with a p-value less than 0.05 considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis retrospective study involved 65 patients at Bahrami Hospital from 2011 to 2023 and reported 46 cases (70.8%) of SA and 19 cases (29.2%) of OM. The study population comprised 45 male patients (69.2%) and 20 female patients (30.8%). The mean age of patients with SA was greater than OM. Eight patients (12.3%) were hospitalized due to symptom recurrence. The mean duration of hospitalization for patients with SA was 8.13 days, whereas for patients with OM, it was 15.32 days (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The average duration of hospitalization for patients with comorbidities was significantly longer than that for those without (18.4 days vs. 9.1 days; p: 0.004). Eighteen patients (27.7%) had recently used antibiotics following the onset of symptoms. Cefixime (38.9%), amoxicillin (16.7%), and penicillin (16.7%) were the most commonly used antibiotics. Four patients (6.1%) had a history of corticosteroid use or other immunosuppressive drugs (cyclosporine, methotrexate). Additionally, two patients (3%) were using antiepileptic drugs (phenytoin and phenobarbital). In total, 10 patients (15.4%) reported a recent history of trauma to the affected limb (bone, joint). The mean time from symptom onset to hospitalization for patients with SA was 7.1 days, and that for patients with OM was 9.8 days.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic distribution of patients with SA and OM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeptic Arthritis (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOsteomyelitis\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewborn (0\u0026ndash;28 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfant (29 days \u0026minus;\u0026thinsp;1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToddler (1\u0026ndash;3 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreschooler (3\u0026ndash;5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (34.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool age (6\u0026ndash;12 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (34.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (71.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (63.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (91.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (94.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfection type, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (91.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (78.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of hospitalization (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnderlying Disease, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (63.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (45.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonspecific viral symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (41.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAplastic Anemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAchondroplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum sickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESRD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e73.9% of patients with SA had monoarticular involvement, whereas the remaining 26.1% had oligoarticular (two-joint) involvement. The most commonly affected joints were the knee (43.1%), hip (32.8%), and ankle (12.1%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among the OM patients, except for two patients (10.5%) with simultaneous infection of two bones, the remaining patients (89.5%) had single bone involvement. The most frequently infected bones were the femur (33.3%), tibia (23.7%), and humerus (19%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe most common clinical signs and symptoms in OM patients were pain or discomfort (100%), tenderness (89.5%), and fever (78.9%). For SA patients, the most common clinical signs and symptoms were pain or discomfort (100%), reduced range of motion (84.8%), and tenderness (78.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean temperature recorded upon admission was 38.0\u0026deg;C (95% CI: 37.7\u0026ndash;38.3) for patients with SA and 38.6\u0026deg;C (95% CI: 38.2\u0026ndash;39.0) for those with OM (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of Clinical Signs, Laboratory Parameters in Patients with OM and SA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eClinical Signs and Symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSeptic Arthritis (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteomyelitis (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (63.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (78.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLocal signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (65.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (68.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (78.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (89.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased ROM\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (84.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (73.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (76.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInability to bear weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (61.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (\u0026times;10\u0026sup3; cells/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElevated (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNLR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElevated (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR\u003csup\u003e3\u003c/sup\u003e (mm/h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElevated (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3\u0026thinsp;\u0026plusmn;\u0026thinsp;31.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.0\u0026thinsp;\u0026plusmn;\u0026thinsp;31.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP\u003csup\u003e4\u003c/sup\u003e (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElevated (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.2\u0026thinsp;\u0026plusmn;\u0026thinsp;34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.9\u0026thinsp;\u0026plusmn;\u0026thinsp;34.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet (\u0026times;10\u0026sup3;/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e353.9\u0026thinsp;\u0026plusmn;\u0026thinsp;178.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e456.2\u0026thinsp;\u0026plusmn;\u0026thinsp;192.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eNote: Values are presented as Number (%) and Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eROM: range of motion\u003c/p\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eNLR: Neutrophil-to-Lymphocyte Ratio\u003c/p\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003eESR: Erythrocyte Sedimentation Rate\u003c/p\u003e \u003cp\u003e\u003csup\u003e4\u003c/sup\u003eCRP: C-Reactive Protein\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn OM patients, leukocytosis (WCC\u0026thinsp;\u0026gt;\u0026thinsp;12000) was present in 57.9% of cases, 52.6% had an ESR\u0026thinsp;\u0026gt;\u0026thinsp;40, and 68.4% had elevated CRP levels (qualitative values of 1\u0026thinsp;+\u0026thinsp;or higher and quantitative values of 20 or higher). Blood culture was positive in 23.1% of OM patients, and bone culture was positive in 20% of the patients whose culture reports were available in their hospital records. In patients with positive blood cultures, the most common identified organism was \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (75%). In OM patients with positive blood cultures, although the occurrence of clinical symptoms and increases in the WCC, NLR, and inflammatory markers were more severe and frequent than those in culture-negative patients, statistical analysis revealed that only the increase in the ESR was significantly and nonrandomly associated with positive blood cultures (p: 0.045) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In SA patients, leukocytosis was present in 50% of cases, 54.3% had an elevated ESR, and 80.4% had elevated CRP levels (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Among SA patients with available culture results, positive blood cultures and positive synovial fluid cultures were found in 13.3% and 23.5% of cases, respectively. In patients with positive synovial fluid cultures, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (75%) was the most commonly identified organism. Similar to osteomyelitis patients, only the ESR showed a significant and nonrandom increase in association with positive cultures (p: 0.007) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Clinical Symptoms and Laboratory Parameters Based on Blood/Synovial Culture Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Signs and Symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eOsteomyelitis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSeptic Arthritis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive Blood Culture (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative Blood Culture (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePositive Synovial Fluid Culture (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative Synovial Fluid Culture (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (77.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTenderness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (77.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10 (76.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased ROM\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (\u0026times;10\u0026sup3; cells/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNLR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR\u003csup\u003e3\u003c/sup\u003e (mm/h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP\u003csup\u003e4\u003c/sup\u003e (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.881\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eNote: Values are presented as Number (%) and Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eROM: range of motion\u003c/p\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eNLR: Neutrophil-to-Lymphocyte Ratio\u003c/p\u003e \u003cp\u003e\u003csup\u003e3\u003c/sup\u003eESR: Erythrocyte Sedimentation Rate\u003c/p\u003e \u003cp\u003e\u003csup\u003e4\u003c/sup\u003eCRP: C-Reactive Protein\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the ultrasound examination of 35 patients with SA, 26 patients (74.3%) had joint effusion, 10 patients (28.6%) had increased synovial thickness or joint capsule swelling, and 8 patients (22.8%) had normal ultrasound findings or no findings suggestive of SA. Among the 46 patients with SA included in this study, 18 patients underwent plain radiography of the affected limb, with 11 patients (61.1%) reported as normal and 7 patients (38.9%) showing soft tissue swelling accompanied by decreased bone density. The mean hospitalization duration for SA patients with abnormal ultrasound or X-ray findings was longer than that for those with normal imaging results (9.3 days vs. 3.8 days; p: 0.005). The most common findings in plain radiographs of 11 OM patients were the formation of osteolytic foci (54.5%) and soft tissue edema (36.4%). Three patients (27.3%) had normal radiographs. MRI reports of 8 OM patients revealed increased signal intensity in the affected bone, the most important diagnostic finding, in 7 patients (87.5%). Periosteal reactions (50%) and the presence of abscesses or collections (37.5%) were other reported findings in these patients. According to hospital records, 11 out of 19 OM patients underwent bone scans, all of which (100%) reported increased uptake of contrast material by the affected bone as a diagnostic finding. The most common antibiotic regimens used for patients were ceftriaxone\u0026thinsp;+\u0026thinsp;cloxacillin (27.3%), cloxacillin (22.7%), and ceftriaxone\u0026thinsp;+\u0026thinsp;clindamycin (15.9%) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAntibiotic Regimens Used in Patient Treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotic Treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftriaxone\u0026thinsp;+\u0026thinsp;Cloxacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCloxacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftriaxone + Clindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftazidime\u0026thinsp;+\u0026thinsp;Vancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftriaxone\u0026thinsp;+\u0026thinsp;Cefotaxime + Clindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftriaxone\u0026thinsp;+\u0026thinsp;Vancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefotaxime\u0026thinsp;+\u0026thinsp;Clindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefotaxime\u0026thinsp;+\u0026thinsp;Cloxacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefotaxime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftriaxone + Cloxacillin + Vancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCloxacillin\u0026thinsp;+\u0026thinsp;Amikacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u0026thinsp;+\u0026thinsp;Linezolide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to investigate the demographic, clinical, laboratory, and imaging characteristics of patients with SA and OM at Bahrami Children's Hospital in Tehran. The findings reveal significant similarities and discrepancies with prior research. The prevalence of SA (70.8%) exceeded that of OM (29.2%), which aligns with the findings of previous studies indicating that SA is more prevalent in children. However, some studies have reported that the prevalence of OM is similar to or even greater than that of SA (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). These discrepancies may stem from variations in diagnostic criteria, study populations, and access to healthcare services. Both diseases were more prevalent in male children, which is consistent with the epidemiological patterns reported in most studies. This sex difference may result from differences in physical activity, exposure to trauma, or hormonal factors, which warrant further investigation (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The mean age was greater in patients with SA than OM. Similar to several studies, the 2\u0026ndash;14 year age group was the most common age group for patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The mean time from symptom onset to hospital admission was high in both groups. According to previous studies, treatment outcomes are significantly better in patients who present within one week of symptom onset than in those who present later. Our findings indicate that the presence of underlying diseases and the use of immunosuppressive medications lead to increased disease severity, prolonged treatment courses, and extended hospital stays for patients with SA and OM. A history of trauma (15.4%) and symptoms similar to viral respiratory or gastrointestinal infections prior to limb involvement (36.9%) highlight the importance of obtaining a detailed medical history and considering OM and SA as two important differential diagnoses in these patients (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In this study, similar to previous studies, the knee, hip, and ankle were the joints most commonly affected in patients with SA, whereas the femur, tibia, and humerus were the bones most commonly affected in patients with OM. This similarity in the distribution pattern of joint and bone involvement in patients from this region with the global pattern is noteworthy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Although pain was the most common symptom in both diseases, other symptoms exhibited different patterns (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In patients with OM, tenderness and fever were more common, whereas in patients with SA, a reduced range of motion was more prominent. These differences can assist physicians in the initial and differential diagnosis of these two diseases. Fever was observed in fewer than 80% of the patients with both diseases, which contrasts with the findings of several previous studies reporting fever as the most common symptom or present in more than 80% of patients (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This difference may be attributed to prior antibiotic use (27.7%) or delayed presentation. Elevated WBC counts and inflammatory marker levels showed different patterns in both diseases. In patients with OM, the mean of WBC was greater, whereas in patients with SA, elevated CRP was observed in more patients (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These findings can improve the diagnosis and follow-up of patients. A previous study in Singapore indicated that the incidence of sequelae in SA patients with positive fluid cultures was greater than that in culture-negative patients (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, Chen et al. reported that the rates of surgical intervention and complications are higher in culture-positive patients than in culture-negative patients (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Notably, in our study, the ESR was the only parameter significantly associated with positive cultures in both diseases (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This highlights the importance of the ESR in assessing infection severity in the absence of culture results or in infections with atypical strains that may yield negative results in standard culture media, making it valuable for patient follow-up and treatment decision-making. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was the most common pathogen in both diseases, which is consistent with the global pattern and emphasizes the importance of appropriate antibiotic coverage for this pathogen (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The positive culture rate in this study was relatively low, similar to some comparable studies but contrary to other studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This finding underscores the importance of prompt empirical treatment initiation, even in the absence of positive culture results. This low rate could be due to prior antibiotic use or delayed sampling. However, in the study by Lansell et al., no significant associations were found between blood, bone, and joint fluid culture results in patients with OM and SA and prior antibiotic use (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Statistical analysis indicated that the presence of involvement in ultrasound or X-ray findings is directly related to the severity and activity of the disease, which can guide treatment plans. Conversely, although the detection rate of OM via X-ray findings of the affected limb was higher than that reported in Fan's study, both studies indicated that this modality lacks sufficient sensitivity in diagnosing OM (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In patients with OM, MRI demonstrated high sensitivity which is consistent with previous studies that introduced MRI as the gold standard for diagnosing OM (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). All patients received intravenous antibiotic treatment during their hospital stay. The combination of ceftriaxone and cloxacillin (26.1%) was the most common antibiotic regimen used in this hospital, providing adequate coverage for common pathogens, especially \u003cem\u003eStaphylococcus aureus\u003c/em\u003e. However, there is a need for periodic reviews of antibiotic resistance patterns in each region. The results of several clinical trials have shown that in patients with uncomplicated OM and SA, a short course of intravenous antibiotics followed by oral antibiotics is safe and effective. Evaluating the effectiveness of this treatment protocol in future studies is recommended (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Among patients diagnosed with OM, two patients with special conditions were noteworthy. Both patients, without prior underlying disease or suspicious family history and presenting with common manifestations of fever, pain, weight-bearing intolerance, and leukocytosis, were initially treated with antibiotics under the probable diagnosis of AHO. Following clinical improvement, the patients were discharged. However, subsequent follow-up revealed symptom recurrence and multifocal involvement. After infection, neoplasm, and systemic diseases were ruled out through bone biopsy, the patients were diagnosed with chronic recurrent multifocal osteomyelitis (CRMO), also known as chronic nonbacterial osteomyelitis (CNO). CRMO is characterized by subacute or chronic inflammation with gradual onset of pain, swelling, and tenderness in bones, usually symmetrically and multifocally, particularly in the clavicle. The diagnosis is made through a bone biopsy, ruling out infectious and neoplastic issues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These two patients were subsequently treated with methotrexate and, following symptom resolution and the absence of recurrence or complications, discontinued treatment approximately two years prior. This study has several limitations. Its retrospective nature may have led to the loss of some data. Additionally, conducting the study in a single medical center may limit the generalizability of the results. For future studies, it is suggested that antibiotic resistance patterns, long-term treatment outcomes, and disease complications be investigated. In conclusion, this study demonstrated that SA and OM, despite their similarities, have significant differences in terms of clinical manifestations and paraclinical findings. Attention to these differences can contribute to faster and more accurate diagnoses and, consequently, more effective treatment of these diseases. Furthermore, the importance of the ESR in assessing infection severity and its association with positive cultures is a finding that can be useful in clinical decision-making.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eSeptic Arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eOM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eOsteomyelitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eAHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eAcute Hematogenous Osteomyelitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eESR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eErythrocyte Sedimentation Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eC-Reactive Protein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eNLR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eNeutrophil-to-Lymphocyte Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eROM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eRange of Motion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eMRSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eMethicillin-Resistant Staphylococcus Aureus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.1868%;\"\u003e\n \u003cp\u003eCRMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89.8132%;\"\u003e\n \u003cp\u003eChronic Recurrent Multifocal Osteomyelitis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the participating children and their parents, for providing consent, without which the study would not have been possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMahdieh Mousavi (M.M.) and Amirali Barkhordarioon (A.B.) conceptualized and designed the study. A.B. and Ghazal Shariatpanahi (G.S.) contributed to the acquisition, analysis, and interpretation of data. A.B. wrote the initial draft. M.M., G.S. and Yousef Mojtahedi (Y.M.) reviewed the draft. All authors reviewed the final draft of the study and approved it for publication. All authors agree to be personally accountable for the submitted literature.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding or sponsorship was received for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1401.657). Informed consent was obtained from legal guardians of the subjects enrolled in the study for study participation. This study was performed in accordance with the Declaration of Helsinki. Clinical trial number is not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhalesi M, Ghodsi A, Hamedi AK. Clinical and Laboratory Symptoms of Septic Arthritis among Children Hospitalized in Imam Reza Hospital of Mashhad, Iran. International Journal of Pediatrics. 2020;8(10):12205-11.\u003c/li\u003e\n\u003cli\u003eSpyridakis E, Gerber JS, Schriver E, Grundmeier RW, Porsch EA, St. Geme III JW, et al. Clinical features and outcomes of children with culture-negative septic arthritis. Journal of the Pediatric Infectious Diseases Society. 2019;8(3):228-34.\u003c/li\u003e\n\u003cli\u003eThakolkaran N, Shetty AK. Acute hematogenous osteomyelitis in children. Ochsner Journal. 2019;19(2):116-22.\u003c/li\u003e\n\u003cli\u003eJeyanthi JC, Yi KM, Allen Jr JC, Gera SK, Mahadev A. Epidemiology and outcome of septic arthritis in childhood: a 16-year experience and review of literature. Singapore medical journal. 2022;63(5):256.\u003c/li\u003e\n\u003cli\u003ePanjavi B, Kalantar SH. Assessment of a new test in diagnosing pediatric septic arthritis. Journal of Orthopedic and Spine Trauma. 2018:38-9.\u003c/li\u003e\n\u003cli\u003eMcNeil JC. Acute hematogenous osteomyelitis in children: clinical presentation and management. Infection and drug resistance. 2020:4459-73.\u003c/li\u003e\n\u003cli\u003eKalantari N, Taherikalani M, Parvaneh N, Mamishi S. Etiology and antimicrobial susceptibility of bacerial septic arthritis and osteomyelitis. Iranian Journal of Public Health. 2007;36(3):27-32.\u003c/li\u003e\n\u003cli\u003ePopescu B, Tevanov I, Carp M, Ulici A. Acute hematogenous osteomyelitis in pediatric patients: epidemiology and risk factors of a poor outcome. Journal of International Medical Research. 2020;48(4):0300060520910889.\u003c/li\u003e\n\u003cli\u003eDodwell ER. Osteomyelitis and septic arthritis in children: current concepts. Current opinion in pediatrics. 2013;25(1):58-63.\u003c/li\u003e\n\u003cli\u003eMontgomery NI, Epps HR. Pediatric septic arthritis. Orthopedic Clinics. 2017;48(2):209-16.\u003c/li\u003e\n\u003cli\u003eLansell A, Vasili Y, Suchdev PS, Figueroa J, Kirpalani A. Impact of antibiotic pretreatment on cultures in children with osteomyelitis and septic arthritis: a retrospective review. BMC pediatrics. 2021;21:1-7.\u003c/li\u003e\n\u003cli\u003eLe Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatrics \u0026amp; child health. 2018;23(5):336-43.\u003c/li\u003e\n\u003cli\u003eNadau E, Joseph C, Haraux E, Deroussen F, Gouron R, Klein C. Clinical features and outcomes in children with bone and joint infections of the ankle or foot. Archives de P\u0026eacute;diatrie. 2020;27(8):464-8.\u003c/li\u003e\n\u003cli\u003eCohen E, Katz T, Rahamim E, Bulkowstein S, Weisel Y, Leibovitz R, et al. Septic arthritis in children: updated epidemiologic, microbiologic, clinical and therapeutic correlations. Pediatrics \u0026amp; Neonatology. 2020;61(3):325-30.\u003c/li\u003e\n\u003cli\u003eChen J-A, Lin H-C, Wei H-M, Hsu Y-L, Lai H-C, Low YY, et al. Clinical characteristics and outcomes of culture-negative versus culture-positive osteomyelitis in children treated at a tertiary hospital in central Taiwan. Journal of Microbiology, Immunology and Infection. 2021;54(6):1061-9.\u003c/li\u003e\n\u003cli\u003eCastellazzi L, Mantero M, Esposito S. Update on the management of pediatric acute osteomyelitis and septic arthritis. International journal of molecular sciences. 2016;17(6):855.\u003c/li\u003e\n\u003cli\u003eWalter N, B\u0026auml;rtl S, Alt V, Rupp M. The epidemiology of osteomyelitis in children. Children. 2021;8(11):1000.\u003c/li\u003e\n\u003cli\u003eShet NS, Iyer RS, Chan SS, Baldwin K, Chandra T, Chen J, et al. ACR Appropriateness Criteria\u0026reg; osteomyelitis or septic arthritis-child (excluding axial skeleton). Journal of the American College of Radiology. 2022;19(5):S121-S36.\u003c/li\u003e\n\u003cli\u003eFan J, Guo Y, Li J, He L, Zhou J. Comparison of clinical effect of CT diagnosis and X-ray Plain film diagnosis in children with Acute Osteomyelitis during emergency treatment. Food Science and Technology. 2021;41(suppl 2):494-8.\u003c/li\u003e\n\u003cli\u003eJeor JDS, Thomas KB, Thacker PG, Hull NC. Multifocal subacute osteomyelitis in adjacent bones in the ankle without septic joint. Radiology Case Reports. 2020;15(10):1927-30.\u003c/li\u003e\n\u003cli\u003eGigante A, Coppa V, Marinelli M, Giampaolini N, Falcioni D, Specchia N. Acute osteomyelitis and septic arthritis in children: a systematic review of systematic reviews. European Review for Medical \u0026amp; Pharmacological Sciences. 2019;23.\u003c/li\u003e\n\u003cli\u003eMa L, Liu H, Tang H, Zhang Z, Zou L, Yu H, et al. Clinical characteristics and outcomes of chronic nonbacterial osteomyelitis in children: a multicenter case series. Pediatric Rheumatology. 2022;20:1-11.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children, Osteomyelitis, Septic arthritis, ESR, Imaging, Treatment","lastPublishedDoi":"10.21203/rs.3.rs-5395455/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5395455/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Septic arthritis (SA) and Osteomyelitis (OM) are critical pediatric emergencies that can lead to severe complications, including mortality. The study aimed to investigate the relationships between risk factors and clinical, laboratory, and imaging findings in these diseases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A retrospective study was conducted on 65 pediatric patients (46 diagnosed with SA and 19 with OM). Relevant demographic data, clinical, laboratory and imaging findings were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 45 (69.2%) patients were male. The mean age was 5.4 years for SA and 4.8 years for OM. The mean duration of hospitalization was 8.1 days for SA and 15.32 days for OM. Eight patients (12.3%) experienced comorbidity, leading to longer hospitalization. The most affected joints were the knee, hip, and ankle, whereas the most affected bones were the femur, tibia, and humerus. The main clinical symptoms and signs of OM included pain, tenderness, and fever, whereas those of SA included pain, limited mobility, and tenderness. Leukocytosis was observed in 57.9% of OM patients and 50% of SA patients. Erythrocyte Sedimentation Rate (ESR) elevation was found in 52.6% of OM patients and 54.3% of SA patients. Elevated C-Reactive Protein (CRP) was present in 68.4% of OM and 80.4% of SA patients. Blood cultures were positive in 23.1% of OM patients and synovial fluid cultures in 23.5% of SA patients, with \u003cem\u003eStaphylococcus aureus\u003c/em\u003e being the most common organism isolated (75%). There was a correlation between hospitalization duration for SA patients and abnormal ultrasound or X-ray findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: SA and OM were predominantly observed in boys aged 2–12 years. Comorbidities and immunosuppressive medications were associated with increased disease severity. Fever was recorded in less than 80% of the patients. The ESR emerged as the only parameter significantly associated with culture results, highlighting its importance in assessing infection severity and patient follow-up. The relationship between ultrasound findings and SA severity can guide clinical management. These findings identified MRI as the gold standard for diagnosing OM. The low culture positivity rates underscore the need for timely empirical treatment initiation, even in the absence of positive culture results.\u003c/p\u003e","manuscriptTitle":"Investigating the Correlations Among Clinical, Laboratory, and Imaging Findings in Pediatric Patients with Osteomyelitis and Septic Arthritis: A 12- Year Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 14:58:13","doi":"10.21203/rs.3.rs-5395455/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-16T16:02:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-09T06:37:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-23T03:49:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116180474062295958036178188772364375086","date":"2024-11-18T05:52:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297019550786029038902177372519670952720","date":"2024-11-14T21:38:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173729939643058312732059115937277864210","date":"2024-11-12T12:49:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-12T12:42:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-12T10:32:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-11T07:39:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-11T07:12:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-11-05T12:39:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"76976d41-1bc9-4725-9731-6112ef913ff4","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:01:26+00:00","versionOfRecord":{"articleIdentity":"rs-5395455","link":"https://doi.org/10.1186/s12887-025-06347-4","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-12-09 15:56:55","publishedOnDateReadable":"December 9th, 2025"},"versionCreatedAt":"2024-12-16 14:58:13","video":"","vorDoi":"10.1186/s12887-025-06347-4","vorDoiUrl":"https://doi.org/10.1186/s12887-025-06347-4","workflowStages":[]},"version":"v1","identity":"rs-5395455","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5395455","identity":"rs-5395455","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}