Response to the letter by Hamza Essaddam

As you have seen, our study had several objectives, one ractical, which reported our experience in Oceania over period of more than 20 years and sought to inform our olleagues of the therapeutic efficacy provided by the easy nd rapid access to a positive diagnosis using ‘‘modern’’ maging techniques, essentially ultrasound. This is all the ore important that this exam is often the only recent eans of investigation for the vast majority of the world’s opulation, particularly children. When, for the reasons dvanced, ultrasound is not effective, CT with injection of ontrast agent can replace ultrasound just as quickly. In ur institution, the time to access and the complexity of mplementing scintigraphy and MRI do not allow the rapidity nd particularly the imaging definition desired to accelerate ptimal patient management. This early access to diagnosis, ased on efficient medical logistics that ensure that chilren are cared for from the first day of disease, associated ith instant visualization on imaging of periosteal elevaion, pathognomic of this disease, has allowed us to organize he treatment accordingly and to nearly eradicate chronic steomyelitis. As for the other objectives—bacteriological, epidemioogical, and physiopathological—Pr Essaddam’s compelling nd valuable comments warrant reflection. However, we would like to emphasize how much we were nfluenced by our observations, whether they stem from clinical or a paraclinical perspective or the therapeutic rogress made of late, to arrive at the pathogenic theory hat we propose. These observations have allowed us to tate that the image of periosteal elevation was consistently he prime motivating factor in the focus on infection, i.e., n the very first hours. The simple incision of the perioseum with evacuation of the infected serous or hematic ollection in the very early stages, or purulent in the later tages, alone sufficed to obtain immediate pain relief and ealing with no sequelae, without ever having had to turn o bone trepanation, which we consider a dangerous pro-