Severity-stratified surgical decision-making may improve outcomes in children with acute hematogenous osteomyelitis (AHO). In 438 children with culture-confirmed Staphylococcus aureus AHO, the Accelerated Severity of Illness Score (ACCEL-SIS) provided objective severity classification within approximately 20 hours of presentation. Among children with Mild or Moderate disease, major bone debridement was associated with longer hospitalization, prolonged antibiotic therapy, and an approximately eight-fold increased risk of pathologic fracture compared with limited or no bone debridement. These findings support matching the extent of surgical intervention to illness severity rather than diagnosis alone and suggest that routine major bone debridement in lower-severity AHO may result in avoidable iatrogenic morbidity.

Keywords: pediatric osteomyelitis; acute hematogenous osteomyelitis; AHO; Staphylococcus aureus; ACCEL-SIS; severity stratification; surgical debridement; bone debridement; pathologic fracture; pediatric musculoskeletal infection; surgical decision-making