The Positive Approach to Chronic Osteomyelitis

Abstract

The extent of the pathological process is underestimated if the condition is regarded only as an infection of bone : many other tissues are affected, including periosteum, muscle, fascia and skin. When sclerosis and fibrosis supervene, strangulation of the small blood vessels causes local tissue anaemia. Thus, even if the correct antibioticis used, it cannot reach all the infected tissues in sufficient concentration to eradicate the infection. Antibiotic therapy without operation to improve the blood supply cannot cure the disease, and may result in an acquired resistance by the organism. The condition can be cured only if the whole scar, both in the soft tissues and in the bone, is excised and an adequate blood supply carrying the correct antibiotic is constantly delivered to the area. The dead space left by the excision must thus be filled by unscarred living tissue with a good blood supply. Such an operation may be of considerable magnitude because success depends upon the thoroughness of the excision. Indications for operation-Operation is indicated by general debility, by loss of working capacity and social enjoyment, or by persistent pain. Some measure of the disability may be appreciated by the fact that many patients in this series requested amputation, and only two refused operation. Pre-operative management-When the decision has been made to operate, a deep swab is taken at once from the sinus so that the infecting organisms and their antibiotic sensitivity can be determined. Blood examination and urine analysis are undertaken to exclude chronic nephritis, diabetes or amyloid disease. Anaemia, if present, is corrected and the patient is given a high-protein and high-vitamin diet. A week before admission, and again on the day of admission, the bacteriological investigation is repeated. An antibiotic to which the organisms are most sensitive is selected to cover the operation and the post-operative period without causing toxic effects. At operation it is sometimes found that pus originating from a different organism lies in the depths of the cavity. If the appearance and odour of the pus are characteristic an additional specific antibiotic can be given during operation, or administered later after laboratory examination of the pus. A bacteriological swab is taken during operation from the deepest part of the sinus.