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Acute Osteomyelitis
415
LEADING ARTICLES
THE LANCET LONDON
20
AUGUST
1960
Acute Osteomyelitis IMPROVING social conditions between the two wars so reduced the incidence of acute osteomyelitis that it became a relative rarity to the medical student of the ’thirties, and the antibiotic age has seen a dramatic fall in its case-mortality; yet it is still not uncommon and there is indeed an impression in some quarters that it is the increase. WINTERS and CAHEN1 have produced evidence that it is becoming more frequent in Louisiana, and, from South Africa, SHANDLING2 reports 300 patients seen in seven years in Cape Town, where it has even proved necessary to maintain a special " osteitis ward " in the Children’s Hospital. Only 50 of these patients were Europeans, but in this country it has been clear for some time that acute osteomyelitis is no longer a disease associated with poverty and malnutrition; the children of a well-to-do farming community will provide as high a proportion of patients as the poorest parts of the on
town.
Neither WINTERS and CAHEN nor SHANDLING give details of the duration of symptoms or treatment before admission to hospital, but certainly many of the patients had already been given penicillin. If one accepts that the treatment of osteomyelitis is essentially surgical it is easy to be critical of an often half-hearted exhibition of antibiotics, which not only tends to mask the local symptoms but may also result in a negative blood-culture and thus the loss of the earliest opportunity of identifying the organism involved and its sensitivity. But, in fairness to the general practitioner, surgeons must remember that when first presented to him the case may differ in no way from a score of others with a general infection of uncertain origin which his experience has shown will settle satisfactorily with the aid of penicillin. Furthermore it can be argued that the fatalities in osteomyelitis derive not from the bone infection but from the septicaemia which causes or at least accompanies it, and that the earlier antibiotic therapy is started the less will be the mortality. We shall never know in what proportion, if any, of such cases the osteomyelitis is completely aborted; but it seems likely that such a happy result never ensues once local symptoms and signs are manifest. In the South African series of 300 cases, 1 child died of malnutrition and 4 children of septicaemia, 3 of whom were infected with a staphylococcus sensitive to all antibiotics. There were no deaths in the 66 Louisiana
patients. As usual, Staphylococcus aureus was responsible for the vast majority of infections in both series; but whereas only 57% of them were penicillin-sensitive in Louisiana, over 80% were penicillin-sensitive in the
adequately followed up, a fact which they attribute to early but inadequate antibiotic treatment. It is apparent, however, that their patients were treated very conservatively, operation being reserved for those not responding favourably, and comparison with SHANDLING’s results points clearly to the benefits of early operation. SHANDLING’s best results unquestionably followed incision and drilling of the bone, and, rather surprisingly, were better still when the wound was drained. Drainage is popular with few orthopaedic surgeons in this country, most of whom have found that after all pus has been removed and the metaphysis adequately drilled the wound can safely be sutured with every hope of primary healing without secondary infection. Adequate immobilisation of the affected part is important but is often forgotten: it adds greatly to the comfort of the patient and to the prospects of cure. In agreement with many authors, WINTERS and CAHEN and SHANDLING consider it wise to start treatment, immediately a blood-culture has been taken, with penicillin combined with one of the broadspectrum antibiotics. Both reports comment on the diagnostic difficulties of osteomyelitis of the femoral neck and the tragic results which may result at this site. Infection in this region is almost always accompanied by some sympathetic effusion into the hip-joint, and the patient often presents as an acute arthritis of the hip-joint rather than a bone infection. Primary suppurative arthritis of the hip-joint in older children is, however, a very rare disease, and there is much to be said for a policy of drilling the femoral neck from below the greater trochanter as a primary diagnostic and therapeutic measure whenever opalescent fluid is aspirated from the hip-joint. Many cases of the so-called septic epiphysitis of infancy are the result of infection primarily in the femoral neck rather than in the hip-joint itself. There can be little doubt that operation is indicated as soon as there is the least suspicion of local abscess formation, or indeed if local signs without definite evidence of pus formation do not settle within twelve to twenty-four hours of the start of adequate antibiotic therapy. Most surgeons will agree that very rarely indeed do they regret having operated, and much more often they are sorry they did not operate earlier. Whether or not pus is found, the metaphysis should be drilled; the presence of a subperiosteal abscess does not mean that the metaphysis has already decompressed itself. Pus will often well up under considerable tension from the drill hole under these circumstances. Similarly the absence of a subperiosteal abscess should not deter the surgeon from drilling the metaphysis. Even if pus is not found within the bone, no harm has been done; a negative exploration does less potential damage than no exploration at all. Acute osteomyelitis remains a surgical disease.
Many Platelets THROMBOCYTOPENIA, the hsemorrhagic disease associSouth African group. ated with diminution of platelets in the blood, is known to WINTERS and CAHEN report the development of most doctors. There is also a much less common condichronic osteomyelitis in 29% of their patients who were tion in which the blood-platelets are greatly increased; 1. Winters, J. L., Cahen, I. J. Bone Jt Surg. 1960, 42A, 691. and, oddly enough, this too is associated with excessive 2. Shandling, B. S. Afr. med. J. 1960, 34, 520. Too
LEADING ARTICLES
THE LANCET LONDON
20
AUGUST
1960
Acute Osteomyelitis IMPROVING social conditions between the two wars so reduced the incidence of acute osteomyelitis that it became a relative rarity to the medical student of the ’thirties, and the antibiotic age has seen a dramatic fall in its case-mortality; yet it is still not uncommon and there is indeed an impression in some quarters that it is the increase. WINTERS and CAHEN1 have produced evidence that it is becoming more frequent in Louisiana, and, from South Africa, SHANDLING2 reports 300 patients seen in seven years in Cape Town, where it has even proved necessary to maintain a special " osteitis ward " in the Children’s Hospital. Only 50 of these patients were Europeans, but in this country it has been clear for some time that acute osteomyelitis is no longer a disease associated with poverty and malnutrition; the children of a well-to-do farming community will provide as high a proportion of patients as the poorest parts of the on
town.
Neither WINTERS and CAHEN nor SHANDLING give details of the duration of symptoms or treatment before admission to hospital, but certainly many of the patients had already been given penicillin. If one accepts that the treatment of osteomyelitis is essentially surgical it is easy to be critical of an often half-hearted exhibition of antibiotics, which not only tends to mask the local symptoms but may also result in a negative blood-culture and thus the loss of the earliest opportunity of identifying the organism involved and its sensitivity. But, in fairness to the general practitioner, surgeons must remember that when first presented to him the case may differ in no way from a score of others with a general infection of uncertain origin which his experience has shown will settle satisfactorily with the aid of penicillin. Furthermore it can be argued that the fatalities in osteomyelitis derive not from the bone infection but from the septicaemia which causes or at least accompanies it, and that the earlier antibiotic therapy is started the less will be the mortality. We shall never know in what proportion, if any, of such cases the osteomyelitis is completely aborted; but it seems likely that such a happy result never ensues once local symptoms and signs are manifest. In the South African series of 300 cases, 1 child died of malnutrition and 4 children of septicaemia, 3 of whom were infected with a staphylococcus sensitive to all antibiotics. There were no deaths in the 66 Louisiana
patients. As usual, Staphylococcus aureus was responsible for the vast majority of infections in both series; but whereas only 57% of them were penicillin-sensitive in Louisiana, over 80% were penicillin-sensitive in the
adequately followed up, a fact which they attribute to early but inadequate antibiotic treatment. It is apparent, however, that their patients were treated very conservatively, operation being reserved for those not responding favourably, and comparison with SHANDLING’s results points clearly to the benefits of early operation. SHANDLING’s best results unquestionably followed incision and drilling of the bone, and, rather surprisingly, were better still when the wound was drained. Drainage is popular with few orthopaedic surgeons in this country, most of whom have found that after all pus has been removed and the metaphysis adequately drilled the wound can safely be sutured with every hope of primary healing without secondary infection. Adequate immobilisation of the affected part is important but is often forgotten: it adds greatly to the comfort of the patient and to the prospects of cure. In agreement with many authors, WINTERS and CAHEN and SHANDLING consider it wise to start treatment, immediately a blood-culture has been taken, with penicillin combined with one of the broadspectrum antibiotics. Both reports comment on the diagnostic difficulties of osteomyelitis of the femoral neck and the tragic results which may result at this site. Infection in this region is almost always accompanied by some sympathetic effusion into the hip-joint, and the patient often presents as an acute arthritis of the hip-joint rather than a bone infection. Primary suppurative arthritis of the hip-joint in older children is, however, a very rare disease, and there is much to be said for a policy of drilling the femoral neck from below the greater trochanter as a primary diagnostic and therapeutic measure whenever opalescent fluid is aspirated from the hip-joint. Many cases of the so-called septic epiphysitis of infancy are the result of infection primarily in the femoral neck rather than in the hip-joint itself. There can be little doubt that operation is indicated as soon as there is the least suspicion of local abscess formation, or indeed if local signs without definite evidence of pus formation do not settle within twelve to twenty-four hours of the start of adequate antibiotic therapy. Most surgeons will agree that very rarely indeed do they regret having operated, and much more often they are sorry they did not operate earlier. Whether or not pus is found, the metaphysis should be drilled; the presence of a subperiosteal abscess does not mean that the metaphysis has already decompressed itself. Pus will often well up under considerable tension from the drill hole under these circumstances. Similarly the absence of a subperiosteal abscess should not deter the surgeon from drilling the metaphysis. Even if pus is not found within the bone, no harm has been done; a negative exploration does less potential damage than no exploration at all. Acute osteomyelitis remains a surgical disease.
Many Platelets THROMBOCYTOPENIA, the hsemorrhagic disease associSouth African group. ated with diminution of platelets in the blood, is known to WINTERS and CAHEN report the development of most doctors. There is also a much less common condichronic osteomyelitis in 29% of their patients who were tion in which the blood-platelets are greatly increased; 1. Winters, J. L., Cahen, I. J. Bone Jt Surg. 1960, 42A, 691. and, oddly enough, this too is associated with excessive 2. Shandling, B. S. Afr. med. J. 1960, 34, 520. Too