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Planned timing in treatment of chronic osteomyelitis under antibiotic control
PLANNED TIMING IN TREATMENT OF CHRONIC OSTEOMYELITIS UNDER ANTIBIOTIC CONTROL CHARLES S. VENABLE, San Antonio,
T
M.D. AND LIEUT.
15, 1950
EDWIN
J.
PULASKI,
Fort Sam Houston,
Texas
HE objective in the treatment of chronic is the arrest and eliminaosteomyelitis tion of active foci with an expectancy of permanent heaIing under a cIosed wound, with the least resuIting deformity in the shortest period of time. To meet this objective we must have comprehensive knowledge of the origin, the processes of destruction, reasons of recurrence and foundation of resistance in order to estabIish principIes for the arrest, control and repair of this condition. In this evaluation it has become apparent that the basic principle of repair of defects in infected bone lesions such as chronic osteitis and osteomyelitis under antibiotic prophylaxis and control is that only with sufficient care in such procedures and sufficient respect for essential detaiIs may a high percentage of recovery be expected. Especially is this so in a preanticipated schedule with a reasonabIe expectancy of wound-healing. Improved surgical management of traumatic wounds in civiIian and miIitary Iife together with the judicious use of potent antibiotics has reduced greatly the incidence of post-traumatic osteomyelitis in the hospita1. NevertheIess, these patients continue to be seen in a11 general hospitats and many present a challenge to even the most experienced of surgeons. That the treatment of this condition demands patience from both the surgeon and patient is evidenced by the fact that the average stay in hospitaIs may be many months. This is the case particularly in government hospitals where the patient must be kept in the hospital until he has received maximal benefits of treatment. AIthough no new principles for the treatment of OsteomyeIitis have been discovered recently, it would seem there is a need for greater diffusion of knowledge as to what constitutes adequate operation and what is considered proper timing for completion of the steps necessary for bringing the wound resulting from operation to a permanent1y closed system. BasicaIIy the steps comprising treatment of osteomyelitis November
COL.
M.C.
Texas
incIude preparation of the patient for surgery, eradication of bacteria-Iaden compromised tissue, provision of- adequate bIood supply, reinforcement of bone where necessary to provide a functioning limb and fuIl skin-thickness cover. Preparation qf the Patient. This entails simultaneous concentration on the patient as a whole and on his disease cornpIes. Attention is directed early to correction of bIood and protein deficiency, well known deterrents to recovery from infection, and to good woundhealing. CharacteristicaIly chronic suppurative disease is accompanied with anemia and hypoproteinemia, with a shrunken circulating blood value which is frequentIy masked by norma hemoglobin and tota bIood protein values. Wherever facilities are avaiIabIe repeated quantitative blood volume determinations by Evans’ blue dye or tagged ion methods are most accurate criteria of the blood and protein needs of the patient than by hematocrit, hemoglobin and plasma protein determinations. Where such facilities are not availabIe, blood and plasma transfusions folIowed with frequent hematocrit readings are usefu1 for gauging additional blood and pIasma requirements. When a hematocrit of $0 is sustained after bIood transfusion, the cardiovascular tree is fiIIed and replacement therapy is then considered adequate. No change in the hematocrit reading after transfusion indicates the vascular tree is not f3Ied and additional repIacement is
649
necessary. Preparation limb for adequacy extremity.
of the Limb.
surgery begins of peripheral ProIonged
Preparation
of the
with estimation circulation of
immobilization
of the
or disuse
of an extremity contributes to diminution of the bIood suppIy and a cold limb. Lumbar sympathetic blocks often result in improvement in circulation of the extremity and are beneficia1 in bringing about conditions favorable to wound-healing.
630
Venable,
Pulaski-Chronic
The wound itseIf is given detailed study. Koentgenograms in severat pIanes, with contrast media in jetted through the fistuIous tract if necessary, assist in visualization of the path of fistula connecting surface with bone, location of sequestra and estimation of the extent of pathologicaIly altered bone. The soft parts are critically appraised so that the scheme for excision of scar tissue will encompass a soIution to the probIem of providing muscIe pedicIe fiIling of the bony defect if indicated and, most importantly, of providing’fulI-thickness cover. FuIl-thickness cover is often the keystone to successful management in chronic osteomyelitis. Due consideration is given to improvement of local hygiene. The skin surrounding the fistula is brought to a condition of as near normalcy as possibIe by ehmination of maceration and dermatitis. Whenever drainage is profuse, dressings are changed at frequent intervals. The limb is bathed at least twice a day for three days before surgery with G-I I compound in soap or cream base. We neither employ nor recommend the use of antiseptics or antibiotics around or in the wound because their efficacy is questioned and the danger of inducing sensitization is great. The bacterial flora of the wound exudate are determined and cuIture sensitivity tests are made. Although there are several methods for determining cuhure sensitivity, the agar platemedicated disc method is simplest. It consists of the appIication to freshIy seeded blood agar pIates discs containing measured amounts of each antibiotic. Premeditated discs are now or shortly will be commercially avaiIabIe. Zones of inhibition can be read after tweIve to eighteen hours of incubation in most instances. Spot sensitivity determinations with several test organisms show close correIation with corresponding tube sensitivities. Culture sensitivity data provide information not only concerning the probable drug of choice and the possible alternative agents but also a clue as to the dosage required. In chronic osteomyelitis the wound flora is more apt to be heterogenous than monobacterial, with proteus, pyocyaneus or coliform bacteria prominent. The mixtures notwithstanding, bacteria in wounds capabIe of producing invasive infection are the hemolytic staphylococcus aureus, hemolytic streptococcus and the toxigenic clostridia. About 60 per cent of staphylococci isolated by us are peniciIlinsensitive while nearly 80 per cent of hemolytic
Osteomyelitis
streptococci are penicillin-sensitive. Penicillinresistant cocci are penicillinase producers as are coliform bacteria, proteus and pseudomonas. For these two reasons \ve prefer now to employ the newer, broader spectrum antibiotics, aureomycin, terramycin or chloromycetin, alone or combined with penicillin. We prefer chloromycetin with or without penicillin because it is h’rghI y e ff ect’ rve against cocci and therapeuticalIy active on manv strains of proteus and pyocyaneus. In the ordinary case antibiotics in fuIl doses are begun the day before operation so as to perfuse the tissues freely with a bloodborne drug, and are continued for five to seven days postoperatively. Topical applications, it is reiterated, are not empIoyed routinely and are reserved for the exceptional case. Postoperatively, cultures are again made to aid and abet chnical appraisal of the thoroughness with which compromised tissue capabIe of perpetuating infection has fleen removed. Persistence of invasive bacteria postoperatively warrants delay in further surgery until the cause for this persistence has been determined and removed. In summary, the patient is ready for surgery of chronic osteomyelitis of Iong bones when the nutritional, blood and protein deficiencies have been corrected, circulation of the limb has been brought to optimal efficiency, type and extent of scar and bony damage has been determined clinicaIIy and roentgenologically, causa1 bacteria have been identified, antibiotic culture sensitivity tested and held against invasion by trauma into contiguous structures and, finally, plans have been formulated for providing allimportant early full skin cover and indicated fiIling of the bony defect. When the wound site is ready for closure, the choice of muscle or bone to be used in filling the defect must be made. Transposed muscle must have a pedicIe for its blood supply. To obtain this muscle a strip sufficient to tiIl the cavity is separated from its parent in its long axis and divided distally with sufficient length to be transposed and fixed into its new bed without tension; or chips of cancellous bone sufficient to fill a cavity are obtained from a section of the iliac crest or bone bank of canceIIous bone and chopped into pea-sized chips which are snugly packed into the cavity. According to the depth, size, Iocation and position of the wound the timing for and method of closure of the wound is to be determined.
American
Journal of SurgeTy
Venable,
Pulaski-Chronic
If the lesion is in the femur, there is practicaIIy aIways sufficient muscIe and skin to fill or cover a bone cavity of any size. ParticuIarIy is this true above the condyIar expansion where ample muscIe may be transposed with a good blood suppIy. The tibia, however, presents a different problem which at times requires a11 the ingenuity and judgment we may possess. Muscle may be transposed only in the middle third which may be onIy from a section of the anterior tibia1 muscle. Above that area it must be reversed on its pedicle with only a poor blood suppIy if it is to be inserted into the upper one-third of the tibia, and it is much too fibrous to use in the lower one-third of the shaft. The covering of tibia1 defects with fufl-thickness skin is one of our most serious probIems and, will aIways remain a sine qua non of success. Transposed muscle or bone into a bone cavity must be covered with Iiving tissue or else it dies. This is so because there is never sufficient supportive blood suppIy to be derived from a tibia1 cortex or refiIIed cavity to support and maintain Iife in unattached skin whether it is split-thickness or whofe-thickness. To five a blood suppIy must be transposed with the skin and this part of the problem must be figured out and decided upon before other steps of cIosure are undertaken. Otherwise, the procedure from the beginning will be to foIIow the oIder plan of closure by granular filling from the bottom of the wound and coverage by fibrosis and dermatization or split or pinch graft. The preparation of these covering flaps when determined upon should be begun one to three weeks before they are needed to insure their active viability with the source of their bIood supply and its expectancy reasonably known. Our procedure is to decide whether the flap may be slid across the defect and attached to the
November
15, 19p
Osteomyelitis
651
skin on the opposite side and so retain its proximaf and distaf attachments or is to be freed from its distal attachment or be brought from above by a reversed tubuIar transfer. When this is decided upon and the cavity ready, we prefer first to transfer and suture this flap in pIace over a Vaseline pack to test its viability for tive to seven days and then reopen the wound, remove the pack and fill the cavity with bone or muscle as previousIy determined and resuture this Iiving flap to its bed. The defect from which it came is covered with split-thickness skin. This eIaborate preparation will be wasted if it does not culminate in good surgery. There can be no compromise with the principIe of thorough, compIete excision of al1 devitalized tissue. HaIf-hearted efforts always lead to repetition of infection and extension of necrosis. Removal of diseased tissues as well as bone is most easily effected in a dry fieId which is secured by the use of a tourniquet. We have been using the tourniquet almost routineIy without evidence of spreading infection or of circulatory compfications ensuing. In addition, blood loss is kept to a minimum. FinaIIy, it is our considered opinion that the personal
attention
operatively
given by the surgeon
to detaiIs
as the operation the operator, evolution of
post-
of care are as important
itself. Constant
observation
by
not his junior staff, during the the lesion postoperatively will
often resuIt in the discovery
of small devitalized
areas about which the operator may have felt insecure at the time of surgery, with the result that
time
and effort
are saved
by getting
at
these earIy. Continuity of effort by the same surgeon is the best insurance for a successful campaign
of attack
on the lesion.
T
M.D. AND LIEUT.
15, 1950
EDWIN
J.
PULASKI,
Fort Sam Houston,
Texas
HE objective in the treatment of chronic is the arrest and eliminaosteomyelitis tion of active foci with an expectancy of permanent heaIing under a cIosed wound, with the least resuIting deformity in the shortest period of time. To meet this objective we must have comprehensive knowledge of the origin, the processes of destruction, reasons of recurrence and foundation of resistance in order to estabIish principIes for the arrest, control and repair of this condition. In this evaluation it has become apparent that the basic principle of repair of defects in infected bone lesions such as chronic osteitis and osteomyelitis under antibiotic prophylaxis and control is that only with sufficient care in such procedures and sufficient respect for essential detaiIs may a high percentage of recovery be expected. Especially is this so in a preanticipated schedule with a reasonabIe expectancy of wound-healing. Improved surgical management of traumatic wounds in civiIian and miIitary Iife together with the judicious use of potent antibiotics has reduced greatly the incidence of post-traumatic osteomyelitis in the hospita1. NevertheIess, these patients continue to be seen in a11 general hospitats and many present a challenge to even the most experienced of surgeons. That the treatment of this condition demands patience from both the surgeon and patient is evidenced by the fact that the average stay in hospitaIs may be many months. This is the case particularly in government hospitals where the patient must be kept in the hospital until he has received maximal benefits of treatment. AIthough no new principles for the treatment of OsteomyeIitis have been discovered recently, it would seem there is a need for greater diffusion of knowledge as to what constitutes adequate operation and what is considered proper timing for completion of the steps necessary for bringing the wound resulting from operation to a permanent1y closed system. BasicaIIy the steps comprising treatment of osteomyelitis November
COL.
M.C.
Texas
incIude preparation of the patient for surgery, eradication of bacteria-Iaden compromised tissue, provision of- adequate bIood supply, reinforcement of bone where necessary to provide a functioning limb and fuIl skin-thickness cover. Preparation qf the Patient. This entails simultaneous concentration on the patient as a whole and on his disease cornpIes. Attention is directed early to correction of bIood and protein deficiency, well known deterrents to recovery from infection, and to good woundhealing. CharacteristicaIly chronic suppurative disease is accompanied with anemia and hypoproteinemia, with a shrunken circulating blood value which is frequentIy masked by norma hemoglobin and tota bIood protein values. Wherever facilities are avaiIabIe repeated quantitative blood volume determinations by Evans’ blue dye or tagged ion methods are most accurate criteria of the blood and protein needs of the patient than by hematocrit, hemoglobin and plasma protein determinations. Where such facilities are not availabIe, blood and plasma transfusions folIowed with frequent hematocrit readings are usefu1 for gauging additional blood and pIasma requirements. When a hematocrit of $0 is sustained after bIood transfusion, the cardiovascular tree is fiIIed and replacement therapy is then considered adequate. No change in the hematocrit reading after transfusion indicates the vascular tree is not f3Ied and additional repIacement is
649
necessary. Preparation limb for adequacy extremity.
of the Limb.
surgery begins of peripheral ProIonged
Preparation
of the
with estimation circulation of
immobilization
of the
or disuse
of an extremity contributes to diminution of the bIood suppIy and a cold limb. Lumbar sympathetic blocks often result in improvement in circulation of the extremity and are beneficia1 in bringing about conditions favorable to wound-healing.
630
Venable,
Pulaski-Chronic
The wound itseIf is given detailed study. Koentgenograms in severat pIanes, with contrast media in jetted through the fistuIous tract if necessary, assist in visualization of the path of fistula connecting surface with bone, location of sequestra and estimation of the extent of pathologicaIly altered bone. The soft parts are critically appraised so that the scheme for excision of scar tissue will encompass a soIution to the probIem of providing muscIe pedicIe fiIling of the bony defect if indicated and, most importantly, of providing’fulI-thickness cover. FuIl-thickness cover is often the keystone to successful management in chronic osteomyelitis. Due consideration is given to improvement of local hygiene. The skin surrounding the fistula is brought to a condition of as near normalcy as possibIe by ehmination of maceration and dermatitis. Whenever drainage is profuse, dressings are changed at frequent intervals. The limb is bathed at least twice a day for three days before surgery with G-I I compound in soap or cream base. We neither employ nor recommend the use of antiseptics or antibiotics around or in the wound because their efficacy is questioned and the danger of inducing sensitization is great. The bacterial flora of the wound exudate are determined and cuIture sensitivity tests are made. Although there are several methods for determining cuhure sensitivity, the agar platemedicated disc method is simplest. It consists of the appIication to freshIy seeded blood agar pIates discs containing measured amounts of each antibiotic. Premeditated discs are now or shortly will be commercially avaiIabIe. Zones of inhibition can be read after tweIve to eighteen hours of incubation in most instances. Spot sensitivity determinations with several test organisms show close correIation with corresponding tube sensitivities. Culture sensitivity data provide information not only concerning the probable drug of choice and the possible alternative agents but also a clue as to the dosage required. In chronic osteomyelitis the wound flora is more apt to be heterogenous than monobacterial, with proteus, pyocyaneus or coliform bacteria prominent. The mixtures notwithstanding, bacteria in wounds capabIe of producing invasive infection are the hemolytic staphylococcus aureus, hemolytic streptococcus and the toxigenic clostridia. About 60 per cent of staphylococci isolated by us are peniciIlinsensitive while nearly 80 per cent of hemolytic
Osteomyelitis
streptococci are penicillin-sensitive. Penicillinresistant cocci are penicillinase producers as are coliform bacteria, proteus and pseudomonas. For these two reasons \ve prefer now to employ the newer, broader spectrum antibiotics, aureomycin, terramycin or chloromycetin, alone or combined with penicillin. We prefer chloromycetin with or without penicillin because it is h’rghI y e ff ect’ rve against cocci and therapeuticalIy active on manv strains of proteus and pyocyaneus. In the ordinary case antibiotics in fuIl doses are begun the day before operation so as to perfuse the tissues freely with a bloodborne drug, and are continued for five to seven days postoperatively. Topical applications, it is reiterated, are not empIoyed routinely and are reserved for the exceptional case. Postoperatively, cultures are again made to aid and abet chnical appraisal of the thoroughness with which compromised tissue capabIe of perpetuating infection has fleen removed. Persistence of invasive bacteria postoperatively warrants delay in further surgery until the cause for this persistence has been determined and removed. In summary, the patient is ready for surgery of chronic osteomyelitis of Iong bones when the nutritional, blood and protein deficiencies have been corrected, circulation of the limb has been brought to optimal efficiency, type and extent of scar and bony damage has been determined clinicaIIy and roentgenologically, causa1 bacteria have been identified, antibiotic culture sensitivity tested and held against invasion by trauma into contiguous structures and, finally, plans have been formulated for providing allimportant early full skin cover and indicated fiIling of the bony defect. When the wound site is ready for closure, the choice of muscle or bone to be used in filling the defect must be made. Transposed muscle must have a pedicIe for its blood supply. To obtain this muscle a strip sufficient to tiIl the cavity is separated from its parent in its long axis and divided distally with sufficient length to be transposed and fixed into its new bed without tension; or chips of cancellous bone sufficient to fill a cavity are obtained from a section of the iliac crest or bone bank of canceIIous bone and chopped into pea-sized chips which are snugly packed into the cavity. According to the depth, size, Iocation and position of the wound the timing for and method of closure of the wound is to be determined.
American
Journal of SurgeTy
Venable,
Pulaski-Chronic
If the lesion is in the femur, there is practicaIIy aIways sufficient muscIe and skin to fill or cover a bone cavity of any size. ParticuIarIy is this true above the condyIar expansion where ample muscIe may be transposed with a good blood suppIy. The tibia, however, presents a different problem which at times requires a11 the ingenuity and judgment we may possess. Muscle may be transposed only in the middle third which may be onIy from a section of the anterior tibia1 muscle. Above that area it must be reversed on its pedicle with only a poor blood suppIy if it is to be inserted into the upper one-third of the tibia, and it is much too fibrous to use in the lower one-third of the shaft. The covering of tibia1 defects with fufl-thickness skin is one of our most serious probIems and, will aIways remain a sine qua non of success. Transposed muscle or bone into a bone cavity must be covered with Iiving tissue or else it dies. This is so because there is never sufficient supportive blood suppIy to be derived from a tibia1 cortex or refiIIed cavity to support and maintain Iife in unattached skin whether it is split-thickness or whofe-thickness. To five a blood suppIy must be transposed with the skin and this part of the problem must be figured out and decided upon before other steps of cIosure are undertaken. Otherwise, the procedure from the beginning will be to foIIow the oIder plan of closure by granular filling from the bottom of the wound and coverage by fibrosis and dermatization or split or pinch graft. The preparation of these covering flaps when determined upon should be begun one to three weeks before they are needed to insure their active viability with the source of their bIood supply and its expectancy reasonably known. Our procedure is to decide whether the flap may be slid across the defect and attached to the
November
15, 19p
Osteomyelitis
651
skin on the opposite side and so retain its proximaf and distaf attachments or is to be freed from its distal attachment or be brought from above by a reversed tubuIar transfer. When this is decided upon and the cavity ready, we prefer first to transfer and suture this flap in pIace over a Vaseline pack to test its viability for tive to seven days and then reopen the wound, remove the pack and fill the cavity with bone or muscle as previousIy determined and resuture this Iiving flap to its bed. The defect from which it came is covered with split-thickness skin. This eIaborate preparation will be wasted if it does not culminate in good surgery. There can be no compromise with the principIe of thorough, compIete excision of al1 devitalized tissue. HaIf-hearted efforts always lead to repetition of infection and extension of necrosis. Removal of diseased tissues as well as bone is most easily effected in a dry fieId which is secured by the use of a tourniquet. We have been using the tourniquet almost routineIy without evidence of spreading infection or of circulatory compfications ensuing. In addition, blood loss is kept to a minimum. FinaIIy, it is our considered opinion that the personal
attention
operatively
given by the surgeon
to detaiIs
as the operation the operator, evolution of
post-
of care are as important
itself. Constant
observation
by
not his junior staff, during the the lesion postoperatively will
often resuIt in the discovery
of small devitalized
areas about which the operator may have felt insecure at the time of surgery, with the result that
time
and effort
are saved
by getting
at
these earIy. Continuity of effort by the same surgeon is the best insurance for a successful campaign
of attack
on the lesion.