CHRONIC OSTEOMYELITIS

IRIMARY CLOSURE FoLLOwING SAUCERIZATION

A 1RELIMINARY REPORT

BY BRANDON (ARRELL, M.D., AND J. W. WOODWARD, M.D., DALLAS, TEXAS

b’roi,i the 7’e.ras Scottish Rite Ilospital, Dallas

INTRODUCTION

The (‘ilart- files of many hospitals are stacked high Ivith the voluminous records of
those unfortunate indi-iduals 11ho fell heir to chronic hone infection. In many case
records, tile recent history of the treatment of the condition can be traced. Even records
not. too ycllolled Ilith age tell of the efforts to effect a cure by the use of maggots and, on
subsequent ‘ecttrrenccs, by tile introduction of the tedious Carrel-Dakin method; after a
fell more years came tile Orr technique, which was somewhat more satisfactory but had
many drabacks. The thickness of these charts indicates the many weeks and months of
hospital care, but is not adequate testimony of the pain and suffering associated with
those Il’eal’y days.
With the introduction of the sulfonamides and then a bit later of penicillin, all asso-
ciated ith these cases held hope that at last some progress could be made in the treat-
ment- of both the acute and the chronic infections. Time has borne evidence that these
(!rugs has-c a profound effect in the acute case, but seldom give permanent benefit in the
old establisher! case. It- is recognized by all that antibiotics are blocked from the site of
activity by tile extreme avascularity presented in the average case of chronic osteomyeli-
tis. Many of these patient-s have had repeated operative procedures over a period of
many years Ilith the result that the surrounding soft tissues have been transformed into
a dense fibrous fllaSS, beset Ilith sinus tracts and adherent scars. The bone itself shares
in the picture, Il-it!) a dense sclerotic cortex harboring sequestra and areas of pus and
granulation tissue.
In 1935, Lorrl presented! the idea of a thorough removal of the diseased tissue, filling
the hone cavity Ilitil muscle or fat, and then closing the wound tightly to try to effect a
primary ilealing. Various means llcre used to shift flaps of skin for plastic closures of the
defect.
Buchman and Blair made a careful study of the effect of penicillin on chronic osteo-
myclitis, 1)(Ith 111th and 1Iit-hout surgical measures. It Ivas made evident that the secondary
invaders, predominantly Bacillus proteus and Bacillus pyocyaneus, which abound in the
llounds of those treated! i)y the Orr method, were not markedly retarded by penicillin
therapy. The healing 11-as Ilot hastened, the primary organisms assumed a resistance to
the drug, and! in cases of secondary closure the vounds tended to break dolln. Their pre-
liminary ieports Ilcre highly in favor of primary closure of these Ivounds.

MATERIAL FOR STUDY

The search for a better method of treatment led the staff of the Texas Scottish Rite
Hospital to adopt the primary-closure technique. During a period of five and one-half
years, beginning April 1944, a total of forty-one cases have been so treated ; forty-nine
operations have been performed.
It should be pointer! out that this is a preliminary report, since a far greater time
interval is needed to pass final judgment on the value of the treatment in chronic osteo-
myelitis. At a later date fuither data lvii! be obtained to complete these case analyses.
The a-erage (iuil’atiofl of symptoms prior to this type of treatment was four years

92$ THE JOURNAL OF BONE AND JOINT SURGERY

 CHRONIC OSTEOMYELITIS 929

tiI(l tlli’cc fll(IIltils. Of tile forty-one patients, 27 per cent. had undergone one or moi’c sot’-
gical procedures previously. The average in the series age
of tllenty-six i)oyS and fifteen
girls at the time of operation I1as ele-cn years and nine months. The a-erage duration
of folldlll-ulp Il-as tllO veat’s and till-ce months. In thirty-nine of the cases, the onset was

as ar’ute hematogenous osteomyelitis; in one, the osteomyclitis Il-as a complication fol-

lollving an 0l)1l l’dltatiOnal osteotomy of the tibia; in the other case, the infection of tile
temul’ appearc(! llith Hand-Sch#{252}ller-Christ-ian disease. Roentgcnographic evidence of

S((l1i(5tii1 lVII5 foun! in 73 per cent. of the cases. Cultures taken prior to 01’ at the time of

surgery 5110)11(0! Staphylococcus aureus in 60 petS cent., ‘-)taphylococcus ha(’Pnolytidus in

l)(t’ (‘cflt.. ‘11’e/)lOCOCCu.S !iri(kIfls in 8 per cent., andi no growth in 24 )el’ cent.

TF:(-HNIQUE E11i’LOYED

ihe sui’geiy lVa5 performer! b’%T the senior residents under tile (!iI’edt supel-1-ision (If
the attending staff. Basic surgical principles were as follow-s:
I. Remol-al (If all devitalized! and infect-cc! bone by conserl-ative saucerization of the
i)onc, a\-oi(!ing o1-cl’hanging edges, and opening to normal medullary cavity abol-c told

I )eloIll -

2. \Vhen l)oISSilIle, lcnloval (If avasculat’ soft tissue, illdllldillg a(!hercflt seal’s aild
SiIlIls I l’a(’tS.

3, PrillltLl’y (‘!olslll’e of tile ll(Itlfld, aimer! at bringing vascular soft tissues into the
space d’reate(l by tile sau(’erizat-ion afl(l approximating the skin edges to avoid invasion
I )V secondaiy i)tI(’t erial fi ora.
Witil tile exception of tile first four cases in the series, all patients receil-ed penicillin
for tllO to tilrce (lays priOr to surgery and for as long folloll-ing as conditions indicated,
generally for 5(Cfl to ten (lays. In a few’ of the early cases, one of the various sulfonamides
was used ill a like manner. The operations IVel’e performed I\ith the i)enefit. of a tourniquet;
major -essels Il-crc ligated Il-it-h fine catgut when necessary. After saucerization, tile
11-0011(15 llere generally Ilashed 1\ith green soap, irrigated 11it-h a copious amount of saline,
and then treated by flushing Ilith a small amount of ether; finally this vas remover! by a
second! saline irrigatioll.
Closure technique vas (lesigneol to fill the il)one defect with vascular soft tissue, a
nlillimum (If suture material i)eing i)ui’iedl. In a feIl instances, fine eat-gut Il-as use(l in
fascia, i)tIt generally all layers llcre brought together I%ith several deep figure-of-eight
sutures (If No. 30 dOttoll. Skin eriges Il-crc further appr(lximated with interrupted mat-tress
0l illtcl’lo(’killg running stitches. In eighteen cases, the Ilollnds Ilerc closed tightly, aftet’
sulfanilamide crystals ilad! i)een lightly frosted in the llourl(!s. sixteen, the
In lI-oun(!s

Il_d.c (-l(Ise(l t ightly aroulld! a small soft-rubber catheter, used to instill a penicillin solution
for thi’ec t() four days postoperati-cly. Fifteen IlOlln(!s llel’c closer! tightly IlithOut benefit
of l(Id’ttl alltibiOtics.
\OlllIflifl(Iul5 dressings Il(rc applied!, aildl held firmly in place l! elastic i)andages.
Gencl’ally the Iloulnds w-ei’c inspecter! in three to four clays, at Ililicil time any excessively
t ight sut lli’(5 ei’e released, arir! tile datiletel’, if plescllt-, was removed. The bulky i)an(l-
ages ct’c then ieapplic(l. Plaster encasement was necessary in t-llree cases as insurano’e
against- ft’acture after remo-al of large sequest-ra.

RESULTS

Statistics (Id) Ilot i’eflect the very important. decrease in treatment-produced pain
:111(1 the ilcart-Ilarmiflg impro-ement in morale in these (‘hildren, as compared Ilith those
(lIldel’ (It 11(9’ 1(101 1Il(5. llio t ime iedlliite(l Iir physic-ian audi nurse I 0 care for them is also)
gnat ifyingly sliot’t -

In tilis sci’i(s (If (‘t1SS, healillg by li’imai’y intention took pla(’e in 82 per cent., in an
a o-age I I 1)10 (If I 3. 1 (layS. Fiiesr 1101111(15 healer! in tiit’ ent ii’ety ; t hose llicakillg dolvil in

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#{182}132 nIt.INDoN dARRELL AND J. IV. WOODWARD

TABLE I

RESUlTS (IF PRIMA RY (‘LeISURE Fott.0wING SAuCERIZA-rioN

Location No. of Cases Primary Healing Sorondarv Healing

Femur 15 11 4
Tibia 19 15 -1
Humerus 6 6 0
Radius 3 3 0
ITI19 :3 2 1
Ilium 2 2 0
Ischiuni I 1 0

Total 49 40 9

only a segment of the incision were classified as healing by secondary intent-ion. The
average hospital stay sas fifteen days, as compared Il-ith tIs-enty-seven days in the nine
cases in which healing was not satisfactory. In those cases where breaking down in all or
part of the incision occurred, healing took place in an average of seventy-five days, which
compares favorably wit-h those treated by the Orr technique. Seven of the nine cases in
Ilhich breaking doll-n of the wounds occurred Il-crc in the first tll-o years of the series.
There have been only tll-o failures in the last thirty-seven cases.
Some degree of recurrence was noted in 40 per cent. during the foiloll-up period,
IShiCh averaged two years and three months. Additional surgery was necessary in 16
per cent. ; in the other cases, the recurrences I%crc controlled by antibiotics, rest, and the
application of heat.
Before compiling tile results, it had been felt that those cases in which a rubber
catheter had been used to instill penicillin ere more prone to failures in healing. It was
found, ilollever, that- primary healing took place in 87 per cent. of that group, as com-
pared Ivith 72 per cent. in those closer! Il-it-h sulfanilamide in the Il-ound, and 86 per cent.
in those closed tightly 11-it-h flO local antibiotic.

CONCLUSIONS

Primary closure (If the wound following saucerization procedures in chronic osteo-
myclitis resulted in primary healing in 82 per cent. of a series of forty-nine cases.
This technique is dependable and has outstanding advantages to both the patient
and those attcnc!ing him.

REFERENCES

BUCItMAN, JOSEPH, and BIAIR, J. E. : Penicillin in the Treatment of Chronic Osteom\-elitis: A Preliminary
Report-. Arch. Surg., 51 : 81-92, 1945.
BUCHMAN, JOSEPH, and BLAIR, J. E. : Report on the Use of Penicillin in the Treatment of St-aphylococcal
Infections with Special Reference to Acute and Chronic Osteomyelitis and Several Collateral Studies.
Bull. Hosp. Joint Dis., 6: 114-125, 1945.
Lo)RLI, J. P.: The Closure of Chronic Osteomvelitic Cavities by Plastic Methods. Surg., Gynec., and Obstet.,

60: 853-856, 1935.

THI- JOURNAl. (II-’ BONE ANt) JOINI ‘t’R(;I’:RY