Pus in muscles, bones, and joints
From Primary Surgery
Pyomyositis
This is a disease of disadvantaged tropical communities in which abscesses form in a patient's muscles. It is common between the ages of 5 and 25, and becomes less common as living conditions improve.
There are several syndromes in which large collections of pus form in the muscles. The first is much the most common. You may see:
Classical pyomyositis in which one or more of a patient's muscles becomes exquisitely painful, tender, and swollen, and the skin over it smooth and shining. A single muscle may be involved, or a group of them, or he may have several abscesses in different parts of his body. His larger muscles, such as those of his thighs, buttocks, shoulders, back, and abdominal wall are more often involved than his smaller ones. Infection makes them hard and indurated, so that movement is painful. Later, the signs of inflammation may subside as the infected muscle is replaced by pus and becomes fluctuant. Infection of the muscle limits the movement of joints nearby. If his abscess is large, he may occasionally be quite ill with fever and rigors. Lymph node involvement is not conspicuous.
Septicaemia associated with pyomyositis may be fatal and is often not diagnosed. He is very ill and drowsy, with a high fever, and multiple tender areas over his muscles. He may have a history of a trivial skin laceration, a blister, or a small sore. The condition rapidly progresses, so that he becomes desperately ill with a swinging fever, weakness, prostration, dehydration and hypotension.
Pyaemia associated with pyomyositis results in a sequence of abscesses in one muscle after another.
Staphylococci are usually responsible. Before pus forms, antibiotics alone may occasionally cure him; but you almost always have to drain it.
SITA (38) presented with fever and a vague, mild pain in her left hip, which was made slightly worse by movement. No malaria parasites were found and no definite diagnosis was made. She was treated with gentamicin and cloxacillin and her fever improved. Ten days later she returned with a huge abscess in her left inguinal region. This was incised and she recovered completely. LESSON Pyomyositis may cause large abscesses in the deeper muscles with few localizing signs. Fig. 7-1 PYOMYOSITIS. A, shows an abscess in one of the muscles of a patient's thigh. B, the common sites. C, the distinction between pus in the muscles (as in pyomyositis), and pus between them, as in an abscess round a dead Guinea worm, which is one of the differential diagnoses. After Davey WW, Companion to Surgery in Africa', Figs. 11.2 and 11.5. Churchill Livingstone, with kind permission.
PYOMYOSITIS THE DIFFERENTIAL DIAGNOSIS includes osteomyelitis (7.2) and septic arthritis (7.16). The exact site of the tenderness and swelling will usually lead you to the correct diagnosis. There are several other possibilities which depend on the site of the abscess:
In the patient's upper abdomen, think of a kidney swelling, a perinephric abscess (5.11a), an amoebic liver abscess (31.12), a subphrenic abscess (6.4), or an acute abdomen.
In his lower abdomen, think of an appendix abscess, suppuration of his iliac glands (5.12), a psoas abscess, a strangulated inguinal hernia (14.6), or an acute abdomen.
In his loin, an inflammatory mass is more likely to be pyomyositis than a perinephric abscess or a pyonephros.
If he has an abscess in his iliopsoas, his hip is flexed, and he resists all attempts to straighten it (5.12). Careful comparison with his normal side may show a swelling medial to his anterior superior iliac spine. An iliac abscess (5.12) may be the result of pyomyositis of his iliacus or psoas muscle, suppurating iliac adenitis, osteomyelitis of his spine (7.15), or septic arthritis of his hip (7.18). Lightly banging his greater trochanter with your clenched fist will cause him pain if he has septic arthritis or osteomyelitis, but not in the other conditions. Examining his back should distinguish osteomyelitis. The distinction of pyomyositis from iliac adenitis may be impossible and is not important (5.12).
In his thigh, think of acute osteomyelitis, guinea worm infection, a haematoma, or a sarcoma.
In his calf think of a deep vein thrombosis, or a sickle cell crisis with bone infarction.
INVESTIGATIONS If osteomyelitis is a possibility, X- ray the part, but don't expect any changes for 10 days. Drill it (7.5). Measure his haemoglobin before you operate.
MANAGEMENT depends on the severity of his disease:
If his pyomyositis is early, in that there is merely induration over a small area of muscle, antibiotics alone may cure him. Give him penicillin, or chloramphenicol (2.7).
If he has one or more well localized lesions drain them.
If he has signs of spreading infection, give him antibiotics and drain the lesions.
If he has a succession of abcesses (pyaemia), drain them as they appear, culture the pus, and give him an appropriate antibiotic as soon as you know the results of culture. Give him chloramphenicol meanwhile.
If he is very ill indeed with multiple tender areas over his muscles, give him intraveous chloramphenicol (2.7). Change to oral chloramphenicol as he improves. Drain his abscesses.
If necessary, correct his dehydration with saline or Ringer's lactate. If he is severely anaemic, transfuse him before you drain his abscess.
DRAINAGE. Give him ketamine or a general anaesthetic. If you are not sure if pus is present or not, aspirate it with a needle.
Make a small incision to begin with, if possible in the most dependent position, and open his abscess by Hilton's method (5- 3). If it is large, extend the incision, so that you can insert your finger, break down any loculi and explore the whole cavity. Don't curette it. You may find a litre or more of pus.
If the bone feels rough and craggy at the bottom of the abscess cavity, it may be involved; if so, he has osteomyelitis, not pyomyositis.
DIFFICULTIES [s7]WITH PYOMYOSITIS If BLOOD POURS FROM THE ABSCESS, pack the cavity tightly with gauze for 36 hours. If you don't curette an abscess, it is unlikely to bleed much.
If he has very MANY or very SEVERE lesions, you may have to make 20 or more incisions, with repeated visits to the theatre, to evacuate pus and remove dead muscle.
If he has BLACK NECROTIC SKIN, removing it may reveal a huge quantity of avascular greyish-pink, mushy suppurating muscle extending deeply underneath. Remove this, taking care: (1) not to injure vital structures, (2) not to let him lose more blood than he can stand. His life depends on aggressive (but not too aggressive) surgery, intensive antibiotic treatment, and fluid replacement. Even so, he stands a good chance of dying. If you have had to remove much muscle, he will inevitably be left with weakness, deformity, and loss of function[md]a worthy price to pay for survival.
If he has FEVER and RIGORS after drainage, he is septicaemic, and may form new abscesses.
If he has any tendency to develop CONTRACTURES, apply skin traction (70.10) or a cast, as appropriate.
Fig. 7-2 THE PATHOLOGY OF OSTEOMYELITIS. A, Brodie's abscess is an uncommon form of chronic osteomyelitis: the upper end of the tibia or the lower femur are the common sites. B, the initial infection in osteomyelitis is typically in the metaphysis. After the age of 6 months the epiphyseal plates have developed sufficienty to prevent infection spreading to the joints, except in the hip. Before this age infection spreads to the joints. C, chronic osteomyelitis with sequestra and a sinus. D, under the age of 6 months osteomyelitis is always associated with septic arthritis. E, osteomyelitis of the proximal femur is always associated with septic arthritis, regardless of the age of the patient, because the epiphysial line is intracapsular.
The pathology of osteomyelitis
Osteomyelitis is a particularly tragic preventable disease, which has almost disappeared from the industrial world, where it was once common, particularly among the poor. It is now almost entirely a disease of the disadvantaged children of the developing world, whom it often disables for life if it is treated late or inadequately. You can only treat osteomyelitis satisfactorily if you treat it early. Later treatment is difficult, expensive, and time-consuming.
There are several kinds: (1) Haematogenous osteomyelitis in which bacteria reach bone through the circulation, and which is the concern of most of this chapter. (2) Traumatic osteomyelitis, particularly following road accidents and war injuries, in which bacteria reach bone through a badly treated open fracture, as the result of: (a) an inadequate wound toilet (54.1), and (b) immediate instead of delayed wound closure (54.4). One of the main purposes of Chapter 54 is to prevent this preventable disaster, so nothing more will be said about it here. (3) Osteomyelitis following unskilled orthopaedic procedures in unsterile theatres, particularly the fixation of femur fractures with Kuntscher nails. The fracture methods described in Volume Two minimize this risk, and about the only possibility of it occurring with the methods described there is the osteomyelitis of the upper tibia that may occasionally follow the insertion of a Steinmann pin for skeletal traction (78.6). Fortunately, this is usually mild and localized.
Acute haematogenous osteomyelitis is a surgical emergency. It is also the supreme example of the axiom[md]Where there is pus let it out'. Your challenge is to drill the site of infection and to let out the pus before it causes pressure necrosis of the bone, and to do so with the least possible delay. If you don't explore an infected bone early enough, or don't explore it at all, the patient may be severely disabled. Drilling is not difficult; but the sequestrectomy that may be necessary later if you fail to drill it will be very difficult.
Staphylococci are usually responsible. But if osteomyelitis complicates sickle-cell disease, or some other haemoglobinopathy, other organisms may cause it, particularly E. coli (common) and S. typhi (rare). If the patient is a neonate, streptococci or enterobacteria may be infecting him. The metaphysis of a long bone is the usual site. In decreasing order of frequency you are likely to see osteomyelitis in the proximal tibia, the distal femur, the proximal femur, the proximal end of the humerus, the distal radius or ulna, the distal tibia, or the calcaneus. But any bone can be involved, and sometimes several of them at the same time.
Infection thromboses the end arteries of a metaphysis, and so kills the bone that they supply. Pus accumulates under pressure, breaks out through a hole in the bone, and comes to lie under the periosteum. Pus then strips the periosteum off the shaft and deprives part of the bone of its blood supply, so that it dies and forms a sequestrum. The stripped periosteum responds by producing new bone, which is the beginning of the involucrum. Later, this may become so extensive that it forms a new shaft. If the disease progresses, large areas of bone, and perhaps even its entire shaft, become separated from their blood supply, die, and form one or more sequestra. These lie inside the involucrum, bathed in a pool of pus, which discharges through sinuses in the skin.
Occasionally, the disease does not go through this acute stage, and does not form sequestra, or sinuses. Instead, the infected bone becomes sclerotic, and its marrow cavity is obliterated (Brodie's abscess, A, Fig. 7-2).
Before the age of six months an epiphysis offers no barrier to the spread of infection, so that pus in a metaphysis rapidly spreads to a joint. After this age the cartilage of an epiphyseal plate limits the spread of infection, so that a joint is only infected if an infected metaphysis extends inside a joint capsule, as in the proximal femur. Osteomyelitis is uncommon later in life, after the epiphyses have fused.
JOHN (6 years) was admitted late on a Saturday night, in the days before antibiotics, to a London teaching hospital, with the typical symptoms of osteomyelitis. There was no registrar, so the house surgeon consulted his chief (who had gone off for the weekend) over the telephone and was told to Keep the boy until Monday morning'. By then it was too late. The boy was ill- nourished and from a poor home; he just went down and down, running pus from his joints, and getting thinner and thinner, until his iliac crests broke out through his skin, and one iliac epiphysis dropped off. He finally died of amyloid disease of his liver. LESSON This boy became a byword and a terrible example throughout the hospital of what can happen if osteomyelitis is cooked', and pus under pressure is not drained (a story told by H Leader Stirling).
Fig. 7-3 INSTRUMENTS FOR CHRONIC OSTEOMYELITIS. The most important instrument for diagnosing early osteomyelitis[md]the bone drill[md]is shown in Fig. 70-12. You will need a bone drill (70.11), and you will find a pneumatic tourniquet useful. Here are the instruments you will need to remove sequestra.
OSTEOTOME, Swedish model, solid forged stainless steel, (a) 6 mm. (b) 10 mm. One only of each size. Use these for cutting the bones of children. An adult's bones are too hard to be cut by an osteotome alone. Weaken them first with a line of drill holes.
NIBBLER, bone, Read Jensen, one only.
GOUGES, Swedish model, solid forged stainless steel, (a) 6 mm, (b) 10 mm. One only of each size. These curved bone chisels must be sharp. If necessary, get them sharpened on a grindstone. Use them for deepening a cavity in a bone.
MALLET, stainless steel, 350 g, one only. This an adequate size of mallet, there is no need for a larger one.
BONE FILE or rasp, one only.
FORCEPS, bone cutting, Liston, angled on flat, 200 mm, one only. These are general-purpose bone cutters. You can also use them instead of special rib cutters.
FORCEPS, bone-holding, Hey Groves, 210 mm, one only. This is for small bones, such as the radius.
FORCEPS, bone-holding, Lane's 390 mm, one only. This is a heavier pair of forceps for larger bones such as the tibia.
FORCEPS, sequestrum, angled, 190 mm, one only. These are slender, angled forceps to remove sequestra.
CURETTE, or scoop, Volkmann, double ended, size C, four only. Use this to curette infected bone when you operate for osteomyelitis.
LEVERS, bone, Trethowan, 220 mm, four only. Put these round a bone to expose it.
LEVERS, bone heavy, 275 mm, four only
HOOK, bone, 220 mm, one only
ROUGINE, Faraboef, with curved end, chisel edge, one only. Use this to scrape the periosteum from a bone.
ELEVATOR, periosteal, large, one only.
Acute osteomyelitis
Typically, a child from a poor family living under very unhygienic conditions presents with fever and an exquisitely painful tender bone near a joint which he is unwilling to move. Or, his mother may bring him to you with fever, pain, and a limp. When you first see him the tender area will probably not yet have started to swell. Soft tissue swellling is a late sign which shows that pus has already started to spread out of the bone.
Unfortunately, many children present late after they have already sought help from traditional practitioners. Often, the history is atypical and may be misleading: (1) There may be no history of an acute illness; the first sign may be a boil-like lesion which discharges spontaneously or is incised, and which is followed by a chronically discharging sinus. (2) If an infant is very ill, he may have no fever and few general signs of infection. (3) He may have signs of a severe general infection, but few local signs. So beware of osteomyelitis in any ill child who is not using one of his limbs.
X-rays are of little help in the early stages because periosteal elevation, and bone rarefaction, which are the first signs, do not appear until after infection is established[md]if the patient is over 15 years you may not see them for 10 days. Later, you will see new bone laid down under the periosteum, and patchy rarefaction. In neonates bone changes appear about the 5th day, but even this is too late for diagnosis and treatment at the optimum time.
The only sure way to confirm or exclude osteomyelitis is to incise the periosteum and drill the bone[md]urgently. In an early case fluid under pressure comes out of the hole, but this soon becomes pus. Only if nothing comes out can you be sure that a child has not got osteomyelitis[md]in that bone. Many doctors are only used to soft tissue surgery[md]they don't like drilling bone and look upon it as specialized orthopaedics. The main message of this chapter is that you must drill urgently and early! If you don't have a surgical drill, use a carpenter's drill. Unlike acute ostemyelitis, operations for chronic osteomyelitis are never urgent, and you may be able to refer the patient.
Do your utmost to drain pus from a patient's infected bone before it has stripped the periosteum off the shaft. After this has happened, the bone can only heal by forming a sequestrum and an involucrum, with all the disability that this causes. Early treatment needs early diagnosis, so everyone who provides primary medical care must be aware of osteomyelitis. Make sure that your staff in the clinics know about it, and immediately refer any child with fever and a painful limb which is not obviously pyomyositis. Because of the common practice of giving antibiotics and seeing if the patient improves, osteomyelitis is apt to be one of the worst treated diseases in primary care. One reason why it is such an important disease in the developing world, whereas it has almost disappeared elsewhere, is that patients are so often referred to hospital late, after they have been mismanaged in peripheral units.
Any of the diseases in the list below can cause pain, fever, and inability to move a limb. Local redness and oedema are later signs. The important decision is not what the exact diagnosis is, but whether you should drill or not. The site of the greatest tenderness (at the end of a metaphysis near a joint) is a useful point of differential diagnosis, and so is the young age of the patient. The tenderness is localized and is greatest on direct pressure and percussion.
MURARULAL (9 years) was brought in by his mother with a one- day history of a limp. He was tender over his right fibula and had a mild fever, but no other signs, and no X-ray changes. The diagnosis was uncertain, so his his fibula was explored. It looked normal when it was exposed, but even so it was drilled. Pus came out under pressure. His wound was dressed and left open and he was given an antibiotic. He rapidly improved and his wound healed spontaneously. A month later he had no limp and no discharge, but an X-ray showed periosteal elevation. A year later his X-ray was normal.]] BUROO (8 years) was admitted with a swelling over the upper end of her right tibia for 4 days. A small abscess pointed. This was incised and drained. A week later an X-ray was taken and considered normal. After three months of antibiotic treatment, her wound was still discharging, and X-rays showed obvious chronic osteomyelitis. LESSON (1) If osteomyelitis is a possibility, drill the bone, especially the upper tibia. (2) Drill it even if it looks normal when you expose it. If Buroo's bone had been drilled early, she would have been spared many years of disability. (2) When you have found pus, leave the wound open. FEVER AND A TENDER BONE ARE THE CRITICAL SIGNS
DIAGNOSING OSTEOMYELITIS If a child is acutely tender over a bone, he has osteomyelitis until you have proved otherwise. If his mother tells you that he has had an injury, remember that she may be wrong, and have invented an injury to explain his symptoms. 50% of patients with osteomyelitis have a history of minor trauma to the affected limb within 14 days of the onset of infection. X- rays don't help in the early diagnosis of osteomyelitis (see above), but they will exclude a fracture.
If she complains that he is ill and is not using a limb, poliomyelitis is a possibility, but there is no swelling and no bony tenderness.
If the tenderness is in his soft tissues, rather than over a bone, he is more likely to have cellulitis or pyomyositis than osteomyelitis.
If his lower leg is swollen, oedematous, tender and warm, but the tenderness is not particularly localized over a bone, should you explore it or not? Its exact site may help you to decide. If you are still in doubt, be safe[md]drill. You will probably operate on some cases of cellulitis unnecessarily, but if you don't operate, you will miss osteomyelitis.
If the point of maximal tenderness is over a joint, not over the adjacent bone, and all its movements are exquisitely painful, he probably has a primary septic arthritis. Aspirate his joint and if necessary, drain it.
If he has fever and an acutely painful hip which he refuses to move, he has osteomyelitis of the neck of his femur with septic arthritis (they are in effect the same disease). Aspirate to confirm that pus is present (7.17). Drill his upper femur and its neck, and drain his hip (7.18).
If his muscles are swollen and tender, he probably has pyomyositis[md]feel the site of tenderness carefully.
If sickle-cell disease is common in your district, suspect that infarction of the bone which is common in this condition may be causing his symptoms if: (1) Several of his bones are involved. (2) An unusual bone is involved, such as his skull, or the small bones of his hands or feet, particularly if he is an infant. Osteomyelitis can complicate avascular necrosis, so he may have both diseases. There is no certain way of distinguishing a sickle-cell crisis from osteomyelitis except by drilling. An SS patient is usually obvious clinically, but SC patients (quite common in West Africa) are not. If he is a sickler, a wait of 24 hours is reasonable, because the pain of an infarct improves rapidly.
If lesions in his hands are causing diagnostic difficulties, remember that: (1) Tuberculous dactylitis is much less painful than sickle-cell dactylitis. (2) Syphilis will probably show abundant new bone-formation elsewhere.
If his disease is some weeks old, but there are no signs of new bone-formation on his X-ray, suspect that he has tuberculosis, or AIDS, or both. This is most likely to be a diagnostic problem in the spine. Tuberculosis usually forms no new bone, whereas chronic pyogenic osteomyelitis is more likely to. Patients with AIDS make very little involucrum.
If there is much swelling, but not much fever, suspect that he may have a sarcoma, which can mimic subacute osteomylitis and may cause fever. X-rays should distinguish it. Confirm it by biopsy.
If he has pain in many joints, he probably has a rheumatic polyarthritis. Rheumatic fever and parvovirus infections are other acute and subacute causes.
If he has any other septic lesion, such as a carbuncle or middle ear disease, suspect this may be the source of his osteomyelitis.
If the diagnosis is still difficult, consider brucellosis, yaws, syphilis, and leprosy.
Fig. 7-4 DIAGNOSING OSTEOMYELITIS. A, and B, the critical signs are fever and a painful tender bone, especially close to an epiphysis. C, the only way to confirm or exclude osteomyelitis is to drill the bone. If a patient comes when pus is already present, he is too late to be easily cured, so try to diagnose osteomyelitis [f10]before [f11]this stage.
The general method for osteomyelitis
In the developing world osteomyelitis almost never presents early enough for antibiotics to cure it, so drill all patients in whom you suspect it[md]unless they happen to be so privileged that you see them within 24 hours of the start of symptoms.
As soon as you have taken pus for culture, give antibiotics systemically in high doses. Sterilizing a patient's infected bone takes a long time, so continue to give them in adequate doses for 2 weeks in acute cases, or 3 to 6 weeks in chronic ones[md]if the organisms remain sensitive. Antibiotics are of limited value in chronic osteomyelitis, especially if there is a sequestrum, so don't waste them[md]they are no use after 6 weeks. Give them again as short-term cover when the patient has a sequestrectomy.
You have three ways to find the organism responsible[md]from a blood culture, from the pus, and from any septic lesion that might have been the source of his infection. If you cannot culture the organism, at least stain the pus to find out if Gram- positive cocci or Gram-negative bacilli are responsible.
In an area in which antibiotics have not been used, penicillin may be the drug of choice. Unfortunately, the staphylococci of most districts have become resistant to it, so that chloramphenicol is likely to be the most practical drug. Cloxacillin is an alternative, but is usually more expensive. Sensitivities differ from one district to another, so adjust your treatment accordingly. Even if you have no facilities for culture, other hospitals may have, so ask them what organisms they find, and what antibiotics they use.
IF YOU SUSPECT OSTEOMYELITIS[md]DRILL!
THE GENERAL METHOD [s8]FOR ACUTE OSTEOMYELITIS EXAMINATION. Look for a septic lesion anywhere, but especially on the child's skin, from which the infection may have spread. If you find one, culture it.
BLOOD CULTURES. If he is febrile, take a blood culture (if you can), and preferably 2 more at 2-hourly intervals, before you start antibiotic treatment. If treatment has already started, they will probably be negative.
X-RAYS should always be taken, because they will give you a baseline against which to assess future changes. Expect no bony changes for 10 days in an older child, or 5 days in an infant. Examine the edge of his bone with care[md]the earliest sign is the faintest second line of new bone about a millimetre away from the shaft. You will see this more easily if you look at the film obliquely.
TOURNIQUET. A bloodless field will make the operation much easier (3.9). Elevate his limb first. Don't use an exsanguinating bandage, because this may spread the infection.
CAUTION ! Avoid using a tourniquet on an SS or a CS sickler[md]his diagnosis should be obvious clinically. In practice, no harm follows from using one on an AS sickler. So, if your's is a high sickle-cell district, there is no need to test everyone for sickling before you apply one, even if it is practical, unless haemoglobin C is present in your community.
WHITE COUNT. This will show a polymorph leucocytosis and a shift to the left.
NEEDLE ASPIRATION may be useful in deciding where to drill. Unfortunately, if pus is present under the periosteum the patient has presented late. Good results are obtained by drilling bone earlier than this. Aspiration is also useful for diagnosing septic arthritis, but not for treatment. It is no substitute for drilling or for draining a joint!
CAUTION ! (1) Explore his bone, as in Section 7.5, whether or not you find pus. (2) Failure to aspirate pus does NOT exclude osteomyelitis! The indication for drilling is the suspicion of osteomyelitis!
SPLINTS. If necessary, splint his limb in the position of function, or use skin traction for a leg.
GENERAL CARE. If necessary, correct his dehydration. Ease his pain with analgesics.
ANTIBIOTICS. Start these immediately after you have taken a swab of pus from the drill hole, and if possible a blood culture also.
If you have been able to drain the lesion early and it is clinically quiescent, and there is no bone necrosis, 2 or 3 weeks' treatment will be enough.
Before you know the results of culture, or if culture is impossible, give him oral chloramphenicol 10 mg/kg 6-hourly, or 50 mg/kg/24 hours. If possible give it intravenously for the first 24 hours. Monitor his white count. Other possibilities are: (1) Intravenous benzyl penicillin, the adult dose being half a megaunit 6-hourly. Give children 25,000[nd]90,000 units/kg/24 hours. Divide the daily dose into 6 and give it 6 times a day. (2) Any antibiotic which is effective against the common staphylococci in your district. This might be cloxacillin or trimethoprim.
CAN AN OPERATION BE AVOIDED? Almost certainly not. If he has had symptoms for less than 24 hours, and, after 24 hours on antibiotics, he is showing obvious local and general signs of improvement, antibiotics alone may cure him. Drill all other cases. Although fever and local tenderness may be improving, the infection in his bone may still be continuing, so the lesion needs draining. If he is not obviously improving on antibiotics, don't delay operation more than 24 hours. You are unlikely to see these really early cases.
Exploring a bone for pus
If you suspect that a patient has osteomyelitis, the critical procedure is to drill his painful tender bone. There is little point in aspirating it first, except sometimes to localise the site, because you will have to drill it anyway, even if aspiration is negative. If you don't find pus, or tissue fluid under pressure when you drill, you can now be sure he has not got osteomyelitis in that part of that bone, and you have done him no harm.
Although a single drill hole will drain a small abscess, it will not drain a large one, so if your drill finds pus, drill a line of at least three staggered holes at least 1 cm apart in the length of his bone. If you find pus under his periosteum, you may find that it has made its own hole in the bone: if this is big enough there is no need to drill.
NEVER HESITATE TO DRILL FOR PUS
EXPLORING ACUTE OSTEOMYELITIS INDICATIONS. Operate on any patient, particularly a child with a history of 48 hours or more of fever and a painful bone.
EQUIPMENT. A general set (4.12). One light-toothed dissecting forceps. One light plain dissecting forceps. Four light bone levers. Four heavy bone levers. One periosteal elevator. A bone drill, or a carpenter's twist drill with a 4 mm bit: don't use a smaller one.
ANAESTHESIA. Mark the tender area on his skin before you anaesthetize him. Give him ketamine or a general anaesthetic. If he is a sickler, give him 50% oxygen, make sure that he wakes quickly postoperatively, and leave an airway in until he is fully awake.
A TOURNIQUET should always be used, if the site makes it possible[md]see Section 7.4.
INCISION. Expose his bone on either side of the point of greatest tenderness. Try to incise over a bony surface which is covered with muscle, rather than one which is covered only with skin. Make the incision long enough, and start it at the epiphysis. Incise his oedematous subcutaneous tissues.
If you find pus in his muscles away from the bone, don't automatically think that he has pyomyositis. Explore deeper by blunt dissection and make sure that the pus is not arising in his bone, and has escaped into his muscles. If the pus is close to the bone, it is probably coming from a subperiosteal abscess. Use bone levers to retract his soft tissues.
If you don't find pus in his muscles, continue your incision down to the periosteum. Incise it longitudinally.
If pus immediately floods up from under his periosteum, there are three possibilities: (1) If there is no obvious hole, drill; it will help drainage. (2) If there is a big hole, the bone is already adequately decompressed, so there is no point in drilling. (3) If there is a small hole, drilling may help pus to drain.
Drill a minimum of 3 holes into the bone in a lazy zig-zag line, starting about 1 cm from the epiphyseal line and at least 1 cm apart. Make a separate small incision in the periosteum for each drill hole. Drill vertically, not obliquely, because drilling will be easier. If no pus or tissue fluid under pressure comes out, he has probably not got osteomyelitis[md]provided you really have drilled the tender area.
If pus flows from the first hole, send a specimen for culture. Drill two or more holes 1 cm apart in a lazy zig-zag line down the shaft of his bone until only blood or tissue fluid flows out of the hole from healthy bone.
Close most of the wound loosely with a corrugated drain, in the most dependent part of the wound.
CAUTION ! (1) Don't elevate his periosteum, because the bone under it will die. (2) Don't elevate too much muscle either, because periosteum receives its blood supply from the muscles over it. (3) Don't incise his periosteum beyond his epiphyseal line, or you may spread the infection to his epiphysis. (4) Don't remove any periosteum, because the bone under the raw area will not regenerate. (5) Never drill a row of holes across a bone, because they weaken it. (6) A single drill hole will not drain an abscess sufficiently.
POSTOPERATIVELY, if there is any danger that the bone might break, apply a plaster gutter splint. In his lower femur or upper tibia, apply skin traction. If his limb is painful, elevate it.
If at 2 weeks, the lesion is clinically quiescent, and X- rays show no bone necrosis, stop antibiotics. Otherwise continue them for a maximum of 6 weeks. Follow him up for 3 months; if his X-ray is normal then you need not see him again.
CAUTION ! If the bone is very osteoporotic, apply a cast before he is discharged to prevent a pathological fracture, especially if his leg is involved.
DIFFICULTIES [s7]WITH ACUTE OSTEOMYELITIS If a child has X-RAY CHANGES WHEN YOU FIRST SEE HIM, chronic osteomyelitis will follow. Proceed as above: pus in his tissues or under his periosteum will need draining. If, when you open his periosteum, you cannot see any obvious holes in his bone, drilling it will still be useful.
If he is UNDER 6 MONTHS, osteomylitis arising in the metaphysis is inevitably complicated by septic arthritis. Drain the joint also. Bone necrosis is less likely, because the arteries are not end arteries.
Fig. 7-5 UNTREATED OSTEOMYELITIS. A, late osteomyelitis of the knee with a severe valgus deformity. B, destruction of the humerus causing angulation, combined with contractures of the elbow and wrist. C, osteomyelitis in several joints. This patient could run with simple boots after his exostosis had been excised, and both his Achilles tendons had been lengthened. So save a patient's limb if you possibly can: amputation is almost always avoidable. Kindly contributed by Ronald Huckstep.
Chronic osteomyelitis
Try to refer all patients with chronic osteomyelitis[md]surgery is difficult, bloody, and dangerous. If you have to operate, do so only to relieve persistent pain or remove persistent sinuses, not merely to improve their X-rays. You will see two kinds of disease and some intermediate forms.
(1) The common form of chronic osteomyelitis with an involucrum and sequestra is the result of neglect, or treatment which was too late in the acute stage. At the right moment, when a patient's involucrum is sufficiently formed, he needs his sequestra removed and his sinuses curetted. To do this you will either have to enlarge the existing gap in his involucrum, or you will have to cut a window in it.
If an area of bone is abnormally dense on the X-ray, showing that it is dying or dead, it may be a absorbed slowly if it is attached to existing healthy bone. But if it is lying free as a sequestrum it will it act as a foreign body and will not be absorbed, so you will have to remove it. Occasionally, you can remove a small sequestrum through a sinus, but you usually need to operate.
Don't remove a sequestrum until a patient has formed enough involucrum to make a new shaft for his entire bone. Deciding when to operate is critical. Never remove a sequestrum until an X-ray shows that removing it will not leave a gap in his bone. Once you have removed a sequestrum no new involucrum will form. This is an important exception to the general rule that a foreign body should be removed immediately, especially in the presence of infection.
How can you encourage a strong involucrum to form? Encourage him to use his limb so that the newly growing bone of his involucrum is gently stressed, without being angulated or shortened. For example, in his femur put him into a hip spica, or a cast from his groin to his knee, give him crutches and allow cautious weight-bearing.
(2)Localized chronic osteitis without an involucrum, and usually with no sequestra (Brodie's abscess), takes the form of a cavity surrounded by dense sclerotic bone, and is much less common. The patient is usually an adult with a long history of localized bone pain, most often in his upper tibia or lower femur, usually without any history of an acute phase. His pain comes and goes, and gradually gets worse. When his infection flares up he has fever and a warm, painful, tender, thickened limb. X-rays show dense sclerotic bone surrounding a translucent abscess cavity. His marrow cavity is obliterated, he has no sinuses, and seldom any sequestra.
Antibiotics are unlikely to cure him. So, if you cannot refer him, explore, curette, and if possible saucerize the cavity. This will relieve his pain dramatically. If possible, leave it open to the outside, and let it granulate from the bottom. If not, leave it open to his soft tissues. If he is unwilling to accept an operation, try antibiotics for 3 weeks only.
Closing the hole in his leg. When you have removed a sequestrum, or cleared an abscess cavity, the hole that you have left behind will have to be filled somehow: (1) If you can, try to saucerize it, which means making a nearly flat surface against which muscle will lie, and eliminate any dead space. This is ideal, but is usually impossible. (2) If saucerizing it would require removing so much involucrum that it would unduly weaken the bone, make a deeper cavity, and accept dead space filled with blood clot, even though it is liable to become infected. Close it loosely with a drain. (3) You can line a gutter you have made in the tibia with a skin graft later. Don't try to make an elaborate flap, this is an expert's task.
An alternative method of closing the wound is said to have advantages under difficult conditions. Pack it with gentamicin-impregnated polymethyl methacrylate (PMMA) beads on a string (Streptotal' beads, E Merck). Close the wound by primary closure, leave one bead outside, and pull out the string at 10 days. Get the patient up at 24 hours and consider discharging him before the beads are removed. Drains and frequent dressings are unnecessary. H[um]o[um]ok M, Lindberg L, The treatment of osteomyelitis with gentamicin-PMMA beads'. Tropical Doctor, 1987;17:157. OPERATE FOR PAIN AND SINUSES, NOT FOR X-RAY APPEARANCES DON'T REMOVE A LARGE SEQUESTRUM UNTIL THERE IS A STRONG INVOLUCRUM
Fig. 7-6 SEQUESTRECTOMY. A, a sequestrum is presenting through a cloaca (hole) in the bone. B, the cloaca has been enlarged and the sequestrum is being removed. Kindly contributed by John Stewart.
SEQUESTRECTOMY INDICATIONS. If possible refer the patient. If you cannot refer him, consider removing any sequestrum which you cannot remove through a sinus. Don't operate to remove a large sequestrum until: (1) The involucrum extends across the defect that will follow. (2) The involucrum is made of rigid bone. If you remove a sequestrum too early, involucrum will not form to bridge the gap. (3) His limb must be capable of being supported, either by the remaining healthy shaft, or by a sufficiently strong involucrum.
CAUTION ! If you remove the sequestrum too early the involucrum will stop making new bone, and will collapse, so that he has no hope of a sound limb.
ANTIBIOTICS. Culture the pus and give the appropriate antibiotic for at least 4 days before you operate, and for at least 2 weeks afterwards.
X-RAYS. Examine AP and lateral films carefully to see where the sequestra are. If ordinary films don't show enough detail inside the bone, take more with greater penetration.
METHYLENE BLUE may help to show up sequestra during an operation. Get it from the laboratory, sterilize a 1% solution, and inject it into the sinus 24 hours beforehand. It will stain everything blue, except the sequestra, which will remain white.
EQUIPMENT. As for acute osteomyelitis (7.5), plus 6 and 10 mm osteotomes and gouges; 10 and 15 mm chisels; a 250 g mallet, a Volkmann's scoop, a curved sequestrum forceps, and a bone nibbler. In the thigh you will need strong retractors, a strong assistant, and a good light. Sterile saline to flood the wound.
ANAESTHETIC. Ketamine (A 8.1) or general anaesthesia (A 10.1). Have blood cross matched, and a drip running.
TOURNIQUET. Bleeding can be alarming, because infected tissues are very vascular, so always use a tourniquet (3.9), unless you are operating on the patient's proximal femur or humerus, or he has sickle-cell disease (7.4). His anatomy may be very distorted, and if you don't use a tourniquet, important structures will be even more difficult to recognize. If you happen to see any vessels as you operate, tie them.
INCISION. Drape everything so as to leave only the operation site exposed. Wrap the distal part of his limb in a towel. Start by probing any sinuses to see where they go. They often go to the same place. Where possible, make one of the standard incisions described later. These are given for the entire length of the bone. You will usually only need part of an incision. Very often it will include the draining sinuses. If possible, make the incision over one of the larger gaps in the involucrum. The tissues will be tough, so use a sharp scalpel.
Open his indurated periosteum in the length of the incision, and elevate it on each side. Either: enlarge an existing gap in the involucrum with a gouge. Or: drill holes so as to outline a window, as in Fig. 7-6. Then open it with an osteotome.
CAUTION ! (1) Scar tissue may have disturbed the normal position of the nerves and arteries. (2) Don't break the bone. If you have carefully outlined the window with drill holes, this will be less likely.
Use a hammer and gouges or chisels to cut bits of bone from the involucrum until you get to his marrow cavity. Look for sequestra inside it.
Sequestra move separately from the surrounding involucrum. If they have been covered by tissues they are ivory white and have a brittle texture which is different from ordinary bone. If they have been exposed to the air they may be black or grey.
Use a hammer and gouge to chip away the involucrum around each sequestrum so that you can remove it. To minimize weakening, window the bone longitudinally. Round or taper the ends of the window; these will be stronger and allow it to fill with soft tissue more easily. Pull out sequestra with sequestrectomy forceps. If necessary, remove more involucrum to free a sequestrum. There will be pus, but usually not much.
When you have removed all the sequestra you can find, explore the abscess cavity up and down quite widely with a probe. If necessary, extend the skin incision and enlarge the hole in the involucrum until you have explored the whole cavity. Scrape the granulation tissue in its walls with a bone curette (Volkmann's spoon), until you reach healthy bone. If sinus tracts in the soft tissues are short, excise them. If they are long, curette them.
If bone overhangs the edge of the cavity, chisel it away. When necessary, flood the wound with warm saline and suck it out.
CAUTION ! (1) If the operation is to succeed, you must remove all sequestrated bone. The X-rays will suggest how much there is, but expect to find more.
CLOSURE. If possible, don't close the wound. Instead, leave it open and allow his soft tissue to fall into it, as in Fig. 7-10. Or, close the soft tissues loosely over the bone and keep the most dependent place open with a corrugated drain. Fix the drain to the wound with a stitch, because it may go inside the wound, get lost, and act as a foreign body.
If you leave the wound open, apply vaseline gauze followed by plenty of plain gauze.
If the wound is deep and large, pack it with ribbon gauze or a bandage.
Apply a pressure dressing for the first 48 hours, but watch his circulation distally. After some weeks there will be a floor of healthy granulation tissue, which will either epithelialize spontaneously, or can be grafted. As you change the dressings you will find that fewer are needed as it closes. A large wound takes a long time to close.
CAUTION ! (1) Vaseline gauze is a useful first dressing; thereafter use plain gauze. (2) Remove all the dressings you put into a wound. If any fragments remain, they will act as foreign bodies, and cause infection to persist. If you use pieces of gauze to pack a wound, knot them together, so that you can pull them all out at the same time.
POSTOPERATIVELY, the wound will ooze. If he is anaemic and ill, consider transfusing him, but remember the danger of HIV. Do all you can to improve his nutrition.
He will need quantities of sterile dressings. Change them daily at first, then twice a week, until his wound is small enough for you to treat him as an outpatient. Remove any dead tissue as necessary. Encourage him to use his limb, to walk with crutches without weight-bearing if the lesion was in the leg, and to use his arm as much as he can. In severe cases this active movement will encourage the periosteum to produce a really robust involucrum, which will not happen if he rests his limb completely.
If his involucrum might fracture, apply a cast and window it. Or, in the leg, apply skin traction. If a large area of bone has been destroyed, careful splinting is essential.
X-ray him at a convenient time postoperatively. This is only necessary to assess the strength of his leg for weight bearing, or, if sinuses persist, to look for more sequestra.
LOCALIZED OSTEITIS [s7]BRODIE'S ABSCESS This is the sclerosing type of osteomyelitis. Follow most of the steps above. Use gouges and chisels to remove enough sclerotic bone to reach the abscess cavity. Curette it, saucerize it if you can; failing this, leave it with gently sloping edges. Pack the medulla with sterile gauze as described above.
DIFFICULTIES [s7]WITH CHRONIC OSTEOMYELITIS If he BLEEDS SEVERELY into his dressings, take him back to the theatre, open the wound, tie off any bleeding vessels, repack it tightly, and apply a pressure bandage. Back in the ward raise his limb, and put a cradle over it, so that you can inspect it readily. Don't leave a pressure dressing in place for more than 48 hours, or it will promote infection.
If PUS CONTINUES TO DISCHARGE from his wound it may be due to: (1) Inadequate excision of fibrous tissue and curettage of the granulations. (2) Leaving sequestra behind. (3) Leaving a swab or piece of dressing or vaseline gauze in the wound. (4) Not opening up the cavity in the bone widely enough.
If his leg has united in a DEFORMED POSITION, accept it if you can.
If he has a PATHOLOGICAL FRACTURE, splint his limb in the correct position in a cast until it has healed soundly. While it is healing pay special attention to the alignment of his knee and ankle. Keep the wound open, dress and toilet it regularly. Skin traction is suitable for the femur and upper tibia, especially under the age of 14. Bone traction is contraindicated because you should not put a pin through bone if there is infection nearby. This may be unavoidable if there is significant shortening (unusual).
If you are wondering if AMPUTATION is justified, refer him for a second opinion before you do so. It may be indicated if: (1) The infection is so extensive that antibiotics and surgery have been unable to cure him. (2) So much bone has to be removed that his leg would work better with an amputation and a prosthesis. (3) His life is in danger from infection. (4) He is in constant pain.
If osteomyelitis has followed the ILL-ADVISED APPLICATION OF A PLATE, remove it. The only exception is an AO compression plate. If this is still maintaining compression, leave it. If it is holding a gap open between the fractured ends, remove it.
If he is an INFANT, his bone will probably heal well, even after you have removed a large sequestrum. If an operation is needed, don't hesitate to operate as soon as a satisfactory involucrum has formed.
If he has SICKLE-CELL DISEASE, he is likely to form new bone particularly slowly.
If he has ARC, (he is HIV-positive with weight loss and lymphadenopathy), he may have an unusual type of low-grade slowly progressive and sometimes multiple osteitis, with little sclerosis or involucrum and no large sequestra. Infection may spread from his tibia through his knee to his femur. Antibiotics have little effect, and you will probably have to amputate.
Osteomyelitis of the humerus
Osteomyelitis usually occurs at the ends of a patient's humerus, more often at the upper than the the lower end. You can expose and drill them through quite limited incisions; the upper end anteriorly and the lower end either anteriorly or posteriorly. If absolutely necessary (rare), and if you cannot refer him, you can expose his humerus from end to end by approaching it from the antero-lateral side.
The main danger is that you may injure his radial nerve, as it winds round his humerus posteriorly. If you are working near it, find it first so that you can avoid it.
Proximally, enter his arm between his pectoralis major and his deltoid. Distally, enter it between his brachioradialis and his biceps. As you do so, retract his radial nerve laterally, and his musculo-cutaneous nerve medially with his biceps.
Fig. 7-7 OSTEOMYELITIS OF THE HUMERUS. A, the approach for the upper end. B, the anterior approach to the lower end. C, the posterior approach to the lower end. D, the incisions to approach the ends of the bone. E, a cross section a little below the mid point of the arm above the origin of brachioradialis, to show the approach to the middle of the shaft and the position of the radial nerve.
OSTEOMYELITIS OF THE HUMERUS Follow the general methods for osteomyelitis, in Sections 7.4 to 7.6. Always apply a tourniquet for operations on the middle (difficult in a young child) or lower third of the humerus.
PROXIMAL END. Approach this in the patient's deltopectoral groove. Find his cephalic vein, and try to displace it medially. If necessary, tie it proximally and distally.
Reflect his deltoid laterally, and expose his humerus by using two pairs of bone levers. Both the heads of biceps, and coracobrachialis lie medial to the insertion of the tendon of pectoralis major.
DISTAL END, POSTERIOR APPROACH. Make a midline incision in the posterior surface of his lower arm, and end it 3 cm above his epicondyles, so as to avoid his olecranon pouch. Don't extend the incision up into the middle third of his arm, or you will injure his radial nerve. Divide the tendon of his triceps and the muscle under it to expose his humerus.
DISTAL END, ANTERIOR APPROACH. Open his arm between his brachioradialis laterally, and his biceps medially, as in B, Fig. 7-7. Separate these muscles by blunt dissection, find his radial nerve and leave it laterally. Incise his brachialis medial to the nerve and expose his humerus. Retract his muscles by placing two pairs of bone levers subperiosteally.
If necessary, you can split his brachialis to within two fingers' breadth of his epicondyles without entering his elbow joint. Don't extend the incision beyond the flexor crease of his elbow, because you may cut his radial artery.
THE SHAFT OF THE HUMERUS. Refer him if you can. If you cannot refer him, put a sandbag under his shoulder on the same side. Drape his whole arm. Extend the approach to his upper humerus distally, or the lower anterior approach proximally.
Distally, divide the deep fascia to expose division between biceps and brachialis. His musculo-cutaneous nerve lies between these muscles. Displace it medially with his biceps. Separate his biceps and his brachialis and find his radial nerve. Above the origin of his brachialis, it lies between biceps and his triceps and winds posteriorly round his humerus in his radial groove.
Postoperatively, put his arm in a sling and encourage active movements within the confines of the sling, or apply a backslab.
Osteomyelitis of the radius
You can expose the distal two-thirds of the shaft of a patient's radius by approaching it from its anterolateral side. The difficult part is its proximal third, which is covered by his supinator muscle, through which his posterior interosseous nerve passes. So avoid operating here if you possibly can. Enter his forearm between his brachioradialis laterally (it has a characteristic flat broad tendon) and his flexor carpi radialis medially. His radial artery lies between these two groups of muscles. Pronator teres is inserted into the middle of the radius. You can approach the bone on either side of this muscle, and displace it medially or laterally. Distally, pronator quadratus covers the radius, so you will have to divide it.
OSTEOMYELITIS OF THE RADIUS Follow the general methods for osteomyelitis in Sections 7.4 to 7.6. Apply a tourniquet (3.9, 7.4).
Lay the patient on his back with his arm on a side table, and his forearm supinated. Define the line of the incision by identifying the tendons of his palmaris longus and his flexor carpi radialis at his wrist. Incise just lateral to his flexor carpi radialis. Cut here along the dotted line in B, Fig. 7-8. You will probably only need to incise over the distal third of the bone. If necessary, you can continue the incision proximally to include its middle third.
CAUTION ! Don't extend the incision to the proximal third, or you may injure structures on the front of his elbow.
Cut the deep fascia in the line of the skin incision. Tie any vessels you meet. Retract laterally the three muscles that lie along the lateral border of his forearm[md]brachioradialis, and extensor carpi radialis longus and brevis. When you retract them, his superficial radial nerve will be included with them. This is sensory only.
Find his radial artery and vein, which lie between the lateral group of muscles and flexor carpi radialis. Retract them laterally. You will now have exposed the anterolateral surface of the distal two-thirds of his radius.
Postoperatively, apply plaster only if a fracture threatens or has occurred. If so, apply a tubular forearm cast leaving his wrist and elbow free. The remaining bone will prevent angulation. Encourage him to use his arm.
Fig. 7-8 EXPOSING THE RADIUS AND ULNA. A, a cross-section of the arm at the level of the radial tuberosity. A, B, and E, to expose the patient's radius, enter his forearm between his brachioradialis and his two radial wrist extensors laterally, and his flexor carpi radialis medially. Brachioradialis (E) has a long flat tendon, so you can recognize it easily. The ulna is subcutaneous, so you can approach it easily (C). D, a transverse section through the middle of the arm. E, brachioradialis and flexor carpi radialis, showing the incision for the lower part of the radius passing between them. Note: E, is schematic only, both tendons lie much more laterally in the arm. Partly after Watson Jones, Longman, with kind permission.
Osteomyelitis of the ulna
The ulna is not uncommonly involved by haematogenous osteomyelitis. It has a subcutaneous border throughout its whole length, so it is easy to expose.
OSTEOMYELITIS OF THE ULNA Follow the general methods for osteomyelitis in Sections 7.4 to 7.6. Apply a tourniquet.
Drape the patient's arm separately from his trunk. Make an incision anywhere from the tip of his olecranon to his ulnar styloid. Use part of the incision in C, Fig. 7-8, not all of it. Cut straight down on to the shaft of the bone and elevate his periosteum. This will carry the muscular origins of his flexor carpi ulnaris anteriorly, and those of his extensor carpi ulnaris posteriorly.
Postoperatively, apply plaster only if a fracture threatens or has occurred. If so, apply a tubular forearm cast leaving his wrist and elbow free. The remaining bone will prevent angulation. Encourage him to use his arm.
Osteomyelitis of the femur
This is common. If you make the diagnosis early, you need only drill the upper or lower end of a patient's femur, for which you will only need a limited incision. If you make the diagnosis late, osteomyelitis may have involved the entire shaft of the bone. If you approach it laterally, you can expose it from its greater trochanter to its lateral condyle. Cut straight through his vastus lateralis down to the bone. The head and neck of his femur are more difficult to reach. If osteomyelitis has involved the neck, which is partly inside the capsule of his hip joint, it will have also involved the head and his hip joint. This will need draining. You will find the anterior approach easiest for drilling the femoral neck (7.18). Refer him if you can.
Osteomyelitis of the femur commonly involves the hip joint, and occasionally the knee, but seldom both. When a child's knee is involved, his distal femoral epiphysis may slip. When this happens, the shaft of his femur usually slips anteriorly in front of the distal epiphysis[md]unlike trauma in which it slips posteriorly (79.16). Try to diagnose and treat him early; prevent further slipping by applying skin traction up to his mid thigh. You may need to manipulate him under anaesthesia.
Fig. 7-9 EXPOSING THE FEMUR. You can expose a patient's femur by cutting straight down to it along the lateral side of his thigh. A, prop him up on a sandbag. B, the middle third of his femur exposed. C, a cross-section of the middle of his thigh. D, a cross-section about 4 cm above his adductor tubercle. Kindly contributed by John Stewart.
THE SHAFT OF THE FEMUR Follow the general methods for osteomyelitis in Sections 7.4 to 7.6. Cross-match two units of blood for the patient[md]this can be a bloody operation, especially if you go too far posteriorly.
Lay him on his back with a sandbag under his hip on the infected side. Use a tourniquet when you operate on the middle or distal thirds of the bone.
Cut along the relevant part of the dotted line in A, Fig. 7- 9. This extends from just distal to his greater trochanter to just above his lateral femoral condyle. Cut through his skin, subcutaneous fat, and fascia lata. Then cut straight through his vastus lateralis, down to the lateral side of the shaft of his femur. There will be some bleeding, but much less than there would be if you cut posteriorly on to his linea aspera.
CAUTION ! (1) Take care to stay on the lateral surface of his femur. (2) Avoid his linea aspera, and the vessels which run close to it. (3) Remember that a small child does not have the blood volume of an adult, and that in him the loss of a given volume of blood is proportionately more serious (53-3).
If you are operating towards the distal end of a patient's femur: (1) Don't enter his knee joint or his suprapatellar bursa. (2) Stay strictly on the lateral side of his knee. (3) Don't go posteriorly, or you may injure his lateral popliteal nerve. (4) Don't go medially because you may injure the main vessels.
If he bleeds from the vessels of his linea aspera, catch them with a haemostat, and transfix them with a ligature on a curved needle. Pass the needle round under the haemostat and the vessels at least twice. Pull the ligatures tight as you release the haemostat. They are usually too deep into the wound to tie on the tip of a haemostat. If you cannot reach a bleeding vessel, pack the wound tightly, raise the foot of the table and wait for the bleeding to stop.
Postoperatively, apply skin traction. This will be easier than applying a medial plaster splint, which is the alternative. Later, put him in a hip spica or a plaster cylinder from his groin to his knee, give him crutches, and encourage weight- bearing.
Fig. 7-10 OSTEOMYELITIS OF THE TIBIA. A, and B, exposing the upper end of a patient's tibia. Note that the incision has been made over muscle on the lateral side. C, and D, exposing his lower tibia; again the incision has been made over muscle on the lateral side. E, F, and G, exposing the shaft of his tibia. The main part of the incision has been made on the lateral side and a flap reflected medially. H, and I, allowing the edges of the flap to fall into the wound to close it postoperatively.
Osteomyelitis of the tibia
The tibia is one of the most common sites for osteomyelitis, which is fortunate, because it is one of the easier bones to approach. If you operate early, drill it through a short incision. If you operate late, don't do so before firm involucrum has formed, or you will leave a gap in the bone which will need extensive reconstructive surgery to repair. A gap is particularly likely in the tibia, because so much of it is subcutaneous.
CHEPESOK was a charming little Pokot girl of about 8 with osteomyelitis of her tibia. The stock of ketamine was finished, so, rather unusually, she was given a subarachnoid (spinal) anaesthetic. Half way through the operation she sat up and said You will take out all the bad bone, won't you! LESSONS (1) These can be very rewarding patients. (2) Primary Anaesthesia' considers childhood a contraindication to subarachnoid anaesthesia unless you are expert (A 7.4).
OSTEOMYELITIS OF THE TIBIA Follow the general methods for osteomyelitis in Sections 7.4 to 7.6. Apply a tourniquet.
DRILLING. Make a linear incision 1 cm lateral to the anterior border of the patient's tibia, as in Fig. 7-10.
SEQUESTRECTOMY. Make the main part of the incision over his muscles rather than his bone. Make the longitudinal part of the incision 1 cm lateral to its anterior border. Proximally, don't extend it higher than his tibial tubercle. If possible, avoid taking it across his tibia where this is infected, because the scar from the incision will stick to the bone and become painful later. If necessary, curve its upper and lower ends to cross the anterior border of the bone.
Reflect his skin with his periosteum. They will probably be so closely bound together that you will be unable to separate them. Hold the skin flap lightly with skin hooks. Incise the periosteum midway between the anterior and posteromedial borders of the bone.
If the position of sinus tracks make it necessary, you can make a medial flap in the same way, with most of the length of the incision over the muscle on the medial side of his tibia.
After you have removed the sequestrum: (1) If the tissues are not too tight, you can close the wound lightly and insert a drain in its lower part. Or, (2) if the tissues are tight, you can let the skin edges fall into the wound and leave it unsutured, as in H, and I, Fig. 7-10. Healing will take longer like this. Apply a posterior slab or a long leg cast with his ankle in neutral, and his knee in 20[de] of flexion. Mark a window in it while it is still soft, cut out the window with a knife (70.2), or with a plaster saw 2 days later when it is hard. Dress the wound through this window.
If you have left a deep trough in the front of the tibia which is slow to granulate and epithelialize, graft it.
CAUTION! (1) Don't go directly anteriorly through the subcutaneous surface of his tibia. (2) Make sure your assistant retracts the skin flaps gently, because they can easily necrose.
Give him a long leg cast with a walking heel, then encourage early weight bearing with as normal a gait as possible.
DIFFICULTIES [s7]WITH OSTEOMYELITIS OF THE TIBIA If there is a VERY LARGE SKIN DEFECT IN A PATIENT'S TIBIA which is slow to heal consider making relieving incisions about 15 cm long down the medial and lateral sides of his calf, and pushing his tissues forward to cover part of the gap. Hold them in place with sutures or strapping. Graft the gap made by the relieving incisions.
If a LARGE PART OF HIS TIBIA has been destroyed, and inadequate involucrum has formed, try to get this fibula to hypertrophy before referring him. Walk him in a below-knee caliper. Later, refer him for an operation in which a length of his fibula is moved across to form a new tibia. This is done in two steps, moving one end at a time. The transposed piece of his fibula can hypertrophy greatly. Destruction would not have occurred if you had removed the sequestrum at the right time.
If: (1) you MISTAKENLY REMOVED A SEQUESTRUM before a firm involucrum had formed, or (2) the periosteum in the middle third of the shaft of the tibia is destroyed, keep him in a Sarmiento cast (81.5), to support his leg and prevent his foot going into inversion until such a time as you can refer him to have his fibula moved over under his tibia.
If osteomyelitis has COMPLETELY DESTROYED A CHILD'S TIBIA, his fibula may hypertrophy, and push his foot into varus; refer him.
Fig. 7-11 OSTEOMYELITIS OF THE FIBULA. Approach a patient's fibula between his peroneal muscles anteriorly, and his soleus posteriorly.
Osteomyelitis of the fibula
Osteomyelitis of the fibula is uncommon. If the patient's tibia is not involved, you can remove a sequestrum from his fibula as soon as is convenient, without waiting for an involucrum to form, because his tibia will support his leg. You can expose any part of his fibula by approaching it between his peroneal muscles anteriorly and his soleus posteriorly. His posterior tibial nerve and vessels are well out of harm's way; but be careful not to injure his peroneal artery and veins which are close to the postero-medial angle of the shaft of his fibula. If the head of his fibula is involved (rare) be very careful not to injure his common peroneal nerve.
OSTEOMYELITIS OF THE FIBULA Follow the general method for osteomyelitis in Sections 7.4 to 7.6. Apply a tourniquet.
INCISION. Lay the patient on his side with his affected leg uppermost, and his knee slightly bent. Use the appropriate part of an incision which starts 5 cm below the head of his fibula, and curves gently posteriorly down towards his lateral malleolus. Reflect short skin flaps anteriorly and posteriorly. Avoid the head and neck of his fibula, because his common peroneal nerve winds round it. If you have to remove sequestra from the head, try to pull them down from below.
If you are working on the middle third of his fibula, incise the periosteum vertically, and separate muscle from bone subperiosteally.
CAUTION ! The peroneal vessels are close to the medial side of the fibula, so strip the muscles carefully.
EXCISING THE FIBULA. If necessary, and he is more than 10 years old, you can remove the entire shaft of his fibula, except for its lower 5 cm. Use a Gigli saw, not an osteotome, or bone- cutting forceps, which will splinter it. Be very careful to avoid his common peroneal nerve winding round its upper end.
Fig. 7-12 OSTEOMYELITIS OF THE CALCANEUS. Splitting a patient's heel is the easiest approach to his calcaneus; a split heel is no disability. This is the Gaenslen incision. A, and B, after the operation. C, exposing the calcaneus. D, osteomyelitis of the right calcaneus with a sinus. After Edmondson AS and Crenshaw AH, Campbell's Operative Orthopaedics', Fig. 10-18. CV Mosby, with kind permission.
Osteomyelitis of the calcaneus and talus
Osteomyelitis of the calcaneus can follow blood spread, a septic infection of the heel, traction with a calcaneal pin, or an open fracture. The calcaneus is a completely cancellous bone which never forms an involucrum and seldom an isolated sequestrum. Pus soon perforates its periosteum without destroying much of its cortex. The most practical operation, and some would say the only one, is to remove the whole of the patient's calcaneus to give him an ugly but surprisingly useful foot.
Fungi sometimes infect the calcaneus and cause multiple sinuses. If chemotherapy fails, as it usually does, try radical excision in early cases, and consider amputation in late ones (31.3, 56.6).
OSTEOMYELITIS [s8]OF THE CALCANEUS AND TALUS THE CALCANEUS ANAESTHESIA. You will need to lie the patient prone, which makes anaesthesia difficult (16.12). If possible, intubate him and control his ventilation. If this is not possible, give him a general anaesthetic and lie him on his side.
INCISION. Follow the general methods for osteomyelitis, in Sections 7.4 to 7.6. Apply a tourniquet.
If infection is limited to the pin track, and he is lucky, opening up and scraping out the granulation tissue from around the pin track may occasionally be all that he needs.
If you are draining a soft tissue abscess or want to remove a window from the cortex during the acute stage, you can approach his calcaneus from either side.
If his whole calcaneus is involved, remove it completely. Make a longitudinal incision right down to the bone, and shell it out. You cannot remove it from inside its periosteum, so strip this away from the soft tissues of his heel and remove the bone completely, either as a single piece or in several smaller ones.
Lie him prone with a support under his foot. Make a longitudinal incision exactly in the middle of his heel. Start it in the midline level with the base of his fifth metatarsal. Extend the incision proximally to split the distal end of his Achilles tendon for about 3 cm. Incise his plantar aponeurosis in a plane between his flexor digitorum brevis and his abductor digiti minimi.
CAUTION ! Start in the midline, stay close to bone and reflect everything you meet medially and laterally. In this way you will avoid important structures, especially his plantar nerves entering from the medial side of his foot.
POSTOPERATIVELY, allow the wound edges to collapse together, but don't suture them. Apply much gauze. Hold his ankle in a neutral position with a gutter plaster splint held with a crepe bandage. As his wound heals, start him walking with crutches; later he can progress to full weight-bearing. The edges of the scar will turn deeply inwards and split his heel into two cushions. If its surface is uneven, suggest that he pads his shoe.
THE TALUS He presents with a painful ankle. X-rays show an irregular dense talus. Sequestra are unusual. If you apply a below knee cast and give him an antibiotic for 3 weeks the infection will probably settle without surgery, but degenerative arthritis may follow. If he has severe persistent disease refer him for the removal of his talus.
Fig. 7-13 A SEQUESTRUM IN THE SKULL. This patient has a dense white sequestrum in his skull, which has moved forwards. He was reported as having osteomyelitis. Burns of the scalp are however the commonest cause of necrosis of the skull. Another cause is septic thrombophlebitis of the scalp, which causes it to necrose and expose the bone underneath. Kindly contributed by Gerald Hankins.
Osteitis of the cranium
Flat bones like those of the skull differ from long ones: (1) They have little marrow between their diploe, so that when they are infected the condition is an osteitis, rather than an osteomyelitis. (2) Unlike long bones, which make much callus when they fracture, and an obvious involucrum and sequestra when they are infected, fractured flat bones make little callus; infected ones seldom sequestrate, and don't form an involucrum. When sequestra do form in the skull, it is usually because a burn has destroyed the blood supply to the outer diploe.
A patient with osteitis of the skull has pain (headache'), combined with tenderness and swelling over the lesion which may be particularly marked. It may be secondary to:
A burn (common, 58.32), as when an epileptic falls into a fire and burns his head.
A head injury (63.7). Minimize the risk of osteitis by toileting his wound carefully. If it does occur, you may have to remove a dead piece of bone.
Frontal sinusitis (25.8). He presents with a persistent headache. The bone above his orbit is prominent and tender, and he may have a swelling of his scalp which may extend as far as his vertex. X-rays show thickening of his skull and enlargement of his frontal sinus.
Pyaemia causing metastatic lesions in his skull. The skull is very vascular and has no end arteries, so the infection will probably settle without the need for drainage.
An extradural abscess (5.4a). The pus under his skull is more important than the pus in it.
Septic thrombophlebitis of his scalp which has caused it to necrose and expose his underlying skull. This condition is seen in malnourished children, and is related in its pathology to cancrum oris (26.6). It is not a true osteitis, but is rather a loss of the outer periosteum leading to sequestration of the diploe.
OSTEITIS OF THE CRANIUM When you plan the incision, consider the arteries of the patient's scalp, and incise between them. For example, don't make a transverse incision in his temple which will divide his temporal artery. Split skin grafts will not take on bare skull, but they will take on granulations. So, if necessary, remove dead bone, apply saline dressings for a few days, and wait for granulations to form. See Figure 63-11 and Sections 57.3 and 58.32.
CAUTION ! (1) If a sequestrum is firmly anchored, use an osteotome and light taps from a heavy hammer[md]don't open his dura or injure his brain.
FOLLOWING FRONTAL SINUSITIS. If you cannot refer him, define the extent of his frontal sinus with X-rays. Shave the anterior 3 cm of his scalp. Make a long incision above his hairline from ear to ear, and reflect the skin of his forehead downwards as a flap, based on his supraorbital vessels.
Remove the anterior wall of his frontal sinus; try to curette away all its lining, so that no more fluid will form. If possible, try to establish drainage through into his nose. Insert drains through stab incisions above the outer end of each eyebrow. Lead them horizontally from the frontal region of the sinus through these incisions. Or, insert them below his inner eyebrows. Close the flap.
Osteomyelitis of the jaws
Osteomyelitis can affect either of a patient's jaws, usually the lower one, and can take various forms:
Osteomyelitis complicating an infected tooth socket in an adult is more common in the mandible (5.8, 26.3). Suspect it if he has pain, swelling, tenderness, trismus, and fever after he has had an infected tooth removed (sometimes months before), or an alveolar abscess drained. If his osteomyelitis becomes chronic he may have sinuses over his lower face, or over the inferior border of his mandible (see Fig. 26-8). Often, he has trismus. His offending teeth are usually loose, and you may see pus discharging around them.
Osteomyelitis complicating an open fracture, (62.7, 69.7), especially a comminuted one of his lower jaw (unusual). A thorough wound toilet should prevent this, provided it is done reasonably early. The mandible has a good blood supply, so that even small pieces of bone may live, if they have some soft tissue connection.
Osteomyelitis in children, especially malnourished ones, may be the result of a subacute necrosis folowing septic thrombophlebitis. This is probably a manifestation of the same process that causes cancrum oris (26.6) and septic thrombophlebitis of the scalp (7.14). Osteomyelitis, particularly of the maxilla, can also be a complication of sickle-cell disease. A child's upper teeth become loose, a sequestrum forms, and pus discharges: (1) inside his mouth, (2) on the surface of his cheek close to his nose, or (3) at his zygomatic process.
OSTEOMYELITIS OF THE JAWS ACUTE OSTEOMYELITIS If a patient's osteomyelitis is due to an infected tooth, extract it, and see Section 26.3.
If it is due to an open fracture, it is probably subacute and can be satisfactorily treated by antibiotics. If infection persists, look for a sequestrum and if you find one, remove it.
If it is haematogenous (unusual, and more often in his lower jaw), drilling is not required, treat him with antibiotics. If infection persists, look for a sequestrum and remove it.
CHRONIC OSTEOMYELITIS X-RAYS. PA and oblique views may show a sequestrum (uncommon), or a patchy osteoporosis accompanied by new bone formation (dense thickened bone).
TREATMENT. Give him antibiotics (penicillin or chloramphenicol, 2.7) for up to 2 weeks. Improve his oral hygiene. Remove any loose teeth in the area.
If no sequestrum is present, extract his tooth or teeth.
If a sequestrum is present, remove it. There is no need to wait for an involucrum to form unless the sequestrum is very large. Involucra form poorly in the mandible, which, in this respect, is intermediate in its behaviour between a long bone and a flat one.
SEQUESTRECTOMY MAXILLA. As the dead bone separates, it loosens. Wait for the child's nutrition to improve. If the sequestrum is small and loose, remove it under sedation only. If it is larger, remove it under ketamine in toto or in pieces. If necessary, chip away a little living bone. Curette the residual defect. If the cavity bleeds, pack it for 5 minutes.
MANDIBLE. To avoid an unsightly scar, incise 1 cm below the inferior border of the ramus of his mandible. Cut through healthy skin and subcutaneous tissue near the sequestrum. Avoid, or clamp and tie, his facial artery and vein, as they cross the the ramus of his mandible 3 cm (in an adult) anterior to its angle. Chisel away the outer bone covering the sequestrum and curette the cavity. Close the wound loosely, leaving a corrugated drain through one end, or through a separate stab wound.
CAUTION ! Don't operate on a malnourished child until his general condition is acceptable.
DIFFICULTIES [s7]WITH OSTEOMYELITIS OF THE JAWS If a patient has has a HARD DISCOLOURED SWELLING of the soft tissues of his neck, suspect ACTINOMYCOSIS (rare), especially if it has multiple sinuses (uncommon in osteomyelitis), and persistently negative jaw X-rays rays. Look for sulphur granules' in the discharge from them. If the diagnosis is confirmed treat him with large does of penicillin (500 mg 4 times a day), or tetracycline over a period of at least 6 weeks.
Osteomyelitis of the spine and pelvis (both uncommon)
The spine can be affected by tuberculosis, or by suppurative osteomyelitis due to a variety of pyogenic organisms, especially Staphylococcus aureus, streptococci, Brucella, and occasionally S. typhi. Tuberculosis is always chronic, but pyogenic osteomyelitis can be acute, subacute, or chronic.
A patient with acute osteomyelitis of his spine is usually a very ill child with fever and severe back pain, usually in his lumbar region. There may be some inflammatory oedema over his spine, which is very tender, and may be arched backwards by muscle spasm, as if he had tetanus or meningitis. X-rays may show a paravertebral abscess, usually with normal bones. He may be paraplegic as the result of inflammatory oedema involving his cord. If he is to have any chance of survival the pus must be drained, by removing the transverse processes of some of his vertebrae and part of some of his ribs.
If his osteomyelitis is chronic, he is usually an older child or adult. He is in pain, but has little or no fever, and no arching of his back.
Tuberculosis of the spine is described in Section 29.4, which also gives a detailed description of costotransversectomy for the drainage of a cold abscess. Here we give a short description of the same operation for acute osteomyelitis.
Paraplegia associated with osteitis of the spine, is usually due to inflammatory oedema pressing on the cord. If you can see an abscess on the X-ray, operate; but if there is no X- ray evidence of an abscess, you may still find pus. If he has no spasms, he will probably recover in 3 to 6 months. But if he has extensor, or worse, flexor spasms, his paraplegia is likely to be permanent.
OSTEOMYELITIS [s8]OF THE SPINE AND PELVIS THE SPINE DIFFERENTIAL DIAGNOSIS. See also Section 29.4a and Fig. 29-3a.
If the bodies of a patient's vertebrae are abnormal, but not his intervertebral discs, suspect malignancy.
If the disc and the adjoining bone are diseased, especially if this is maximal anteriorly, suspect infection. The diseased bone softens, and the vertebral bodies become wedge-shaped.
If there is other evidence of tuberculosis (a positive sputum or suggestive chest X-rays etc), treat him for it.
If there is marked osteoporosis but no osteosclerosis, and tuberculosis is common in your district, treat him for it.
If there is porosis and sclerosis, he may have osteomyelitis or tuberculosis, so:
(1) Refer him for costotransversectomy, or if this is impossible, do it yourself, especially if tuberculosis is uncommon in your district and the condition is acute or subacute.
Or, (2) treat him for both diseases for 3 to 6 weeks. During this time a non-tuberculous lesion should have improved greatly (no pain and little or no tenderness), whereas a tuberculous one will have changed very little.
If you are in doubt as to the diagnosis, treat him for tuberculosis. In most developing countries 90% of cases of osteitis of the spine are tuberculous.
If he is paraplegic, or has a paravertebral abscess (pyogenic or tuberculous) he needs a costotransversectomy. If he has acute osteomyelitis, this is particularly urgent, so refer him or proceed as follows. Aim to drain the pus; there is no need to drill.
METHOD. Give him a general anaesthetic, intubate him, and control his ventilation (A 18.1). Lie him prone with a pillow under his chest to keep his abdomen free. Make a straight longitudinal 10 to 15 cm incision over his spinous processes, or, better, an incision curved towards his left side with its ends over his spinous processes. Use a scalpel and a periosteal elevator to approach the bodies of his vertebrae, by separating his spine from his sacrospinalis muscle on the left. Control bleeding by packing the wound with a large swab and waiting.
In the thoracic area, remove the proximal 3 cm of a rib opposite the middle of the abscess with its transverse process. Cut the rib distally with rib shears or bone cutters, push away the soft tissue deep to the bone, and dissect its proximal end. You will find that it has a small joint with its corresponding vertebral body and another with the transverse process. Cut this transverse process at its base and remove it with the piece of rib. Do the same for one or two neighbouring vertebrae.
Push your finger between the side of the vertebral body and the tissues covering his pleura[md]recognize this by its movement. If you feel close in front of his spine, you should find pus.
In the lumbar region, when you reach his transverse processes, remove two or three of them with bone nibblers. You will now reach the plane between his quadratus lumborum and the bodies of his vertebrae, where you should find pus.
Clean this out and remove any obviously dead bone. His muscles will fit back snugly next to his spine. Suture his deep fascia. If much pus was present insert a drain. Close his skin. Send pus for culture. For more details see Section 29.4a.
If you don't find pus, nibble away a little bone next to a vertebral disc and send this for histology; it may be tuberculous.
THE PELVIS Osteomyelitis of the pubis occasionally follows symphysiotomy (18.4). If it involves his innominate bone, try antibiotics for up to 6 weeks. Sequestra are unusual. If pain and or sinuses persist treatment is difficult, so refer him.
Fig. 7-14 DISASTER WITH AN INFECTED HIP. This is patient Hasina whose story is given in the text. Infection has displaced the epiphysis of her femur, and moved its shaft upwards. The infection in her thigh is producing gas shadows.
Septic arthritis
This is another disease in which failure to drain pus early is a real disaster[md]a severe and probably painful disability for the rest of the patient's life. If you don't drain his infected joint early, it will be destroyed and may ultimately ankylose. If he is a child, the epiphyses near it may displace, or dislocate. As soon as you have made the diagnosis, drainage is urgent[md]this is not an operation to leave until tomorrow!
Bacteria can reach a joint: (1) Before the age of 6 months from osteomyelitis in the metaphyses of any long bone. After this age the epiphyseal plates prevent spread like this. (2) At any age in the hip, because the proximal metaphysis of the femur is partly within the capsule of the hip joint. This anatomical peculiarity makes septic arthritis of the hip and osteomyelitis of the neck of the femur, virtually the same disease. (3) Through the blood from a distant septic focus. This is haematogenous septic arthritis, which involves the knee, hip, shoulder, and ankle in this order of frequency. (4) Through a penetrating joint wound of a joint, especially of the fingers or knee.
The first sign of septic arthritis is that a patient cannot use his limb. One of his joints, commonly his hip or his knee, becomes so painful that moving it even a little in any direction causes him great pain. Sometimes, several of his joints are involved at the same time. He is usually febrile. The combination of fever and a limb which is too painful to move is either osteomyelitis, or septic arthritis, until you have proved it is not. Later, if the infected joint is near the surface, you will be able to feel that it is warm and swollen with fluid. Unfortunately, the shoulder and the hip are so deep that you cannot easily detect fluid, so that the only local sign is acutely painful limitation of movement.
If septic arthritis always ran a typical course, it would be easier to diagnose. Unfortunately, it often runs a very atypical one. Here are some of the difficulties: (1) If a patient is very old or very young, he may have few general signs of infection, and his effusion may not even appear to be inflammatory. There is only one way to be sure[md]aspirate all joint effusions, and examine them. (2) In the spine, the sacroiliac joints, and the hips, pain may be the only presenting symptom. (3) Only half the patients have a fever or a leucocytosis. (4) You can easily confuse tuberculous arthritis with the subacute type of suppurative arthritis. To distinguish them rely on the X-ray, and your findings on aspiration (pus or caseous tissue). If you are still in doubt, treat the patient for both diseases. Review his progress at 3 and 6 weeks, when suppurative arthritis should show much improvement, whereas it is still too early for tuberculosis to show much change.
The diagnosis is particularly difficult in babies as this case shows.
AHMED (1 year) was brought by his mother saying he had fever and was drawing up his left hip in pain. This in itself was unusual, because, if a baby does this, he usually draws up both of them. He was found to have suppurative arthritis of his right hip, which was too painful to move. It was aspirated, chemotherapy was started within 24 hours, and he recovered. LESSON The diagnosis was made early and treatment started immediately. Remember the risk factors[md]some patients have several: (1) As with infections of other kinds, septic arthritis is more common in the disadvantaged and malnourished. (2) Infancy and old age. (3) Systemic diseases which affect the body's response such as diabetes, chronic renal failure, liver disease, malignancy, the arthritides, intravenous drug abuse, alcoholism, and immunosuppression, especially by AIDS. (4) Local joint-damage due to earlier earlier surgery or osteoarthritis.
Although Staphylococcus aureus is the dominant organism, each risk group has its own characteristic infective organisms, patterns of joint involvement, and clinical response. If the patient has sickle-cell disease, you may find E. coli or salmonellae in his joint. Haemophilus influenzae is the most frequent organism in newborns, but is seldom seen in older patients. Other organisms include streptococci, brucellae, and gonococci. The gonococcus often affects young healthy adults without any obvious risk factor except sexual activity. With other organisms there is usually a risk factor.
When infection is well established, antibiotics seldom help. Occasionally, if you are fortunate, and are able to give the right one early enough, a patient may be lucky and recover without any other treatment.
The X-ray signs of septic arthritis are: (1) Widening of the joint space. (2) The signs of early osteitis (7.4). You may see the first signs of new bone formation as early as the 5th day in an infant, but it will not appear before the 10th day in an older child, and may take longer.
The critical investigation is to aspirate the joint as soon as you suspect infection. Frank pus in the syringe, or even slightly cloudy synovial fluid, confirms the diagnosis. You may get a false negative result, but apart from contaminants in the culture, you will never get a false positive one. Aspiration alone is not enough; it only tells you that pus is present, so incise the joint and wash out the pus. Then insert a corrugated drain, or (in the knee) leave the incision open.
Aspirating the more superficial joints is usually easy, but you may fail to aspirate the shoulder, or the hip. If aspiration succeeds or fails, you must incise and drain the infected joint. The results of not doing so are so serious, that the dangers of attempting it are well worthwhile. If you allow pus to accumulate under pressure in a patient's hip, it may impair the blood supply to the head of his femur within 24 hours, so that it necroses. Pus can also damage a joint, even if the blood supply is not impaired.
If, when you incise an infected joint and wash out the pus, you feel that its surfaces are smooth, he has a good chance of having a normal or a nearly normal limb. His prognosis is worse if cartilage has been lost, if the joint surfaces are rough, if the bone is soft, or if the X-ray shows severe joint destruction. Even so, he still has some hope of a movable joint, especially if he is young[md]a child's epiphysis may appear to be largely destroyed on an X-ray, and yet regenerate considerably.
Several things can happen to a severely damaged joint: (1) It can dislocate. (2) An epiphysis can slip, either immediately, or several weeks later, as with the patient Hasina in Fig. 7-14. Prevent this happening by splinting the joint or applying skin traction. (3) A painless stable bony ankylosis can form in the position of function. Provided it really is stable and is in the position of function, this may be only a minor disability. (4) The patient may get a painful unstable fibrous ankylosis, which can be a serious disability. If ankylosis fails, and his symptoms are severe enough, you may be able to refer him to have his joint fused.
If the patient is a child, and is lucky, he will have a painless joint with a useful range of movement. If he is unlucky he will have a painful joint that will ultimately need operative fusion, but meanwhile his limb will have had time to grow. Fusing a joint is difficult in a child, and is rarely necessary; if it is done too early, there will be growth problems. The decision to fuse an adult's painful joint can be taken much earlier.
If movement in a joint is going to be absent or limited, the position in which it lies is critical. This is described in the next section.
HASINA (17 years) was admitted with pain in her left hip and inability to walk for 3 days. She was given physiotherapy, nursed on a fracture bed for 3 weeks, and discharged on crutches. Some weeks later she was readmitted, febrile, and with a swelling of her right thigh extending from her knee to her iliac crest. Three litres of yellow-green pus were aspirated. Her X-rays are shown in Fig. 7-14.]] MARIAMU (12 years) was admitted with osteomyelitis of her tibia. This was settling nicely when she developed pain in her left hip and became febrile. The X-rays of her hip were normal, septic arthritis was diagnosed, and she was given large doses of the latest broad-spectrum antibiotic. Her pain improved slowly but her fever continued. Later, X-rays showed destruction of the head of her femur. Traction was applied. Sinuses developed, and she was never able to walk again. Two years later her pain was so severe that she had to have her hip disarticulated. All this happened in a good' hospital. LESSONS (1) The early diagnosis of septic arthritis of Hasina's hip was not made, although the history and signs were obvious. (2) Rest in bed on traction would have prevented her epiphysis slipping. At best she will have a painful hip, either for life, or until her hip has ankylosed spontaneously, or been fused surgically.(3) Explore a hip on the [f10]suspicion [f09]of septic arthritis. Fig. 7-15 ASPIRATING A JOINT may confirm the diagnosis, if pus is thin enough to come out of the needle. It is not effective treatment because it does not provide enough drainage, and pus may reform. [f10]So always open and drain an infected joint. [f11]A, the shoulder and elbow. B, the wrist. C, the posterior approach to the hip. D, the anterior and anterolateral approach to the hip. E, the knee, and F, the ankle. G, and H, the anterior and posterior approach to the shoulder. A, to F, after Hamilton Bailey's Emergency Surgery', edited by HAF Dudley. John Wright, with kind permission. G, and H, kindly contributed by Jack Lange. ASPIRATE AND EXAMINE ALL JOINT EFFUSIONS DRAIN ALL INFECTED JOINTS
SEPTIC ARTHRITIS If possible take several blood cultures from the patient.
ANAESTHESIA. (1) Ketamine (A 8.1). (2) General anaesthesia (A 10.1). (3) To aspirate his joints sedate him and use local anaesthesia.
ASPIRATION. This is diagnostic only: follow it immediately by operative drainage. Push a large (1.2 mm) needle down into the joint, and aspirate as in Fig. 7-15.
SPECIAL TESTS. Culture of the synovial fluid isolates the organism in 30% of cases and blood culture in another 14%. A leucocytosis of [lt]20 000 [gm]l makes the diagnosis unlikely but does not exclude it, especially if the gonococcus is responsible.
ANTIBIOTICS. Give the appropriate antibiotic. If you cannot isolate the organism, chloramphenicol is likely to be the most suitable one (2.9). In acute cases give it for 2 to 3 weeks. In chronic cases give it for up to 6 weeks.
EXPLORATION. Open his infected joint by the methods described in the next section. Operate under a tourniquet where possible, and if his hand is involved, watch out for its nerves. Irrigate the interior of the joint forcefully using a syringe and a litre or two of Ringer's lactate or 0.9% saline. Do this until the fluid comes back clear. Feel the surfaces of the joint.
Leave the wound open. The linear incision you have just made will become elliptical, and you will see the cartilage underneath. If the joint is superficial, it needs no drain. If it is deep, as in the hip and shoulder, insert a rubber drain. The wound will heal spontaneously as the infection subsides.
If his joint surfaces feel smooth, his prognosis is good. After 10 days of rest start gradual active movements.
If his joint surfaces feel rough but some cartilage still covers the bones, he may still have useful function in his joint. If all its cartilage has been destroyed, his prognosis is bad. His best hope is a stable ankylosis in the position of function (7-16).
If there is any danger of his joint ankylosing, make sure it does so in the position of function. If his hip or knee are involved, apply temporary skin traction.
If, later, he has a persistently painful joint with limited movement, refer him for operative fusion. In a child, delay this as long as possible.
Methods and positions for particular joints [s8]apart from the hip, most of the methods for which are in the next section
Joints need to be in particular positions for particular purposes, so be sure to use the right one. These positions seldom coincide with one another, and at least one of them, the position of function is absolutely critical.
The position of function is the best position for a joint to be in if it is going to be fixed, or if its movement is going to be severely limited. It is also called the position for ankylosis. Any kind of ankylosis, stable or unstable, is a dreadful disability if a patient's joint becomes fixed in the wrong position, so make sure that, if it is going to ankylose, it does so in the most useful position for him. The position of function varies from joint to joint, and may depend on what he wants to do with it. You never know for sure when a joint is going to ankylose, so put it into the position of function when you first see a patient with septic arthritis. For example, splint his knee just short of full extension; splint his right (or dominant) elbow flexed. Make quite sure he is in this position before you discharge him! Don't leave this task to a physiotherapist in the hope that it will be achieved later!
The position of rest is the most comfortable position for a joint to lie in. Put it into this position if it has to be rested for any reason, but is in no danger of ankylosing.
The neutral position of a joint is that from which its movement is measured. It is for anatomical description only, and is shown in Fig. 69-1.
The position of safety is for the hand only, and is shown in Fig. 75-8. It is the position in which the collateral ligaments of the finger joints are stretched, and in which fingers which are temporarily not going to be moved are least likely to become stiff.
THE POSITION OF A JOINT IS ALL IMPORTANT!
METHODS AND POSITIONS FOR JOINTS THE SHOULDER ASPIRATING THE SHOULDER. There are two approaches:
Anteriorly, feel for the patient's coracoid process just below his clavicle in the space between his pectoralis major and his deltoid muscle. Push the needle into the joint slightly below and medial to the tip of his coracoid process. Slope it laterally 30[de] and push it backwards, until it enters the loose pouch under the lower part of his shoulder joint (A, and G, Fig. 7-15).
Posteriorly, sit him in a chair to face its back, ask him to touch his opposite shoulder with the arm that is to be aspirated, so as to adduct and internally rotate his shoulder. Feel for the head of his humerus. Keeping the needle horizontal, push it it 30[de] medially into the joint space, from a point just under the posteroinferior border of his acromnion as in H, Fig. 7-15.
Fig. 7-16 THIS ILLUSTRATION OF THE POSITIONS OF FUNCTION is one of the most important ones in these manuals. If a joint is going to ankylose, the position in which it does so is critical. Notice that this patient's shoulder is abducted, his right elbow is flexed and in mid-pronation, his left elbow is extended (for toilet purposes), his knee is just short of full extension, and his ankle is in neutral and slightly everted.[] The girl in box B had an infected burn of her right elbow. The joint became infected. Tragically, it was allowed to ankylose in nearly full extension, so that she cannot eat with it or write! Kindly contributed by John Stewart.
EXPLORING THE SHOULDER. Approach his shoulder joint as if you were operating on his upper humerus for osteomyelitis as in Fig. 7-7, and separate his deltoid from his pectoralis major in his deltopectoral groove. Keep the wound open with a drain into the joint.
POSITION OF REST FOR THE SHOULDER. Put his arm in a sling.
POSITION OF FUNCTION FOR THE SHOULDER. If there is gross bone destruction, or you expect that he will have a stiff shoulder, put his shoulder into a spica in 45[de] of abduction, with his elbow just anterior to the coronal plane, in 70[de] of medial rotation so that he can get his hand to his mouth.
ELBOW ASPIRATING THE ELBOW. See also Fig. 72-4. Bend his elbow to 90[de]. Feel for the head of his radius. Using this as guide, push the needle into the posterolateral aspect of the joint, between the head of his radius and his humerus.
EXPLORING THE ELBOW. Make a 3 cm longitudinal incision posteriorly in the sulcus between his olecranon and the head of his radius. Go through the skin and fascia, insert a haemostat, and open it. Keep the joint open with a drain.
CAUTION ! Stay close to his olecranon, and remember that his posterior interosseous nerve winds round the neck of his radius 2 fingers' breadth distal to its head.
POSITION OF REST FOR THE ELBOW. Keep his arm in a sling in 90[de] of flexion.
POSITIONS OF FUNCTION FOR THE ELBOW depend on whether one, or both of them, are going to ankylose.
If his major elbow is going to ankylose, consider his needs. For example, Muslims and many other African peoples write and eat with their right hands and use their left hands for toilet purposes. If so, his right elbow should be more flexed than his left.
His major elbow will probably be most useful to him if it is flexed 10[de] beyond a right angle, with his forearm pronated 45[de] so that he can feed himself, scratch his nose, and write. Put it into this position by fitting him with a collar and cuff (72-9).
If both his elbows are going to ankylose, arrange their positions so that his major arm can reach his mouth. Let his minor one fuse in 10[de] short of full extension, so it can reach his anus.
THE WRIST ASPIRATING THE WRIST. Feel for his radial styloid; it will show you the line of his joint. Feel for the tendons of extensor pollicis longus on the ulnar side of his anatomical snuffbox' (74.4). Aspirate on its ulnar aspect, at the level of his wrist joint. Push the needle between extensor pollicis longus and the index tendon of extensor digitorum into the joint inclining it proximally 45[de] (B, Fig. 7-15).
EXPLORING THE WRIST. Flex and extend his wrist, as you feel for the exact line of the joint. Feel for the hollow between the tendons of extensor pollicis longus and the index tendon of extensor digitorum. Make a 3 cm transverse incision, taking care not to cut the cutaneous branch of his radial nerve which runs in the web space of his thumb.
Retract the skin edges and expose the joint through a longitudinal incision between the two tendons.
POSITIONS OF REST AND FUNCTION FOR THE WRIST. Keep it in 30[de] of extension with a volar plaster slab.
THE HAND THE POSITION OF SAFETY (James position) is peculiar to the hand and is the position which will minimize stiffness after an injury (75.2). Keep his MP joints nearly fully flexed, his PIP joints in 15[de] of flexion, and his DIP joints in 5[de] of flexion (Fig. 75-8 and many surgeons keep both IP joints fully extended). Keep his thumb well forward of his palm in opposition to his fingers, with its pulp about 4 cm from them. To maintain this position use aluminium finger splints, plaster slabs, or a boxing glove dressing (75.1), as appropriate. See also Sectiom 75.3.
THE HIP See also Section 7.18.
ASPIRATING THE HIP is difficult. The anterior approach is easier than the anterolateral one. His hip lies immediately behind his mid inguinal point. Use a thick lumbar puncture needle. If the anterior approach fails, try the posterior one.
For the anterior approach, feel for his femoral artery 2.5 cm below his inguinal ligament midway between his anterior iliac spine and his pubic tubercle. Insert the needle 1.5 cm lateral to the artery (and thus lateral to the femoral nerve). Push the needle in, inclining it 15[de] medially and 15[de] superiorly. This will aim it at the joint directly behind his mid inguinal point. Push it through the capsule into the joint. Aspirate. If you don't find pus, advance it into the cartilage. To prove that the needle is in the cartilage, rotate his thigh internally a little. This should move the adaptor of the needle medially. Withdraw it slightly to remove it from the cartilage, and aspirate. If necessary, alter its position and try again, if need be several times. If you cannot feel his femoral artery, insert the needle 2.5 cm below and 2.5 cm lateral to his mid inguinal point.
For the posterior approach lay him prone. Feel for his posterior inferior iliac spine and the centre of his greater trochanter. Insert your needle midway between these two points into his hip joint.
EXPLORING THE HIP. See Section 7.18.
POSITION OF REST FOR THE HIP. If you are sure that his painful hip is only temporary, rest it in moderate flexion and 15[de] of abduction. In this position his legs are comfortably spread apart. Hold his hip in this position with skin traction. To produce abduction, bring the cord holding the weight to the end of the bar at the foot of his bed. If necessary, make sure it stays there by moulding a plaster pulley on the bar. Or, have a detachable bar with notches at suitable places, which you can tie to the foot of his bed. Or, put both his legs into abduction.
POSITION OF FUNCTION FOR THE HIP. The minimum amount of flexion, and preferably none; 5[de] of abduction, and no rotation.
If possible, don't make the decision to aim for fusion yourself[md]refer him. If you cannot refer him, and decide to aim for fusion, don't apply a spica with his hip in the position of function, especially if he is a child. If you do, you will find, when you remove it, that spasm has rotated his pelvis anteriorly, and there is too much flexion. Instead, immobilize his hip in a spica in complete extension and 15[de] of abduction. When you remove the spica, you will find that it has gone into 15[de] of flexion, which is where you want it to be.
THE KNEE See also Section 79.3.
ASPIRATING THE KNEE. Extend the patient's knee. Push the needle into his suprapatellar pouch 2.5 cm above the upper border of his patella, from either the medial or the lateral side.
EXPLORING THE KNEE. With his knee extended, make a 5 cm incision one finger's breadth behind the medial edge of his patella and its tendon. Go through his quadriceps expansion, longitudinally, and put a curved haemostat into his suprapatellar pouch, under the surface of his patella. Put your finger into the joint and use it to remove the pus. Leave the wound open, or sew up the upper part, and leave a corrugated drain in place. Dress his wound and apply skin traction, or a plaster backslab. Without one or other he is likely to have a painful flexion contracture. Leave the drain in for 4 to 7 days.
BIOPSY OF THE KNEE. Make a 5 cm incision a finger's breadth behind the medial margin of his patella. Cut through his quadriceps expansion, and take a piece of diseased joint capsule for biopsy.
POSITION OF REST FOR THE KNEE. Apply skin traction to his lower leg to prevent flexion. Or apply a plaster backslab held on with a crepe bandage.
If he already has a flexion contracture following septic arthritis, put his knee in extension traction until it has been corrected. Then apply a cylindrical cast and encourage him to bear weight. With luck he will develop a painless bony ankylosis. If this does not happen, refer him for a compression arthrodesis of his knee.
POSITION OF FUNCTION FOR THE KNEE. Make sure his knee ankyloses in 10[de] of flexion, so his foot can just clear the ground when he walks. Do the same when both knees are ankylosed.
THE ANKLE ASPIRATING THE ANKLE. Find the line of his joint by moving his ankle. Insert the needle into its anterior aspect just medial to his lateral malleolus. Push it backwards and slightly downwards, so that it enters the space in the angle between his tibia and his talus.
EXPLORING THE ANKLE. The following incision will expose both his ankle and his tarsal joints. Start the incision on the anterolateral aspect of his ankle, 5 cm above the joint, and continue it downwards 1 cm in front of his lateral malleolus to the base of his fourth metatarsal, lateral to the extensor tendons of his toes.
Divide his superior and inferior extensor retinaculum as far as is necessary, so as to expose the capsule of his ankle joint. Then divide this and open the joint.
POSITION OF REST FOR THE ANKLE. Keep his ankle in neutral, without any flexion, extension, inversion, or eversion. Apply a plaster gutter splint.
POSITION OF FUNCTION FOR THE ANKLE. Keep it neutral and slightly everted. Inversion will produce painful callus under the head of his fifth metatarsal when he walks.
ANKYLOSIS IN THE WRONG POSITION IS A REAL DISASTER! Fig. 7-17 SIGNS IN SEPTIC ARTHRITIS OF THE HIP. A, Lie the patient flat, place your hand on his thighs and try to roll his leg to and fro. A normal hip rolls easily; if it is infected, this will be acutely painful. B, if you flex a normal hip, it will flex without rotation. If it rotates externally into position X' as you flex it, his upper femoral epiphysis may have slipped. This can happen spontaneously in teenagers (77.10); it also happens in late septic arthritis. Kindly contributed by John Stewart.
Septic arthritis of the hip
If a patient has an acutely tender hip in varying degrees of flexion, and fever, suspect that it is infected. The general methods for septic arthritis are described in Section 7.16. An important sign is spasm of his hip muscles. Test for this by rolling his thigh as in Fig. 7-17. If this is acutely painful, suspect that his hip is infected. If he has septic arthritis or osteomyelitis banging his greater trochanter lightly with your clenched fist will be painful; if he has deep inguinal adenitis or pyomyositis it will not, see Sections 5.12 and 7.1. In septic arthritis or osteomyelitis the epiphysis of his femur may become indistinct, or even absent on an X-ray, but it often reappears. This is not an indication for removing it.
Many doctors, and even many general surgeons, are afraid to open the hip joint, and look on this as a specifically orthopaedic' procedure. The hip does however require exploring and draining just like any other joint. The problem is that it lies a little deeper than the others. There are three operations you may need to do, but only the first is common. Be prepared to: (1) Drain pus in septic arthritis. (2) Remove the head of a patient's femur, when this has been destroyed as the result of infection. (3) Do Girdlestone's operation in chronic septic arthritis to remove the head and neck of his femur.
Here we are only concerned with septic arthritis of the hip. If you don't treat a patient early, any of these things may happen to it:
(1) He may may develop a flexion contracture of his hip, which will be a great disability, if you let it become permanent. You can prevent and treat this in two ways: (a) You can apply extension (skin) traction to his lower leg (70.10). This is very effective prevention, so do it routinely. (b) If a contracture has started to develop, you can extend his leg by laying him on his front for some time each day[md]if he will tolerate it. Few patients, especially children, will do this for long if their head faces the wall. So make sure his bed faces the centre of the ward.
(2) His upper femoral epiphysis may slip off the shaft of his femur, and become a dead sequestrum in his hip joint, as in Fig. 7-14. Later in the course of the disease there is a useful test to find out if it is slipping. Bend his knee to 90[de] and then flex his hip, as in B, Fig, 7-17. If his leg goes into external rotation as you do this, the head of his femur may have slipped. Confirm it by taking a frog-leg X-ray view, as in Fig. 77-9. If it has slipped and is forming a sequestrum, you will have to open his hip joint and remove it, as described below.
(3) His hip joint may be destroyed. When this happens, there are two possibilities: (a) Fusion of his hip in the position of function. If you decide that this will be best for him, achieve this position by applying a spica in the position described in Section 7.17, until his hip has fused. (b) If the head and neck of his femur have been partly destroyed, he may benefit if their remains are removed by Girdlestone's operation (7.19). This will give him a much more comfortable joint with some movement.
(4) The infection may extend into his acetabulum and involve the bones of his pelvis. When this has happened, there is little you can do, except drain the pus. His osteitis usually settles.
To explore and drain the hip you can approach it anteriorly or posteriorly. If you can safely anaesthetize a prone patient (A 16.12), the posterior approach is easier, because it allows better drainage. If you cannot do this, use the anterior one, and anaesthetize him in the supine position.
Fig. 7-18 THE ANTERIOR APPROACH TO THE HIP. A, the incision. B, the muscles retracted. C, preparing to incise the capsule.
1, the anterior superior iliac spine. 2, the pubic tubercle. 3, the femoral vein, artery and nerve from medial to lateral in this order. 4, sartorius. 5, rectus femoris. 6, the ascending branch of the lateral circummflex vessels. 7, the exposed surface of the ilium. 8, gluteus medius and tensor fascia lata. 9, the incision in the capsule.
SPECIAL METHODS FOR THE HIP For the methods of aspiration, and the positions of rest and function, see Section 7.17.
THE RELIEF OF SPASM. If the patient is a child, apply up to 1/7th of his body weight of extension (skin) traction, depending on his weight. This will relieve the spasm of his muscles, and will prevent him developing a flexion contracture.
THE ANTERIOR APPROACH [s7]TO THE HIP (really the anterolateral approach, 7-18) ANAESTHESIA. Ketamine, or general anaesthesia with spontaneous respiration.
POSITION. Lay him supine, but tilt him to the other side by putting a sandbag under his affected hip.
ASPIRATION is useful to check that pus is present. If you don't find it, but think that he probably has got septic arthritis, explore his hip anyway.
INCISION. Cut from the mid-point of his iliac crest to his anterior-superior iliac spine. Extend the incision distally down his leg for 10 or 12 cm. Divide his superficial and deep fascia. Use a periosteal elevator to separate his gluteus medius and tensor fascia lata from his iliac crest. Continue the dissection distally between his tensor fascia lata posterolaterally, and his sartorius and rectus femoris anteromedially. Divide the ascending branch of his lateral circumflex vessels between ligatures.
Insert two bone levers on each side round the upper shaft of his femur and retract his muscles. You will now see the capsule of his hip joint. Check that it is his joint by aspirating. Now open the joint with a cruciate incision. Ask an unsterile assistant to grasp the patient's ankle and externally rotate his hip. You will see the head of his femur moving inside his acetabulum. If you want better access to the joint, insert levers round the neck of his femur. If you suspect osteomyelitis, drill at least 4 holes into the neck and upper shaft of his femur.
Insert a corrugated drain from the joint to the surface, and leave it in for 5 to 7 days. Don't suture the capsule. Bring his muscles together lightly with a few 0' chromic catgut sutures. Close the fascia over his iliac crest. Close his skin with 0' monofilament.
POSTOPERATIVELY, apply 2 to 5 kg of skin traction up to his mid thigh, with his leg in in 1 to 15[de] of abduction and minimal flexion. Raise the foot of his bed.
Fig. 7-19 EXPLORING THE HIP THROUGH OBER'S POSTERIOR APPROACH. A, incise patient's gluteus maximus. B, separate its fibres. C, be careful not to injure the sciatic nerve. D, incise the hip joint.
THE POSTERIOR APPROACH [s7]TO THE HIP (OBER'S APPROACH) Intubate the patient and control his ventilation. Lie him on his side, slightly inclined towards the prone position. Find the tip of his great trochanter. Cut medially from it for 5 cm in line with the fibres of his gluteus maximus. Cut through his skin and superficial fascia.
Separate the fibres of his gluteus maximus using your index finger and the end of a curved haemostat, until you meet the capsule of his hip joint. Open the incision with retractors.
If you find pus in the muscles of his buttock, before you reach his hip, stop. He has pyomyositis. If you go further and open a normal hip through an abscess in his muscles, you will probably infect it.
Ask an assistant to take hold of his ankle and rotate his hip internally, so as to increase the space between his trochanter and his acetabulum.
Make a small incision in the distended capsule of his hip joint and widen it with a haemostat.
CAUTION ! (1) His sciatic nerve leaves his buttock half way between his greater trochanter and his ischial tuberosity. There is no need to incise or dissect this far medially. (2) The capsule of the hip joint is only a finger's breadth wide between the posterior aspect of the greater trochanter and the posterior margin of the acetabulum.
If his upper femoral epiphysis has slipped and is forming a sequestrum, remove it. Approach his hip posteriorly as above. Modify this by carrying the incision down his greater trochanter. Remove the loose head of his femur with large bone forceps, and as much of its neck as is necrotic.
POSTOPERATIVELY, reduce the tendency of his hip to slide proximally by putting him into traction for 6 weeks postoperatively, while fibrous tissue forms to limit movement. He will have an unstable hip and will need a crutch, but he should be pain-free and he will be able to walk.
Girdlestone's operation for an infected hip
The previous hip procedures described in this chapter are mostly needed by children. This one may help an adult whose hip has been partly destroyed by infection, avascular necrosis or a painful ununited femoral neck fracture (77.6). He will walk less painfully, if what is left of the head and neck of his femur is excised, so as to allow the upper end of his femur to bear on scar tissue on the under side of his ilium. A false joint will develop, his leg will be short and he will need a stick, but he will probably have very little pain. This is a difficult procedure and is for more experienced surgeons only, which is why it is in small print. If you are inexperienced: (1) The joint cavity may become infected and seal off. (2) You can injure his sciatic nerve. (3) You may have to abandon the procedure uncompleted, in which case you will feel ashamed, and he will be made worse.
Girdlestone's operation is a salvage procedure to relieve pain when an arthrodesis or, exceptionally, a prosthesis is impractical. It is inelegant and old-fashioned, and is not indicated if you can refer him for an arthrodesis or a hip prosthesis. If this is impossible, [f10]and you are fairly experienced [f09]Girdlestone's operation will be much better than nothing. There are two varieties: (1) For a previously septic or tuberculous hip infection which is now inactive. This is the method which is described below. (2) For an ununited fracture of the neck of the femur, as described in Section 77.13.
Use a posterior approach, like Ober's (7.18), except that you carry the incision further down his femur, for 25 to 40 cm. Make sure that his sciatic nerve is out of the way, and that your assistant does not grasp it with his retractor.
GIRDLESTONE'S OPERATION INDICATIONS FOR INFECTIVE CONDITIONS. A patient who is walking painfully as the result of: (1) Previous septic arthritis, which is now inactive. (2) Previous tuberculous arthritis, which is now inactive but is still painful. (3) Aseptic necrosis of the head of the femur. (4) A longstanding ununited fracture of the femoral neck. (5) An infected prosthesis.
If you cannot refer him, proceed as follows.
EQUIPMENT. An orthopaedic set (4.12). A Gigli saw. Ideally, two special retractors. Have two units of blood cross- matched.
INCISION. Follow the method in Secction 77.13 until you get to the paragraph Cut the neck[...]' then proceed as follows:
Incise the capsule of the patient's hip joint to expose the head and neck of his femur and the remainder of his greater trochanter. Now open up his exposed hip joint by incising its capsule widely. Ask your assistant to move the patient's leg to help you identify the head of the femur.
If the head of his femur is not necrotic, or his hip is ankylosed, end the operation here.
You will find that removing the head is easier if you excise part of the rim of his acetabulum. Curette all necrotic and infected bone from his acetabulum. Make the excision as complete as possible and leave only the raw surfaces of vascular cancellous bone. Remove the neck down to its base, and smooth it by chiselling away all sharp edges.
Sew back the edges of his incised gluteus maximus. If there is little active infection and you have suction drainage, use it. If you find the bone seriously infected, leave the wound partly open. Insert 2 or 3 rubber drains.
POSTOPERATIVELY, to prevent shortening, apply 3 to 10 kg of skeletal traction through his tibia with his hip in 20 or 30[de] of flexion for 6 weeks. This will not be necessary if his hip is already fibrotic.
CAUTION ! Try to prevent proximal displacement of his femur. This will prematurely seal off' the area and defeat the purpose of the operation, which is to saucerize his acetabulum and allow free drainage when there is active infection.
