Treatment Excision of

of Chronic Bone
M.S.

Osteomyelitis Secondary
M.S. (0RTH0.) M.L.N.
,

by Radical Skin-Grafting
ALLAHABAD, College, INDIA Allaha bad

and
(SuRG.), of Orthopaedics,

BY R. C. GUPTA, From the Department

Medical

ABSTRACT: elitis

Treatment

was

sequesirectomy,

in six cases saucerization,

of a total of 724 cases of chronic removal of infected granulation

osteomytissue, and

secondary skin-grafting. it was used. Secondary ment change. lion was begun. Skin-grafting The

Primary skin-grafting skin-grafting was done take was from wide allowed excision

had failed in the two patients in whom at ten days to four weeks after Ireatat the time skin and of the helped first dressing of infected in oblitera-

25 to 80 per cent

of cavities. in treatment, occasional cases those with extensive cavitation ofosteomyelitis and sequestration. still are difficult In most pa-

Despite advances to resolve, especially tients after

management is straightforward and successful-the removal of the sequestra. Saucerization of the bone removal of the sequestra and infected granulation tissue

cavities are obliterated and closure of the skin after is the procedure most com-

monly used but in many patients in whom, for example, cavities extend down into the femoral condyles or into the upper part of the tibia, it may be difficult to drain the cavity effectively and pocketing may then lead to recurrent episodes of infection. Elimination ofthe dead space is important; occasionally it may be more difficult than removal been applied of the
It is in this

infected
type

bone.
of patient that radical excision and secondary skin-grafting has

found

to be very over

useful.

Armstrong bone

and and

Jarman held

used in

split-thickness place by means

skin of

grafts molds.

primarily

saucerized

Others 3-6 have advocated the early use of all types of skin grafts to cover the deformed cavities. The present method of treatment, used on eleven patients, has been previously reported by Evans and Davies. Material In uary Swarup and Rani December Nehru Hospital, Allahabad,
patients with

during
chronic

the

period

between
were

Jantreated.

I 964

1 97 1 , 724

osteomyelitis

Six of these granulation

(Table I) were treated by sequestrectomy, saucerization, and removal of and scar tissues followed by secondary skin-grafting ten days to four weeks later. Their ages ranged from eighteen to sixty-eight years. All of them were men. In these six patients the sites of lesions were the lower end of the femur and the middle third of the tibia in two patients each, and the upper end of the tibia and the upper halfofthe tibia in one patient each. a compound fracture following a gunshot tient superficial osteomyelitis of the tibia In one patient the predisposing injury was wound with bone loss (Fig. I ). In one padeveloped following repeated ulcerations

and infections after an electric burn. Chronic osteomyelitis developed in one patient after intramedullary nailing done for a compound fracture in the middle third of the tibia. In three patients an acute osteomyelitis had been improperly managed, resulting in a chronic infection with sequestra and sinuses.
*

M.L.N.
NO.
2,

Medical
MARCH

College,
1973

Park

Road,

Allahabad,

India.
371

VOL.

55-A,

372

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THE JOURNAL OF BONE AND JOINT SURGERY

TREATMENT

OF CHRONIC

OSTEOMYELITIS

373

FIG.

I-A

FIG.

I-B with over limb.

FIG.

1-C

Fig. 1-A: Case 1. Clinical photograph showing infected skin. Fig. 1-B: Roentgenogram showing multiple pellets ofgunshot Fig. 1-C: Clinical picture postoperatively showing skin graft skin around. Note the amount of muscle wasting of the affected

bone loss. the bone defect

and

healthy

and

In the present series the preliminary roentgenograms

patients ofthe

were admitted to the hospital before operation limb and sinograms ofthe sinuses were made. any other operation. injected in the sinuses under general One per cent sterto stain the tracts. anesthesia. A pneu-

The limbs were thoroughly prepared as for ilized aqueous solution of gentian violet was The
matic

operation
tourniquet

was
was

performed

with

the

patient

applied if possible on the upper part of the thigh so that radical surgery could be done in a bloodless field. The tourniquet was released intermittently to ensure that the circulation of the limb was maintained as well as to visualize the vascular structures. The bone was then exposed through healthy skin and the sequestra sible.
The

along with The infected

bone was powder,

infected tissue and skin and fibrosed

to the extent

granulation surrounding
of three-quarters

were removed tissues were

of its

as radically extensively
diameter. The

as posexcised.
cavity

saucerized

was the the

this

then

thoroughly was

tomycin

washed with and petrolatum removed.

saline gauze. was

and packed A Robert then applied.

with crystalline Jones bandage

penicillin, was applied

strepand

tourniquet The pus organisms

period were

A cast

and infected tissues were was determined. It took

and streptomycin

cultured and the sensitivity seventy-two hours to get

were given intramuscularly.

the

to antibiotics of report. During

The appropriate

penicillin

antibiotics

started

after

the

sensitivity

report

became

available.

The wounds healthy granulation later, the patient the thigh of the

were opened on the tenth day, at which time they usually showed tissue with minimum discharge. From ten days to four weeks was prepared for skin-grafting. Split skin grafts were taken from same limb and applied over the raw area. The first dressing was were applied throughout the at the time of
I, Figs. 1-3).

opened on the fourth day and take of the graft was estimated. Dressings and the wounds were allowed to heal. The antibiotics were continued period of four to six weeks. The results of operations were estimated
discharge ofthe patient, and at each follow-up examination (Table

The take of the graft after four days to two weeks was from 25 per cent to 80 per cent. In the one patient with 25 per cent graft take, a second skin graft was applied after fourteen days and the total take after this second grafting was 90 per cent.
VOL. 55-A, NO.
2,

MARCH

1973

374 The rest of the wound healed

R. C. GUPTA

by proliferation present series, split skin-grafting

of skin

and

by scarring. done and for

In four

other and or anwhich

patients, not wide excision

included in the were done but

sequestrectomy was not

saucerization one reason tissue to close.

other. The cavities thus resulted in thin, unstable,

produced papery

were allowed to heal scars which took about Discussion

by granulation six months

In cision

most

patients bone

with and

osteomyelitis connective tissue

with

extensive

sequestration, by skin closure

radical is an accepted

ex-

of infected

followed

method of treatment, may lead to pocket Limited

in these

but in a few patients formation which may of the infected over the skin
split

closure of the skin may be responsible for recurrence the sinuses

seems

be difficult and of infection. and we tried it is that or

of choice.

excision
patients

and failed

may patients

not

be successful
treatment

that

secondary

skin-grafting

to be the

Primary method cortical tissue. An

skin-grafting

bone

in the

two

for whom

of treatment. A split skin graft can bone especially when it has a thin indirect advantage of this procedure

easily survive on a bed covering of periosteum has been that the radical

of cancellous or granulation excision

of the

infected tissue can be done with confidence because the skin-grafting is then to be done some time later. The assurance that covering the area will be possible, however extensive it is, encourages sibly infected tissue. the surgeon to be really radical in his excision of all pos-

The successful results we obtained seemed to stand the test of time, and except for minor occasional ulcerations in two patients, the scars were healthy and stable. The follow-up period has been from nine months to four and a half years. Our results who have
intendent,

as regards skin-graft had 80 per cent take been comparable.

NOTE: The S.R.N. authors and other are grateful associated

take have not been as good as those of Evans and of skin graft on the first dressing, but the over-all
to Professor Pritam Allahabad, Das, for Principal, permitting M.L.N. us to publish Medical these College, case

Davies, results
and Super-

hospitals,

reports.

References
1.
2.

3.
4.

5.
6.

T. F.: A Method of Dealing with Chronic Osteomyelitis by Saucerization, Followed by Skin Grafting. J. Bone and Joint Surg., 18: 387-401, Apr. 1936. EVANS, E. M., and DAVIES, D. M.: The Treatment of Chronic Osteomyelitis by Saucerization and Secondary Skin Grafting. J. Bone and Joint Surg., 51-B: 454-457, Aug. 1969. KELLY, R. P.; RosAn, L. M.; and Muiuuy, R. A.: Traumatic Osteomyelitis: The Use of Skin Grafts. Part I. Ann. Surg., 122: 1-1 1, 1945. KELLY, R. P.: Skin Grafting in the Treatment of Osteomyelitic War Wounds. J. Bone and Joint Surg., 28: 681-691, Oct. 1946. KNIGHT, M. P., and WooD, G. 0.: Surgical Obliteration of Bone Cavities Following Traumatic Osteomyelitis. J. Bone and Joint Surg., 27: 547-556, Oct. 1945. ROBERTSON, IVOR: Treatment of Chronic Infective Osteitis. in Proceedings of the British Orthopaedic Association. J. Bone and Joint Surg., 27: 729, Oct. 1945.
ARMSTRONG, BASIL,

and

JARMAN,

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