University of Nebraska Medical Center DigitalCommons@UNMC MD Theses Special Collections 5-1-1942 Chronic osteomyelitis : with special reference to treatment Richard R. Altman University of Nebraska Medical Center This manuscript is historical in nature and may not reflect current medical research and practice. Search PubMed for current research. Follow this and additional works at: https://digitalcommons.unmc.edu/mdtheses Part of the Medical Education Commons Recommended Citation Altman, Richard R., "Chronic osteomyelitis : with special reference to treatment" (1942). MD Theses. 901. https://digitalcommons.unmc.edu/mdtheses/901 This Thesis is brought to you for free and open access by the Special Collections at DigitalCommons@UNMC. It has been accepted for inclusion in MD Theses by an authorized administrator of DigitalCommons@UNMC. For more information, please contact [email protected]. by Hichard F. Altnan Senior Thesis Presented to the College of Medicine University of IJebrA.ska Omaha, 1942 CONTl::NTS page I. INT:LWDUCTIOJJ •• . 1 II. ETIOLOGY ••••• . .. .. 3 Cormnon Causes of OsteoJ'llYelitis •• .. .. .. 3 Unusual Causative Agents in Osteom.yelitis. • • • 6 Predisposing Causes •••••••••••••••••••••••••• 12 IncidP-nce ••• .. .. •• 14 III. PATHOLOGY •••••• . .. .. .. .. .. •• 18 Acute Bncl Chronic Osteomyelitis ••• .. .. • .18 Brodies' Abscess ••••••••••••••••••••••••• • • 22 Sclerosinfj Non-sup:pur11tive Osteomyelitis. • • 22 IV. SYl.1PT01.'IS JJJD DIAG1JOSIS ••• . .. .•• 24 Acute Osteomyelitis •• . .. .. .. .. • • 24 Chronic Osteomyelitis •• .. .. .. .. .. • .25 v. HISTORY OF TH CATMJi;HT •• ~ ••••• . .. .. .26 VI. TJ(]~fl Tl~{T~I,TT •••••••••••••••••• . .. TreRtment of Acute Osteonyelitis ••• . • .40 TreRtnent of Chronic Osteonyelitis. .. .43 Common Metho<l.s of TreAtMent •••• . .. • • • 45 Less ':!idely Used Hethods of TrP-Atment •••• 54 Factors For and A~ainst the VAribus Methods of TrentBent ••••••••• . .. .. .62 Results of TreAtment. .. .. .. ••• 70 -J'II. COlJf.PLIC.l\.TIOI'TS ••• •••••••••••••••••••••••••••••••• 80 page VIII. CO~JCLU~3 IOI.JS •••••••••••••••••••••••••••••••••••• 86 IX. R~-~F_J~lr,,~NC :-~S. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 1 nrTRODUC'EION The object of this paper is to review rather gener­ ally the problems fqcinp: the physician in patients with bone infections, especially chronic bone infections. The main problem in chronic osteomyelitis is the treatment of the condition. In order to consider the problem prop­ erly it is necei:rnA.ry to take up ri.11 phases of the dis- ease includinro acute bone infections. It is important in discussinP- treatment to knov1 the possible etiolopic agents, predisposing CA.uses, incidence, patholor:~r, svnp­ toms, and complications and these will be considered brief­ ly here. Etioligic agents will be discussed here rather ex­ tensively ( for the size of the paper ) for the reason that in most instances in discussion of osteomuelitis they are not consider~d as a ~roup but singly or not at all. Trentment of osteomyelitis, both a~ute and chronic, as it appears in the literature has in the past been rather confus~ne;. There arA almost as mnny Methods as there are physicians and surgeons treating the diRe,qse. For this reason A.n attempt will be made to r9.in the con­ sensus of opinion and the trRn~8 towRrd present nR~r treR.tment. it gener11.l review of previous methods of treRtment and their effectiveness in the past will be presented as I will also the nost widely accepted nresent day methods of treatment and their results. Complications and statistics regardin~ them will be presented to ~ain an idea of the problems yet to be overcome in treatment of this important diRease. 2 i!:TIOLOGY There is no sharp line of demarcation between acute and chronic osteoI!lyelitis. Just where an acute hematoe;­ enous osteomyelitis becomes chronic depends more or less on the individual surgeon. Therefore in many case~ the organism involved in the acute hematogenous osteomyel­ itis is the same when the inf~ction becomes chronic. There are some bone infections which have no acute course and are considered subacute or chronic when first recognized. Conmon Causes Of Osteomyelitis Infection ren.ches the bone in three ways: by the blood stream; by direct extension from soft parts; by open wounds of the bones. Infection by blood stream---. He:matoeenous osteo­ myelitis is by far the most common form of infection. The hemolytic stR.phylococcus is the cause of the blood born infection in about 90 percent of the cases (59). The staphJrlococcus aureus is found t\'lice as often as stanhylococcus albus (0g), and is present in about 75 percent of cases (75). The skin is the most frequent portal of entry for this organism. In the first month of' life, infections such as folliculitis are the most ·common cause of osteomyelitis. It may develop also from infection of the unbilical cord and occAsionally from 3 an infected cephalematoma. Later in life boils arc the most frequent nredisposing lesions. Others less common are : paronychiae, acne Dustules, blisters arising from friction, burns, freezing, impetigo, eczema, chickenpox, smallpox, and vaccination. In adults a carbuncle is occasionally a cause. Small wounds ap~arently produce osteornyelitis more often than do larr,e deep ones. Infection by direct extension from soft parts---. In comparison with hematogenous osteomyelitiR thi9 occurs rather rarely. According to Kulowski (47) these comprise about 25 percent of all cases of osteomyelitis. It is seen most frequently as a result of infection of acces­ sory sinuses, staphylococci, streptococci or pneumo­ cocci being the most common organisms involved, and the middle ear with the pneumococcus and the strepto­ coccus being the causative organism here. The phalanges of the fingers ma~r be infected from the adjoining soft parts and also osteomyelitis may develop from a primary arthritis by direct extension. Decubitus ulcers and extensive chronic varicose ulcers may extend down to bone, the stA.phylococcus, streptococcus, and the colon bacillus beinR the most common organisms. Simple fracture, with a non-communicat1ng wound of soft parts may become infected by direct ex­ tension. 4 Infection by o:i-ien wounds of the bones---. Osteomyel­ itis may develop in several types of fr~ctures: I. Open wounds in which there is a fracture. This infection us­ ually remains localized but may become diffuse. 2. Osteo­ myeli tis following operation on a simple fracture in which the simple fracture is made compound. Cleveland (2I) feels that entirely too many chronic suppurative bone and joint infections "are due to ill-advised original surgical treatment, where superimposed on vascular and infectious trauma is the insult of improperly placed incisions, too wide removal of uninvolved bone and fail­ ure to immobilize the damagecl part.'' 3. Skeletal traction producing osteomyelitis at sites of introduction of tonr.s, pins, and wires. Also should be mentioned here, the importance of proper transporting of a patient with a. simple fract­ ure in order to prevent comnounding of the fracture. Too many patients are subjected to a long drawn out disabling disease because of neglect or ignorance in handling a simple fracture at the time of the accident. Gunshot wounds involving bone esJ)ecially when prod­ uced by shell fragments are particularly ant to result in osteomyelitis. Extraction of teeth, block anes­ thesia, or curettage of apicnl abscesses may lead to osteomyelitis of the jaw. ( 69, 75, 36, 40, 2I, 47 ). 5 Unusual CausA.tive Agents In Osteomyelitis The more uncoT'JJ".lon and rare organisms causing osteo­ meli tis will be considered here because of their in­ frequent mention in textbooks and because they are usually so lightly skimned over generally. Every attempt should be made to reco~nize the causative orp;Rnism in osteomyelitis because of the importA.nce in prognosis and treatment. (?). I. The streptococcus as a cause of osteomyelitis--. The hemolytic streptococcus is the causative organism in about 3 to 5 percent of cases of osteomyelitis. The usual known portal of entry is the resperatory tract. Predisposing conditions are acute otitis media, acute rhinitis, tonsillitis, bronchitis, influenza, pneumonia, lung abscess, and empyema. Very often the portal of entry cannot be determined. The streptococcus is con­ sidered the most frequent secondary invader in those debilitated from chronic bone infection. ( 75, 49 ). Hemic infections due to streptococcus behave differ­ ently from those due to the staphylococcus as is shown by both the gener2l reaction and the locAl rea~tion. (?). There are many cases of streptococcus osteom.yelitis re­ ported in the literature. Hosmer, Burnham, and Davis '40 (32), report an unusual case resulting from sinus dis­ ease due to a hemolytic streptococcus, and associated 5 with particularly severe diabetes and with recovery from the bone infection. In 1926, Phemister and Gordon (23) reported two f!ases of solitary bone cyst in which streptococcus viridans was isolated. Few attempts have been made to culture orgRnisms from the sol i tar:,r bone cyst, benign giant cell tumor, or osteitis fibrosa. Day (23) reported two cases in which streptococcus viridans was found in bone cysts but in eight other cases no etiological agent was found. Compere {23) reported a case of localized osteitis fibrosa without cyst formation in which streptococcus viridans vms recov­ ered. Another similar case was negative as to an et­ iological agent. Phemister and Gordon