Page 15 - 61 surgical-infection&infestations20-24_opt

138 Haematogenous Osteomyelitis and Septic Arthritis

Figure 22.6: Stage 4 HO in a 12-year-old female with sickle-cell (SS) haemoglobin: (A) initial presentation with large abscess of left thigh, (B) x-ray showing giant
sequestrum of femur, (C) drainage of abscess and sequestrectomy performed through a lateral thigh incision, (D) thigh wound, (E) child after complete healing by
secondary intention with antibiotics used only to control the systemic sepsis.

retractors (self-retaining Gelpis are ideal); periosteal elevator; bone holes are placed in the area and a curette and bone rongeur are used to
curette; bone rongeur; and bone drill. True orthopaedic bone drills are remove a 2-cm cortical window. This window serves to decompress the
very expensive and justification of the cost is difficult for hospitals medullary canal and allows for irrigation of the canal. The medullary
in LWATs. However, simple carpenter drills and bits can be used for canal in acute HO should not be curetted for fear of damaging the
orthopaedic purposes if proper sterilisation capabilities (ethylene oxide precarious endosteal blood supply. The wound is left open and the
or formalin gas) are available. Cordless electric drills, commercially patient brought back daily for irrigation of the medullary canal using
available in hardware stores, are relatively inexpensive and also can be ketamine anaesthesia. When there is no more purulent drainage, an
effectively used for orthopaedic procedures if properly sterilised. They attempt can be made to close the incision (this is often unsuccessful),
must, however, be used on a low speed because a high-speed mode or it can simply be left open to heal by secondary intention.
13
will burn the bone. An orthopaedic exposure book is a valuable asset The treatment of chronic HO (stages 3 and 4) often requires a more
in determining the safest approach for draining and debriding bones extensive operative approach. There is rarely a total cure for chronic
affected by HO. The cost of such books is prohibitive in most LWATs, HO, but very long periods of remission can be achieved if all of the
however, and a basic anatomy book can be substituted to determine nonviable bone is removed. Sometimes the child with chronic HO has
appropriate approaches to bones and joints in the least potentially been neglected for so long that the sequestrum begins to spontaneously
14
destructive manner. The low-cost Primary Surgery textbook presents extrude (see Figures 22.3 and 22.4). When this happens, the child can
good exposure techniques for the more commonly affected bones and be appropriately treated by simply removing the sequestrum, curetting
joints. Ketamine anaesthesia is a very effective and safe technique in the inner surface of the involucrum, and irrigating the medullary canal
15
the operative management of children with HO in LWATs. Using an to remove any remaining smaller pieces of the sequestrum. Sometimes
extremity tourniquet significantly decreases the operative blood loss, the sequestra are incarcerated by the involucrum, and removal
but tourniquets should not be used in children with SS or SC haemoglo- requires a cortical trough to adequately visualise and remove all of
binopathies because this may precipitate a sickling crisis. the sequestra (Figure 22.7(A)). After the removal of the sequestra,
Treatment of acute HO (stages 1 and 2) begins with the soft tissue advanced techniques for closure are available, including muscle and
approach to the bone. The recommended approach to the proximal fascio-cutaneous flaps. Placement of antibiotic-impregnated beads
tibia (the most commonly affected bone) is from the medial or lateral can be used to decrease the number of relapses for chronic HO. Most
aspect of the tibia so that there will be soft tissue remaining to cover of these advanced procedures are not commonly used in LWATs
the affected bone. For the health care provider unaccustomed to since in such locations the incidence of HO is so common as to be
approaching the tibia in this manner, however, it is acceptable to overwhelming for the resources of the hospital. In these instances, the
incise the soft tissue directly over the tibia with as small a soft tissue large wounds can be left completely open, and they eventually will
incision as necessary. Usually the periosteum has already been elevated heal by secondary intention as long as all of the nonviable bone has
from the bone and needs to be incised longitudinally to drain the pus been removed (Figure 22.7(B)).
under pressure. If microbiological techniques (gram stain, culture) are Parents can manage the wounds with daily water irrigation and
available, a sample is taken. A periosteal elevator should not be used for coverage with a bandage made from scrap cloth. In hospitals with
this classic presentation because the increasing subperiosteal pressure adequate health care personnel and facilities, the wounds can be
has already stripped the periosteum from the cortex, and further managed in a wound care clinic, but hospitals without such facilities
periosteal elevation may impair blood flow to the remaining bone. can provide alternatives. For example, the Baptist Medical Center in
After the periosteum is incised, a drill is used to enter the metaphyseal Ogbomoso, Nigeria, provides a water hose so each day children and
medullary canal. Usually pus drains from the drill hole. If so, other drill parents can use the handheld shower apparatus to wash any debris