5.3. The management of Chronic Osteomyelitis and Septic Arthritis (continue)
3. Achievement of good skin cover 
Again this is easy to say, but can be difficult to do and there remain substantial differences of opinion as to how best to achieve this. Ideally after adequate sequestrectomy and saucerisation and removal of the retractors, the sides of the wound will fall together and can be ‘tacked’ in this position over a large corrugated drain by using large deep sutures placed about 1.5cms apart. This drain is removed by daily shortening. Some surgeons do not like to insert a drain in this situation relying either on repeated aspiration with or without instillation of an appropriate antibiotic. Others make NO attempt at this type of closure preferring to allow all of these wounds to heal by secondary intention, i.e. granulation and epithelialisation (with or without split skin grafting).
With a subcutaneous bone such as the tibia it is often impossible to achieve complete full thickness skin cover in this way, but even if part of the wound has to be left to granulate the flap/s of surviving skin can often be loosely sutured and this will substantially reduce the exposed area.
Split skin grafting can expedite ‘healing’, but grafts placed directly on to a granulating decorticated part of the tibia should be protected when possible by elastic compression bandaging for some months after they have ‘taken’ as otherwise they can ‘float off’ and thus be lost.
 |
 |
 |
| Granulation after removal of a plate and screws, | and
after skin grafting. |
X-ray of a saucerised
tibia - awaiting skin grafting, |
To summarise we believe that when possible it is better to cover as much as possible of the decorticated bone with surrounding healthy soft tissue, leaving a large drain in place. If this impossible then closure by spontaneous granulation and epithelialisation (aided when indicated by split skin grafting) will usually succeed, but these grafts require protection for some months.
If much bone has had to be removed then immobilisation is necessary either with a plaster gutter or by traction. This will also encourage soft tissue healing.
These same principles apply in the management of old compound (open) fractures, and in spite of the commonly held belief that infection may delay or prevent union, in practice infected open fractures usually will unite if the three basic tenets of management are applied. It should again be stressed that ‘too early sequestrectomy’ must be avoided, and the fracture allowed to unite before any dead bone is removed. This is similar to the essential need to allow the formation of adequate involucrum before performing sequestrectomy in blood borne osteomyelitis. An infected ‘bone gap’ can be very difficult to treat.
 |
 |
A whole shaft sequestrum
in a very late presenting compound tibial fracture. |
A whole shaft sequestrum
in a very late presenting compound tibial fracture. |
 |
 |
After several months
of rest in plaster the fracture united and the sequestrum is being extruded. |
Union |
 |
| After lifting out the sequestrum - Bude Gobe - Open tomorrow. |
