5.2. Surgery in osteomyelitis.
Open operation or aspiration 
The basic surgical tenet ‘Where there is pus – let it out’ remains as true with osteomyelitis and septic arthritis as when this occurs at other sites. However, we have the impression that Paediatricians prefer aspiration, and Orthopaedic Surgeons prefer an open operation. We may never know who is right but as Surgeons we prefer adequate open exploration and drainage.
This should be performed under general anaesthesia, and with an ‘exsanguinating tourniquet’ in place when this is anatomically possible. Gravity resulting from elevation of a limb produces adequate exsanguination (we do not like to use Esmarch’s rubber bandages) and the tourniquet where possible should be pneumatic.
Osteomyelitis should usually be explored at the site of maximum tenderness using an incision which will be unlikely to produce a scar problem (joint contracture, cosmesis). Dissection should continue to the periosteum which should be adequately opened (although pus may have already spread into the soft tissues). In most cases pus will then be revealed and may be under some pressure. It can be helpful and wise to use a curved flap type of incision both for the skin and periosteum as this may facilitate partial closure (see below).
If no pus is found then it is wise ‘to drill the bone’ and very occasionally pus may ‘spurt out’. However, this does not always happen, and indeed several more judiciously placed drill holes may not reveal anything abnormal. In this case ‘so much the better’ unless the pus is lurking in a neighbouring joint. This may on a rare occasion be revealed by careful joint aspiration, but this should not be undertaken lightly as the joint could be infected by this procedure.
After thorough ‘drainage’ it is important to irrigate thoroughly the area. Some prefer to do this with an antibiotic solution, however, simple mechanical cleansing may well be adequate, and in fact this is what we do.
The World remains divided as to whether or not these wounds should be closed and drained. Most will granulate and eventually heal if they are left widely open, but with a subcutaneous bone such as the tibia there is a danger that the exposed bone surface may die and sequestrate, thus prolonging the whole problem. For this reason there is a good deal to be said for using a curved/flap type of incision, and then closing this loosely with sutures placed 2-3 cms apart in order to avoid leaving any bone exposed.
The next debatable point is whether or not to drain these wounds. One of us prefers to insert a corrugated drain (when this is available) which usually can then be shortened on each, or every other day, or until it falls out spontaneously. It is wise if this ‘drain care’ remains the responsibility of the surgeon who put it in.
Suction drainage is of course quite useless although it is occasionally used. Presumably by those who do not remember that it can not work unless it is placed in a ‘water-tight’ area.
The limb should then be ‘rested’
in an appropriate padded plaster gutter (i.e. a slab with two additional side
pieces, a simple slab will always break at a joint). This will both rest the
affected part, and also allow wound management. In due course it can be temporarily
removed, under supervision, to allow gentle passive and active joint movements.
If however there is an increase of pain, rise of temperature or other constitutional
symptoms and signs then it may be necessary to slow the rate of attempted
mobilisation. Of course if further pus has collected then this will have to
be released but with the management already described this should be a rare
occurrence.