5.2. Surgery in osteomyelitis.
Open operation or aspiration (continue)
5.2.1. Aspiration We have no personal
experience of this as the definitive treatment of acute osteomyelitis and
believe that unless local circumstances do not allow open operation, it is
then always better to explore the area as described above.
5.2.2. Surgery – acute septic arthritis
– open operation or aspiration A very ill febrile
baby or child with a probable acute septic arthritis should be managed in
the manner already described for treating an acute osteomyelitis.
However, with the hip and shoulder it is
not possible to use a tourniquet so care must be taken with haemostasis. The
joint is approached by any of the classical routes, probably best by the one
with which the operating surgeon is most familiar.
When exposed the joint capsule is likely
to be distended (with pus) but an exploring needle and syringe may occasionally
be helpful to clinch the diagnosis. The joint should then be adequately opened
(classically in cruciate fashion). The cavity and the articular surfaces are
carefully inspected and the joint washed out. Any dislocation (e.g. the hip)
reduced and the wound ‘tacked together’ leaving a corrugated
drain in the joint cavity. With an anterior (Smith Petersen approach) one
or two sutures will anchor the mobilised antero-lateral muscles to the anterior
superior iliac spine, and thus eradicate a potential dead space.
The limb/joint is then immobilised with
traction or plaster, or on occasion with a combination of both. In the hip
joint the head of the femur should have been placed as deeply and as congruously
as possible in the acetabulum, and maintained there by keeping the affected
limb in abduction and internal rotation. The knee is probably best rested
in a few degrees of flexion
Post-operative and drain management is as
described for acute osteomyelitis.
Occasionally a septic arthritis of the hip
(or an other joint) may be ‘mis-diagnosed’ as an osteomyelitis
of the femoral neck, and vice versa. If this occurs, and the joint cavity
is found to be normal, a drill hole in the femoral neck may reveal pus under
considerable pressure – it can really squirt over your shoulder.
However, remember that a sympathetic sterile
knee effusion can occur in association with a local osteomyelitis and if there
is doubt a sterile needle passed into the joint before the bone is explored
will show whether or not there is ‘obvious pus’ in the joint.
As with acute osteomyelitis the decision
to start joint mobilisation is based on the result of repeated clinical examination
of the joint and it is best ‘to make haste slowly’. Any sign
of renewed joint irritability or of constitutional upset is likely to demand
a further period of appropriate rest.
