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JANUARY, 1905.

No. 6


Complete Removal of the Shaft of the Tibia for Osteo

myelitis, with Restoration of the Bone.'

BY GEORGE BEN JOHNSTON, M. D., Richmond, Va., Chief of staff Memorial Hospital, Fellow of the American Surgical Association.

HE following six cases of removal of the entire shaft of the

tive treatment were so satisfactory, restoring otherwise hopelessly damaged limbs to usefulness.

Osteomyelitis is a disease which occasions much suffering, produces many deformities, and causes many deaths. It is therefore of sufficient importance to warrant a word of warning to physicians and ask on their part early recognition of it and prompt reference to a surgeon.

It is not meant to review the subject of osteomyelitis to this body of surgeons, but merely to present these cases and briefly make a few suggestions to such physicians as may see this report. Some forms of osteomyelitis are so obscure as to be difficult of recognition, and great damage is often done before a correct diagnosis is made and surgical treatment practised. The milder forms are mistaken for "growing pains," malarial fever, typhoid fever, and rheumatism; the more violent and active, for erysipelas.

When it is remembered how destructive this malady is and how dangerous to limb and life, the importance of early diagnosis and prompt reference to a surgeon are manifest.

The infection is not always of the same degree of virulence. The milder forms may pursue a more or less chronic course, but the acuter forms are so violent as often to cause prompt death or at least to destroy a bone, and this in a few hours.

1. Read at the annual meeting of the American Surgical Association at Saint Louis, Mo., June 16-18, 1904.

The diagnosis is commonly not difficult. It generally attacks young, growing children, usually males. The bones oftenest involved are the exposed ones, notably the tibia. It is almost invariably traced to an injury, which is sometimes too trivial to be noticed at the time it is inflicted.

The constitutional manifestations vary all the way from malaise, general indisposition, and slight fever to a profound, overwhelming, and even fatal septicemia.

Where infection is slight the course of the trouble is mild and more or less obscure. Where the infection is virulent the symptoms are violent.

The age and sex of the patient, the history of an injury, the character of the pain, generally worse by night, a tender spot in the course of a bone, with redness and swelling, if superficial, suggest osteomyelitis.

Treatment must be prompt. Free drainage is imperative. If the disease involves only the superficial aspect of the bone, a free incision with proper disinfection and maintained drainage may be all that is required. Should the infection be in the medullary cavity or be otherwise deep seated, it must be found and proper drainage established. If the lesion has advanced to complete destruction of the bone, the treatment must be sufficiently.radical to encompass the removal of all dead bone. This will occur in the more violent forms unless treatment is resorted to early enough to destroy the infection and thus prevent complete destruction. Where the major portion of a bone's shaft is destroyed, or is so involved as to require removal, this must be done. Where the entire shaft is removed, regeneration can only be of periosteal origin, and therefore the periosteum must be carefully preserved.

After free incision and removal of all diseased or dead bone, the wound should be most carefully antisepticised and maintained in this condition. Throughout, immobilisation is important and gives much comfort. For this purpose an ordinary fracture-box is the best appliance.

The dressings are to be as infrequent as is consistent with asepsis and always gently done. As new bone tissue begins to form, the parts may be shaped by the proper adjustment of adhesive strips and bandages, so that deformity may be lessened. When cicatrisation is complete, a light plaster-of-Paris cast is applied for the purpose of affording protection to the young and tender bone. The body weight should not be borne on the limb until the new bone has attained sufficient rigidity to support it

safely. The general health will always require attention. Tonics, ample food, and fresh air will expedite recovery.

Where a disk of bone can be left covering the epiphyseal line, no deformity in the length of the bone will result. If the epiphyseal junction is destroyed, there will necessarily occur shortening. This may mean aggravated deformity, but no great impairment of limb function.

When one of a pair of companion bones is destroyed, the other invariably takes on compensatory hypertrophy.

Case I.-1888. T. R., a boy, aged 7 years, had an injury to the right tibia, falling against a curbstone. Seven days after a painful swelling appeared over the lower third of the left shin. The family treated him for rheumatism, and not until the symptoms became alarming was a physician called. The family physician treated him with poultices, quinine, and opium for three weeks. I saw him in October, 1888, when the disease had existed over six weeks. He was much run down in health and very septic. The swelling was immediately opened by a free incision. It was discovered that the tibia was dead and the periosteum detached from an inch above the junction of the lower end of the shaft with the epiphysis to a point two inches below the upper epiphyseal attachment. The dead portion of bone was removed with a thin disk of healthy bone attached. This was accomplished by stripping away the periosteum where it was attached in small islands to the diseased portion of the bone, and separating it from the healthy bone a short distance above and below the diseased portion, and then with a chisel dividing the shaft in healthy bone and lifting the shaft thus separated out of its bed. The periosteum was intact throughout. An antiseptic dressing was applied after disinfecting the enormous wound thus made, and the dressed leg was placed in an ordinary fracture-box.

Almost immediately the child's general condition improved, all pain subsiding and fever disappearing, and nutrition was resumed.

The wound granulated rapidly, and in the course of three weeks a needle could be made to indicate the presence of bone tissue in the granulations. Three months were required for the new bone to form and the wound to cicatrise completely. When this was accomplished the leg was encased in a plaster-of-Paris splint and the boy allowed to go on crutches. He was not permitted to use the limb for a year, at the end of which time he walked freely without limp or pain. The new tibia was somewhat ill-shapen, being flattened from before backward, but had sufficient strength to meet all requirements.

I was able to keep track of this little fellow for six years after the removal of the shaft of his tibia. During this time he seemed perfectly well and suffered no inconvenience from the loss of his bone, the function of the leg being perfect.

I regret I have no photographs of this case.

Case II.-1894. T. S., a boy, aged 8 years, while playing ball was injured on the right shin, the trouble being so trifling at the moment as to receive no attention either from the boy or

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his parents. A week later he began to complain of a deep-seated pain in the shin, aggravated at night; had high fever, loss of appetite, and rapid wasting of flesh. When these symptoms had progressed a few days I was consulted.

A diagnosis of osteomyelitis was made and surgical treatment applied. Exposure of the tibia displayed a deeply congested and thickened periosteum. The medullary cavity was trephined

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