In conclusion, it may be of value to recapitulate the principles which have already been outlined.
(1) The periosteum is the medium by which the blood-vessels are distributed to the shafts of the bones. Reflection of the membrane produces superficial necrosis and should never be done when sepsis is present or feared.
(2) The periosteum as reflected in an ordinary surgical operation is merely a fibrous tissue membrane and is not osteogenetic. It should, therefore, never be relied on to restore the shaft after resection.
(3) Mild chronic septic infection is a strong stimulant of inflammatory osteogenesis. It causes widespread osteoporosis, increased vascularity, and abundant callus-formation. This is the state in which cavities are most apt to heal, and fractures to unite, unless prevented by some definite condition such as the presence of sequestra or the existence of too large a gap.
(4) When the irritation subsides or disappears, this rarefying osteotitis gives place to an intense sclerosis which is very inimical to the healing of cavities or the union of fractures.
(5) Treatment should therefore take advantage of the pathological condition which is present at the time the sequestra have separated, and aim at a complete cure before osteosclerosis has supervened. It should consist of the complete excision of the scar and sinus, and the wide removal of the walls of the cavity for the purpose of thorough evacuation of sequestra and unhealthy granulation tissue. All irregularities and pockets must be obliterated, and when possible the depth of the cavity should be reduced by allowing the soft structures to fall into it. Pedunculated muscle or fascia-flaps are of great assistance in promoting rapid healing. Finally, wide-open drainage must be provided so that the cavity can heal from the bottom without depending on the dangerous alternative of a narrow sinus.
(6) Taylor's apparatus is useful in cleansing these wounds before operation and is of great value in the treatment of post-operative sepsis.
(7) Non-union in compound fractures, uncomplicated by great. loss of bone, is rare. When present, the fact that the wound is septic is no contra-indication to active treatment of the fracture, as well as of the osteomyelitis. Gratifying results may be anticipated from thorough freshening of the ends and adjusting of the fragments, providing efficient drainage is secured.
(8) The best time to correct mal-union in septic cases is at the time of the operation for the cure of the disease in the bone.
(C) 1919 All Rights Reserved.The Journal of Bone and Joint Surgery, Inc.