The use of cancellous bone grafts in the treatment of subacute and chronic osteomyelitis.

Compound fractures and gunshot wounds of bone are common injuries of war. Compound fractures are becoming common injuries of civilian life with the increasing number of traffic and industrial accidents. In spite of careful primary excision, the use of antibiotics and the early immobilisation of the affected limb, a bone infection may become established because of contamination of the wound, loss of skin and injury to adjacent soft tissues. With the present-day use of blood or plasma transfusions and the ability of antibiotics to localise the infection, the constitutional reaction of osteomyelitis is not great. The problem then confronting the surgeon consists of a low-grade infective process in bone associated with a bone defect, sequestra and sinuses. If further treatment of the subacute osteomyelitis is not undertaken within a few months the condition of the lesion changes. Adjacent bone is further destroyed or becomes sclerotic, and an involucrum is slowly formed ; muscles atrophy and scar, joints become stiff, and circulatory changes occur. The patient suffers economic loss and slowly develops an anxiety state. Such is the character of chronic osteomyelitis. The tenacity of an established bone infection is well known and has often influenced the surgeon to advise amputation rather than undertake a prolonged and arduous reconstruction of the involved extremity. But attempts have been made throughout this century to develop a more acceptable method of treatment. The earliest were those of Carrel and Dakin, On (1927) and Baer (1931). With the advent of antibiotic agents new advances were made. Kelly et al. (1945), Knight and Wood (1945), Robertson and Barron (1946), Fischer (1946) and Reynolds and Zaepfel (1948) all reported satisfactory results with saucerisation followed in one to two weeks by a split-skin grafting. Shannon (1953) used saucerisation with immediate skin grafting and claimed good results. Buchman and Blair (1951) advocated initial closure by adjacent soft tissue after saucerisation ; they stressed the use of antibiotics, especially aureomycin. Dickson et al. (1953) had equal success from a similar method with emphasis on local sulphathiazole and systemic penicillin. The use of chip grafts of cancellous bone became popular after Mowlem (1 944) reported success with the use of such grafts to restore skull contour, bridge mandibular defects and restore the continuity of long bones. Gordon (1946) also used chip grafts successfully for non-union of the mandible, despite the presence of infectien in some cases. Ham (1950) found that, in experimentally transplanted cancellous bone grafts, most of the osteocytes died but that the covering osteogenic cells and osteoblasts might live if placed near capillaries and a good supply of tissue fluid. Coleman et al. (1946) undertook saucerisation and cancellous bone grafting in a single stage for infected bone defects of the extremities. Later, Toumey and Shipp (1948), Hogeman (1949), Bickel and Bateman (1950) and Cleveland and Winant (1952) used cancellous chip bone grafts in the treatment of chronic osteomyelitis, and confirmed their remarkable viability and resistance to infection. This paper is a review of the late results of the method employed by Coleman et al. (1946) in the treatment of Canadian Army veterans in Toronto, in which cancellous chip bone grafts were inserted at the time of saucerisation, or a few weeks afterwards, for subacute and chronic osteomyelitis.