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THE CLASSIC: The Treatment of Acute Osteomyelitis by Drainage and Rest*

2006; Lippincott Williams & Wilkins; Volume: 451; Linguagem: Inglês

10.1097/01.blo.0000238778.34939.66

1528-1132

H. Winnett Orr,

History of Medical Practice

Hiram Winnett Orr was born on March 17, 1877 in West Newton, Pennsylvania, where he was raised. After graduating from high school, he moved to Lincoln, Nebraska to live with his uncle, Dr. Hudson Winnett. Dr. Winnett was a busy general practitioner and young Winnett Orr (who did not like the name Hiram) made calls with his uncle and helped with the practice. Orr attended the University of Nebraska as an undergraduate student and went on to attend the University of Michigan Medical School, from which he graduated in 1899. He then moved to New York and spent several months at the Bellevue Hospital. He subsequently returned to Lincoln and joined his uncle in practice for several years, during which time he took a few months off to study orthopaedics with Dr. John Ridlon at Northwestern University in Chicago. This experience made him aware of the plight of children with crippling deformities and, as a result, he worked aggressively with several other concerned citizens to open the Nebraska State Hospital for the Crippled and Deformed in 1905. Dr. Orr served as Chief Surgeon at the Hospital and he maintained a profound interest in the institution for the rest of his life. In 1917 he enlisted in the Army Medical Corps and was one of an elite group of young American orthopaedic surgeons to work with Sir Robert Jones at British Orthopaedic Hospitals. Dr. Orr further developed his interest in treating infections in the medical corps and in France during the war, and came to believe that the application of the principles of Robert Jones and Hugh Owen Thomas would lessen the severity of bone infections seen in the wounded. The principles involved incision, drainage, and prolonged immobilization in a plaster cast without inspecting or redressing the wounds during that time. The classic article presented here imparts his philosophy regarding the ‘Orr Treatment’ of osteomyelitis in the years before the discovery of antibiotics. Dr. Orr was also a bibliophile and a noted medical historian. He collected thousands of rare books and left many of them to the library of the American College of Surgeons. He was the Editor-in-Chief of the Journal of Bone and Joint Surgery from 1919 to 1921 and served as President of the American Orthopaedic Association in 1937. He moved the Journal from Boston to Lincoln, Nebraska during his tenure as Editor-in-Chief, but when he stepped down in 1921 the Journal promptly moved back to Boston and has remained there since. Dr. Orr died in 1956. Henry H. Sherk, MD In order to clear the atmosphere it seems desirable to state exactly what it is that requires emphasis in the treatment of wound infections and of acute osteomyelitis in particular. In the method proposed in this paper for the treatment of wound infections, especially those affecting bones and joints, there are three principal points. It must be borne in mind, however, that the point with which we are most concerned at this time is the desire to do away with the employment of the active antiseptic methods now in common use in the postoperative treatment of infected wounds. It is believed that the antiseptic methods now in general use not only fall short of being truly antiseptic, but that as a rule, partly by inefficiency and partly from the manner of their use, they add to or complicate rather than prevent or relieve infections. In this paper is advocated a special type of drainage in acute osteomyelitis and the immobilization in plaster-of-Paris of all inflamed parts. Most important, however, is the advocacy of the discontinuance of active antiseptic methods in the after-care of osteomyelitis, compound fractures, septic joints, etc.Fig: Dr. Hiram Winnett Orr is shown. This image of Dr. Orr is ©1957 by the Journal of Bone and Joint Surgery, Inc., and is reprinted with permission from Hiram Winnett Orr: 1877-1956. J Bone Joint Surg Am. 1957;39:466-467 .Lister taught us the fundamentals of both asepsis and antisepsis. Lister's teachings with regard to asepsis have been understood and his aseptic methods and technique have been developed and improved. Lister's teachings with regard to antisepsis, however, as related to the treatment of wounds in which infection has become established, have been largely misunderstood. Such treatment at the present time is not only no better but on the whole rather worse than in Lister's time. 1. Adequate drainage. Of course, this is not new. Drainage of infected areas is commonly taught but poorly practised, especially as regards infections in bones and joints. For acute osteomyelitis incisions through the skin or even through the periosteum are insufficient, but these have been common practice. Drill holes into the diaphysis at the point of most severe infection, as advocated by Starr, is, of course, much better treatment than periosteal drainage, but inadequate in many cases. Larger openings into the infected area are usually necessary, and it should be emphasized that the entire area must be left open. Drainage through tubes or leakage between sutures is inadequate. This entire program of drainage was perfectly described by Dr. E. H. Nichols in his article in Keen's Surgery in 1907. Dr. Nichols leaves us at the end of his drainage operation, however, without a suggestion as to the subsequent care of the wound or the patient in the acute cases. He does say, however, that in the chronic cases he has found methods of filling bone defects by sponge, skin flaps, blood clot and Mosetig Moorhof paste useful only in selected cases. The author has advocated large openings into the bone in every case. For the method of dealing with a primary acute osteomyelitis, however, he is indebted to Dr. Osgood for an important suggestion. Dr. Osgood has pointed out that the primary focus is commonly limited early to the cancellous bone of the metaphysis. Having made a window into this area it is quite important to limit our surgical procedure so that neither the epiphysis nor the diaphysis is invaded, if they have so far remained uninvolved. If this primary drainage of the metaphysis is properly timed and is adequate, a prompt and brilliant recovery without extension and without complications may be obtained. If on the other hand the surgical procedure is the means of carrying infection either into the uninvolved epiphysis or into the medulla of the diaphysis, great damage may be done. Accuracy in diagnosis either before or during the surgical procedure becomes, therefore, most important. The exposure of the infected area is partly to reduce the amount of infection present, but chiefly to give a clean field for the application of the sterile dressings that are to serve to exclude secondary infection from the diseased area. In other words, no attempt is to be made to remove all diseased bone tissue. 2. An aseptic dressing of considerable extent (vaselin pack) is to be placed in and about the wound, and it is not to be disturbed for a number of weeks or until healing is thoroughly established. No drainage tubes or sutures are employed. This is simply an elaboration of the method of Lister himself and is not new except for its application to acute and intramedullary bone and joint infections. A window having been made into the infected area, the wound and surrounding skin are carefully dried, painted with tincture of iodin and the entire wound packed open and covered over with a sterile gauze-vaselin mass. This is not to be disturbed for subsequent dressings until healing is well established. This is a matter of several weeks. Subsequent dressings are to be done in the same manner and at similar or longer intervals. Two to four dressings are usually sufficient to secure healing. All of the writer's earlier suggestions to this effect were met by the response that it could not be done. For several years, however, this method has been employed successfully in every case in which it has been attempted and, although the number of cases is not large, there has been no death in the series. This cannot be said for any other series of cases of acute osteomyelitis known to the author. 3. Immobilization of the affected part in a well fitting plaster-of-Paris cast. Makeshift splint methods will not do; the cast must be applied in such a way that the affected part is well fixed in correct position and free from muscle spasm. Moreover, the wound area should be well covered with plaster and is not to be opened except for definite and urgent signs of secondary trouble. In from three to six weeks the healing process will have become so well established that if, for change of dressing, reapplication of cast, or any other good reason, a change becomes necessary, it may be done. But it should be done under the same conditions of asepsis and protection of the parts against irritative motion as were observed at the original operation and the secondary period of non-disturbance should be as carefully observed as the first. Immobilization should not be discontinued until healing is complete. By this method: The patient is relieved at once. Complications are avoided. Convalescence is simplified. Labor and materials are saved. The patient makes an earlier recovery with a minimum of deformity and disability. One of the points strongly emphasized by Lister, and which has been pretty generally disregarded ever since, is that suppuration (discharge) is greatly aggravated by the application of antiseptics directly to the wound surface. Quite commonly patients are seen, who are pouring out quantities of secretion only exceeded by the amounts of irrigating, and irritating fluids poured in by the overzealous surgeon. By the rest method advocated by the author these wounds will remain quiet and dry for weeks, because of the fact that they are protected both against motion of the part and against daily irritation by antiseptics and exposure to new infection. During a certain stage of my experience in France it fell to me to send some thousands of men with bone and joint wounds from France to the United States in casts. If I had sent any of these on shipboard for transportation to the United States without making windows in the casts for the daily dressing of open wounds I should probably have been censured or worse, and at that time I should not have thought of doing so. Yet later observations show that most of those men would have had less suffering, fewer complications, and better ultimate results if they had been prepared according to the method now advocated, put in closed casts and left undisturbed during the entire period of transportation to the United States or longer. The two things that are responsible for most wound complications (whether in the wound or in other parts of the body) are secondary dressings and failure to immobilize the inflamed part. Mixed infection and irritative motion of inflamed parts are the two things most to be feared in all wound treatment. Failure to appreciate the principles involved in this kind of treatment or unwillingness to take pains in carrying out the essential details may either or both be responsible for failure to obtain good results; and it is very common for those who do so fail to blame their poor results on defects in the method. Lister himself refers very pointedly to this difficulty in speaking of the antiseptic system. Lister says-"The antiseptic system does not owe its efficiency to any such cause, nor can it be taught by any rule of thumb. One rule, indeed, there is universal application of,-namely this: whatever be the antiseptic means employed (and they may be very various) use them so as to render impossible the existence of a living septic organism in the part concerned. But the carrying out of this rule implies a conviction of the truth of the germ theory of putrefaction, which, unfortunately, is in this country the subject of doubts such as I confess, surprise me, considering the character of the evidence which has been adduced in support of it. Yet, without this guiding principle, many parts of the treatment would be unmeaning; and the surgeon, even if he should attempt the servile imitation of a practice which he did not understand, would be constantly liable to deviate from the proper course in some apparently trivial but essential detail, and then, ignorant of his own mistake, would attribute the bad result to imperfection of the method. For my own part, I find that, in order to approach more and more to uniform success, it is necessary to act even more strictly in accordance with the dictates of the germ theory. Failure on the part of those who doubt or disbelieve it, is therefore only what I should expect." Similar comments might be made with reference to failure to obtain satisfactory results from splinting. Very little so called splinting gives anything like true immobilization. Even when plaster-of-Paris (the ideal splint material) is employed, good immobilization is by no means always or even usually obtained. The method of treatment by drainage and rest advocated by the writer rests upon the suitable combination and employment of a few details of technique all of which rest upon unquestioned fundamental truths of surgical practice. Any failure to comply with these principles will place the patient in jeopardy. A careful regard for the principles of drainage, antisepsis, and rest, however, even if other details of technique are employed, will usually lead to satisfactory results. The therapeutic scheme proposed has yielded far better results in acute osteomyelitis than methods previously taught, and previously employed by the author in his own practice; moreover the results are better than in similar cases observed by him treated elsewhere by other methods. It is firmly believed that lives and limbs may be saved by this method and that suffering for the patients, labor for the surgeon and materials for the hospital may all be reduced. REPORT OF AN ILLUSTRATIVE CASE No. 7005, aged six years. This child came two hundred and fifty miles on the train and was admitted to the hospital September 1, 1926, with a temperature of 105 degrees, pulse 140, respiration 32, white blood count 28,000. There had been pain in the left knee and thigh for three days previously. Hot packs had been used to allay the discomfort but during the last twenty-four hours the least movement of the left lower extremity caused severe pain. The temperature taken twelve hours before admission to the hospital was 106 degrees and had been 104 degrees on the previous day. The lower third of the thigh was swollen and tender. There was a definite redness radiating to the outer side of the front lower portion of the thigh. Movement of the knee or hip caused severe pain. The child was negative as to other physical findings except for a mild furunculosis on the back of the neck and an infection of one finger. X-ray findings were negative as to any bone lesion. The child was taken to the operating room with a diagnosis of acute osteomyelitis of the lower third of the femur. The operation was done by the author and his associate, Dr. Thomson. An incision was made laterally just behind the quadriceps group about six inches long. The skin, muscles and periosteum were reflected in one mass and a small chisel hole made in the cortex of the metaphysis just proximal to the epiphyseal line. Immediately a yellow, creamy pus welled out. The opening in the bone was extended toward the diaphysis to about three inches long and one-half inch wide so that the entire lower third of the femur was well drained. Pus exuded freely and was apparently under pressure. Very little exploration of the medullary cavity was done and the wound was filled to the depth of the medulla with a vaselin gauze pack and vaselin covering placed over the entire area. A double plaster-of-Paris spica cast was applied. In twelve hours his temperature had dropped to 99 degrees; it went up in the afternoon to 101 degrees, but was down in the morning. The temperature ranged within these limits for three days; after which it remained under 99.6 for four days. After this he had a normal temperature, once or twice rising to 99. At the end of six weeks the cast was removed and the dressings taken out. There had been considerable drainage under the cast, but removal of the vaselin pack showed the wound had filled in to practically one half the previous depth and was covered from the base with healthy granulation. A new single spica cast was put on and worn for a month longer, when it was removed and the wound was found to be healed, with the dressings pushed entirely out of the wound and the serum which had come from the wound entirely dried. This wound which had gaped open originally about two inches, closed to less than one-half inch at the widest portion of the scar. He was placed in a caliper brace and physiotherapy, massage, and active and passive motion instituted. Since he has been up and around he has had no temperature and on January 10, 1927, was apparently entirely well. DISCUSSION DR. ELLIS JONES, Los Angeles, Calif.: I am extremely grateful to Dr. Orr for introducing to me his method of treatment of chronic osteomyelitis six years ago. My enthusiasm for that method, however, did not give me sufficient courage to attempt his treatment of acute osteomyelitis until this last year. I have had experience in only two cases, one a child of nine years sent in on the third day. That child had three dressings in nine weeks. The other child, aged nine years, had five dressings in eleven weeks. I confess to many timorous moments. The temptation on the third and fourth days to remove the dressings was tremendous. I know of no other method by which such end results could have been obtained. Infrequent dressings spare the patient and the surgeon. It is a tremendous temptation to examine the wound at frequent intervals. We should, however, remember that the exudate is pre-formed connective tissue and that we should permit that exudate to form new tissue, undisturbed by repeated dressings. Multiple dressings are traumatic, no matter how carefully the dressings are done. I am sorry that my experience has been such a limited one, but I am tremendously encouraged by even such a limited experience. DR. F. J. GAENSLEN, Milwaukee, Wis.: I have heard Dr. Orr's method of treating osteomyelitis condemned by a good many during the past few years as being unscientific. When I first heard of it in 1922 I condemned it on the same grounds. I felt that it violated a principle of surgery which I had always tried to comply with, namely to provide adequate drainage in case of infection. I felt that the vaselin pack as recommended prevented adequate drainage and I did not use it. A year later I had a chance to discuss the method with Dr. Orr and to learn of his uniformly good results. Knowing him as I do, I felt I could take his statements at face value and therefore gave the method a trial at the first opportunity. Since then, in 1923, I have operated on sixteen private cases and twenty-four cases at the University Hospital at Madison. Some of these were multiple so there were really more than forty altogether. I have had no deaths and my results were so satisfactory that I have not considered any other method since that time. I have here a summary of my forty cases which shows that in many of these the hospital stay was under one week, and that complete healing after radical operation resulted after two, or three, or sometimes four plaster casts put on at intervals of two or three weeks, the patients being brought into the hospital only for renewal of cast and immediately discharged. No windows were cut in the cast for dressings during the interval between cast changes and as a rule the patients were not seen except at time of change of cast. I feel that when results such as these can be shown, it is science which legs behind in the explanation of demonstrated facts and that we must endeavor to advance this to meet the situation. The essentials of the treatment are: First: adequate drainage without suture. There are no objections to this. Second: less antiseptics. I use antiseptics in these wounds occasionally to case the conscience of assistants who feel that swabbing with iodin is of advantage. I have not used it in over half the cases and feel that it is unnecessary. Third: the vaselin pack. Objections raised are that it may dam up secretions. I believe on the contrary that the vaselin mass is an excellent drain. It is a large, more or less conical, mass which recedes and is extruded only as the granulation tissue gradually fills in the wound. What secretion there is finds its way out readily between the wound walls and the vaselin mass. Redness and pain suggesting a cellulitis from retained secretion is uniformly absent. Fourth: absolute immobilization. I think this is extremely important. If we could study the wound repair daily with the microscope I think it would be extremely interesting. No matter how carefully you carry out your dressings you will interrupt the repair processes nature is making. There is one other point which I believe is important and that is one suggested in an article by Dr. Vilray P. Blair of St. Louie. In closing defects of the floor of the mouth he used skin grafts placed over previously prepared paraffin molds. These molds were then introduced into the mouth so that the defects were accurately covered with the grafts. In spite of the infection which the mouth constantly harbors, his results were excellent, and this Blair attributed to the beneficial effect of the pressure of the paraffin mold. He feels that pressure has never been given sufficient consideration as a factor of importance in wound healing. It seems to me that in this method of Dr. Orr, the beneficial effects must also be attributed in considerable measure to the element of pressure of the vaselin mass filling the wound. This pressure approximates normal intracellular pressure under which growth and repair processes must be best served. In a wound without adequate surface pressure the superficial cells are apt to be more or less water-logged from reduction of surface tension. As a result the normal cell physiology is disturbed and the defense of the cell to infection is impaired and the process of repair greatly delayed. The offensive odor, of course, is an objection, but one which my patients have been only too glad to put up with, when rapid and steady progress is made in a condition so serious as an osteomyelitis. I feel that Dr. Orr has made a very wonderful contribution in the treatment of chronic as well as of acute osteomyelitis. I feel that I can recommend the method on a basis of a fairly large and to me a very satisfactory experience. Dr. Kleinberg has asked me to say that he has used this method in nine cases and that his results make him a warm advocate of the method. DR. M. S. HENDERSON, Rochester, Minn.: Dr. Orr has given us and has repeatedly emphasized in the last few years a sound surgical principle in the treatment of osteomyelitis. When he first talked to me about it, I was very skeptical, but I finally tried it out and was surprised how well these cases did. The objections to it are few, the chief one is the odor that comes from not changing the dressings and sometimes this is seriously inconvenient. However, the good points far out-rank the bad ones and this method has enabled us oftentimes to send patients home, if they live within a moderate distance, and when they return a month or two later we often find the sinuses healed. I think that if you try this method of Dr. Orr conscientiously, it will be of distinct advantage in many cases. DR. H. W. ORR, Lincoln, Neb. (Closing the discussion): I have already heard all of the objections to my method that have been mentioned here and a good many more. There are always many questions asked. Here is one that has just been sent up to me in the form of a note regarding the danger of sequestrum formation in these cases. It is my opinion that sequestrum formation depends upon whether or not an early efficient operation has been done. We have all been taught that at least in some cases it is better to wait until an osteomyelitis becomes chronic and until there has been extensive formation of involucrum before we undertake to do radical drainage. In such cases the sequestrum is a necessary feature of the case. If good drainage is done during the first few days, however, it is my experience there will be no death of bone and consequently no formation of sequestrum. If we wait for the formation of involucrum, we wait too long. If we relieve the condition at once by drainage, a sequestrum will not form, because there is not the extensive infection and death of bone. With regard to the application of plaster-of-Paris in these cases, there is no objection to it whatever, if you follow the suggestions made with regard to the matter of drainage. I have shown that frequent dressings are not necessary, and that if frequent dressings are not done we do not have much discharge. Moreover, with the excellent immobilization that one gets in a double spica, another irritating factor is removed and dressings are not necessary. I consider that good immobilization in a double plaster-of-Paris spica is necessary and helpful in the cure of these cases. I regret very much that Dr. Starr is not here, I am sure he could add many interesting and useful comments to the discussion. With regard to this method of treating open wounds the important point is that we must avoid covering up the pockets of infection. If the wound heals from the bottom all the way up, such pockets do not form and complete and final healing is the result.