Download THE THREE TYPES OF ACUTE HAEMATOGENOUS

THE
THREE
TYPES
OF
ACUTE
A Clinical
and Vascular
J. TRUETA,
OXFORD,
the Nuffield
Orthopaedic
Fronz
clinical
It has been known
characteristics
child
and
from
adult
for many
according
constitute
the generalised,
Fraser
(1924),
HAEMATOGENOUS
years
to the
three
that
age
separate
or septicaemic,
Paschlau
(1932)
OSTEOMYELITIS
Study
ENGLAND
(‘entre,
Oxford
acute
haematogenous
of the patient;
thus
clinical
entities
with
osteomyelitis
osteomyelitis
few
features
phase
of the disease
from which
and Green
and Shannon
(1936)
varies
in its
of the infant,
in common
apart
they all suffer.
were among
the
first
to
isolate
the infantile
type from that of the child and to describe
its main characteristics
during
early life, including
its high mortality-up
to 45 per cent in the series of Green
and Shannon.
Since
the inception
of antibiotic
treatment,
Greengard
(1946),
Thomson
and
Lewis
(1950)
and Dennison
(1955)
have
further
contributed
to the study
newborn
and have insisted
on the existence
of two forms,
the severe
nevertheless.
be pointed
out that the so-called
mild type refers
only
of this form
of the disease,
for even the milder
to bone and joint
in the infant.
The separate
nature
of acute
osteomyelitis
years.
years
but the first full description
ago (Zadek
1938).
In a systematic
study
of
treated
202 patients.
This
of
acute
experience
of these three types of osteomyelitis.
the disease
in childhood,
which
sixteen
in the
years
adult.
inclusively.
This
the
form
in the
condition
be used
I will begin
in osteomyelitis
is followed
OF
majority
of contributing
factors
vary,
has
including
and
been
adult
was
to summarise
by mentioning
covers
the
by a summary
ACUTE
severe
the
many
twenty-one
since
1944
main
clinical
disease
damage
for
only
the main clinical
span
of life between
of the
in the
It must,
figures
lasting
recognised
given
osteomyelitis
here
in the
we
have
features
features
one
of
and
infant
and
OSTEOMYELITIS
This study
of the severity
of acute
osteomyelitis
inception
of antibiotics
(Table
I).
It is well recognised
that acute
haematogenous
the
cause
adult
in the
haematogenous
will
SEVERITY
may
of osteomyelitis
and the mild.
to the mortality
is based
on
osteomyelitis
the
nature
experience
is a disease
and
pathogenesis
collected
since
in which
of the
the
causal
germ.
Thus,
whereas
the prevalent
bacteria
in the older age groups-the
child and the adultis the coagulase-positive
staphylococcus
pyogenes
aureus,
the streptococcus
pyogenes
appear
responsible
for most
acute
bone
infections
in infants
(63
per cent
in the
series
of
Green
and
Shannon;
53 per
cent
in this
series).
The
almost
present
on the severity
and clinical
characteristics
of the three
by an equal
consensus
of opinion
regarding
the causes
responsible
In the present
paper
I shall attempt
to offer an explanation
characteristics
of acute
osteomyelitis
far been unable
to find any similar
As it is not my purpose
here
osteomyelitis,
of the
41 B,
VOL.
B
I have
three
variants,
NO.
4,
presented
without
NOVEMBER
1959
the
any
general
age
agreement
existing
at
types is not accompanied
for the three different
types.
for the diversity
of clinical
in the three ages in which
they are grouped.
I have so
explanation
in the medical
literature
at my disposal.
to study
the clinical
aspect
of the three
types
of acute
table
aim
on the
at statistical
severity
of the
disease
as a simple
reminder
accuracy.
671
672
J. TRUETA
LOCALISATION
Since
the early
experiments
OF
of Lexer
PATHOGENIC
(1896)
BACTERIA
it has
been
generally
accepted
that
artery
is the main route
for bacteria
causing
osteomyelitis,
even if other
be excluded
as a route for the infecting
organisms.
From
the experiments
know
that an intravenous
injection
of bacteria
localises
in the metaphysial
only
two
hours
Hobo
metaphysial
children.
in that
after
(1921)
His
region.
inoculation
showed
and
the
side of the growth
diagram
(Fig.
part
that
a focus
played
plate in causing
1) is based
of infection
the vascular
by
the
on observations
TABLE
THE
SEVERITY
OF
ACUTE
may develop
arrangement
localisation
of the
of the
normal
OSTEOMYELITIS
(per
General
severity
before
.
and
pathogenic
structure
AT
to
the
bacteria
of the
in
vessels
Adults
(under
cent)
one
year)
(per
cent)
Aors
DIFFERENT
Infants
of all patients
there.
adjacent
I
HAEMATOGENOUS
Children
Frequency
the nutrient
bone vessels
cannot
of Koch
(191 1) we
veins in the bone
(over
sixteen
years)
(per
cent)
.
80
7
13
during
early treatment
Very severe.
.
.
.
10
15
5
Severe
.
.
.
25
20
10
.
65
65
85
5
23
20
.
15
20
25
.
80
57
55
.
Moderately
Local
damage
during
early
Permanent
severe
.
sustained
before
and
treatment
.
.
Transient
.
None
Disability
Very severe.
In his studies
.
#{149}
,
15
5
15
15
6
12
18
94
58
62
Severe
#{149}
.
.
Moderate
.
.
.
None
.
of experimental
.
.
infection,
Starr
(1922)
showed
that
the organisms
responsible
for the bone infection
were carried
by the blood
stream
until they reached
what is referred
to
as “the finer capillaries
of the juxta-epiphysial
region of a long bone,”
but he attributed
the
infection
to the lowering
of an undetermined
general
resistance”
of the patient.
Wilensky
(1934) pointed
out the importance
of what
he called
the fixation
points
of the disease
and
supported
the views of Hobo on the vascular
responsibility
in the onset of infection.
Finally,
Leveuf (1947) denied
that the disease
in the child was initially
Iocalised
in the metaphysis,
as
suggested
by Lnnnelongue
in 1879, and favoured
the hypothesis
of thrombosis
of the main
trunk of the nutrient
artery from the onset of infection,
as had been suggested
by l-Iartmann
as early as 1855,
I cannot
trace that proper
mention
has been made by any author
of the fact that the
vascular
pattern
of the long bones occurring
during
the first year of life, during
childhood,
THE
JOURNAL.
OF
BONE
AND
JOINT
.SUR(4ERV
THE
THREE
Epiphysial
Primary
marrow
TYPES
OF
ACUTE
HAEMATOGENOUS
673
OSTEOMYELITIS
marrow
outgrowths
Epiphysial
cartilage
point
Descending
limb-
artery
Venous
network
in
Nutrient
artery
Nutrient
vein
Transition
FIG.
Diagram
of
marrow
the
course
of a young
I
blood vessels
in the
rabbit. (After Hobo)
of
the
‘,L
2
1oops
FIG.
Figure
sinusoids
VOL.
41 B,
NO.
4,
2-Vascular
where the venous
NOVEMBER
1959
FIG.
under
the
growth
limb of the vascular
plate.
Figure
3
3-Large
loops under the growth
venous
plate end.
674
and
J.
at
puberty,
purpose
is responsible
here
to suggest
for
that
each
of
ACUTE
by referring
the
it is precisely
limit which
explains
the diverse
clinical
groups
in which
it presents
itself.
I begin
TRUETA
to this
both its clinical
and vascular
osteomyelitis
“par
excellence.”
three
the
types
picture
of acute
OSTEOMYELITIS
IN
age
group
aspects,
for
apart
of
changing
one
which
has
been
studies
age
of the
age
the
and
b,
We
from
as the
out
the
growth
Morgan
in
to
both
(Trueta
Trueta
able
adjacent
this
plate,
1959,
been
acute
vascular
microradiography
have
capillaries
studied
shown
underlying
and
best
carried
repeatedly
photography
1958a
Morgan).
one
by all authors
vascular
have
arrangement
the
in every
considered
The
by
It is my
at each
CHILDREN
being
centre
osteomyelitis.
arrangement
osteomyelitis
it is the
from
acute
vascular
and
to confIrm
the
growth
that
plate
in
its metaphysial
side are, apart
from
a narrow
fringe
at the periphery
of the
plate,
the
last
ramifications
of the nutrient
artery;
these.
after
turning
system
down
in acute
of large sinusoidal
others
for
the
loops
(Fig.
2), reach
a
veins responsible
with
haemopoietic
activity
of the
marrow
(Fig.
3).
It is here
that
slows
down
and that
the pathogenic
particularly
:.
the
#{182}:
end
4
FIG.
supply
of the
from that of the
specimen
of eighteen
epiphysis
metaphysis.
months.
is
periosteal
and
venous
sinusoids
In a study
growth
cartilage
eighteenth
largely
Human
metaphysis
“child”
The
causes
where
vessels
because
none
has
distributed
at the periphery
changes
1957).
is first obvious
month,
except
a
capillary
of the
staphy-
of eight
peripheral
(Fig. 4). Thus.
from the point
the age of one year.
lakes,
beginning
spreads
for
at
through
in a pattern
labelled
exactly
end-arteries,
of the
occur
loops.
initially
of vascular
loops
growth
cartilage.
of the vascular
are
Eventually
along
the
proximal
to
upper
femoral
epiphysis
represented
by the growth
months
and is definitely
vascular
connections
of view
medium
loop,
side
not
of the vascular
pattern
of the human
it was found
that the vascular
barrier
at the age
for some
blood
ideal
that
of the distribution
of
early stages
of osteomyelitis.
branches
of the nutrient
erroneously
a system
of the
its
metaphysis
by spreading
infection
from the venous
is thus occluded.
Bone infection
does
metaphysial
like those
of the
(Trueta
of
the
corresponding
to
bone sepsis
in the
The
peripheral
artery,
thrombosed
artery
itself
finds
system
of
the whole
__________
secondarily
the nutrient
aureus,
development.
This
the
during
coagulase-positive
*
lococcus
The arterial
disconnected
bone
blood
flow
bacteria,
established
before
between
epiphysis
anatomy,
the infant
the
and
becomes
at
extensive
early oedema.
it is thinnest,
involvement
of the
Transudates
over the distal
metaphysial
veins
in acute
expand
towards
the surface
part of the metaphysis,
and
from
the cortex,
disrupting
all vascular
connections
between
oedema
and the periosteum
lays down
a new layer of bone-the
from
the cortex,
visible
after a few days on a radiograph
(Fig.
THE
osteomyelitis
of the
of the bone across
here the periosteum
them.
Soon
involucrum-at
5).
In another
JOURNAL
OF
BONE
child
the cortex
is raised
pus follows
the
some distance
work
we have
ANt)
JOINT
SURGERY
THE
found
evidence
of blood
soon
to the
after
by
accompanies
that
are
THREE
typical
OF
ACUTE
HAEMATOGENOUS
of the
mechanism
of involucrum
inner
half
cortex
the
the
TYPES
of the
interruption
of
lifting
of the
of osteomyelitis
the
formation
by the
blood
periosteum,
in the child
(Fig.
thrombosis
supply
of
the
is responsible
(Fig. 7).
On the other
hand,
the isolation
of the epiphysis
epiphysial
plate provides
protection
both for the epiphysis
the rarity
of joint
infections
and epiphysitis
with growth
treatment
is defective
(Fig. 8).
675
OSTEOMYELITIS
6).
The
of the
nutrient
outer
half
for
the
of
large
early
deprivation
artery.
the
cortical
6
FIG.
FIG.
6-Experimental
involucrum
in the radius
periosteum
the two
sheath.
S
A large
involucrum
covering
the dead
girl of six years.
Radiographs
taken
after
the onset
of the disease.
Summary-The
aim
children
should
formation
of
cause
of the
be to protect
an
sequestration.
In the child
severe
generalised
It seldom
causes
41 B,
NO.
surgeon
involucrum
the
tends
disease
toxaemia
permanent
4, NOVEMBER
to be more
early
1959
stimulated
from
each
which
abscess.
a large
by lifting
the
and keeping
by a polythene
other
haematogenous
it is
7
of
7-A
large cortical
the ischaemic
bone
Figure
acute
production
of a rabbit,
cortex aseptically
sequestrum
and
separated
by the
marrow
osteomyelitis
to the outer
side of the cortex
to prevent
the cortex
separated
from its periosteum
dangerous
by massive
absorption
damage
to growth.
On
was
9).
from the
separated
enclosed between
the involucrum,
from
in treating
the blood
supply
which
would
leave
cases in children
growth
of the growth
plate (Fig.
VOL.
cortex
in a
eight
weeks
which
sequestra
from
the metaphysis
caused
by the
itself and for the joint,
and explains
inhibition
in children,
even if early
Figure
FIG.
followed
cortex
by the
to life
than
to limb,
for
it may
in
the
and
cause
of toxins
from
the whole
of the shaft.
the contrary,
in over 30 per cent of our
increased
vascularity
of the
metaphysial
side
676
J. TRUETA
ACUTE
Table
I shows
that
the
OSTEOMYELITIS
important
IN
characteristic
the local severity
ofthe
disease,
even in many cases
As stated
before,
a particularly
severe
group
umbilicus.
It is my conviction
that
the
THE
more
of
INFANT
acute
considered
occurs
in
outstanding
osteomyelitis
the
clinical
in
the
infant
is
in some classifications.
newborn,
infected
from
benign
“
“
features
of the
disease
at this
the
age
should
be attributed
to the foetal
vascular
arrangement
that persists
in some bones
up to the
age of one year.
with
local variations
corresponding
to the time of full development
of the
epiphysial
bone nucleus.
Some
research,
published
in this Journal
(Trueta
1957),
and others in the course
of
publication,
may help to clarify
this point.
From
the time in the embryo
when the ossification
of the central
part
of the shaft
FIG.
Figure
years
caused
feature
of the
long
bones
has
started,
the
8
FIG.
perichondral
vessels
progress
9
8-Radiograph
showing
acute osteomyelitis
of the left femur in a girl of four
taken
three months
after the onset of the disease.
That no damage
was
by the infection
to either
of the epiphyses
or adjacent
joints
is a common
in children.
Figure
9-Marked
overgrowth
of the affected
tibia
in a child
of seven
years
persisting
three
years after the inception
of osteomyelitis.
towards
the two ends of the cartilaginous
“anlage”
in a tortuous
way, turning
back when
reach the still unossified
cartilaginous
ends of the bone.
From
the last stages of intra-uterine
up
to
not
yet limited
the
first
by bone
the
“anlage,”
perforating
expand.
forming
situated
close
six
months,
large
to
the
in some
epiphyses,
on the epiphysial
the
venous
surface
side,
pre-existing
lakes
of
the
when
vessels
growth
resembling
epiphysis.
the
from
plate
growth
cartilage
the metaphysis
(Fig.
10).
At their
they
life
is established
penetrate
ends
metaphysial
sinusoids
(Fig.
This
explains
the frequency
the
those
11).
of
but
end
of
vessels
They
are
infections
of the joint
and of the epiphysial
side of the preliminary
growth
cartilage
in the infant.
In experimental
work
in this centre
(Trueta
1958) it was shown
that any severe
damage
to the cells at the epiphysial
side of the growth
plate is irreparable
(Fig.
12); thus,
both joint
damage
and arrest
or disorganisation
of growth
are the consequences
of the spread
of bacteria
to the
ends
of the
nutrient
artery
in very
early
life (Fig.
13).
THE JOURNAL
OF BONE AND JOINT SURGERY
THE
THREE
TYPES
FIG.
10
Figure
10-Vessels
perforating
epiphysis(in
the infant).
Figure
from
the
metaphysis
Permanent
growth
epiphysial
Another
sometimes
characteristic
monstrously
the bulging
will remain
the
periosteal
side
richness
vessels
(Fig.
the
of blood
and
the
OSTEOMYELITIS
True
acute
haematogenous
bones
in adults
haematogenous
HAEMATOGENOUS
growth
plate
in the
But,
(in
only
the
rapid
spread
is the
involucrum
fertility
of
a transient
alteration
______________
of which
NO.
_______
the
osteomyelitis
On
of
occasions
osteomyelitis
along
the
All
occurs
in
whole
this
leads
r
..
length
to
FIG.
1959
___________
13
Examples of permanent
epiphysial damage
and lower
ends
of
the
femur
caused
osteomyelitis
in the infant.
large
extraperiosteal
abscesses
been proper
treatment
from the
the typical
features
of the disease
of the vascular
arrangement
penetration
of the growth
4, NOVEMBER
lesion.
no trace
______
following
cartilage
to
and
the
by
upper
acute
chronic
early stages.
may be attributed
the fusion
of the growth
cartilages.
by metaphysial
vessels,
its height
reduced
until finally vascular
connections
are established
between
the epiphysial
and
system
of vessels
(Fig. 16). From
then on, the blood
in the nutrient
artery
reaches
of the epiphysis
through
large anastomoses;
thus bacteria
penetrating
the nutrient
VOL. 41 B,
formation.
ADULT
sinuses
when
there
has not
adult,
as in the other
types,
to the peculiarities
By the progressive
involucrum
of the epiphysial
are responsible
reactions
and for
that
occurs
in
is rare.
formation.
profuse
severity
through
of the bone,
the frequency
of joint
infections,
the lack of large sequestration,
and instead
the
irregular
atrophy
of the cortex,
and the limited
discharging
In the
rabbit).
a young
to the
the adult
but is usually
localised
to the short
bones,
particularly
the vertebrae,
following
infections
of the pelvis (Trueta
and Wiley
1959).
The main features of the condition
in adults
are
677
OSTEOMYELITIS
infant
contrary
represents
flow
IN THE
long
acute
the
14).
the shaft
15).
cambium
layer of the periosteum
both
for the early exuberant
the extraordinary
remodelling
succeeding
years.
ACUTE
of
of osteomyelitis
large
new bone along
in later life (Fig.
The extreme
ACUTE
FIG.
11
FIG.
12
the preliminary growth
plate and expanding
throughout
the cartilaginous
11-Note
the vascular expansions
at the most distal part of the vessels ascending
the surface
of the cartilaginous
femoral
head (in early
infancy).
Figure
12plate damage caused by experimentally
interfering
with the blood
flow to the
towards
epiphysial
OF
is
metaphysial
the surface
artery
may
678
J.
TRUETA
FR’. 14
Figure
14-Enormous
involucrum
in an infant
for
which
the elasticity
of the periosteum
and its osteogenic
power
are
responsible.
Figure
I 5-The
large
involucrum
has
completely
disappeared
four
and
a
half
years
afterwards
but
the
permanent
epiphysial
damage
is interfering
severely
with
growth.
15
FIG.
be brought
spread
to the
the
The
detachment
thus
vascular
infection
into
fibrosis
of the
by pus
preserves
the
more
blood
loops
under
the joint.
periosteum
difficult;
supply
the articular
in
this
to the
the
adult
prevents
outer
cartilage
half
and
the
(Trueta
its
adhesion
formation
of the cortex.
not
to
the
and
progressive
(Fig.
a fracture
to occur
The
tendency
to
from
joint
infection
responsible
for
make
Instead,
absorption
if no
chronic
phlebitis
protection
infection
within
the
its
18).
after
and
seq uestra
the
rapid
may
allow
is used.
in the
bone,
are
the two
main
the crippling
severity
in the adult
(Fig.
capacity
apparent
and
abscesses
large
17).
cortical
1953)
cortex
Consequently,
formed
condition
reparative
Harrison
of subperiosteal
are
marrow,
and
and
factors
of the
The lack
the fusion
the epiphysis
makes
chronic
infection
frequent
sequel
of acute
osteomyelitis
of
of
the most
in the
adult.
DISCUSSION
FIG.
16
An example
end
of
established
anatomical
of acute
of the vascular
arrangement
growth.
Ample
anastomoses
between
the epiphysial
and
vessels.
vascular
osteomyelitis.
research-the
after
the
have
been
metaphysial
object
It is beyond
enlarge
on
my
purpose
therapeutic
in this
considerations,
paper
but
to
it
may not be out of place to suggest
some lines
of treatment
which
are supported
as much
by
of this paper-as
by fifteen
years of clinical
study
Specific
antibiotic
treatment
instituted
as early and as radically
as possible
must
be the
main aim of any treatment
of acute haematogenous
osteomyelitis
in any of its three age forms.
If started
soon enough,
it may control
the infection
before
severe
vascular
damage
has been
caused
I) in the epiphysial
anlage”
and joint
in the infant,
2) in the cortex
of the shaft in
“
THE
JOURNAL
OF
BONE
ANt)
JOINT
SURGERY
THE
TYPES
THREE
the child,
and 3) in the joint
and severely
affected
regions
When
some
antibiotic
vascular
lavage
adults,
conservative
what
the
still
joint
the
occurs,
the main
effective,
object
radical
679
OSTEOMYELITIS
frequently
the
most
because
commonly
the
of the treatment
must
aspiration,
or preferably
appropriate
be to reduce
incision
and
in the infants
and
periosteum.
are the
for
of the
and
treatment
known,
Early,
remain
bone
HAEMATOGENOUS
joint.
the preservation
blood
flow
One
thing
in
must
be
never
forgotten,
and
this
is that
no
will ever reach
the foci of infection
the preservation
ofsome
local blood flow.
The
vascular
anatomy
predominance
of
infancy
early
In
antibiotic
procedures
may
affected
antibiotic
without
in
in the
of
ACUTE
and bone marrow
of the adult,
these being
in the three age types of bone infection.
available
or
to the utmost.
of the affected
and splitting
most
of
delay
is not
damage
OF
may
also
to
a cellulitis
streptococcus
activity,
has
and
invades
On
the
a
in childhood.
been
rightly
germ
such
with
the
other
joint
hand,
the
infection
haemolyticus,
easily
epiphysis.
explain
streptococcal
and the staphylococcal
life bone
infection
compared
the
the
and
the
as
lytic
its
nearby
coagulase-
positive
staphylococcus
aureus,
the common
aggressor
of the bone in childhood,
needs for its
development
a stagnant
or moderately
active
circulation
such as that in the venous
sinusoids
under
the growth
plate.
It may well be that the
rarity of streptococcal
bone infections
in children
is not so much
due
bacteraemia
at that
this germ
to localise
this
it
is. as
highly
yet.
to a lack of a streptococcal
age as to the incapacity
in metaphysial
sinusoids;
mere
conjecture,
but
I.
The
clinical
Figure
17-Acute
osteomyelitis
of the
The infection
extends
from
end to end
No large cortical
sequestra
are formed.
I consider
Severe
joint
possible.
CONCLUSIONS
three
age
features
types
of acute
by the
differing
AND
haematogenous
2. In the infant
the condition
joint
infection,
a large involucrum
FIG.
17
FIG.
of
damage
infection
of their
causes
but
severe
and
only transient
by phlebitis
within
the bone
caused
in acute
osteomyelitis
in an adult.
and
of
the femur
SUMMARY
osteomyelitis
nature
18
adult
fibula.
of the bone.
Figure
18-
vascular
are conditioned
bone
in their
respective
pattern.
often
permanent
damage
to the
epiphysial
shaft and
damage
metaphysis.
and
3. In the child
the condition
is responsible
for extensive
cortical
damage
with involucrum
formation,
but, except
for some
stimulation
of growth,
permanent
damage
to the growth
cartilage
and to joints
is exceptional.
Chronicity
of the disease
is rare if treatment
has been
effective.
4.
In the
infection;
and
5.
adult
the
frequently
The
6.
VOL.
Some
41 B,
leaves
vascular
of infection
osteomyelitis
is absorbed
chronic
general
of
the
instead
of the
long
bones
is rare.
of sequestrating.
infection
characteristics
are
NO.
acute
cortex
in the
bones
The
bone
marrow.
in each
age
group
It causes
whole
and
very
of the
their
relation
described.
directives
4, NOVEMBER
for
1959
management
based
on these
facts
are
frequent
bone
suggested.
joint
is invaded
to the
onset
680
TRUETA
.
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