F - CLINICAL ASPECTS OF SPINAL CORD INJURIES
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to be removed, as otherwise the infection will spread further. Following removal of the
infected trochanter there is, of course, the danger of a fracture of the femur underneath
the trochanter later, especially under weight-bearing. More destructive is the operation
if the infection, spreading from ischial or trochanteric sores, has affected the head of the
femur involving the hip joint. Under these circumstances, the head of the femur has to be
excised and the infected parts of acetebulum removed. Needless to say, systemic courses
of antibiotics and blood transfusions before and after such operation are indispensable.
Once the infection has subsided, it is sometimes amazing to what degree a new, though
only incomplete, hip joint may develop. The regenerative forces of restoring a joint
following healing of osteomyelitis as a result of pressure sores has been mentioned
previously (Guttmann, 1953) and Fig. 209 show the restitution of a completely disinte
grated terminal joint of a big toe following healing of a pressure sore (in this case by
conservative treatment).
Ectopic bone formation in soft tissues following ischial sores affecting the ischial
ramus (Fig. 206) represents a relatively frequent complication, and, unless this is excised
together with the infected ramus, the sore will not heal or will recur. However, total
ischiectomy should be reserved for very selected cases, the more so as, following this
operation there is a shifting of weight bearing to the other side, and there were a few
cases where an ischial sore developed later on that side. However, this can be avoided,
as Walsh found, by cutting a hole in the sorbo rubber cushion on the non-operated side
which considerably relieves pressure when the patient sits in his wheelchair. Bilateral
radical ischiectomy (Comarr, 1951) may have serious effects on the perineal urethra,
and Comarr & Bors (1958) found perineal urethral diverticula in 58 per cent of cases
following bilateral ischectomies. In contrast Arregui
et al.
(1965) do not mention this
complication in their review on 94 patients, in whom 43 unilateral and 51 bilateral ischiec-
tomies were carried out. Urethral damage following bilateral ischiectomy can be avoided
if the ischiectomy is performed less radically—i.e. if the excision of the medial part of the
ischial ramus is not extended too close to the symphysis.
Sores over the coccygeal area often tend to recur, and if the bone is infected a coccy-
gectomy followed by primary suture will be necessary.
Sores over the knee may be very dangerous, once they have affected the knee joint
(Fig. 208), and in this particular case because of causing septicaemia an amputation above
the knee became imperative.
Sores over the shin usually heal conservatively by preventing any pressure on the sore
or they can be treated by pinch grafts.
Chronic malleolus sore will only heal following resection of the infected bone.
Sores over the heels, which frequently occur due to inadequate care, will, as a rule,
heal easily without surgery, apart from the removal of slough, as even the slightest
pressure can be avoided in that area by the placing of two or three pillows underneath
the calf. The heel and Achilles tendon will then be absolutely free from pressure whatever
the patient's position may be.
Sores over the spine are now very rare since plaster casts and plaster beds were aban
doned, and I have not seen any for many years. During the war, they were sometimes found
to be present over several vertebrae, and resection of spinous processes was necessary.
