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Silver Anode Treatment
of
Chronic Osteomyelitis
DWIGHT
.
WEBSTER,
M.D.,
*
J.
A.
SPADARO,
H.D.,**
R.
0.
BECKER,
M.D.,t
AND
S.
KRAMERS
Even with the wide use of broad-spectrumantibiotics, effective control of osteomyelitishas not been consistent. The use of systemicantibiotics, while helpful, has not eliminatedthe need for other approaches, especially forthe disease in its chronic The use ofanodic silver therapy is a new concept whichstems from the well-known antibacterialproperties of ~ilver.~lthough these prop-erties have long been re~ognized,~he clin-ical uses of silver have been limited and itspotential may not yet be
fully
realized. Thesilver cation is known to have an exception-ally broad spectrum involving gram-positive,gram-negative, aerobic and anaerobic mi-croorganisms. A number of species havebeen found
to
have a minimum inhibitoryconcentration for anode-derived silver con-siderably lower than antibiotics in currentuse,2 and resistance to the silver ion is rare.'Despite these properties, the penetration ofsilver from a topical agent into infected tis-
Supported by the U.S. Veterans Administration.From the Orthopedic Research Laboratory, V.A.Medical Center and the Department of Orthopedic
Sur-
gery, Upstate Medical Center, State University of NewYork, Syracuse, New York 13210.
*
Chief, Orthopedic Section, V.A. Medical Center,and Assistant Professor, Department of Orthopedic
Sur-
gery, Upstate Medical Center, S.U.N.Y.
**
Research Biophysicist, Orthopedic Research Lab-oratory, V.A. Medical Center, and Assistant Professor(Research), Department
of
Orthopedic Surgery, Up-state Medical Center, S.U.N.Y.
t
Professor, Department of Orthopedic Surgery, Up-state Medical Center, S.U.N.Y.
$
Senior Medical Student, Upstate Medical Center,S.U.N.Y.Received: February
13,
198
1.
0009-921X/81/
1200/105
sue is limited. This is due in part to its chem-ical characteristics (low solubility and/ortoxicity of some of its salts, precipitation ofsilver chloride, and ready binding to pro-teins). On the other hand, electrically acti-vating metallic silver, while in contact withthe wound surface, avoids the use of extra-neous anions such as nitrate.
As
long as asmall current is flowing, a continuous supplyof silver ions is emitted from the metal sur-face and is available for antibacterial action.Since
1975
we have made use of this prin-ciple, mainly in the form of anodically po-larized, silver-coated nylon fabric as an aidto the surgical management of deep-boneinfection. The initial experience with thistechnique showed it to be free
of
local orsystemic toxicity while being able
to
main-tain a clean wound and permitting healingto occur.' The present report summarizes theexperience with the use of silver in
25
pa-tients with actively draining chronic osteo-myelitis. The patients selected for this pro-cedure were considered clinical failures ofconventional treatment (debridement, sys-temic antibiotic therapy, skin and muscle-pedicle grafting, antiseptic irrigation, etc.)and many were candidates for amputation.Since the chronic draining sinus has the po-tential for degeneration to squamous cellcarcinoma when present for many years, weconsidered an experimental approach to bejustified.The tendency for osteomyelitis to remainquiescent for long periods would demand avery long-term follow-up to demonstratepermanent elimination of infection by this
%01.00
0
J.
B.
Lippincott
Co.
105
 
106
Webster, et
al.
Clinical Orthopaedicsand Related Research
or any technique. For this reason, the elim-ination of chronic drainage and pain andreturn to a more productive life for eachpatient may be considered a satisfactory re-sult. Under these conditions, a well-con-trolled study is difficult to develop. Expand-ing the clinical experience
is
a reliable way
to
confirm the usefulness of this approach.
MATERIALS AND METHODSTwenty-five patients (24 males and one female)were treated for osteomyelitis at the VA MedicalCenter in Syracuse, New York. Their average agewas
40
years (range, 23-64 years; median. 37)and each had at least one previous operation onthe infected bone (average, 4.1 operations) priorto consideration for this treatment. The age ofinfection ranged from
0.1
to 33.0 years (median,four years). The tibia was the most commonlyaffected bone, accounting for
19
of the
25
infec-tions. The femur was infected in three cases; therewere two cases of pyoarthrosis, one at the kneeand one at the ankle; and there was one case ofan infection in the distal tibia and fibula. Sincethis was a new and experimental technique, onlypatients who demonstrated failures of the morecommonly accepted treatments for osteomyelitiswere accepted for the anodic silver treatment pro-tocol.The general procedure for patients treated bythis technique was:
(1)
a thorough debridement;(2) single daily irrigation; and (3) placement ofa fresh silver nylon dressing that
is
continuouslyactivated electrically. Since the penetration of freesilver ionsorsilver complexes cannot be assumedto be greater than
1
cm,8 the debridement mustinclude resection of all necrotic tissue, opening ofall pockets of infection and removal of overhang-ing tissue. This produces a wound in which thesilver nylon can be placed in good contact withall surfaces.The first application of the silver electrodedressing takes place
in
the operating room follow-ing thorough surgical debridement. The dressingis cut to cover the entire wound cavity, leaving atail extending out of the wound for electrical con-tact. The dressing
is
placed in close contact withall exposed bone and soft tissue with the exceptionof tendons and ligaments, which are protectedwith two to three thicknesses of saline-soakedgauze (Fig.
I).
The wound cavity is then packedwith a wet gauze stent and covered with dry dress-ing, leaving the dry tail of the silver nylon exposed.This tail portion is then connected to the positivepole of the electrical source unit. On the sameextremity, directly opposite the depth of thewound, a nonabrasive electrode cream is appliedand the return skin electrode (negative pole)
is
taped firmly in place. The current source is a bat-tery-operated, FET-controlled,
DC
supply with
0.9
volts, 300 pAmp upper limits and provisionfor measurement of current and potential.’ Thesevalues were chosen to permit a flow of
1
to
2
pAmps per cm2 of silver nylon.The original silver nylon dressing
is
left in placefor two
to
three days and then changed, usuallyFIG.
1.
Diagram illus-trating the application ofa silver anode dressingto the saucerized tibiaand the connection
of
the voltage-controlled
DC
source which con-tinuously activates thesilver.
Carbon -Silicone Skin Electrode
 
Number
161
November-December,
1981
Silver Anode Treatment
107
without analgesia. There is minimal adherence ofthe dressing to the wound. The wound is irrigatedwith normal saline and a new silver nylon elec-trode, moist stents, and dry dressing are applied.The surface return electrode is changed and,moved to a new position to avoid possible skinirritation. After the initial change a fresh silvernylon dressing
is
reapplied daily in a similar man-
ner
and, in many cases, the patient can be taughtto perform the dressing change alone after a fewdays. Beginning at about one week after the sur-gical debridement, daily whirlpool therapy is usedwhenever possible. Local treatments with Beta-dine (Perdue Frederick, Norwalk, Connecticut)and Phisohex (Winthrop Laboratories, New York,New York) are carefully avoided because theyappear to retard the growth of granulation tissue.Bacteriologic cultures were taken at three- tofive-day intervals throughout therapy. These wereobtained by sampling the entire surface of thewound bed with a dry sterile swab and within
30
minutes directly streaking the surface of a freshlyprepared brain/heart infusion agar culture plateusing a consistent 20-streak pattern. Colonieswere counted at
7X
magnification after incubationfor 24 hours at
37°C.
It was found that this
rou-
tinely gave a semiquantitative measure of the bac-terial flora.Because of significant
loss
of bone tissue, eitherfrom the original injury
or
surgical debridement.an open (Papineau) bone graft procedure was per-formedon
13
patients, but only after the bacterialcounts in the debrided bone were reduced to tencolonies
or
less
on
three consecutive cultures. Asexperience was accumulated, this technique
was
used less often in the cases of osteomyelitis with-out nonunion. If grafting was performed, the silverdressing was placed over the grafted bone to main-tain bacteriostasis. The dressing was electricallyactivated and changed daily as in the pregraftingsituation. Both grafted and ungrafted woundsgradually granulated and then epithelized underthe silver nylon mesh. Usually after two to threemonths it became clear if the wound was healing
or
developing apersistent sinus tract. Largerwounds took more time to epithelize.
If
areas ofpersistent drainage developed, the considerationwas made for
a
second formal surgical debride-ment and extended silver electrode therapy. Whenit became clear that the wound was epithelized
or
thesinustract was permanently established,the silver nylon mesh therapy was discontinued.
RESULTSFollow-up
of
all 25 patients by personalexamination was from six months to two andone-half years. The success of treatment wasassessed by serial X-rays, clinical evaluationof stability, absence of pain, the amount ofresidual drainage, the requirement of
or-
thopedic devices and other walking aids,
sur-
gical
or
medical complications, local
or
sys-temic reactions to silver, total time requiredfor treatment, and time to procure a negativeculture in the wound. In the absence of sat-isfactory prospective controls, each patientwas considered their own control as eachrepresented the failure of previous standardorthopedic treatments for osteomyelitis.BACTERIOLOGICESULTSBacteriologic data were compiled system-atically during treatment on
19
of the
25
patients entered in this study; two patientshad two sites treated with silver nylon, givinga total of 21 wound sites. The frequency ofoccurrence of bacteria species initially cul-tured from the wound sites is shown
in
Table
1.
Eighteen of the sites had multiple bacteriapresent. Eleven out of the
21
sites had bac-TABLE
1.
Bacteria Isolated Prior toTreatment with Anodic Silver
Frequency
(No.
of
Speries
Patienis)
Gram-positive 26
Staphylococcus aureus
16
Staphylococcus epidermis
1
Streptococcus
Group A
1
Streptococcus
Group
D
3
Streptococcus
Group G
I
Streptococcus
Mutans
1
Streptococcus
species
1
Yeast
1
Clostridium
species
1
Gram-negative 32
Pseudomonas aeruginosa
12
Enterobacter cloacae
5
Enterobacter hafniae
I
Escherichia coli
4
Proteus mirabilis
4
Klebsiella pneumoniae
3
Serratia marcescens
2
Acinetobacter calcoaceticus
1
of 00

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