Chronic osteomyilitis of femur with a large diaphysial sequestrum in an eight year old boy

1. Chronic osteomyilitis of femur with a large diaphysialsequestrum in an eight year old boy Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia

2. Case history An eight year old boy presented to us in June’06 with a H/O discharging sinus since last 1 year in lower and medial aspect of right thigh.

3. Clinical picture of the case

4. History.. In May’05, patient developed high fever with acute pain in the lower part of thigh.

5. History.. About two days later,a diffuse swelling appeared in the lower part of thigh. It was hot & very painful, and progressed rapidly to involve entire thigh

6. History.. Pt. was t/ted with some oral drugs & IM inj. Pain, fever and swelling persisted for a month until pus was drained from the thigh swelling at a local hospital.

7. History… Pain, fever and swelling decreased considerably after the drainage of pus

8. History… Since then pus continued to flow intermittently from the site of drainage, the quantity was variable, sometimes serous, sometimes frank purulent pus was coming out from the sinus

9. History.. The patient was getting the dressing changed at a nearby health post. No h/o passing bone chips through the wound

10. On examination The patient was afebrile and pale Right knee was in FFD The limb was shorter Right thigh was wasted, minimal swelling was present in the mid third of thigh

11. On palpation There was moderate rise of temp locally, the femur was tender, broader and irregular all along the length.

12. Fixed flexion deformity

13. Examination of sinus • There was a discharging sinus on the medial aspect of lower third of thigh • The sinus was fixed to the underlying bone

14. Examination of sinus • There was puckering of skin around the sinus • There was seropurulent discharge through the sinus

15. Clinical findings • There was true shortening of 1 cm in the infra-trochanteric thigh segment, • There was no distal neurovascular deficit

16. Clinical findings • Right knee was in twenty degree fixed flexion deformity, further painless movement up to 90 degree was also present. • Right hip movements were painless and full range

17. Clinical diagnosis Chronic osteomyelitis of lower right femur with a discharging sinus on medial aspect of lower thigh with 1 cm shortening and 20 degree of fixed flexion deformity of right knee in a 8 yr. old boy

18. Investigations • Blood - Hb - 11.0 g/dl - ESR – 86 mm/hr - Neutrophils- 80

19. Culture and sensitivity Heavy growth of Staph. Aureus, and scanty growth of gram negative bacilli

20. X- RAY • X-ray showed involvement of entire diaphysis and lower metaphysis

21. X - RAY There was large sequestrum lying medially & extending almost to entire diaphysis of femur

22. X - RAY There was formation of mature involucrum around the sequestrum predominantly on anterolateral aspect of sequestrum

23. Sequestrum Involucrum

24. Management We planned to remove the entire sequestrum and all infected tissue with it.

25. Difficulties Large diaphysialsequestrum Medially lying sequestrum Proximity to femoral vessels Intra operative bleeding from hyperemic infected tissue and bone

26. Approach We decided to approach the femur antero-medially. Superficial plane was developed between rectus femoris and vastusmedius

27. Antromedial approach Vastusintermedius was now into view It was split in midline to expose the femoral diaphysis The femoral vessels are protected by medial part of the muscle

28. Sequestrum being exposed

29. Approach • Sequestrum was exposed to its entire length and then extracted out

30. Sequestrum out from the wound

31. Sequestrum

32. Approach • Surrounding infected granulation is also removed giving a good clearance of infected tissue Sequestrum was lying here v.intermedius v. medius Rectus femoris

33. Debridement Local tissue looked healthy after debridement The sinus tract was also debrided After through irrigation wound was closed over a suction drain

34. Wound is now looking clean after sequestrectomy & debridement

35. Post op • Drain was removed after 48 hrs - First dressing There was only minimal bleeding through the sinus - Subsequent dressing were dry

36. Post op • There was fever on first two post op days which was probably due to handling of infected tissue, • Appropriate antibiotics were given IV for 6 weeks post operatively.

37. Post op Skin traction & physiotherapy was used to correct the flexion deformity And other measures were taken to improve the general condition of the patient

38. Pre operative Post operative

39. Happy patient !

40. Thank you