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Chronic osteomyilitis of femur with a large diaphysial sequestrum in an eight year old boy Dr Nirmal Kumar Sinha& Dr Rajaram Pai [Manipal campus]

Melaka-Manipal Medical College,MalaysiaCase history An eight year old boy presented to us in June06 with a H/O discharging sinus since last 1 year in lower and medial aspect of right thigh.

Clinical picture of the caseHistory.. In May05, patient developed high fever with acute pain in the lower part of thigh.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 thighHistory.. 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.HistoryPain, fever and swelling decreased considerably after the drainage of pusHistory 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 History.. The patient was getting the dressing changed at a nearby health post. No h/o passing bone chips through the wound On examination The patient was afebrile and paleRight knee was in FFD The limb was shorterRight thigh was wasted, minimal swelling was present in the mid third of thighOn palpationThere was moderate rise of temp locally, the femur was tender, broader and irregular all along the length.

Fixed flexion deformityExamination of sinus There was a discharging sinus on the medial aspect of lower third of thighThe sinus was fixed to the underlying bone

Examination of sinus There was puckering of skin around the sinusThere was seropurulent discharge through the sinus

Clinical findingsThere was true shortening of 1 cm in the infra-trochanteric thigh segment, There was no distal neurovascular deficitClinical findingsRight 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 rangeClinical 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 boyInvestigations Blood - Hb - 11.0 g/dl- ESR 86 mm/hr- Neutrophils- 80Culture and sensitivityHeavy growth of Staph. Aureus, and scanty growth of gram negative bacilliX- RAYX-ray showed involvement of entire diaphysis and lower metaphysis

X - RAY

There was large sequestrum lying medially & extending almost to entire diaphysis of femurX - RAY There was formation of mature involucrum around the sequestrum predominantly on anterolateral aspect of sequestrum

SequestrumInvolucrumManagement We planned to remove the entire sequestrum and all infected tissue with it.Difficulties Large diaphysial sequestrumMedially lying sequestrumProximity to femoral vessels Intra operative bleeding from hyperemic infected tissue and boneApproachWe decided to approach the femur antero-medially.Superficial plane was developed between rectus femoris and vastus mediusAntromedial approachVastus intermedius was now into viewIt was split in midline to expose the femoral diaphysisThe femoral vessels are protected by medial part of the muscle

Sequestrum being exposedApproachSequestrum was exposed to its entire length and then extracted out

Sequestrum out from the wound

SequestrumApproachSurrounding infected granulation is also removed giving a good clearance of infected tissue

Rectus femorisv.intermediusv. mediusSequestrum was lying hereDebridementLocal tissue looked healthy after debridementThe sinus tract was also debrided After through irrigation wound was closed over a suction drain

Wound is now looking clean after sequestrectomy & debridementPost opDrain was removed after 48 hrs - First dressing There was only minimal bleeding through the sinus - Subsequent dressing were dry

Post opThere 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.

Post opSkin traction & physiotherapy was used to correct the flexion deformity

And other measures were taken to improve the general condition of the patient

Pre operativePost operative

Happy patient !Thank you