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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 16  |  Issue : 1  |  Page : 68-71

A case report of complete tibia diaphysis extrusion in chronic osteomyelitis


College of Medicine, Imo State University, Owerr; Ireneth Hospital LTD, Enugu, Nigeria

Date of Web Publication5-Jul-2017

Correspondence Address:
Thaddeus C Agu
College of Medicine, Imo State University, Owerri
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajmhs.ajmhs_7_17

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  Abstract 

Late presentation to hospital is still a common occurrence in Nigeria. Chronic osteomyelitis of the tibia is not an uncommon infective condition in a 4-year-old boy, but delaying the search for hospital treatment until a full length of the diaphysis is extruded is uncommon. He complained of pain and fever and was noticed by the mother to be listless and was no longer playful. Over several months, his condition seemed to be improving, but a large bone was sticking out of a sinus. It was at this advanced stage that the patient was brought to our level II surgical facility. The entire tibia diaphysis was removed as a sequestrum, and the boy was ambulant again after 11 weeks. The aim of this report is to highlight this unusual condition and the need for continued health education as well as for the clinician not to despair in the management of similar neglected cases in a resource-poor setting.

Keywords: Chronic osteomyelitis, extrusion, sequestrum, tibia diaphysis


How to cite this article:
Agu TC. A case report of complete tibia diaphysis extrusion in chronic osteomyelitis. Afr J Med Health Sci 2017;16:68-71

How to cite this URL:
Agu TC. A case report of complete tibia diaphysis extrusion in chronic osteomyelitis. Afr J Med Health Sci [serial online] 2017 [cited 2019 Oct 18];16:68-71. Available from: http://www.ajmhs.org/text.asp?2017/16/1/68/209489


  Introduction Top


Osteomyelitis is the infection of the bone and the bone marrow, and it is very common in children. The long bones like the femur, tibia, and humerus are commonly involved.[1] Acute osteomyelitis is associated with high grade fever and bone pain, and if not treated or when not properly treated, it would progress to chronicity.[2] The patient’s innate immune system could contain the infection and the patient would appear to be improving. However, the infection and sequestration of the bone continue amidst acute exacerbations. In chronic osteomyelitis involving weight bearing bones like the tibia, an initial duration of conservative treatment is also a waiting period for significant involucrum to form and replace the infected degenerating bone in providing strength and structural support. The literature is awash with reports of chronic osteomyelitis, describing the pathogenesis and treatment[3] of large sequestrations from hematogenous osteomyelitis and the negative effects of malnutrition on the pathology,[2] but none described a whole tibia diaphyseal sequestrum extrusion. This report highlights the continued ill effects of the trio of ignorance, poverty, and disease in our environment and the need for the clinician not to despair in the management of such neglected cases as the outcome may turn out alright at least in the short-term like in this index patient.


  Case Presentation Top


A 4-year-old limping boy was brought to our out-patient department by the mother in October 2015. The major complaint was that a bone was sticking out of his leg for the past 3 months. Before this, patient had a high grade fever associated with severe bone pain, listlessness, and inability to play with his mates for several weeks. His symptoms improved with drugs bought from the patented medicine dealers. Despite the resolution of fever and pains, purulent discharge was noticed from the leg. This continued until bone started protruding from the discharge point. Physical examination revealed a male child who was looking malnourished, he was limping and a discharging sinus was seen on the anteromedial aspect of his left leg through which a sequestered bone was protruding [Figure 1]. The surrounding skin was hyperpigmented and indurated. He was pale but not jaundiced. The groin nodes were not enlarged. There was no limb length discrepancy.
Figure 1: Clinical photograph showing extruding tibia diaphysis from a sinus

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His complete blood count showed a hemoglobin level of 8.8 g/dl, normal leucocyte count, Erythrocyte Sedimentation Rate was 43 mm/1st hour Westergreen. Urinalysis was normal, hemoglobin electrophoresis was AA. Plain radiograph (not shown) showed hazy opacity between the proximal and distal ends of the tibia, and the intervening diaphysis extruding as a sequestrum. Patient’s mother could not afford any other supportive investigations like serum protein. We assessed his nutritional status clinically from his anemia, triceps skin-fold thickness, and the color and texture of the hair that confirmed malnutrition.

Informed consent was obtained, and under general anesthesia, a vertical incision was extended up and down from the sinus. Following deeper dissection, the sequestrum was pulled out of a pussy bed without much force [Figure 2]. A swab was taken for microscopy culture and sensitivity that showed growth of Staphylococcus aureus. The surrounding length of soft tissue was thickened and indurated and was judged to be the involucrum. The distal end from where the sequestrum was detached had pathological fracture. Careful curettage was done. All the denuded, infected soft tissues were debrided, and thorough irrigation was done with hydrogen peroxide and saline. The muscles on both sides of the involucrum were loosely approximated over it with few stitches and the skin closed leaving the sinus point open for drainage and wound care. A windowed protective above knee cast was applied [Figure 3]. Histopathologic examination was not done because the clinical findings were quite diagnostic. Broad spectrum intravenous antibiotics were commenced and continued based on the culture and sensitivity result for 2 weeks after which oral antibiotics was continued for another 4 weeks. There was clinical resolution of symptoms and healing of the sinus. Nutritional build up with high protein and high carbohydrate diets were prescribed and enforced. He stayed in the hospital for 5 weeks specifically to ensure the provision of his dietary needs. The first follow-up at 8 weeks was uneventful, and by 16 weeks, he had started ambulating without pain and without a limp. Some of the postoperative investigations ordered were not done because of lack of fund. At 6-month follow-up, patient was looking better nourished, still no limp, no recurrence of pain or discharge, but there was 1-cm shortening of the left leg. He was lost to follow-up thereafter [Figure 4].
Figure 2: Clinical photograph showing the entire tibia diapysis removed as sequestrum

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Figure 3: Post-operative clinical photograph of the patient’s leg in a protective cast

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Figure 4: Eight weeks post operation showing healed wound

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  Discussion Top


Structural changes in the tibia in children are more likely to be due to fracture than infection.[1] Osteomyelitis is a childhood disease, and it is common in the tibia. Poorly treated or unrecognized acute osteomyelitis will naturally progress to chronic osteomyelitis[2],[4] with bone sequestration. Malnutrition and low immune status are risk factors in the pathogenesis of osteomyelitis.[2] Malnutrition worsens the prognosis and grade of the chronic osteomyelitis.[2] These risk factors pervade in a situation of ignorance and poverty like in our patient. Usually, the sequestra are extruded in bits but occasionally as a large bone that compromises the structural stability of the bone. S. aureus is the commonest organism implicated in osteomyelitis,[3],[4],[5] and the culture showed profuse growth of this bacterium. In children, osteomyelitis is commonly a blood borne infection. This primary osteomyelitis causes widespread infection of the bone that could lead to massive sequestra. This is unlike the secondary osteomyelitis whereby direct inoculation of bacteria in open fracture or infected implant surgeries can only affect a limited part of the bone resulting in minimal sequestrum. Therefore, it is not surprising though very unusual for almost the entire tibia to sequester and extrude in this child.

The diagnosis at such advanced stage is unmistakable but could be supported by radiologic features. Blood culture is positive only in 50% of acute osteomyelitis[6] and less so for chronic osteomyelitis, and so blood culture was not necessary. A tissue biopsy was not done because the diagnosis seemed reasonably clear from the clinical, radiologic, intraoperative findings, and culture result. This was also imperative because of financial constraints. In uncertain cases and when resources are available, scintigraphy, computerized tomography (CT) scan, or magnetic resonance imaging (MRI) are useful diagnostic tools. However, MRI and CT scan may give a misdiagnosis of malignancy in some cases[7] and then tissue biopsy would become absolutely necessary.

The strength of the involucrum should be considered before surgery in weight bearing bones. Inadequate strength of the involucrum is a contraindication to surgery especially where the sequestrum still provides structural support. In our patient, the involucrum appeared thin on radiograph nevertheless the sequestrum had to be removed. We prevented iatrogenic fracture by gentle curettage and by applying protective cast in addition to avoiding weight bearing some weeks after the operation. Some authors advocate a well vascularized muscle flap to ensure adequate antibiotic delivery to the bone and to obliterate the dead space, and this is the current gold standard for the treatment of chronic osteomyelitis.[8] The dead space could also be obliterated with antibiotic beads where available. Furthermore, a prolonged antibiotic use is recommended postsurgery,[1],[4] and clinical resolution of symptoms and normalization of laboratory indices are guides to the length of antibiotic therapy.

The short-term result was fairly satisfactory. The shortening was insignificant, but it may worsen with time or it may resolve with the leg catching up especially with increased vascularity caused by chronic inflammation. Any long-term complication like LLD, genu varum, or pathological refracture could be managed by lengthening, osteotomies, and bone transport with external frames supplemented by bone grafting.[9],[10]


  Conclusion Top


Chronic osteomyelitis of the tibia is common, but what is not common is the prolonged delay until the complete tibia diaphysis was extruding through the sinus before hospital presentation. The trio of ignorance, poverty, and disease played a major role in the pathology and management of this patient. Giving these unusual circumstances, the clinicians need to do the best they can for the patient despite the gloomy state on presentation because the result sometimes may not be as bad as it seemed at least on a short-term, just like in this index case.

Limitations

A major limitation in this case report was the inability to show the radiographs because they were not archived before the decision to publish.

Financial support and sponsorship

The work was self-sponsored by the author.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Stone B, Street M, Leigh W. Pediatric tibial osteomyelitis. J Ped Orthop 2016;36:534-40. doi:10.1097/BPO. 0000000000000472.  Back to cited text no. 1
    
2.
Cierny G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res 2003;414:7-24.  Back to cited text no. 2
    
3.
Bouchoucha S, Drissi G, Trifa M, Saied W, Ammar C, Smida M et al. Epidemiology of acute hematogenous osteomyelitis in children: a prospective study over a 32 month period. Europe PMC 2012;90:473-8.  Back to cited text no. 3
    
4.
Kanakaris N, Gudipati S, Tosounidis T, Harwood P, Britten S, Giannoudis PV. The treatment of intramedullary osteomyelitis of the femur and the tibia using the Reamer-Irrigator-Aspirator system and antibiotic cement rods. Bone Joint J 2014;96-B:783-8.  Back to cited text no. 4
[PUBMED]    
5.
Chang BY, Li HG, Li ZY, Zheng XM, Wang W, Zhoa JJ. Treatment of chronic osteomyelitis of tibia with debridement and vacuum sealing drainage (VSD) of cavitas medullaris. Zhonqquo Gu Shang 2011;24:952-4.  Back to cited text no. 5
    
6.
Krespi YP, Monsell EM, Sisson GA. Osteomyelitis of the clavicle. Ann Otol Rhinol Laryngol 1983;92:525-7.  Back to cited text no. 6
[PUBMED]    
7.
Girschick HJ, Krauspe R, Tschammier A, Huppertz HI. Chronic recurrent osteomyelitis with clavicular involvement in children: diagnostic value of different imaging technique and therapy with non-steroidal anti–inflammatory drugs. Eur J Paediatr 1998;157:28-33.  Back to cited text no. 7
    
8.
Gokalp MA, Guner S, Ceylan MF, Dogan A, Sebik A. Results of treatment of chronic osteomyelitis by ‘gutter procedure and muscle flap transposition operation’. Eur J Orth Surg Traumat 2014;24:415-9.  Back to cited text no. 8
    
9.
Beal RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in adult. Clin Orthop Relat Res 2005;433:212-7.  Back to cited text no. 9
    
10.
Lin CC, Chen CM, Chiu FY, Su YP, Liu CL, Chen TH. Staged protocol for the treatment of chronic tibial shaft osteomyelitis with illizarov’s technique followed by the application of intramedullary locked nail. Orthopedics 2012;35:1769-74. doi:10.3928/01477447- 20121120-23.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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