Chronic Osteomyelitis Diaphyseal Sequestrum

Vinod NaneriaConsultant Orthopaedic SurgeonChoithram Hospital & Research

Centre, Indore India

Diaphyseal Sequestrum

• Usually a very large piece of diaphysis.• Takes long time to separate from main bone.• Involucrum forms slowly & usually incomplete.• Sequestractomy is required.• Post surgery some protection is necessary.• End result is always good.

Tips & Tricks

• Time line 6 months to 1 year.• Culture and sensitivity.• Antibiotics 2 days before surgery.• A sinogram or CT Scan for clear demarcation.• Methylene Blue can be used.• Surgery under X-ray or CCTV control.• Protection from re-fracture by splints.

Case One

• 10 years old Male child• Acute osteomyelitis rt. Femur lower shaft• Tx at Primary health centre in a village • Developed a long diaphyseal sequastrum.• The sequestrum was removed when

involucrum was adequate.• Final healing

Case studies

• Case 1 : classical example.• Case 2 : required post surgery protection.• Case 3 : early age, rapid involucrum, small

sequestra absorption, joint dislocation.• Case 4: extrusion of the diaphysis, absoption of

whole shaft, reconstruction by fibula thrice harvested from the same location.

Initial X-ray

Soft tissue showing pus collection

Periosteal Reaction all along the shaft

Diaphyseal Sequestrum Demarkation

Involucrum formation in progress

Involucrum is still incomplete

Complete healing After removal ofDiaphyseal sequestrum

Summary

Case two

• A 12 years old male presented late with diaphyseal sequestrum.

• A seperation / fracture develop at the proximal end.

• Prolonged immobilization in Toe-to-groin cast.• Sequestractomy was done after involucrum

formation.• Complete healing

Diaphyseal Sequestrum

Developing separation

Sequestrum in the process of separation

Dressing through window

Sufficient involucrum

Diaphyseal Sequestrum removedAdditional protection providedby Skeletal traction in ThomasSplint.

Healing underProgress.

Complete Healing

Case three

• Acute osteomyelitis in a 3 years old child.• Complete diaphyeal sequestration with

multiple cloacae and sequestra.• Observation & immobilization• Rapid involucrum formation with absorption of

small sequestra.

Acute Osteomyelitis

Whole shaft involvementWith dislocation of Hip & absorption of capital epiphysis

Rapid involucrum formation

Dislocated hipDiaphyseal sequestrumComplete involucrum

Case four

• Post BCG acute osteomyelitis of humerus in an infant

• Diaphyseal sequestration and extrusion before the involucrum formed.

• Absorption of the remaining shaft leaving a long gap between shoulder and elbow.

• Reconstructed by Fibula three times harvested from the same site.

Post BCG acute osteomyelitis of humerus in an infant

Reconstruction by fibula and a thin K-wire second time

Wire broke but part of the Fibula was incorporated giving length toproximal & distal stumps.

After two years

After three years

Third time fibula grafting

References• Chronic Osteomyelitis in ChildrenDavid A. Spiegel, M.D.* and John Norgrove Penny, M.D., F.R.C.S.(C)†

Techniques in Orthopaedics® 20(2):142–152 © 2005 Lippincott Williams & Wilkins, Inc., Philadelphia

• Natural course of Hematogenous Pyogenic Osteomyelitis Kharbanda Y; Dhir R S., J. Postgraduate Medicine, 1991, 37(1): 69-75.

• sequestra in chronic haematogenous osteomyelitis.

Jain AK, Sharma DK, Kumar S, et al. Incorporation of diaphyseal Int Orthop1995;19:238 –241.

• Reincorporation of earlydiaphyseal sequestra and bone remodelling in extensive haematogenous osteomyelitis in children, Varma BP, Tuli SM, Srivastava TP, et al, Indian J Orthop 1974;8:39–44.

DISCLAIMER• Information contained and transmitted by this presentation is based on

personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 25 years.

• It is intended for use only by the students of orthopaedic surgery. • Views and opinion expressed in this presentation are personal opinion.• Depending upon the x-rays and clinical presentations, viewers can make

their own opinion.• For any confusion please contact the sole author for clarification.• Every body is allowed to copy or download and use the material best suited

to him. I am not responsible for any controversies arise out of this presentation.

• For any correction or suggestion please contact• naneria@yahoo.com