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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
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