Single-stage surgery for complex chronic femoral osteomyelitis: A case report

INTRODUCTION

Osteomyelitis represents a heterogeneous disease whose etiology varies across age groups. In children, it most commonly arises from acute hematogenous spread. In contrast, in adults, it is more frequently associated with open fractures, surgical interventions, or post-traumatic contamination, where disruption of the skin barrier permits bacterial invasion of bone tissue.^[1,2]

Over time, improvements in trauma care have shifted the epidemiology of chronic osteomyelitis toward post-traumatic and post-operative causes rather than progression from untreated acute infection.

Regardless of origin, chronic osteomyelitis is a debilitating condition characterized by persistent infection, progressive bone destruction, and devitalization of surrounding tissues. Host-related factors such as diabetes mellitus, impaired vascularity, immunocompromise, and repeated surgical interventions further contribute to disease persistence and recurrence. Clinical presentations range from indolent sinus tract formation to severe complications, including pathological fractures, limb deformity, and functional disability.^[1,2]

Unlike acute osteomyelitis, antibiotic therapy alone is insufficient in chronic osteomyelitis because bacterial biofilms on necrotic bone and devitalized soft tissue impede antibiotic penetration and eradication.^[1,3,4] Effective management, therefore, requires a combined surgical and medical approach aimed at eradicating infections, restoring stability, and promoting functional limb recovery.^[3,5]

Clinicians often guide treatment planning for chronic long-bone osteomyelitis using the Cierny–Mader (C-M) classification, which categorizes infection by anatomical extent and host physiology.^[1,3,5] However, the absence of standardized host status in this stratification subjectively varies based on the treating surgeon’s clinical judgment. This underscores the complexity of treatment decisions, in which many distinct strategies are developed and tailored on a case-by-case basis, as there are no guidelines recommending definitive treatments.^[3,5]

CASE REPORT

A 42-year-old man with type II diabetes mellitus, hypertension, and dyslipidemia presented 5 months post-motorbike accident with a pathological right midshaft femoral fracture. The fracture resulted from chronic osteomyelitis following neglected initial injuries, complicated by a sinus tract extending into the intramedullary canal and posterior thigh.

He initially underwent wound debridement, bone resection, limb reconstruction system (LRS) external fixator application, and right femoral corticotomy. Following the first LRS removal, he sustained a refracture of the right femur requiring further debridement, second LRS application, and manipulation under anesthesia of the knee a year later. Despite that, he returned with the same infection 6 months later, necessitating extensive bone curettage. His disease was further complicated when the patient sustained a second refracture following bone transport. This necessitated a revision of the LRS two months later, followed by its removal the next year.

Subsequently, he developed recurrent right thigh cellulitis and abscesses, necessitating repeated hospital admissions for incision and drainage as well as intravenous antibiotic therapy.

Seven years after his initial presentation, he returned with fever (39.5°C), right thigh pain, swelling, and erythema. He reported no recent trauma, sensory deficits, or open wounds but experienced difficulty with ambulation. Radiograph [Figure 1] of the right thigh showed a sequestrum over the right distal femur but no gas shadows. Despite outpatient antibiotics, his symptoms worsened, prompting clinicians to admit him for definitive management.

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Figure 1:

Anteroposterior radiograph of the right femur showing cortical irregularity and possible sequestrum (white arrow) in the distal shaft, suggestive of chronic osteomyelitis.

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Examination of the right lower limb revealed a healed sinus tract scar over the lateral thigh with diffuse swelling, erythema, and tenderness. A fluctuant area was palpable distally, and the medial thigh was firm and tender. The right knee exhibited an effusion with a restricted range of motion due to pain; however, the neurovascular status remained intact. Clinically, a 2 cm limb-length discrepancy (right shorter) was observed. Radiographically, the right femur appeared shortened compared to the left, reflecting remodeling and segmental bone loss.

Aspiration of the right knee yielded 14mL of straw-colored fluid without pus. He subsequently underwent wound extension and thorough debridement, including a sinusotomy of the right thigh. Computed tomography scan [Figure 2] revealed a right femoral malunion with a midshaft fracture, a sequestrum at the distal third, a cloaca in the mid-shaft lateral cortex, and an involucrum extending superiorly from the midshaft.

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Figure 2:

Computed Tomography (CT) of the right femur. (a) 3D reconstruction showing characteristic features of chronic osteomyelitis, including sequestrum, involucrum and cloaca. (b-e) Sequential sagittal CT slices demonstrating chronic osteomyelitis involving entire femoral shaft; sequestrum (yellow arrow), involucrum (white arrow), and cloaca (blue arrow).

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To address chronic osteomyelitis and restore structural stability, intramedullary reaming with Stimulan insertion was performed, followed by application of an LRS external fixator to the right femur, all in a single-stage approach.

Under general anesthesia, the surgeon made a skin incision over the right greater trochanter of the femur to establish an entry point. Using a surgical awl, the surgeon then opened this point to create the initial entry canal into the proximal femur under intraoperative fluoroscopic guidance. The team performed antegrade intramedullary reaming of the right femur. Although they noted no purulent material intraoperatively, intramedullary samples grew methicillin-resistant Staphylococcus aureus and Klebsiella pneumoniae, confirming the presence of a persistent infection.

Stimulan, impregnated with vancomycin and gentamicin, was inserted into the intramedullary canal. The surgical wound was then irrigated with copious amounts of normal saline to remove all debris and contaminants before closure. A uniplanar LRS external fixator was applied and secured with pins [Figure 3], guided by an image intensifier (II). A post-operative plain radiograph [Figure 4] confirmed the placement of antibiotic cement and evaluated the stability of the fixator.

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Figure 3:

A uniplanar external fixator with the limb reconstruction system was applied and secured with pins on the patient’s right femur.

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Figure 4:

Figure 4: Anteroposterior radiograph of the right femur was postoperatively taken to confirm the placement of anterior cement (white arrow) and external fixator.

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The patient was then kept in the ward postoperatively for monitoring. In addition to clinical improvement, the team monitored his complete blood count, inflammatory markers, liver function tests, and renal profile.

The patient was discharged after a 40-day admission, with regular follow-up and radiologic imaging to confirm the LRS placement.

Throughout regular follow-up, the wound of his right thigh was clean, and there was no discharge from the pin sites or tracts. He denied any complaints. Three months later, the LRS was removed and replaced with a cylindrical cast for continued immobilization. The latest plain radiograph [Figure 5] confirmed fracture union with consolidation 6 months following the most recent surgery.

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Figure 5:

Anteroposterior radiograph of the right femur taken 6 months post-limb reconstruction system insertion showing a united fracture with consolidation.

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DISCUSSION

According to the Cierny–Mader classification, we categorized the patient as having Type IV (diffuse) disease because the infection involved the full thickness of the femoral shaft, with cortical destruction, a pathological fracture, and resulting mechanical instability. He also met criteria for a compromised (Type B) host due to his diabetes mellitus and multiple prior surgeries, which impaired vascularity and delayed healing.

In C-M Type III and IV cases, an aggressive approach is necessary.^[6] This involves extensive wound debridement of all infected and necrotic tissues, bone grafting to promote osteogenesis, followed by reconstruction of the resulting bone defects. Alternative strategies, such as a traditional two-stage procedure or the Masquelet technique, may include antibiotic-coated beads (polymethyl methacrylate [PMMA]) to fill the dead space temporarily. This multifaceted approach aims not only to eradicate the infection but also to restore the limb function and, subsequently, improve the patient’s quality of life. However, the use of PMMA beads requires a second removal operation because they do not readily resolve and may become colonized if left in situ for extended periods, potentially leading to biofilm formation.^[3,4,7]

In C-M Type IV infections, stabilization is crucial for restoring limb integrity and promoting union.^[1,3,8] While both internal and external fixation methods are effective, the optimal choice depends on a careful evaluation of several factors, including the local soft-tissue condition, the status of any prior external fixation, the lesion location, and the patient’s preference.^[8] Internal fixation provides greater biomechanical stability but is less favorable in cases of recurrent infection or compromised soft-tissue quality, owing to a higher risk of biofilm formation and reinfection.^[1,3] However, external fixation also presents drawbacks. Prolonged use (beyond 14 days) in the femur or tibia increases the risk of postoperative infection.^[8] Despite this, external fixation remains the preferred option in patients with a history of recurrent osteomyelitis. However, external fixation has drawbacks; prolonged use of more than 14 days in the femur or tibia increases the risk of post-operative infection.^[8]

The key difference in our approach is the use of bioabsorbable calcium sulfate beads for dead-space management, replacing traditional PMMA beads and eliminating the need for subsequent surgical removal.^[4,6,7] This method is also associated with a higher infection eradication rate, lower revision rate, and potential osteogenesis.^[7] A systematic review and meta-analysis by Lari et al. [9] concluded that single- and two-stage procedures show no significant difference in non-recurrence rates. However, two-stage procedures are associated with longer hospital stays and higher costs. Despite this, surgeons often prefer the two-stage approach for complex cases involving more aggressive or extensive infections.^[9,10] This approach allows for an initial focus on infection eradication, potentially reducing the risk of recurrent infections by enabling surgeons to confirm the status before proceeding with reconstructive surgery.^[9,10]

CONCLUSION

This case illustrates the successful management of complex chronic femoral osteomyelitis using a single-stage surgical approach that combined intramedullary reaming, bioabsorbable calcium sulfate antibiotic beads, and LRS external fixator. This strategy achieved effective infection control, fracture union, and functional recovery while minimizing the need for multiple operations. In patients with Cierny–Mader Type IV osteomyelitis and compromised host factors, such an individualized and multidisciplinary approach can yield excellent clinical outcomes. Although long-term surveillance remains essential given the risk of late recurrence, achieving infection resolution, mechanical stability, and functional independence within 6 months represents a clinically meaningful success in the context of this patient’s prolonged and refractory disease course.