Complete incorporation of long diaphyseal sequestrum without surgical intervention in chronic hematogenous osteomyelitis of tibia in an immunocompetent child

Abstract

Traditionally, the management of chronic osteomyelitis emphasizes the excision of necrotic and infected material (sequestrectomy/debridement) followed by prolonged administration of antibiotics. Most children with chronic osteomyelitis undergo surgery with the inherent risk of damage to their growth plate. Treatment regimen based on findings of imaging with emphasis on antibiotics to potentially reduce the rate of surgical interventions is being increasingly reported. An 8-year-old thin built Indian boy belonging to lower socio-economic group presented to the orthopedic department with the chief complaints of pain in the left upper leg for the last 3 months. Radiograph of the affected limb showed features of chronic osteomyelitis with a large diaphyseal sequestrum on the medial cortex of tibia with incomplete involucrum. No surgery was performed; not even incision and drainage. The sinuses healed completely in 6 weeks time with appropritate antibiotics alone. Gradually, over a period of 8 months, the large tibial diaphyseal sequestrum got fully incorporated into the healthy diaphyseal bone indistinguishable from normal bony architecture with complete clinical remission of sepsis. Our rare case is an example of the evolving notion that antibiotics and supportive care alone may be sufficient enough in the treatment of chronic osteomyelitis even with large diaphyseal sequestrum in paediatric cases where excellent healing potential of the immune-competent child may potentially make surgical intervention redundant.

Role of micronutrients in uptake of sequestrum in paediatric chronic diaphyseal osteomyelitis: An analysis of 15 cases

“…One of the most common modes of treatment employed for chronic osteomyelitis is sequestrectomy which comes with its own pros and cons. Depending on the size of sequestrum, mechanical stability of remaining bone is determined [6] . Diaphyseal sequestrums are frequent in the paediatric age group which may be difficult to tackle following its removal needing further surgical procedure increasing the morbidity as well as financial implication for the family.…”

“…It is usually advised to remove the sequestrum as early as possible to make the bone heal faster [5] . It is also associated with increased risk of growth plate injury as well as risk for pathological fracture during operative procedure [6] .…”