Osteomyelitis in children has various clinical manifestations causing diagnostic and therapeutic difficulties. Inappropriate treatment of acute osteomyelitis may lead to chronic, serious and complicated condition. Chronic osteomyelitis continues to be a major cause of morbidity and disability in children living in developing countries. We present three cases of tibial osteomyelitis that have different presentations and sequalae. Our intention is to alert our colleagues, particularly primary physicians, regarding the variety of presentation and the important of early diagnosis and treatment to reduce the risk of morbidity following osteomyelitis

Awang, Mohd Shukrimi

Sharifudin, Mohd Ariff

Taib, Mai Nurul Ashikin

Zakaria@Mohamad, Zamzuri

English

The International Islamic University Malaysia Repository

48 Med J Malaysia Vol 70 No 1 February 2015SUMMARYOsteomyelitis in children has various clinical manifestationscausing diagnostic and therapeutic difficulties.Inappropriate treatment of acute osteomyelitis may lead tochronic, serious and complicated condition. Chronicosteomyelitis continues to be a major cause of morbidityand disability in children living in developing countries. Wepresent three cases of tibial osteomyelitis that have differentpresentations and sequalae. Our intention is to alert ourcolleagues, particularly primary physicians, regarding thevariety of presentation and the important of early diagnosisand treatment to reduce the risk of morbidity followingosteomyelitis.KEY WORDS:Chronic osteomyelitis, ipsilateral vascularized fibular graft,paediatric, tibia.INTRODUCTIONOsteomyelitis in children continues to cause diagnostic andtherapeutic difficulties. The clinical manifestations may vary.The signs and symptoms of infection are not always present.The clinical features of bony tenderness, limp or musclespasm should raise suspicion of osteomyelitis, possibly withpyrexia and malaise. Inappropriate treatment of acuteosteomyelitis may lead to chronic, serious and complicatedcondition. Chronic osteomyelitis continues to be a majorcause of morbidity and disability in children living indeveloping countries. We present three cases of tibialosteomyelitis that have different presentations and sequalae.The intention of this article is to alert our colleagues,especially primary physicians, regarding the variety ofpresentations and the importance of early diagnosis andtreatment, hence to reduce risk of morbidity followingosteomyelitis.CASE REPORTCASE 1An 11-year-old Malay boy presented with boil like lesion witha swelling over the medial aspect of his right upper tibia. Itwas associated with mild pain and low-grade fever. There wasno preceding trauma or fall. He was started on a week of oralantibiotics at a district hospital, but later opted for atraditional healer when his condition was not improving. Hewas referred to our centre only after a month for furthermanagement. He was noted to have a diffuse swelling of hisright upper tibia with boils like lesion present on top of thelesion. It was warm with mild tenderness. His right kneemotion was restricted. His erythrocyte sedimentation rate(ESR) was 90mm/hr. Blood culture and sensitivity wasnegative. Neither open biopsy nor bony aspiration was done.Plain radiograph and MRI showed features of osteomyelitisinvolving the proximal aspect of right tibia (Fig. 1).Patient was given two weeks of intravenous, followed byanother six weeks of oral Cloxacillin. No surgicalintervention performed on him. His condition improvedfollowing treatment. He was able to continue his dailyactivity as other normal school children six month followinginitiation of treatment. At 18 months, plain radiographshowed evidence of a complete recovery (Fig. 2).CASE 2A nine-year-old aboriginal girl presented with history of skinlesion, pain and swelling of her right leg for one-monthduration. There was no history of trauma or fall prior to theonset. She received an initial treatment at a local clinic, inwhich “incision and drainage” was done twice over her leg.She also received a one-week course of antibiotic. She wasreferred to us for further management after no improvementwas observed. Upon admission, she was noted to have adiffuse swelling of the whole right leg, with a sinus dischargeat the medial aspect of her lower leg. ESR level was raised to80mm/hr. Plain radiograph show lytic lesions withpathological fracture of the distal tibia (Fig. 3a and 3b).Surgical debridement and curettage of the affected bone wasperformed. The culture grew Staphylococcus aureus species,which was sensitive to Cloxacillin. She was given a course ofantibiotic for two months. Her condition improved clinically,and evidence of sclerotic repair of the bone and union of thepathological fracture was observed on plain radiographs (Fig.3c). Unfortunately, she did not turn up for further follow-ups. CASE 3An 18-month-old baby girl was referred for pain, diffuseswelling of her left leg, and fever following a fall from a chairsix days prior to admission. There were increments in herwhite cell count of 16,000, ESR of 95mm/hr and C-reactiveprotein (CRP) of 30g/dl. Incision and drainage was performedand 50cc of pus was drained out. Culture and sensitivity grewStaphylococcus aureus, which was sensitive to Cloxacillin.Chronic Tibial Osteomyelitis in Children. A Case Review atHospital Tengku Ampuan Afzan, KuantanMohd Shukrimi Awang, MMed (Ortho)*, Mohd Ariff Sharifudin, MMed (Ortho)*, Zamzuri Zakaria, MS (Ortho)*,Mai Nurul Ashikin Taib, MMed (Paediatics)***Department of Orthopaedics, Traumatology and Rehabilitation, **Department of Paediatrics, Kulliyyah (Faculty) of Medicine,International Islamic University Malaysia, 25150 Kuantan, Pahang, MalaysiaCASE REPORTThis article was accepted: 13 October 2014Corresponding Author: Mohd Ariff Sharifudin, Department of Orthopaedics, Traumatology and Rehabilitation, Kulliyyah (Faculty) of Medicine, InternationalIslamic University Malaysia, 25150 Kuantan, Pahang, Malaysia     Email: ariffs@iium.edu.myChronic Tibial Osteomyelitis in Children. A Case Review at Hospital Tengku Ampuan Afzan, KuantanMed J Malaysia Vol 70 No 1 February 2015 49Fig. 1: Case 1: Anteroposterior (a) and lateral (b) plain radiographs of the proximal right tibia showing osteolytic lesion involving themetaphyseal region with periosteal reaction (white arrow). Tumour-like osteolytic lesion was seen on MRI (white arrow) (c).Fig. 2: Case 1: Anteroposterior (a) and lateral (b) plain radiographs at 18 months after treatment showing a complete recovery.Fig. 3: Case 2: Anteroposterior (a) and lateral (b) plain radiographs at presentation, showing a lytic changes and pathological fractureof posteromedial aspect of the lower tibia. Two months, following treatment, sclerotic changes and union of pathologicalfracture was observed (posteromedial cortex) on plain radiograph (c).Case Report50 Med J Malaysia Vol 70 No 1 February 2015Her clinical condition worsens despite intravenous antibiotic.Plain radiograph at one month of presentation showedevidence of pan-osteomyelitis of the tibia complicated withpathological fracture. Patient was put on full length cast andantibiotic was continued for another two months. However,subsequent plain radiograph showed an approximately 5cmbony resorption in the mid-shaft of the tibia (Fig. 4a). At thispoint of time, patient remained clinically aseptic. She startedback to walk without any form of immbolization, causingvarus deformity of the ankle. The affected leg was also shortof about 3cm compared to the contralateral leg. We performed reconstruction of the tibial defect at six monthsafter infection had clinically settled. This involved theisolation of pedicle fibular graft from the ipsilateral leg,removal of fibrous tissue from the tibial defect, and transferof 5cm fibular graft to bridge the tibial gap. External fixatorwas applied and was kept for two months (Fig. 4b), whichwas then changed to full length cast for another six weeks.Patient showed excellent recovery from the surgery. On herrecent follow up at two years after surgery, there was no limblength discrepancy and the transferred fibula graft hadbecome hypertrophied. The varus deformity of the ankle wasalso corrected (Fig. 4c). DISCUSSIONPaediatric musculoskeletal infections remain an importantcause of morbidity. Recent prospective studies indicateuncomplicated osteomyelitis can be treated by three to fourweeks of antibiotics.1 However, a small group of children willhave an overwhelming disseminated infection causingsignificant morbidity, like in our third case. Hematogenousosteomyelitis may lead to extensive bone necrosis andformation of sequestra, with resultant pseudarthroses andsegmental bone defects. In this case review, we highlighted three cases of chronicosteomyelitis. Even though all the cases had similarpresentations at initial stage, however, their clinicalprogression varies. It is important to alert primary carephysicians and also orthopaedic specialist and districthospital regarding their possible sequalae and complicationsthat can lead to severe morbidity to the patients.  In all cases,infection started at the metaphyseal region; two involvedproximal tibial (case 1 and 3), and one distally (case 2).Staphylococcus aureus were isolated in two of the cases,whereas no specific organism was isolated in the other case.This is consistent with findings by Yeargan et al., in which78% of their cases are positive of this organism.2Recent studies have demonstrated a 90% response rate tomedical therapy alone when treatment was initiatedpromptly and continued for an appropriate time.1 In chronicosteomyelitis, the indications for surgical treatment are thepresence of local pain and swelling with or without drainage,the presence of osteolytic lesions or sequestrum, or both.However, it has a risk of damaging the physis if theosteomyelitis involved cavitation near to it. Reinehr et al.found that their diagnostic procedure was useful to reduce therate of surgery in chronic osteomyelitis.3 They reserve surgicaltreatment only for patients presented with abscess, septicarthritis or frank sequestrum. In case 1, the patient wastreated with antibiotic only, and had a full recovery. Therewas no residual infection or deformity. With the presence ofboil-like lesion over the proximal tibia, it was moresuggestive of infection rather than tumour. Hence, no biopsywas performed at initial presentation. Patient also respondedvery well with antibiotic treatment. It was supported byimprovement in clinical findings and reduction of ESR. Incase 2, patient was surgically treated with debridement of thesequestrum and drainage of the pus. Intra-operative sampleswere obtained and assisted in identifying the causativeorganism. With correct and appropriate duration oftreatment, the patient showed signs of recovery till she lostfrom our routine follow-up. Many authors had described the treatment of osseous defectusing either ipsilateral or contralateral vascularized fibulargraft since Albert first described it in 1877.4 Tibialisation ofthe fibular with some preservation of the surroundingmuscles attachments retained the vascularity of the graft.This method does not require performing a micro-anastomosis between the graft pedicle and the recipient site.Zahiri et al. successfully used this method to treat chronicosteomyelitis of the entire tibial shaft in nine children.5Fig. 4: Case 3: Anteroposterior and lateral (a) plain radiographs showed segmental bone loss at mid-shaft of the tibia, and afteripsilateral vascularised fibular graft with external fixation (b). The graft hypertrophied and corrected the length discrepancy andvarus deformity of the leg (c and d).Chronic Tibial Osteomyelitis in Children. A Case Review at Hospital Tengku Ampuan Afzan, KuantanMed J Malaysia Vol 70 No 1 February 2015 51Surgery was performed in three stages. In case 3, wetransferred the ipsilateral fibular and slotted it in the middleof the resected tibial shaft, and hold it with an externalfixator for six weeks. Unlike Zahiri method, we did it in singlestage procedure using a unilateral external fixator instead ofIlizarov frame. The transferred fibular graft showed acomplete fusion and hypertophied. Patient recovered welland limb length discrepancy was corrected.CONCLUSIONAppropriate administration of antibiotic plays an importantrole in managing acute osteomyelitis to avoid a progressionto chronic osteomyelitis in children. Surgical debridementtogether with appropriate antibiotic is important factor intreatment of chronic osteomyelitis in children. Surgicalreconstruction of bony defect using vascularised fibular graftfor chronic osteomyelitis of tibial in children is reserved forsevere case due to complexity of the procedure and the needof technical experts. REFERENCES1. Jagodzinski NA, Kanwar R, Graham K, et al. Prospective evaluation of ashortened regimen of treatent for acute osteomyelitis and septic arthritis inchildren. J Pediatr Orthop 2009; 29(5): 518-25.2. Yeargan SA 3rd, Nakasone CK, Shaieb MD, Montgomery WP, Reinker KA.Treatment of chronic osteomyelitis in children resistant to previoustherapy. J Pediatr Orthop 2004; 24(1): 109-22.3. Reinehr T, Burk G, Michel E, et al. Chronic osteomyelitis in childhood: issurgery always indicated?  Infection 2000; 28(5): 282-6.4. Atkins RM, Madhavan P, Sudhakar J, et al. Ipsilateral vascularised fibulartransport for massive defect of the tibia. J Bone Joint Surg Br. 1999; 81(6):1035-40.5. Zahiri CA, Zahiri H, Tehrany F. Limb salvage in advanced chronicosteomyelitis in children. Int Orthop 1997; 21(4): 249-52.

Chronic tibial osteomyelitis in children. A case review at Hospital Tengku Ampuan Afzan, Kuantan

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Chronic tibial osteomyelitis in children. A case review at Hospital Tengku Ampuan Afzan, Kuantan

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