A 17-year-old male presented with pain in his right thigh for one month and fever for four days. He had a history of minor trauma to the right thigh one month prior. Examination found swelling and tenderness in the right mid-thigh. Imaging showed an abscess and osteomyelitis of the right femur. Biopsy revealed chronic osteomyelitis. He was treated with antibiotics and surgery to drain the abscess. Further imaging showed increased periosteal reaction concerning for Ewing's sarcoma. Additional treatment was planned including reaming of the femur and repeat biopsy.

1. Dr. Om Parshuram Patil
Dept Of Orthopaedics
Under Guidance Of
Dr G.N.Pundkar
Prof and Head

2.  17 year old male came to the casualtyn with
Chief Complaints of
 Pain in rt thigh since 1 month
 Fever since 4 days
 History of trauma to rt thigh and leg one and half
month before, trivial in nature & due to fall
 No h/o Chronics diseases, weight loss

3.  Pain in rt thigh since one month which was insidious
in onset , gradually progressive dull aching in nature
,with no aggravating factors, reduced in severity since
last 4-5 days with associated fever since then
 Fever was high grade , intermittent, not associated
with chills and rigors

4.  On examination
 Local temp was raised than contralateral side in mid
thigh region
 Minimal swelling in rt thigh
 Diffuse tenderness in mid thigh region
 From hip to calf region
 Could not be localised to a particular area

5. Investigation TLC : 21,600
 Neutro : 80%
 Lympho :15%
 Mono :03%
 Eosino :02%
 Hb :12.3 gm %
 ESR :20 mm
 Sickling :negative
 Blood Group: O negative

6.  Usg Rt Thigh:
Evolving Abscess in rt thigh Deep muscle lateral
side, with surrounding muscle myositis, with
inflammatory changes in rt hip joint.
Started with Ceftriaxone and Linezolid for 7 days

7.  Xray 21/11/14
 Rt thigh AP /Lat
 S/o : Periosteal reaction in mid third upper third
junction of rt femur.. Suggesting
 acute osteomyelitis ?
 Ewings Sarcoma? With onion peel appearance

8. 21/11/14

9.  Pt was subjected biopsy through, latetral approach
and window was made over the lateral cortex with
multiple drilling holes
 Minimal cheesy material was drained out from
superficial part lateral cortex
 Cortical bone and surrounding soft tissue sent for
histopathology and culture

10.  Started with Antibiotics Ceftriaxone with sulbactum,
amikacin for three weeks
 Patient was relieved of symptoms partially after
procedure with reduced severity of pain and fever

11. Histopathology
 Of the tissue was suggestive of chronic osteomyelitis
29/11/14

12. Histopathology
Chronic osteomyelitis,
from infected femur s
The irregular
fragment of
devitalized bone
surrounded by dense
fibrous tissue heavily
infiltrated by plasma
cells, lymphocytes,
and only a few
granulocytes.
Inflammatory
Changes

13. Post operative Xray

14. Post op 3 weeks

15. 8/12/14
 TLC : 10200/cumm
 Neutro : 60%
 Lympho : 32%
 Mono : 04%
 Eosino : 04%
 Hb : 12.0 gm %
 ESR : 15 mm

16. 17/12/14
TLC : 12900/cumm
Neutro : 59%
Lympho : 37%
Mono : 03%
Eosino : 01%
Hb : 12.3 gm %
ESR : 12 mm

17.  Parenteral antibiotics were stopped on 21 days and
shifted to oral antibiotics .
 But radiological picture of the patients rt femur was
S/o
 Increased periosteal reaction disseminated to lower part
of femur
 ??? Onion peel appearance s/o ewings sarcoma

18. Further treatment Plan
 Saucerization and reaming of intramedullary cavity
with antibiotic impregnated nail for six weeks
 Drain window in the distal part of femur laterally
 Simultaneous repeat histopathological and culture
studies from the site.

19. Chronic Osteomyelitis

20. Classification of COM

21. Anatomical classification

22. Classification of COM

23. Diagnosis COM
Based on
Clinical
 laboratory and
 imaging studies

24. Clinical evaluation COM
Skin and soft tissue integrity
Tenderness
Bone stability
Neurovascular status of limb
Presence of sinus

25. Laboratory COM
 Erythrocyte sedimentation rate
 C reactive protein
 WBC count only elevated in 35%
 Biopsy for histological and microbiological
evaluation
 Staphyloccocus species
 Anaerobes and gram negative bacilli

26. Imaging studies in COM
Plain X rays
Cortical destruction
Periosteal reaction
Sequestra
Sinography

27. Sinography

28. Imaging -
 Isotopic bone scanning more useful in acute
than in chronic osteomyelitis
 Gallium scans increased uptake in areas
where leucocytes and bacteria accumulate.
Normal scan excludes osteomyelitis

29. COM Imaging
CT Scan
Identifying sequestra
Definition of cortical bone and
surrounding soft tissues

30. COM Imaging
 MRI
 Shows margins of bone and soft tissue
oedema
 Evaluate recurrence of infection after 1 year
 Rim sign- well defined rim of high signal
intensity surrounding the focus of active
disease
 Sinus tracks and cellulitis

31. Treatment of COM
 Surgical treatment mainstay
 Sequestrectomy
 Resection of scarred and infected bone
and soft tissue
 Radical debridement
 Resection margins >5mm

32. Surgical treatment of COM
 Adequate debridement leaves a dead space that
needs to be managed to avoid recurrence, or bony
instability
 Skin grafts,
 Muscle and myocutaneous flaps
 Free bone transfer
 Papineau technique
 Hyperbaric oxygen therapy
 Vacuum dressing

33. Treatment of COM
 Antibiotic duration is controversial
 6 week is the traditional duration
 1 week IV, 6 weeks of oral therapy
 Antibiotic polymethyl methacrylate (PMMA)
beads as a temporary filler of dead space
 Biodegradable antibiotic delivery system

34. Resection or excision for COM
 Resection of a segment of affected bone may
be necessary to control infection
 With techniques of bone and soft tissue
transport, massive resections can be
performed and reconstructed without
significant disability.

35. Amputation for osteomyelitis
 Amputation indications include
 Arterial insufficiency
 Major nerve paralysis
 Non functional limb-stiffness, contracture
 Malignant change
 Prevalence of maliganacy arising from COM
reported as 0.2 to 1.6% of cases.
 Most are squamous cell carcinoma, also reticulum
cell carcinoma,fibrosarcoma

36. Ewings Sarcoma

37. Epidemiology
 Incidence is 0.6 per million
 Males > Females
 65% in the 2nd decade of life
 Rare in blacks and Asians

38. Clinical Presentation
History:
 Pain most commonly (90%)
 Swelling (70%)
 Fever (20%)
 Pathological fracture
 Weight loss, malaise

39. Clinical Presentation
Physical Exam and Labs
 Local warmth, inflammation
 Pleural effusions
 Neurological signs if spinal involvement
 ESR, LDH, anemia, leukocytosis

41. Radiology
 Site
 Size
 Effect on bone
 Response of Bone
 Matrix
 Cortex
 Soft tissue

49. Pathology
 Cell of origin is unknown
 Previously a diagnosis of exclusion
 Reciprocal translocation

51. Pathology
 Gross: soft, tan, gray tissue
 Micro: nests of small round cells
 No osteoid or chondroid production
 Surface cell glycoprotein

52. Pathology
Differential Diagnosis
 Lymphoma
 Osteomyelitis
 Osteosarcoma
 Malignant Fibrous Histiocytoma
 Metastatic neuroblastoma in toddlers

53. Staging and Prognosis
 Local and distal staging
 Bone marrow aspirate
 Pre-chemotherapy investigations
 Biopsy

54. Staging and Prognosis
 Location
 Tumor Size
 Metastases at diagnosis
 Response to chemotherapy

55. Treatment
 Multidisciplinary approach
 Neoadjuvant chemotherapy, surgery
 Don’t prolong interval between chemo
 Radiation if indicated

56. Summary
 Rare but common
 Main ddx is lymphoma and infection
 Large soft tisse masses
 Neoadjuvant chemo and surgery
 75-80% disease free survival at 5 years

57. Thank you