Osteomyelitis of the great trochanter after removal of a femoral nail: a case report

Abstract

Background

Osteomyelitis following orthopedic hardware removal is a rare but serious complication, particularly in pediatric patients. This case report describes a unique instance of osteomyelitis of the great trochanter following the removal of a femoral nail in a 14-year-old girl, highlighting diagnostic challenges and management strategies.

Case presentation

A 14-year-old Mediterranean white girl presented with persistent pain and swelling at the site of a previously removed femoral nail, used to treat a prior femoral shaft fracture. Symptoms developed 2 weeks post-removal, accompanied by erythema and increased warmth over the great trochanter. Laboratory findings showed elevated inflammatory markers. Imaging studies, including magnetic resonance imaging, confirmed osteomyelitis of the great trochanter. The patient underwent surgical debridement, followed by targeted intravenous antibiotic therapy based on culture sensitivities. The patient responded well to surgical debridement and a 3-week course of intravenous antibiotics, with subsequent transition to oral antibiotics. Follow-up at 1 year showed resolution of symptoms, normalization of inflammatory markers, and no signs of infection recurrence on imaging. The patient was free of pain, demonstrated complete range of motion, and the wound showed no signs of infection, as confirmed by clinical examination and accompanying photographs.

Conclusion

This case underscores the importance of prompt diagnosis and comprehensive management of osteomyelitis following hardware removal in pediatric patients. Early intervention with appropriate surgical and antibiotic treatment can lead to excellent outcomes in managing this rare complication.

Introduction

Osteomyelitis, an inflammatory bone condition primarily caused by bacterial infection, presents significant challenges in pediatric orthopedic care, particularly following surgical interventions. While hematogenous osteomyelitis is common in children, postoperative osteomyelitis following the removal of orthopedic hardware, such as femoral nails, is rare and poorly documented in the literature. This condition not only complicates recovery, but also necessitates aggressive and tailored treatment to prevent long-term complications, including chronic infection, impaired mobility, and further surgical interventions.

This case is particularly notable for its occurrence in a pediatric patient following the removal of a femoral nail, a routine procedure once fracture healing has been achieved. The pathogenesis of osteomyelitis in such cases can be multifactorial, involving direct bacterial inoculation during surgery or activation of dormant infections surrounding the hardware. The rarity of this condition, combined with the diagnostic challenges it presents—often mimicking mechanical instability or soft tissue irritation—makes this case highly relevant to the field of pediatric orthopedics. Through this report, we aim to highlight the importance of early diagnosis, the utility of advanced imaging such as magnetic resonance imaging (MRI) in detecting infections, and the role of multidisciplinary management in achieving favorable outcomes.

In children and adolescents, the femur is a common site for osteomyelitis due to its extensive vascular supply and the frequency of injuries requiring internal fixation. The removal of orthopedic hardware, such as femoral nails, is a routine procedure once healing has occurred; however, it can occasionally lead to infections, including osteomyelitis. The pathogenesis of osteomyelitis post-hardware removal is multifactorial, often involving direct inoculation of bacteria during surgery, hematogenous spread, or reactivation of a quiescent peri-implant infection.

The diagnosis of postoperative osteomyelitis involves a combination of clinical evaluation, laboratory markers, and advanced imaging techniques. MRI remains the gold standard for identifying the extent of bone infection and for guiding surgical intervention. The management typically includes surgical debridement of necrotic tissue, removal of any residual foreign material, and prolonged antibiotic therapy tailored to culture results.

This case report describes the occurrence of osteomyelitis of the great trochanter following the removal of a femoral nail in a 14-year-old girl, emphasizing the diagnostic challenges and detailing the management strategies that led to a successful outcome. Through this report, we aim to contribute to the existing literature on post-hardware removal infections and highlight the importance of vigilance and prompt management in such cases.

Case presentation

A 14-year-old, 50 kg Mediterranean white female patient presented to our orthopedic emergency department with complaints of persistent pain, swelling, and erythema localized to the right hip, specifically around the proximal wound, also with wound dehiscence and pus discharge. The symptoms began approximately 2 weeks following the removal of a lateral femoral nail, which had been placed 15 months earlier for a mid-shaft femoral fracture sustained in a skiing accident (Fig. 1).

Fig. 1

RX showing the femoral fracture (a) and consolidation of the fracture with the femoral nail (b)

The patient’s medical history was unremarkable with no previous chronic illnesses or known allergies. The initial fracture had healed well, and the femoral nail was removed after confirming radiographic union. The first days after the nail removal were initially uneventful until the onset of symptoms. The mother brought her daughter to their general doctor as soon as the symptoms started, who prescribed amoxicillin and clavulanic acid 80 mg/kg/day. Due to clinical worsening, the mother decided to bring her to our emergency room.

Clinical findings and therapeutic interventions

On our examination, a significant amount of pus flowed from the wound and the surrounding skin was hot, swollen, and red. Range of motion in the hip was restricted due to pain. On clinical examination she did not present with fever.

Given the clinical presentation, laboratory tests were performed, which revealed elevated inflammatory markers, including C-reactive protein (CRP) of 13.50 mg/dl, with 16.6 × 1000/µl white blood cells (WBC). Because of the clinical findings we brought the patient in operating room to make a debridement and intraoperative swabs. The patient underwent surgical debridement of the great trochanter. Intraoperative findings confirmed the presence of infected and necrotic soft tissues, with an opened fascia lata and some blood clots. However, the entry point of the previous nail appeared healthy. Samples of soft tissue were sent for and microbial culture. The patient started then an empirical intravenous antibiotic therapy with amoxicillin and clavulanic acid 150 mg/kg/day, and after 3 days switched to clindamycin 40 mg/kg/per day. MRI of the hip was ordered, which showed increased signal intensity around the great trochanter consistent with osteomyelitis and some abscess formations at the level of the fascia lata. There was no evidence of joint involvement. The MRI images (Figs. 2, 3) demonstrated both bone and soft tissue edema, suggesting the infection had not yet stabilized. The findings prompted further surgical intervention.

Fig. 2

Magnetic resonance imaging in frontal view showing abscess and osteomyelitis of the great trochanter (arrow)

Fig. 3

Magnetic resonance imaging showing infection tract (red arrow) (a) and collections in the soft tissue (blue arrows) (b)

Because of those clinical and radiological findings and the positivization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus epidermidis, an infectious disease consultation was requested. They prescribed an intravenous therapy with oxacillin 150 mg/kg/day, administrated four times a day for at least 2 weeks; daptomycin 7 mg/kg/day in one shot of about 30–40 min; and another 5 days of clindamycin 40 mg/kg/day, three times a day. They also suggested an operative second look with collection of three different samples, including part of the bone of the greater trochanter.

In the following days the infection blood values were improving, and the wound showed no signs of infection.

We then performed the second look, which presented a notable improvement of the local soft tissues, and the collections that had been highlighted in the MRI were not present, although a part of the fascia appeared with significant scar tissue.

The bone canal was therefore filled with balls of two different synthetic bone void filler consisting of 40% hydroxyapatite, 60% calcium sulphate, and the antibiotic gentamicin sulphate and vancomycin hydrochloride (Fig. 4).

Fig. 4

RX after the filling of the femur canal with antibiotic cement and the negative pressure wound therapy system

Three different soft and bone tissue samples were then collected and sent for microbiological investigation. A negative pressure wound therapy system was applied to the sutured surgical wound until the complete healing.

In the following days, the girl moved herself with free weight bearing as tolerated from the pain, the wound always appeared without signs of infection, and the blood markers for infection continued to decline. All the three intraoperative samples were then negative. After the complete healing of the wound, we removed the vacuum system and the stitches.

After 3 weeks of intravenous antibiotic therapy, the patient was finally discharged with an oral antibiotic therapy with sulfamethoxazolum/trimethoprimum 800/160 mg twice a day for the following 2 weeks.

The patient underwent several clinical and hematological controls after the discharge, as well as a 3-month MRI; all controls were normal, without any signs of infection. Although the patient demonstrated no signs of recurrence at 3 months, a longer follow-up would be ideal to confirm the durability of the treatment and identify any late-onset complications. At the 1-year follow-up, the patient was pain-free, exhibited a full range of motion, and the wound was completely healed without signs of infection, as shown in photographs taken during clinical evaluation. (Fig. 5).

Fig. 5

The 1-year follow-up showing the wound and the complete restoration of range of motion

Time/event	Date	Clinical notes/interventions	Outcome/follow-up
Initial presentation	T = 0	Swelling, erythema, and pain at the femoral nail removal site. CRP 13.5 mg/dL, WBC 16.6 × 103/μL	Suspected infection. MRI and culture tests ordered
First surgical intervention	T =  + 1 day	Surgical debridement. Necrotic tissue and abscess removed. Empirical amoxicillin/clavulanic acid started	Surgery successful, wound healing initiated
Diagnosis (MRI)	T =  + 1 week	MRI confirmed osteomyelitis of the great trochanter	Diagnosis confirmed; second look planned
Infectious disease consultation	T =  + 1 week	Methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus epidermidis isolated from cultures. Oxacillin and daptomycin therapy initiated	Adjusted antibiotics on the basis of culture results
Second look surgery	T = 8 days	Further surgical intervention with synthetic bone void filler (hydroxyapatite and calcium sulphate with gentamicin and vancomycin)	No recurrence of infection, continued antibiotic therapy
Final follow-up	T = 3 months	No signs of infection. Blood markers normalized	Patient discharged in good condition with no recurrence
1-year follow-up	T = 1 year	Pain-free, full range of motion restored, wound completely healed with no signs of infection	Patient in excellent condition

Discussion

This case underscores the complexities of diagnosing and managing osteomyelitis following the removal of orthopedic hardware in pediatric patients. Osteomyelitis after hardware removal, while not unprecedented, remains rare and poorly understood, especially in young patients recovering from femoral fractures. The delayed onset of symptoms, the overlap with other post-surgical complications such as mechanical pain, and the difficulty in distinguishing between infection and post-surgical irritation complicate early diagnosis, often leading to delays in appropriate treatment [1].

The pathogenesis of postoperative osteomyelitis often involves the direct inoculation of bacteria during the surgical procedure or the activation of latent infection in the surgical site. The risk is particularly heightened in cases where hardware removal is necessitated by previous implant-associated complications or where there is significant manipulation of soft tissue and bone [2]. In our case, the absence of initial infection signs post-nail removal and the delayed onset of symptoms suggest a possible low-virulence infection that became symptomatic once the hardware was removed.

Diagnosing osteomyelitis in the postoperative setting is challenging due to the overlap of symptoms with other post-surgical complications such as mechanical instability or soft tissue irritation. MRI remains a critical tool in the diagnostic arsenal, providing detailed images that not only confirm the presence of infection but also delineate the extent of bone involvement [3]. In this case, the use of MRI played a crucial role in accurately identifying the presence and extent of the infection, allowing for timely surgical intervention. MRI, with its superior soft tissue resolution, remains the gold standard in diagnosing osteomyelitis, especially in differentiating bone infections from other post-surgical complications. The imaging revealed both soft tissue and bone edema, confirming osteomyelitis and guiding the decision for surgical debridement. This case reinforces the need for MRI in the diagnostic algorithm when postoperative infection is suspected, particularly in children where clinical symptoms may be less pronounced.

The management of osteomyelitis typically involves a combination of surgical debridement [4] and prolonged antibiotic therapy, as demonstrated in this case. In our patient, empirical antibiotic therapy was initiated promptly, followed by a targeted approach once culture sensitivities were identified. This aligns with current guidelines from the European Society for Paediatric Infectious Diseases (ESPID), which emphasize early and aggressive treatment to prevent the progression to chronic osteomyelitis. The infectious disease team’s involvement further ensured that the treatment was tailored to the identified pathogens, which included both methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus epidermidis (MRSE) [5].

The guidelines also highlight the high sensitivity of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in diagnosing bone and joint infections, which were pivotal in our case for initiating an early intervention. Moreover, the use of MRI, as recommended by ESPID, was instrumental in our diagnosis, allowing for detailed visualization of the infection extent and guiding the surgical debridement process.

Although the overall prognosis for postoperative osteomyelitis is generally good with early intervention, the risk of recurrence remains a concern. In our patient, the infection was successfully resolved through a combination of two surgical debridements, the use of bone void fillers, and targeted antibiotic therapy, with no signs of recurrence at 3-month follow-up. This highlights the importance of comprehensive and multidisciplinary management in preventing long-term morbidity.

The rarity of postoperative osteomyelitis in pediatric patients following hardware removal adds significant value to the existing literature. While infections after orthopedic procedures are well documented, this case emphasizes the need for vigilance, particularly when dealing with young patients, whose symptoms may be subtle, with potential complications far-reaching. The successful resolution of this case demonstrates the critical role of early diagnosis, advanced imaging, and targeted multidisciplinary intervention.

This case contributes to the literature by providing insights into the diagnostic and therapeutic challenges associated with hardware removal in pediatric patients.

The rarity of postoperative osteomyelitis in pediatric patients following hardware removal adds significant value to the existing literature. Early intervention is critical in these cases to prevent chronic complications and recurrence. This report highlights the importance of combining clinical vigilance with advanced imaging techniques and a multidisciplinary approach to achieve optimal outcomes.

The limitation of this article is that it discusses a single case report and, for those reasons, is not generalizable. However, it provides valuable insights into the complexities of diagnosing and managing post-surgical infections in pediatric orthopedics.

The work has been reported in line with the  2013 CARE Checklist (Case Report Guidelines) [6] criteria.

Conclusion

This case report of a 14-year-old girl developing osteomyelitis of the great trochanter after the removal of a femoral nail provides valuable insights into the complexities of diagnosing and managing post-surgical infections in pediatric orthopedics. The prompt recognition of symptoms and the use of appropriate diagnostic tools, including MRI and biomarkers such as CRP and ESR, facilitated an early diagnosis. This early intervention, coupled with surgical debridement and targeted antibiotic therapy, was crucial in managing the infection effectively. Furthermore, the use of a targeted antibiotic regimen based on culture sensitivities emphasizes the need for a precise microbial diagnosis to guide therapy. Transitioning from intravenous to oral therapy on the basis of microbial sensitivity played a critical role in the resolution of the infection and prevention of further complications, as well as allowing the girl to return home and resume her normal activity.

This case contributes to the literature by detailing the management of a relatively rare complication of orthopedic hardware removal in children. It serves as a reminder of the potential complexities following seemingly routine procedures and the importance of vigilance and readiness to implement aggressive treatment strategies.