Pathologic fracture and hardware failure in Streptococcus anginosus femoral osteomyelitis: Case report

John E Stillson; Connor M Bunch; Anthony V Thomas; Nicolas Mjaess; Joseph A Dynako; Andres S Piscoya; Joel M Post; Brian L Ratigan; Zachary H Goldstein; Mark M Walsh

doi:10.1016/j.amsu.2021.102478

Pathologic fracture and hardware failure in Streptococcus anginosus femoral osteomyelitis: Case report

Ann Med Surg (Lond). 2021 Jun 9:67:102478. doi: 10.1016/j.amsu.2021.102478. eCollection 2021 Jul.

Authors

Affiliations

¹ Indiana University School of Medicine South Bend Campus, Notre Dame, IN, USA.
² Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA.
³ Department of Orthopedic Surgery & Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA.
⁴ Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA.
⁵ Beacon Bone & Joint Specialists Navarre, Memorial Hospital, South Bend, IN, USA.
⁶ South Bend Orthopaedics, South Bend, IN, USA.
⁷ Department of Orthopedic Surgery, Indiana University Health University Hospital, Indianapolis, IN, USA.

Abstract

Introduction: Pathologic fracture of the femur due to Streptococcus anginosus osteomyelitis has rarely been described. With limited evidence for treating S. anginosus osteomyelitis, the orthopaedic surgeon is presented with a difficult treatment decision at index presentation. Presented here is a case of failed conservative management, diagnostic dilemma, failed hardware stabilization, and definitive surgical treatment resulting in good clinical outcome.

Case presentation: A 69-year-old male experienced acute right thigh pain, edema, and erythema after dental treatment 17 days prior. He was diagnosed with right femoral diaphyseal osteomyelitis and Brodie's abscess. Blood cultures grew S. anginosus, but all site-specific tissue cultures resulted negative. Initial management consisted of intravenous antibiotic therapy and percutaneous abscess drainage. Months later, the patient sustained a displaced pathologic fracture of the diaphyseal femur and there was concern for neoplasm, but biopsies were negative. Stabilization was attempted with a lateral plate and screws. This hardware catastrophically failed in the setting of an oligotrophic femoral nonunion. Ultimately, the patient was successfully treated with an intramedullary nail coated with antibiotic-impregnated cement. Twelve months later, the patient achieved clinical and radiographic healing with no evidence of relapse of his osteomyelitis.

Clinical discussion: Conservative management of S. anginosus femoral osteomyelitis was inadequate and corroborates the existing literature. S. anginosus osteomyelitis and pyomyositis may be most optimally treated aggressively with early surgical intervention.

Conclusion: Early surgical debridement and stabilization of the compromised bone with an antibiotic coated intramedullary nail following medullary reaming may prevent pathologic fracture, eradicate infection, and achieve predictable outcomes.

Keywords: CAD, coronary artery disease; CYP450, cytochrome-P450; Case report; DM, diabetes mellitus; Femur; HLD, hyperlipidemia; HTN, hypertension; IV, intravenous; MRI, magnetic resonance image; Orthopedics; Osteomyelitis; RIA, reamer-irrigator-aspirator; Spontaneous fractures; Streptococcus anginosus.

Publication types

Case Reports