Case Of Chronic Osteomyelitis Research Articles

Overview of Chronic Osteomyelitis Cases at Level II Kartika Husada Hospital, Kubu Raya Regency, West Kalimantan Province January 2015 - December 2017

Overview of Chronic Osteomyelitis Cases at Level II Kartika Husada Hospital, Kubu Raya Regency, West Kalimantan Province January 2015 - December 2017

РОЛЬ МОЛЕКУЛЯРНО-ГЕНЕТИЧЕСКИХ МЕТОДОВ ИССЛЕДОВАНИЙ В ЭТИОПАТОГЕНЕЗЕ ОСТЕОМИЕЛИТА ЧЕЛЮСТЕЙ

The subject of the study is the importance of molecular genetic research methods in the study of the etiopathogenesis of osteomyelitis of the jaws. The purpose of the work is to provide up-to-date information to researchers, dental surgeons, and maxillofacial surgeons on the possibilities of molecular genetic research in identifying bacterial pathogens in osteomyelitis of the jaws, as well as to reflect genetic markers of pathogenicity factors for a number of the main causative agents of the disease. Methodology. International scientific databases PubMed, ScienceDirect, Scopus, Cochrane Collaboration, Elsevier, as well as electronic catalogs eLIBRARY.RU and CyberLeninka.ru were used. Results. A review of publications demonstrated that S. aureus and S. Epidermidis dominate the etiological spectrum of causative agents of bone tissue infections. The participation of these microorganisms is determined by a whole range of pathogenicity factors. Toxins and Panton-Valentine leukocidin (PVL) genes play a major role in the pathogenesis of osteomyelitis and disease progression. It has been shown that the pathogenic bacteria Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans are capable of inducing differentiated production of cytokines. The most attention has been attracted to E. faecium, which exhibits multidrug resistance to a wide range of antibiotics. The proportion of infections mediated by S. epidermidis and S. Saprophyticus is, on average, about 25% of cases. The proportion of representatives of gram-negative flora Escherichia, Klebsiella, Enterobacter, Citrobacter, Proteus, Providencia, Serratia reaches 23% of cases. Pathogenic nosocomial strains of P. aeruginosa are also involved in the formation of chronic inflammation in osteomyelitis. According to the results of published studies, more than a third of cases of chronic osteomyelitis are mediated by microbial associations, which are dominated by S. aureus, S. epidermidis and, less commonly, E. faecalis. Conclusions. The use of PCR analysis to identify the causative agents of osteomyelitis and gene amplification using specific primers has a huge advantage over routine microbiological tests, being an informative method for studying the pathogenicity factors of the main pathogens. The high importance of molecular genetic methods in the study of the etiopathogenesis of osteomyelitis of the jaws requires their widespread use in the clinic of surgical dentistry and maxillofacial surgery to successfully solve complex problems in the rehabilitation of patients with this disease.

Enhanced recovery for acute open lower limb fracture ‘fix and flap’

IntroductionEnhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following ‘fix & flap’, return to theatre, rate of successful flap salvage, flap failure and deep infection rates. MethodsAn observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. Results161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. ConclusionIn isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

МИКРОБИОЛОГИЧЕСКИЕ АСПЕКТЫ ЭТИОЛОГИИ ОСТЕОМИЕЛИТА ЧЕЛЮСТЕЙ

Background. Difficulties in the treatment of the inflammatory process of bone tissue focus the attention of researchers and practitioners on the early identification of pathogens of osteomyelitis, which is the key to successful treatment of the disease. According to publications cited in The Cocrane Library database, the epidemiology and etiological structure of osteomyelitis has undergone significant changes in recent years. 
 The aim of the review is to provide up-to-date information on etiologically significant representatives of the microbial flora in osteomyelitis of the jaws. Methodology. Search work was carried out using international scientific databases PubMed, ScienceDirect, Scopus, Cochrane Collaboration, Elsevier, as well as electronic catalogs Elibrary and Cyberleninka on microbiological aspects of the etiology of osteomyelitis of the jaws. 
 Results. A review of publications has demonstrated the dominant position of representatives of the genus Staphylococcus in the etiological spectrum of chronic post-traumatic osteomyelitis. The predominant pathogen is S. aureus. The proportion of infections mediated by S. epidermidis, S. Saprophyticus is, on average, about 25% of cases. The proportion of representatives of the gram-negative flora Escherichia, Klebsiella, Enterobacter, Citrobacter, Proteus, Providencia, Serratia reaches 23% of cases. According to the above information, the causative agents of gram-negative infections make up 1/5 of the etiological spectrum of chronic osteomyelitis. Pathogenic nosocomial strains of P. aeruginosa are also involved in the formation of chronic inflammation in osteomyelitis. According to the results of published studies, more than a third of cases of chronic osteomyelitis are mediated by microbial associations. The latter are dominated by S. aureus, S. epidermidis and, less frequently, E. faecalis. At the same time, dynamic analysis showed the variability of the microbial composition of associations, which determines additional difficulties in choosing the actual etiotropic therapy and may cause further progression of the pathological process. 
 Conclusions. Implementation of effective methods of therapy requires new informative diagnostic approaches. However, the sensitivity of routine microbiological analyzes is not high enough. At the present stage, the diagnostic value of molecular genetic methods based on the polymerase chain reaction has been recognized.

A rare case of chronic osteomyelitis of calcaneum: Case report

Calcaneal osteomyelitis accounts for 7% - 8% of all osteomyelitis cases in adults. It is often seen in association with diabetes and other comorbidities. Infection most commonly presents after a traumatic event (Open fractures or following fixation) or in patients with heel ulceration due to prolonged bed rest or lower limb neuropathy or vasculopathy. The diagnosis is primarily based on clinical features such as localized pain, localized swelling, erythema, local rise of temperature, sinus or heel ulceration. Radiological assessment with radiographs and bacteriological analysis can help to confirm the diagnosis. Successful treatment of calcaneal osteomyelitis requires infection control, excision of all necrotic bone and soft tissue, dead space management while preserving weight bearing capability with good soft tissue cover. We report one case of 45-year-old male with chronic calcaneal osteomyelitis associated with diabetes mellitus treated with sequestrectomy, debridement and G-bone placement.

An unusual case of chronic osteomyelitis in a 4-year-old male child: A case report

Abstract Chronic osteomyelitis is a complex and devastating surgical disease with a variety of etiologies and a multimodal approach towards its treatment. The aim of treatment is eradication of infection and restoration of function of the limb with surgical management being the cornerstone of treatment. Despite the need of surgical debridement in the treatment of chronic osteomyelitis, the reliable radiological and tissue diagnosis along with appropriate antimicrobial therapy is paramount for the success of treatment. Biofilm forms the most notorious reason for persistence of infection in a bone and needs thorough debridement till only viable tissue is left behind. Control of chronic osteomyelitis is challenging for the surgeons even today and demands patience from both the surgeon and the patient. Here, we are going to report an unusual case of osteomyelitis in a 4 year of male child.

CHRONIC OSTEOMYELITIS DUE TO SALMONELLA TYPHI IN A HEMOPHILIA PATIENT-A CASE REPORT

Salmonella causes various intestinal and extra intestinal manifestations. Chronic osteomyelitis is commonly seen in patients with patients of haemophilia. Most common cause of chronic osteomyelitis is Staphylococcus aureus. Very rarely Salmonella typhi causes chronic osteomyelitis. So here we report a case of Chronic osteomyelitis with recurrent discharging sinus caused by Salmonella typhi in patient who was a known case of haemophilia highlighting the pathogenesis which would have resulted in such a clinical presentation. If not treated in time would lead to permanent disability.

Management of Squamous Cell Carcinoma in Chronic Osteomyelitis: Our Experience, Review of the Literature and Role of MRI in Differential Diagnosis.

Background. The authors describe a series of patients with chronic osteomyelitis associated with squamous cell carcinoma, whilst analyzing its incidence in chronic osteomyelitis, surgical options for treatment and focusing on the role of MRI in differential diagnosis. Methods. The authors reviewed 73 cases of chronic osteomyelitis (CO) treated in their department between 1995 and 2019. Six of these patients (8.2%) had a malignant degeneration in squamous cell carcinoma (SCC). All cases with malignancy were evaluated with preoperative gadolinium-enhanced MRI. Results. In this series, the authors observed an incidence rate of 8.2% (6 cases out of 73); all patients were male with a mean age of 63.5 years. The mean time between the occurrence of chronic osteomyelitis and the diagnosis of squamous cell carcinoma was 36 years (range: 21–66). The treatment consisted of amputation in five patients and limb salvage with vascularized fibula autograft in one case. Conclusions. MRI played a key role in the differential diagnosis between infected and tumoral tissue, and was found to be crucial during follow-up. Amputation is the treatment of choice in extended tumoral involvement of bone and soft tissue.

Bioactive glass in the treatment of chronic osteomyelitis in children: Description of four consecutive cases and literature review

IntroductionChronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management. MethodsFour consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated. ResultsAll patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years. ConclusionsBioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children.

Bacteriological profile of osteomyelitis patients in government hospital, Ambikapur

Osteomyelitis is an infection and inflammation of the bone. Bacteria are the primary cause of osteomyelitis. Infections with fungi and viruses can also cause it.It usually affects children and others who are immunocompromised. Although bacteria cannot colonise bone ordinarily, events such as trauma, ischemia, surgery, the presence of foreign particles, or the insertion of prostheses can disrupt bone integration, eventually leading to infection.AIM : To study Bacteriological profile of osteomyelitis patients in Government Hospital, Ambikapur. Material And Material: During the study period of April2021 to Oct 2021 for this study 30 patients who were diagnosed clinically and radiologically as a case of Chronic Osteomyelitis are participating in this study. The risk factors for Chronic Osteomyelitis were obtained from patient case sheets with the help of orthopedic surgeons in the department of orthopedic RSDKSGMC and Hospital.In this study, the total number of cases Chronic Osteomyelitis considered was 30.with age group of 1-60 years and both the sexs. Conclusion: Chronic osteomyelitis is a chronic disease that affects the long bones, particularly the femur and tibia, and is most common in adults. Haematogenous Osteomyelitis is becoming less common as antibiotics become more widely available and children's growing bones have a higher vascular metaphysis.

A case report on rare case of chronic osteomyelitis of the distal fibula in adult

<p>Osteomyelitis of the fibula is uncommon. It can occur secondary to trauma however it can also occur as a result of haematogenous spread from distant sites of infection. There is usually a period of sub clinical infection and this can lead to delay in diagnosis. But it is clinical diagnosis with support of various investigation with proper surgical technique and various differential diagnosis it is treated with good satisfactory result. A 24-year-female was asymptomatic but for last 6 days She started developing pain, swelling and redness of skin from lateral aspect of distal third of leg. We investigated and did incision and pus drainage with abnormal tissue was excised out, but very unusual presentation intraoperative pus and tissue debris was there. However, after biopsy, it was diagnosed pyogenic osteomyelitis 2 weeks of injectable and 6 weeks of oral antibiotics were given. After 4-6 weeks weight bearing was started, the patient returned to his obvious activities with normal range of motion. The osteomyelitis of fibula with various differential diagnosis clinically and intraoperatively with pus discharge but after proper debridement and biopsy report probable diagnosis is made with proper duration of antibiotic treatment chronic osteomyelitis is treated with satisfactory result with good outcome.</p>

Clinical study on orthopaedic treatment of chronic osteomyelitis with soft tissue defect in adults.

To investigate the clinical application value of different flap transfer and repair techniques in adult patients with chronic osteomyelitis of limbs complicated with soft tissue defects. According to the characteristics and defects of 21 cases, different plastic surgery was applied, including debridement, negative pressure device, and tissue flap to cover wound. Among 21 cases of chronic osteomyelitis complicated with local soft tissue defect, 15 patients were repaired with sural neurotrophic musculocutaneous flap transfer, 2 patients were repaired with medial plantar skin flap transfer, 2 patients were repaired with ilioinguinal skin flap transfer, 1 patient was repaired with z‐forming wound, and 1 patient was repaired with soleus muscle flap combined with full‐thickness skin graft. All the 21 patients underwent bone cement implantation after dead bone osteotomy. Among them, 19 patients underwent bone cement replacement with 3D prosthesis within 6 months to 1 year after surgery, and 2 patients carried bone cement for a long time. Early intervention, thorough debridement, removal of necrotic or infection, and then selecting the appropriate wound skin flap coverage are important means of guarantee slow osteomyelitis wound healing and for providing a possible way to permanent prosthesis implantation subsequently.

Chronic Osteomyelitis of Ilium in a Female Health Care Worker – A Case Report

Introduction: Osteomyelitis is the infection of bone that is characterized by progressive inflammatory destruction with appositioning of new bone. Pelvic osteomyelitis is often an unusual condition but accounts for approximately 1% to 11% cases of haematogenous osteomyelitis (2). The most common location is the ilium due its larger size and abundant blood supply and hematopoetic marrow. The average age of onset tends to be between 7 and 14 years, with a slight male preponderance (2). Mechanism of spread of iliac osteomyelitis can be hematogenous, contiguous or direct inoculation due surgical contamination or open fractures. Case report: Here is a 21 year old female health care worker student presented with pain in right Iliac region and difficulty in walking and inability to bear weight since last 18 months. She is a case of Chronic Osteomyelitis where Debridement was performed previously and now Patient also had recurred complaints of on and off Discharge from the site of previous Operated scar site. Patient was operated for Right Iliac Debridement and saucerization. Patient was mobilized and there was relief of symptoms. Conclusion: As is clear by our case here, osteomyelitis can recur even after the conservative Antibiotic and conventional chemotherapeutic regimen for TB along with surgical management. Surgical management of debridement and Saucerization gives better outcomes to perform activities of daily living, and also to decrease the disease load so as to provide symptomatic relief to the patient and helps in recovery. Surgical management acts as an adjuvant to the chemotherapy which obviously remains the mainstay of treatment in reducing the acute symptoms of the patient thus improving the quality of life.

Випадок хронічного остеомієліту ключиці з гіперостозною реакцією при переломі

Наведено випадок хронічного остеомієліту ключиці з гіперостозною реакцією при незрощеному переломі у пацієнта віком 21 рік. Прооперований в ургентному порядку 2,5 міс. назад у травматологічному відділенні за місцем проживання. Проведено остеосинтез відламків лівої ключиці інтрамедулярним стрижнем. Протягом 1 міс. функціонувала нориця. При надходженні до лікарні встановлено діагноз «хронічний остеомієліт лівої ключиці із вираженою гіперостозною реакцією, норицева форма, активна фаза; незрощений перелом лівої ключиці, стан після остеосинтезу інтрамедулярним стрижнем». Нами була виконана операція видалення стержня з правої ключиці, санація некротизованих тканин та остеосинтез відламків стрижневим апаратом зовнішньої фіксації. Після операції проведено курс внутрішньовенної (в/в) антибактеріальної терапії: зинацеф 1500 г в/в краплинно одноразово, а у подальшому 750 г внутрішньом’язово 3 р/д 5 днів, метрогіл 100,0 в/в краплинно 3 р/д 5 днів. Післяопераційна рана загоїлась первинним натягом. Нориця закрилась. Через 6 міс. спостерігалось повне зрощення. Апарат зовнішньої фіксації демонтовано. Видужання.

“A Retrospective Comparative Study between Muscle Flaps and Fasciocutaneous Flaps in Reconstruction of chronic Osteomyelitis Related Wounds of the lower limb in the adult population”

Introduction: Chronic osteomyelitis cases are challenging, as they require a multidisciplinary approach for reconstructive soft tissue coverage and orthopedic management. Proper debridement, stable coverage and effective antibiotic therapy are mandatory before application of flap coverage.Patients and methods: We performed a retrospective comparative study between muscle and fasciocutaneous flaps used for coverage of chronic osteomyelitis related wounds of the lower limb. It included thirty patients who finished a 12 months of follow up to assess the complications rate and the outcome of surgery. Color match, texture match and aesthetic satisfaction were compared between the 2 groups.Results: Thirty-one flaps including six free flaps and twenty-five local flaps were used to treat these cases. Complications included fluid collections in one case, sinus formation in two 2 cases, partial flap loss in one case. These complications were managed by prolonged antibiotic therapy and dressing changes. Cases in group B had higher scores (mean: 9.5 +/- 1.34) in comparison with cases in group A (mean: 7.25+/- 1.29). Yet, there were no statistically significant differences between the 2 groups (P-value: 0.27).Conclusion: A multidisciplinary team is needed for management of cases with chronic osteomyelitis related wounds. Flap coverage can be achieved with either muscular or fasciocutaneous flaps with comparable successful rates.

Antibiogram profiles and efficacy of antibiotic regimens of bacterial isolates from chronic osteomyelitis of the appendicular skeleton: A developing-world perspective

Background. Empirical antibiotic strategies in the treatment of chronic osteomyelitis should ideally be based on local microbiological antibiograms. Objectives. To review the antibiogram profiles of bacterial isolates of patients undergoing surgical treatment for chronic osteomyelitis and identify the most appropriate empirical antibiotic strategy. Methods. A retrospective review of clinical records and microbial culture reports was performed for all patients who underwent treatment for chronic osteomyelitis at two orthopaedic units in Western Cape Province, South Africa, between March 2016 and December 2019. Reported antibiotic susceptibility data were used to predict the potential efficacy of different empirical antibiotic regimens, according to underlying aetiology (fracture related, contiguous, haematogenous). Results. Two hundred patients with chronic osteomyelitis of the appendicular skeleton underwent surgical management. Antibiogram profiles for 218 organisms, isolated from 169 patients, were evaluated. Staphylococcus aureus (41%) and Enterobacterales (30%) were the most common organisms isolated. The combinations of meropenem plus vancomycin, and piperacillin-tazobactam plus amikacin plus vancomycin, as empirical postoperative antibiotics would both effectively treat 78% of chronic osteomyelitis cases overall. The most effective practical oral combinations were co-amoxiclav plus ciprofloxacin (61%) and co-trimoxazole plus ciprofloxacin (61%). Conclusions. This study reports antibiogram profiles in the developing-world setting that could potentially guide empirical antibiotic choices in the management of chronic osteomyelitis.

Treatment of maxillary osteomyelitis after facial trauma

Osteomyelitis is an inflammatory condition in the medullary spaces or the cortical surface of bones. It can be acute or chronic and extend beyond the original site. Also, it can be caused by several factors, among them as a result of untreated dental trauma. Correct diagnosis and individualized treatment are essential for success. The aim is to report a case of chronic osteomyelitis due to a history of dental trauma in the anterior region of the maxilla in a 21-years-old patient without associated comorbidities, focusing on the success of the therapy employed. It is known that the treatment of osteomyelitis is still a challenge because of the microbiota present. The treatment recommended with higher success rates is the removal of bone sequestration associated with antibiotic therapy, which has shown satisfactory results and maintenance of the dental elements in function.

Biological analysis of an innovative biodegradable antibiotic eluting bioactive glass/gypsum composite bone cement for treating experimental chronic MRSA osteomyelitis

A multi-barrier antibiotics loaded biodegradable composite bone cement for resolving chronic osteomyelitis has been studied to understand the physico-mechanical properties, drug loading/eluting efficiency, and different merits and demerits prior to clinical application. After successful induction of bone infection in 28 rabbits using methicillin-resistant Staphylococcus aureus (MRSA) strains, calcium sulfate/bioactive glass based composite cement was implanted in 12 defects to assess its performance over parenteral therapy with microscopic and radiological examination for 90 days. The composite cement revealed acceptable physico-mechanical properties and controlled drug elution kinetics. Furthermore, the antibiotics concentrations in bone up to 42 days were sufficient to kill MRSA without eliciting adverse drug reactions. The striking feature of platelets aggregation by composite cement could assist bone healing. The controlled degradation with simultaneous entrapment of composite cement within the osteoid tissues and complete repair of infected cortical defects (holes) in rabbit tibia at 6 weeks indicated the excellent anti-infective and osteoconductive properties of composite cement. Thus, the animal study demonstrated the superiority of composite over injectable antibiotic therapy based on infection resolution and bone regeneration. We thereby conclude that the composite cement can be effectively applied in the treatment of resistant cases of chronic osteomyelitis.

Ozonated water lavage and physiological saline irrigation combined with vacuum-sealed drainage in the treatment of 18 cases of chronic osteomyelitis.

ObjectiveOzone is a colorless gas used as a disinfectant and to treat diseases by limiting the effects of bacteria, viruses, fungi, yeast, and protozoa. In this study, we investigated the clinical efficacy of ozonated water lavage and physiological saline irrigation combined with vacuum-sealed drainage (VSD) in the treatment of chronic osteomyelitis.MethodsEighteen patients (14 men and 4 women) with chronic osteomyelitis in the limbs (tibia: 13 cases; femur: 4 cases; humerus: 1 case) admitted to our hospital between April 2012 and October 2018 were selected. The patients were aged 9 to 52 years, with a mean age of 31 years. All patients underwent ozonated water lavage and physiological saline irrigation combined with VSD negative pressure closed drainage during hospitalization. The patients were followed up for 18 to 84 months, with a mean of 31 months.ResultsOsteomyelitis recurred in only one case of nonunion. The length of hospitalization was 18 to 29 days, with a mean of 21 days.ConclusionsA combination of ozonated water lavage, physiological saline irrigation, and VSD provided good clinical effects in the treatment of chronic osteomyelitis, and thus, is recommended for such treatment.

Long Term Evaluation of Radiographically Undetected Acute Osteomyelitis Resulting Chronic Osteomyelitis with MRSA

Osteomyelitis is an infection and inflammation of the bone that can spread into all parts of the bone. Methicillin-resistant Staphylococcus aureus or MRSA made the disease’s management far more complex and constrained and 28% of hospitals in Indonesia are suspected to be MRSA endemic. Osteomyelitis combined with MRSA have obscured prognosis knowing its assessment and management are still being developed.
 Presenting a case of Chronic Osteomyelitis and MRSA of 11-year old girl that has been monitored for 5 years after the reported onset since July 2015.
 The patient complained of severe pain in the left hip region causing her to stop using her left limb in July 2015. Signs of acute osteomyelitis couldn’t be confirmed by sequential assessments of X-Ray and USG examination. Cefazolin and Gentamicin injections were administered for 23 days. The family requested the patient to be sent home, due to no significant clinical improvement as indicated by them. Antibiotic regimens changed into oral regimens, which were Co-Amoxiclav and Gentamicin. The patient never appeared for routine check-up, her family conceded that they went to traditional alternative medication and stated the patient's clinical outcomes were showing signs of improvement; where the patient was able to walk normally. 6 months after, the patient's mother observed abnormal gait, however the patient didn't mention nor complain anything. X-ray assessment was then performed, with the result of the entire left femoral head being reportedly destroyed. In January 2016 the patient was referred to dr. Soetomo Academic General Hospital, the patient was diagnosed with chronic osteomyelitis and pathological fracture of 1/3 proximal left femur with a suspicion of avascular necrosis.
 
 The patient was given prophylactics antibiotics. Closed biopsy couldn't be performed hence open biopsy was suggested. The patient had routine check-ups to monitor the disease progression, alongside radiologic assessment and laboratory assessment prior to the operation. Episodes of localised swollen and tenderness in the hip area were accounted. Scenes of seropurulent discharges were additionally reported. In june 2017 patients had surgical debridement and sequestrectomy alongside an open biopsy, where MRSA was diagnosed. No antibiotics had been given after the surgery and the patient routinely washed up with Chlorhexidine Gluconate 4%. The patient still does routine check-ups at the outpatient facility, as radiologic and laboratory examination are routinely observed.
 As of now, the patient has no issue in its daily living activities. There is still limited range of movement at the infected site, with 90 degree of hip flexion and constrained internal rotation. A lower limb length discrepancy is present due to local growth aggravation at the left hip, currently patient using shoe with lift modifications on her left leg. In any case, there has been no complaint of pain, swollen or seropurulent releases throughout the last 18 months