Amputation for osteomyelitis in a patient with spina bifida
A 51-year-old female with thoracic SB presented to our hospital with fever, pyelonephritis and pneumonia. A vascular surgical opinion was sought as the patient developed recurrent infected pressure ulcers in the right hip, right thigh and right heel with exposed calcaneal bone, and cellulitis of the right leg.

The patient had a problematic medical history secondary to thoracic SB. Her comorbidities included neurological bowel and bladder dysfunction, orthopaedic abnormalities and chronic osteomyelitis. She had a functional level at T12 with paraplegia and mobilized with a wheelchair. Since birth, she had undergone multiple operations including a Girdlestone of the right hip for osteomyelitis secondary to pressure ulceration.

She was hospitalized eight times due to chronic osteomyelitis in her hip and lower limb. She had attended 12 outpatient clinic visits and over 100 primary care visits for the same condition over a 23-year period.

Magnetic resonance imaging and a SPECT-CT (single photon emission computed tomography-CT) were requested which showed osteomyelitis in the bone around the Girdlestone and in the calcaneum. The vascular assessment revealed a normal arterial supply.

She was admitted and treated with intravenous antibiotics; pressure relieving measures for the right hip and thigh; and negative-pressure wound therapy for the right heel. Her condition improved with nearly complete granulation tissue growth in the right heel wound. She was discharged after 29 days with a further 6 weeks of intravenous antibiotics.

Despite intravenous antibiotic treatment, healing remained poor and she suffered from chronic pain. A referral was made to rehabilitation medicine for consideration of leg amputation. Other than minor modifications needed to wheelchair set up, there would be no functional deficit from amputating the limb.

With antibiotic cover and with all other wounds now epithelialized, she underwent a right above knee amputation through a fish mouth incision. The operation was uneventful and the patient was discharged at 5 days with no complications.

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