Open Journal of Orthopedics, 2013, 3, 306-310
Published Online November 2013 (http://www.scirp.org/journal/ojo)
http://dx.doi.org/10.4236/ojo.2013.37056
Open Access OJO
Billateral Femoral Osteomyelitis Following Venous
Cutdown
Gbenga Muyiwa Akinsorotan1, Samuel Uwale Eyesan1*, Dike Chijoke Obalum2,
Joseph Chinedum Itie3, Chukwudi Benjamin Aroh1, Afolabi Benjamin Abiodun1
1Bowen University Teaching Hospital, Ogbomoso, Nigeria; 2State House Clinic, Abuja, Nigeria; 3Ladoke Akintola University of
Technology (LAUTECH) Teaching Hospital, Ogbomoso, Nigeria.
[e-mail], [e-mail]
Received September 10th, 2013; revised October 15th, 2013; accepted October 28th, 2013
Copyright © 2013 Gbenga Muyiwa Akinsorotan et al. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
Obtaining rapid access in emergency situations for infusion of IV fluids, blood and blood products or medications is
vital in using various methods. These include venopuncture, intraosseous infusion, percutanous central venous access
and peripheral venou s cut-down. We repor t a case of a 30-year-old woman who dev eloped severe obstetr ic hemorrhage
and had peripheral venous cut-down that was complicated by bilateral femoral osteomyelitis. This is a rare occurrence
and this case report shows the need for strict adherence to safety precautions to prevent complications such as that from
the procedure.
Keywords: Bilateral; Femoral; Osteomyelitis; Venous Cut-Down
1. Introduction
A venous cut-down is one of the methods of gaining ac-
cess to the circulation in a patient in whom direct ve-
nepuncture is difficult. Thus alternative routes must be
sought to obtain rapid access in emergency situations for
the purpose of infusing fluids, blood and blood products,
or medications [1]. These include intraosseous infusion,
percutaneous central venous access, and peripheral ve-
nous cut-down. Although the venous cut-down has
largely been replaced by over-the-wire percutaneous
catheters (Seldinger’s technique) [2], it remains an ex-
cellent alternative when other approaches have failed [1].
This invasive procedure has its attendant risks which
include inadvertent injury to blood vessel and associated
structures, cellulitis, haematoma, thrombophlebitis, ve-
nous thrombosis [3]. Though osteomyelitis rarely com-
plicates venous cut-down, this case report illustrates that
it can occur. Bilateral femoral osteomyelitis from a ve-
nous cut-down is rarer still.
2. Case Report
At a government hospital, a 30 year old woman had pre-
sented with severe episode of bleeding per vagina fol-
lowing delivery and subsequent loss of consciousness.
Efforts at securing intravenous access for resuscitation
using percutaneous venepunture were difficult hence a
saphenous vein cut-down was done on her left leg. She
was resuscitated with intravenous fluids and blood prod-
ucts. Curettage was done to remove retained products.
Haemostasis was achieved; however, the cut-down site
became swollen and extremely painful by the second day
of its insertion. The catheter was only removed on the
fourth day. The patient subsequently developed pain in
the left thigh a week later. The cut-down site wo und also
broke down to leave an ulcer on the leg. She was given
various oral and parenteral analgesics for the pain until
she was discharged home.
Her pre-morbid state was not remarkable. There was
no prior history of blood transfusion. She is no t a known
hypertensive, diabetes or sickle cell disease patient.
Pregnancy lasted for 38 weeks and was uneventful. She
was only on haematini cs duri ng pregnancy.
The patient persistently complained of severe throb-
bing pain in the left lower limb with associated difficulty
in walking which lasted for about 4 weeks before pre-
senting at our orthopaedic clinic. She was neither febrile,
*Corresponding a uthor.

Billateral Femoral Osteomyelitis Following Venous Cutdown 307
nor icteric on examination. There was an ulcer in the
antero-medial aspect of the left leg just above the left
ankle (previous cut-down site) measuring 4 cm × 5 cm
(Figure 1). The neurovascular status of both legs was
normal. There was also a markedly tender swelling in the
distal third of the left thigh, with differential warmth. A
presumptive diagnosis of osteomyelitis was made. Plain
X-ray of the left thigh showed a definite sequ estrum with
bone in ‘bone appearance’ (involucrum) in the middle
and lower third of the left femur (Figures 2(a), (b)).
Other laboratory investigation results includ e haematocrit
which was 35%; total WBC 7500/mm3 (Neut: 38%,
Lymph: 68%). HIV screening was negative. Blood group
was B Rh positive. Haemoglobin genotype was AA.
Test aspiration of the left thigh swelling yielded pus,
and she went on to have trephination of the left femur.
About 200 mls of pus was evacuated from the marrow
and a sample sent for microscopy, culture and sen sitivity.
She was placed empirically on intravenous Ciprofloxacin
(200 mg) every 12 h and intravenous Ampiclox (1 g)
every 6 h. The wound was then dressed daily with nor-
mal saline. Patient became pain-free following the pro-
cedure.
Result of culture yielded heavy growth of Escherichia
coli sensitive to Gentamycin and Chloramphenicol; re-
sistant to Augmentin, Ampicillin, Ciprofloxacin, Per-
floxacin, Ofloxacin, Cefuroxime and Ceftriaxone.
The drugs were changed according to the culture result.
She received intravenous chloramphenicol and gentamy-
cin which she had for two weeks. It was then continued
as oral medications for the next four weeks.
While on admission, she developed throbbing pain in
the right thigh with tenderness on palpation of the distal
aspect of the right femur. There was associated fever.
Test aspiration done at the point of maximum tenderness
was negative. The following investigations were done:
haematocrit 38%, WBC 9700 cells/mm3 (Neut: 59%,
Lymph: 38%, Eos: 03%), ESR: 122 mm/hr. Plain X-ray
Figure 1. The venous cut-down site on the left leg.
(a)
(b)
Figure 2. a: Plane X Ray of the Left Thigh: Lateral view
showing ‘bone in bone appearance’ (sequestrum). b: Plane
X Ray of the Left Thigh: AP view.
Open Access OJO

Billateral Femoral Osteomyelitis Following Venous Cutdown 308
of the right thigh was done which showed early se-
questrum formation (Figures 3(a), (b)).Trephination was
again done on the right femur with drainage of 100 ml of
pus from the marrow with subsequent relieve of the pain.
Culture yielded Escherichia coli with the same pattern of
sensitivity and resistance. Blood culture however was
negative. The patient was discharged to follow-up clinic
after four weeks on admission.
During this period the left thigh incision wound still
discharged purulent fluid while that of the right thigh had
healed. The venous cut-down site on the left leg had
healed completely. The patient also had acute episodes of
fever and pain whenever the chronic discharging sinus on
the left thigh was quiescent. She began ambulation using
bilateral axillary crutches for a period of eight (8) weeks
and then went on to partial weight bearing with a left arm
crutch. The range of motion (ROM) for the right knee
was 0˚ - 120˚ and the left knee; 0˚ - 110˚. She is still on
follow-up visits.
(a)
(b)
Figure 3. a: Plane X Ray of the Right Thigh: lateral View
showing early sequestrum formation. b: Plane X Ray of the
Right Thigh: AP view.
3. Discussion
The use of venous cut-down to obtain access to the cir-
culation could be the last resort in patients who are criti-
cally ill and in whom percutaneous venepunctu re may be
difficult [4]. Examples include patients in shock, paediat-
ric age group, sclerosed veins of intravenous drug abus-
ers.
The most preferred cut-down access site is the
saphenous vein above the medial malleolus of the tibia,
but antecubital, axillary, cephalic and femoral veins are
also suitable [5]. The skin over it is prepared with anti-
septic solution and draped. Local anaesthesia using 1%
lidocaine with or without epinephrine is applied. Via a
2.5 cm transverse incision on the skin, the vein is dis-
sected bluntly from its bed using a curved haemostat to a
length of 2 cm. Sutures are passed inferiorly and the ex-
posed vein is ligated distally, with the free end used for
traction. A careful transverse venotomy is then done us-
ing a scalpel no more than half the diameter of the vein.
A plastic catheter (usually > 14 ga) is introduced into the
vein and it is secured with a proximal suture. The skin
incision is closed with interrupted sutures. Intravenous
tubing is attached to the catheter and a sterile dressing is
applied.
Careful attention to the cut down site, by daily sterile
dressing is mandatory, particularly in the lower extremi-
ties, in view of the increased susceptibility to infections.
If any sign of infection at the site is identified the cathe-
ter has to be promptly withdrawn. Strict asepsis is im-
portant as well as avoiding long duration of procedure.
The usual time to achieve venous cut-down by paedi-
atric surgeons was reported as 6 minutes in children aged
6 - 16 years, 8 minutes in those aged 1 month to 5 years,
and 11 minutes in neonates [6]. This time delay makes its
use unrealistic for most clinicians, and intraosseous or
percutaneous femoral access can be achieved more rap-
idly [7,8].
This invasive procedure can be complicated by cellu-
litis, haematoma formation, thrombophlebitis, venous
thrombosis, injury to vessel and other associated struc-
tures. These complications can be minimized by meticu-
lous technique, with atten tion to proper site selection and
catheter care.
The incidence of osteomyelitis from venous cut-down
is not stated in the literature; however the incidence of
osteomyelitis occurring from intraosseus infusion is 0.6%.
The incidence in children with osteomyelitis that pre-
sented to a teaching hospital over a four year period was
24 cases/year [9], while in another retrospective study an
average of 19 cases of chronic osteomyelitis presented
yearly [10]. Often times the presentation is late making
the infection deeply seated within the affected bone [11].
The commonest sites of chronic osteomyelitis have
been noted in the femur and tibia in various studies
Open Access OJO

Billateral Femoral Osteomyelitis Following Venous Cutdown 309
[10,12,13]. The o ccurrence of multiple bone inv olvement
is noted to be common especially in patients with sickle
cell anaemia [10,14,15,17,18], although a review of
chronic osteomyelitis by Nwadiaro et al. observed the
converse to be true in Jos, Nigeria [16]. Other researchers
have also noted osteomyelitis involving multiple sites. A
case of multiple bone and joint diseases in a 20 year old
male, Nigerian with sickle cell disease was reported by
Olaniyi et al. He developed avascular necrosis (AVN) of
the bilateral femoral and right humeral heads, bilateral
femoral and left humeral chronic osteomyelitis and fixed
flexion deformities of both hips and left shoulder joints,
following a painful vaso-occlusive crisis [14].
Ransool reviewed a series of eight children with bilat-
eral pyogenic osteomyelitis and observed four cases in-
volved the femurs, two cases involved the tibia and one
case each involving the calcaneum and the clavicle [22].
Picillio et al. also reported a case of femoral osteomye-
litis with knee osteoarthritis due to Salmonella enteritidis
in a female patient being managed for long standing sys-
temic lupus erythematosus (SLE) with cytotoxics and
corticosteroids [22]. The aetiological agent found in our
case was E. coli, although the common aetiological agent
has been noted to be Staphylococcus aureus [9,10,13,
19,20]. Infection from gram negative organisms is also
common [9,10,15,19,20].
Treatment modality employed for this patient was
trephination of the affected bones. Other adjunctive mo-
dalities that have been added to this include the use of
hyperbaric oxygen, antibiotic beads, pulsed electromag-
netic fields/ultrasound , biofilm microbiology and platelet
rich plasma [21]. Information on the efficacy of these
methods is limited. However they have been found to
enhance bone healing and control infection by promoting
the bactericidal activity of neutrophils, suppressing an-
aerobic organisms, promoting angiogenesis, collagen
synthesis, osteogenesis and increasing vascularity [21].
Major complications that may arise from chronic os-
teomyelitis observed in the case series by Nwadiaro et al.
are persistent drainage, recurrence, limb length discrep-
ancy, severe osteoarthritis and pathological fracture [10].
In our case, there was only persistent drainage of the left
thigh sinus associated with relapse of pain in the left fe-
mur and fever which then resolves as the sinus becomes
active. The reduction in the ROM is not severe as to af-
fect her gait.
4. Conclusion
We have presented this case to show that osteomyelitis
can complicate a venous cut-down and the bilateral os-
teomyelitis of the femur which is a rare occurrence that
can result from the procedure. It is also advisable to take
the necessary precautions that would prevent this com-
plication. Early detection and prompt commencement of
treatment of acute osteomyelitis would also prevent it
from progressing to chronic infection.
REFERENCES
[1] S. Chappell, G. M. Vilke, T. C. Chan, R. A. Harrigan and
J. W. Ufberg, “Peripheral Venous Cutdown,” The Journal
of Emergency Medicine, Vol. 31, No. 4, 2006, pp. 411-
416. http://dx.doi.org/10.1016/j.jemermed.2006.05.026
[2] J. M. Boon, A. N. van Schoor, P. H. Abrahams, J. H.
Meiring, T. Welch and D. Shanahan, “Central Venous
Catheterization. An Anatomical Review of a Clinical
Skill,” Clinical Anatomy, Vol. 20, No. 6, 2007, pp. 602-
611. http://dx.doi.org/10.1002/ca.20486
[3] B. B. McIntosh and S. A. Dulchavsky, “Peripheral Vas-
cular Cutdown,” Critical Care Clinics, Vol. 8, 1992, pp.
807-818.
[4] A. H. Nikolaus, “Clinical Review: Vascular Access for
Fluid Infusion in Children,” Critical Care, Vol. 8, No. 6,
2004, pp. 478-484. http://dx.doi.org/10.1186/cc2880
[5] N. Kissoon and T. C. Frewen, “Pediatric Venous Cut-
downs: Utility in Emergency Situations,” Pediatric Emer-
gency Care, Vol. 3, No. 3, 1987, p. 218.
http://dx.doi.org/10.1097/00006565-198709000-00022
[6] K. V. Iserson and E. A. Criss, “Pediatric Venous Cut-
downs: Utility in Emergency Situations,” Pediatric Emer-
gency Care, Vol. 2, 1986, pp. 231-234.
http://dx.doi.org/10.1097/00006565-198612000-00006
[7] R. K. Kanter, J. J. Zimmerman, R. H. Strauss and K. A.
Stoeckel, “Pediatric Emergency Intravenous Access.
Evaluation of a Protocol,” American Journal of Diseases
of Children, Vol. 140, No. 2, 1986, pp. 132-134.
[8] M. D. Westfall , K. R. Price, M. Lambert, R. Himmelman,
D. Kacey, S. Dorevitch and J. Mathews, “Intravenous
Access in the Critically Ill Trauma Patient: A Multicen-
tered, Prospective, Randomized Trial of Saphenous Cut-
down and Percutaneous Femoral Access,” Annals of
Emergency Medicine, Vol. 23, No. 3, 1994, pp. 541-545.
http://dx.doi.org/10.1016/S0196-0644(94)70074-5
[9] E. O. Okoroma and D. C. Agbo, “Childhood Osteomye-
litis: A Five-Year Analysis of 118 Cases in Nigerian
Children,” Clinical Pediatrics, Vol. 23, No. 10, 1984, pp.
548-552.
[10] C. H. Nwadiaro, J. N. Legbo, G. O. Igun and B. T. Ugwu,
“Perspective of Chronic Osteomyelitis,” Nigerian Journal
of Surgical Sciences, Vol. 10, No. 1, 2000, pp. 18-21.
[11] K. Pande and K. G. Mamman, “Complications of In-
traosseous Infusion,” Brunei International Medical Jour-
nal, Vol. 7, No. 3, 2011, p. 237.
[12] S. B. Agaja and R. O. Ayorinde, “Chronic osteomyelitis
in Ilorin, Nigeria,” South African Journal of Surgery, Vol.
46, No. 4, 2008, pp. 116-118.
[13] D. O. Ogunjumo, “The Clinical Pattern of Chronic Pyo-
genic Osteomyelitis in a Nigerian Community,” The
American Journal of Tropical Medicine and Hygiene, Vol.
85, 1982, pp. 187-194.
[14] J. A. Olaniyi, A. E. Alagbe, T. A. Olutoogun and O. E.
Open Access OJO

Billateral Femoral Osteomyelitis Following Venous Cutdown
Open Access OJO
310
Busari, “Multiple Bone and Joint Diseases in Nigerian
Sickle Cell Anaemia: A Case Report,” Mediterranean
Journal of Hematology and Infectious Diseases, Vol. 4,
No. 1, 2012, Article ID: e20120.
[15] W. W. Ebong and G. A. Oyemade, “Acute Haematoge-
nous Osteomyelitis in Nigeria,” Tropical and Geo-
graphical Medicine, Vol. 30, No. 4, 1978, pp. 451-461.
[16] C. H. Nwadiaro, J. N. Legbo and B. T. Ugwu, “Chronic
Osteomyelitis in Patients with Sickle Cell Disease,” East
African Medical Journal, Vol. 77, No. 1, 2000, pp. 23-26.
[17] L. D. Givner, R. E. Luddy and A. D. Schwartz, “Aetiol-
ogy of Osteomyelitis in Patients with Major Sickle
Haemoglobinopathies,” Journal of Pediatrics, Vol. 99,
No. 3, 1981, pp. 411-413.
http://dx.doi.org/10.1016/S0022-3476(81)80330-7
[18] L. W. Diggs, “Bone and Joint lesions in Sickle Cell Dis-
ease,” Clinical Orthopaedics and Related Research, Vol.
52, 1967, pp. 119-143.
http://dx.doi.org/10.1097/00003086-196700520-00011
[19] D. P. Lew and F. A. Waldvogel, “Osteomyelitis,” Lancet,
Vol. 364, No. 9431, 2004, pp. 369-379.
http://dx.doi.org/10.1016/S0140-6736(04)16727-5
[20] J. H. Calhoun and M. M. Manring, “Adult Osteomye-
litis,” Infectious Disease Clinics of North America, Vol.
19, No. 4, 2005, pp. 765-786.
http://dx.doi.org/10.1016/j.idc.2005.07.009
[21] R. C. Fang and R. D. Galiano, “Adjunctive Therapies in
the Treatment of Osteomyelitis,” Seminars in Plastic
Surgery, Vol. 23, No. 2, 2009, pp. 141-147.
http://dx.doi.org/10.1055/s-0029-1214166
[22] M. N. Ransool, “Acute Bilateral Symmetrical Pyogenic
Osteomyelitis in Children,” The Bone & Joint Journal,
Vol. 87, 2005, p. 279.