Int J Colorectal Dis DOI 10.1007/s00384-015-2184-z
LETTER TO THE EDITOR
Osteomyelitis as a complication of a pilonidal sinus KJ Gordon 1,2 & TM Hunt 1
Accepted: 8 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: A 17-year-old, fit and healthy, non-smoking male drama student was referred to our outpatient clinic by his GP. He presented with a 4-month history of a spontaneously occurring sinus with an odorous discharge. On examination, there was a grossly infected pilonidal sinus, which was open and contained multiple hairs. Two small pits were present proximally. His inflammatory markers were normal. He was given a daycase theatre appointment for an examination under anaesthesia (EUA) 2 weeks later, which he postponed. Three weeks later, the pilonidal sinus was excised, curettaged and packed with Aquacel® ribbon gauze in one of several accepted primary treatment modalities. Following review at 3 and 5 months post surgery, there was a slowhealing persistent defect; the base of which was granulating and once again contained multiple hairs. A second EUA showed dirty granulation tissue in the wound. The surrounding area was shaved, and the wound was debrided down to the coccyx and packed. The cavity extended down to the coccyx, and the procedure was performed under antibiotic cover. One month later, there was healthy granulation tissue within a more comfortable 5-cm wound. The surrounding skin was shaved to remove hairs. However, little progress occurred subsequently, and the wound became tender once again.
* KJ Gordon [email protected] 1
Consultant Colorectal Surgeon, Royal Shrewsbury Hospital, SY3 8XQ Shropshire, UK
2
Urology Specialty Registrar, Royal London Hospital, E1 1BB London, UK
A third EUA was carried out 8 months after the initial surgery, in part because of the undue level of pain and tenderness the patient was experiencing. There was a persistent 5-cm defect remaining down to the coccyx. The wound was again currettaged clean and the surrounding area shaved. The coccyx felt slightly irregular at operation. There was some initial improvement, but at outpatient review 8 weeks after the latest EUA, now approaching 10 months from his initial surgery, despite a reduction in the defect size, it had become extremely painful again. With a high index of clinical suspicion for osteomyelitis, we performed a limited computerised tomography (CT) scan of the sacrum and coccyx. This demonstrated cortical loss of the bone and overlying soft tissue fluid at the posterior 2nd +/− 3rd coccygeal segment. The CT findings prompted an orthopaedic referral, and a subsequent magnetic resonance imaging (MRI) also supported the diagnosis of coccygeal osteomyelitis. Treatment with a prolonged course of antibiotics failed to achieve significant improvement, and eventually, a coccygectomy with primary wound closure was carried out 8 months after orthopaedic referral, now 18 months after the first treatment. The patient was referred back to the original surgical team once again 3 months later. Although much more comfortable, there was still a 1-cm persistent wound defect and discharge. A further MRI demonstrated a continued collection deep into the sacrum which communicated with the skin defect and contained locules of gas. A 7×3 cm cavity was laid open yet again at day surgery, and tenacious granulation tissue was curetted clean and the wound packed. There were no further hairs present on this occasion. There was no suggestion of any further osteomyelitis in the sacrum. On two further clinic reviews, the wound was failing to progress and there remained a 5-cm defect. A trial of silver nitrate had little effect, and negative pressure therapy initiated in the community was not tolerated. The patient deferred entry to drama school for the second time.
Int J Colorectal Dis
A plastic surgical opinion was sought, and the decision was taken to perform a debridement, washout and perforator propeller flap reconstruction. This was performed 3 years and 3 months after his presentation. At follow-up at 2 and 4 months after the latest surgery, the wound appears to have finally healed completely.
Discussion Pilonidal disease is common and complex. In England alone in 2000–2001, the Department of Health recorded a total of 11,534 admissions due to pilonidal disease [1]. Pilonidal sinus in the sacrococcygeal region usually presents as an abscess or a chronically discharging painful sinus tract. The ideal treatment would be a cure that returns the patient to normal activity with minimal morbidity and low risk of complications. The choice of surgical approach also depends on the surgeons’ familiarity with the procedure and the result. There are many different surgical approaches to pilonidal sinus surgery, including excision and primary midline closure, Bascom’s procedure (pit excision with a lateral draining incision), the Karydakis procedure, or a skin flap to aim to avoid a midline sutured wound. Primary closure may heal more quickly than laying the wound open if all goes well but at the expense of a higher recurrence rate [2]. A common approach is to excise the pilonidal sinus and leave an open wound with the aim of healing by secondary intention. This then requires wound management and usually repeated shaving of the surrounding area during healing, which may be prolonged. A comprehensive literature search undertaken by Thompson et al. [3] reviewed studies from 1980 to 2010 for the preferred surgical approach to pilonidal sinus disease. Simple removal of midline pits, the primary cause of pilonidal disease, is effective in most cases, with some requiring lateral drainage of any abscesses or sinuses. Persistent or recurrent disease with poor healing midline wounds may require repeated surgery. These measures can be performed as daycase
procedures and are associated with fast recovery rates and rapid return to work if there is an uncomplicated recovery. We chose excision and healing by secondary intention as our method because the wound was significantly infected at presentation. This often leads to slower healing rates. However, osteomyelitis was not expected. Our patient had an unusual degree of pain in his wound which was resistant to healing. This led to difficulty in achieving adequate shaving and dressing of the wound, and the pain and subsequent findings at EUA led to the clinical suspicion of osteomyelitis. Further imaging with CT and then MR confirmed coccygeal osteomyelitis. One case has been documented of a presentation of recurring pilonidal cyst who developed a lumbar osteomyelitis and epidural abscess 3 weeks after a pilonidal cyst excision with epidural anaesthesia [4]. However, we present the first case of coccygeal osteomyelitis as a direct complication of a chronic pilonidal sinus and its treatment in a young male who subsequently required a coccygectomy. Our patient presented with a chronic infected sinus present for 4 months, already at a high risk of protracted healing. We suggest consideration of early CT and/or MR imaging for unduly painful and slow-healing wounds in order to exclude osteomyelitis even in the absence of raised inflammatory markers.
References 1.
2.
3. 4.
Chintapatla S, Safarani N, Kumar S, Haboubi N (2003) Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol 7:3–8 McCallum IJD, King PM, Bruce J (2008) Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and metaanalysis. BMJ 336:868 Thompson MR, Senapati A, Kitchen P (2011) Simple day-case surgery pilonidal sinus disease. Br J Surg 98:198–209 Verdu A, Garcia-Granero E, Garcia-Fuster MJ, Martin A, Millan M, Lledo S (2000) Lumbar osteomyelitis and epidural abscess complicating recurrent pilonidal cyst. Dis Colon Rectum 43(7):1015–17
LETTER TO THE EDITOR
Osteomyelitis as a complication of a pilonidal sinus KJ Gordon 1,2 & TM Hunt 1
Accepted: 8 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: A 17-year-old, fit and healthy, non-smoking male drama student was referred to our outpatient clinic by his GP. He presented with a 4-month history of a spontaneously occurring sinus with an odorous discharge. On examination, there was a grossly infected pilonidal sinus, which was open and contained multiple hairs. Two small pits were present proximally. His inflammatory markers were normal. He was given a daycase theatre appointment for an examination under anaesthesia (EUA) 2 weeks later, which he postponed. Three weeks later, the pilonidal sinus was excised, curettaged and packed with Aquacel® ribbon gauze in one of several accepted primary treatment modalities. Following review at 3 and 5 months post surgery, there was a slowhealing persistent defect; the base of which was granulating and once again contained multiple hairs. A second EUA showed dirty granulation tissue in the wound. The surrounding area was shaved, and the wound was debrided down to the coccyx and packed. The cavity extended down to the coccyx, and the procedure was performed under antibiotic cover. One month later, there was healthy granulation tissue within a more comfortable 5-cm wound. The surrounding skin was shaved to remove hairs. However, little progress occurred subsequently, and the wound became tender once again.
* KJ Gordon [email protected] 1
Consultant Colorectal Surgeon, Royal Shrewsbury Hospital, SY3 8XQ Shropshire, UK
2
Urology Specialty Registrar, Royal London Hospital, E1 1BB London, UK
A third EUA was carried out 8 months after the initial surgery, in part because of the undue level of pain and tenderness the patient was experiencing. There was a persistent 5-cm defect remaining down to the coccyx. The wound was again currettaged clean and the surrounding area shaved. The coccyx felt slightly irregular at operation. There was some initial improvement, but at outpatient review 8 weeks after the latest EUA, now approaching 10 months from his initial surgery, despite a reduction in the defect size, it had become extremely painful again. With a high index of clinical suspicion for osteomyelitis, we performed a limited computerised tomography (CT) scan of the sacrum and coccyx. This demonstrated cortical loss of the bone and overlying soft tissue fluid at the posterior 2nd +/− 3rd coccygeal segment. The CT findings prompted an orthopaedic referral, and a subsequent magnetic resonance imaging (MRI) also supported the diagnosis of coccygeal osteomyelitis. Treatment with a prolonged course of antibiotics failed to achieve significant improvement, and eventually, a coccygectomy with primary wound closure was carried out 8 months after orthopaedic referral, now 18 months after the first treatment. The patient was referred back to the original surgical team once again 3 months later. Although much more comfortable, there was still a 1-cm persistent wound defect and discharge. A further MRI demonstrated a continued collection deep into the sacrum which communicated with the skin defect and contained locules of gas. A 7×3 cm cavity was laid open yet again at day surgery, and tenacious granulation tissue was curetted clean and the wound packed. There were no further hairs present on this occasion. There was no suggestion of any further osteomyelitis in the sacrum. On two further clinic reviews, the wound was failing to progress and there remained a 5-cm defect. A trial of silver nitrate had little effect, and negative pressure therapy initiated in the community was not tolerated. The patient deferred entry to drama school for the second time.
Int J Colorectal Dis
A plastic surgical opinion was sought, and the decision was taken to perform a debridement, washout and perforator propeller flap reconstruction. This was performed 3 years and 3 months after his presentation. At follow-up at 2 and 4 months after the latest surgery, the wound appears to have finally healed completely.
Discussion Pilonidal disease is common and complex. In England alone in 2000–2001, the Department of Health recorded a total of 11,534 admissions due to pilonidal disease [1]. Pilonidal sinus in the sacrococcygeal region usually presents as an abscess or a chronically discharging painful sinus tract. The ideal treatment would be a cure that returns the patient to normal activity with minimal morbidity and low risk of complications. The choice of surgical approach also depends on the surgeons’ familiarity with the procedure and the result. There are many different surgical approaches to pilonidal sinus surgery, including excision and primary midline closure, Bascom’s procedure (pit excision with a lateral draining incision), the Karydakis procedure, or a skin flap to aim to avoid a midline sutured wound. Primary closure may heal more quickly than laying the wound open if all goes well but at the expense of a higher recurrence rate [2]. A common approach is to excise the pilonidal sinus and leave an open wound with the aim of healing by secondary intention. This then requires wound management and usually repeated shaving of the surrounding area during healing, which may be prolonged. A comprehensive literature search undertaken by Thompson et al. [3] reviewed studies from 1980 to 2010 for the preferred surgical approach to pilonidal sinus disease. Simple removal of midline pits, the primary cause of pilonidal disease, is effective in most cases, with some requiring lateral drainage of any abscesses or sinuses. Persistent or recurrent disease with poor healing midline wounds may require repeated surgery. These measures can be performed as daycase
procedures and are associated with fast recovery rates and rapid return to work if there is an uncomplicated recovery. We chose excision and healing by secondary intention as our method because the wound was significantly infected at presentation. This often leads to slower healing rates. However, osteomyelitis was not expected. Our patient had an unusual degree of pain in his wound which was resistant to healing. This led to difficulty in achieving adequate shaving and dressing of the wound, and the pain and subsequent findings at EUA led to the clinical suspicion of osteomyelitis. Further imaging with CT and then MR confirmed coccygeal osteomyelitis. One case has been documented of a presentation of recurring pilonidal cyst who developed a lumbar osteomyelitis and epidural abscess 3 weeks after a pilonidal cyst excision with epidural anaesthesia [4]. However, we present the first case of coccygeal osteomyelitis as a direct complication of a chronic pilonidal sinus and its treatment in a young male who subsequently required a coccygectomy. Our patient presented with a chronic infected sinus present for 4 months, already at a high risk of protracted healing. We suggest consideration of early CT and/or MR imaging for unduly painful and slow-healing wounds in order to exclude osteomyelitis even in the absence of raised inflammatory markers.
References 1.
2.
3. 4.
Chintapatla S, Safarani N, Kumar S, Haboubi N (2003) Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol 7:3–8 McCallum IJD, King PM, Bruce J (2008) Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and metaanalysis. BMJ 336:868 Thompson MR, Senapati A, Kitchen P (2011) Simple day-case surgery pilonidal sinus disease. Br J Surg 98:198–209 Verdu A, Garcia-Granero E, Garcia-Fuster MJ, Martin A, Millan M, Lledo S (2000) Lumbar osteomyelitis and epidural abscess complicating recurrent pilonidal cyst. Dis Colon Rectum 43(7):1015–17
