Bilateral femur osteomyelitis: A rare case with successful outcome

Chronic femoral osteomyelitis with segmental bone loss remains a complex reconstructive challenge, particularly in the setting of failed prior fixation and multidrug-resistant infection. Bilateral femoral involvement is extremely rare and lacks a standardized management algorithm. This report aims to describe a staged, limb-salvage strategy employing different reconstruction techniques for each femur based on defect size, biological potential, and infection status.

A 28 years old male presented with bilateral thigh pain and inability to ambulate three years after bilateral femoral shaft fractures complicated by recurrent surgical site infections and multiple revision surgeries. Clinical, laboratory, and radiological evaluation confirmed chronic bilateral femoral osteomyelitis with significant segmental bone defects, more severe on the right side.

The left femur was managed with aggressive debridement and single-stage stabilization using an antibiotic-coated intramedullary SIGN nail, followed by culture-directed antimicrobial therapy for multidrug-resistant organisms, resulting in radiological union at six months. The right femur required staged reconstruction with debridement and Ilizarov-based distraction osteogenesis. Poor regenerate formation necessitated adjunctive teriparatide therapy, followed by definitive fixation using intramedullary nailing and augmentation with a non-vascularized fibular strut graft. At one-year follow-up, the patient was ambulating independently with bilateral radiological union and no evidence of recurrent infection.

This case illustrates that individualized, staged reconstruction combining infection eradication, mechanical stability, and biological augmentation can achieve successful limb salvage in rare and complex cases of bilateral femoral chronic osteomyelitis.