OT notes · Orthopaedics

Sequestrectomy and saucerisation for chronic osteomyelitis

Usual anaesthesia
Spinal (lower limb) or general
Position
Supine for tibia and femur (lateral or other positions as the site needs); tourniquet if the site allows
Setting
elective

Operative note template for sequestrectomy, curettage and saucerisation of chronic osteomyelitis with dead-space management, with a filled example for chronic osteomyelitis of the tibia treated with a cortical slot and antibiotic cement beads.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • infection may persist or recur; further operations likely
  • fracture of the weakened bone
  • significant bleeding, transfusion
  • wound breakdown; need for flap or skin graft
  • second operation to remove beads or spacer
  • non-union or bone defect needing later reconstruction
  • nerve or vessel injury
  • amputation if infection cannot be controlled
  • DVT

Pre-operative details for this operation

  1. Site, side, duration and historybone and segment; cause (post-traumatic / haematogenous); previous surgery and implants; sinus since when
  2. Cierny-Mader stageanatomic type I-IV and host class A / B (local or systemic) / C
  3. ImagingX-ray (sequestrum, involucrum, periosteal reaction), CT (sequestra), MRI (extent), sinogram if done
  4. Antibiotics stopped before surgerydate stopped (to improve culture yield), unless needed for systemic infection
  5. Host optimisationblood sugar, smoking, nutrition (albumin), renal and liver function
  6. Sinus marked with dyeMethylene blue injected 24 h beforeNot done
  7. Blood arrangedgroup and units; sequestrectomy can bleed
  8. Plastic surgery / stabilisation planflap, external fixator, antibiotic nail if needed

Anaesthesia and position

  1. AnaesthesiaSpinalGeneral
  2. Positionsupine / lateral; bumps
  3. TourniquetNot usedUsedif used, time up and down; the bleeding-bone end point can only be judged after release

Operative findings

  1. Sinus tractsnumber, course, communication with bone
  2. Soft tissuescarring, pus volume and colour, granulation
  3. Bonecloaca, involucrum, sequestra (number, size), extent of dead bone, medullary involvement
  4. Implants foundtype, loose or stable, removed or left
  5. End point of debridementpunctate bleeding from bone (paprika sign) all round the cavity
  6. Bone stability after debridementStableUnstable: stabilised with (method)

Procedure (steps)

  1. Incisionsite and length; planned so sinus tracts are excised and future flap options are kept
  2. Sinus tract excisioncomplete excision down to bone; sent for culture and HPE
  3. Periosteumincised and raised 1.3-2.5 cm each side
  4. Cortical window / slotoval window or longitudinal slot outlined with drill holes (holes at the corners), completed with osteotome; no transverse cuts; size in cm
  5. Sequestrectomynumber and size of sequestra removed
  6. Curettage and burr debridementpus, granulation, scar and dead bone removed with curettes, rongeurs, high-speed burr; sealed medullary cavity opened both ways
  7. Intramedullary debridementNot neededReaming with vent holeReamer-irrigator-aspirator
  8. Saucerisationoverhanging bone edges removed to leave a shallow saucer with no dead space
  9. Implant removalNo implantLoose / non-functioning implant removedStable implant retained (reason)
  10. Culturesnumber of specimens: deep soft tissue, bone, sequestrum, pus; aerobic, anaerobic, fungal, AFB; date antibiotics were stopped and time of the prophylactic dose
  11. Irrigationfluid, volume in litres, method (pulse lavage / gravity)
  12. Dead-space managementAntibiotic PMMA bead chainAbsorbable calcium sulfate antibiotic beadsAntibiotic cement nail / rodMuscle flapOpen (Papineau) grafting laterLeft open / NPWTcement amount, antibiotic and dose per 40 g pack, number of beads on the chain
  13. StabilisationNot neededExternal fixator (type)Antibiotic nailSplint / cast

Closure, drains and dressing

  1. SkinClosed loosely without tensionBead pouch (adhesive film)Left open, packedNPWTFlap (separate note)
  2. DrainNone (beads in situ)Suction drainsuction drains lower local antibiotic concentration when beads are used
  3. Splinttype and position; protect against fracture

Specimens and implants

  1. Sequestra and bonefor culture and HPE; number of containers
  2. Sinus tract / soft tissueculture; HPE (malignant change if long-standing sinus)
  3. Antibiotic beads left innumber of beads on each chain and number of chains, cement brand, antibiotic and amount, lot
  4. Implants removedlist; sent for culture if unit practice

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. IV antibioticsempirical drug and dose till culture report; then culture-specific; ID consult; duration (traditionally about 6 weeks)
  2. Limb elevation and splintsplint till wound heals; protect from fracture
  3. Weight bearingnon-weight bearing / protected, based on remaining bone strength
  4. Wound caredressing plan; bead pouch or NPWT changes
  5. Neurovascular checks
  6. DVT preventionaspirin or as per unit protocol
  7. Blood testsHb, CRP, ESR; blood sugar in diabetics
  8. Culture and HPE follow-update due
  9. Plan for next stagere-debridement, bead removal (date), flap, grafting or bone transport

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.K., 42 years, non-diabetic, non-smoker. Compound fracture of the left tibia treated with a plate 6 years ago; plate removed 4 years ago. Discharging sinus on the anteromedial leg for 3 years. X-ray and CT: 4 cm sequestrum in the middle third of the tibia with surrounding involucrum, fracture united. Cierny-Mader stage IIIA.

Case details

Date: 26/08/2026. Elective list. OT 4.

In OT 10:00. Spinal 10:10. Incision 10:35. Closure 12:20.

Surgeon: Dr A. (consultant). Assistant: Dr B. (2nd-year resident, Orthopaedics), who did the sinus excision and closure.

Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Chronic osteomyelitis left tibia, stage IIIA, with sinus and sequestrum. Fracture united, bone stable.

Oral antibiotics stopped 7 days before surgery for culture. Hb 12.1 g/dl, ESR 48 mm/h, CRP 22 mg/L, RBS 98 mg/dl, albumin 3.9 g/dl. 1 unit cross-matched.

Methylene blue injected into the sinus 24 h before surgery.

Consent in Kannada including repeat surgery, bead removal, fracture risk, flap. Left leg marked. WHO checklist done. Inj cefazolin 2 g IV at 10:25. Oral antibiotics had been off for 7 days, so the deep samples below were taken after this single prophylactic dose only.

Anaesthesia and position

Spinal anaesthesia. Supine. No tourniquet, so that bleeding from bone could be judged during debridement.

Painted with povidone-iodine and draped.

Procedure

Longitudinal anteromedial incision 12 cm, elliptical round the sinus opening. Blue-stained sinus tract excised in full down to a cloaca in the anteromedial cortex. Tract sent for culture and HPE.

Findings: thick sclerotic involucrum. About 10 ml pus. Unhealthy granulation tissue in the medullary cavity.

Periosteum incised and raised 2 cm on each side.

Longitudinal cortical slot 6 cm x 1.5 cm outlined with drill holes at the corners and along the edges, completed with an osteotome. No transverse cuts.

One sequestrum 4 x 1 cm and two small sequestra removed. Pus and granulation curetted. Sclerotic ends of the cavity opened into the medullary canal above and below.

Cavity walls burred with a high-speed burr under saline cooling until punctate bleeding (paprika sign) all round. Overhanging edges removed to leave a shallow saucer.

Specimens: 5 separate samples (sinus tract, deep soft tissue, pus, 2 bone samples) for aerobic, anaerobic and fungal culture; sequestrum and bone for HPE.

Haemostasis secured with cautery.

Wound washed with 6 litres normal saline by pulse lavage.

Beads: 40 g bone cement mixed with 2 g vancomycin powder. 20 beads of 7 mm threaded on one polypropylene (Prolene) No. 1 strand, about 14 cm long, knotted at both ends. Chain placed in the cavity, end left under the skin at the upper angle.

Closure

Soft tissue laid back over the beads. Skin closed loosely with interrupted nylon (Ethilon) 2-0, no tension. No suction drain, as suction lowers the local antibiotic level.

Dressing and above-knee posterior slab.

Specimens and implants

Culture: 5 containers. HPE: 2 containers (sequestrum and bone, sinus tract), in formalin.

Left in: 1 chain of 20 PMMA-vancomycin beads. Cement brand and lot as on packet, sticker pasted.

End of procedure

Estimated blood loss 400 ml. No transfusion. Count correct including bead count. No intra-operative complications.

Shifted to recovery, stable. Pulse 88/min, BP 122/78 mmHg. Toes pink and moving.

Post-op orders

Left leg elevated in slab. Toe movement and capillary refill 4-hourly.

IV antibiotics as per ID team till culture report, then culture-specific.

Non-weight bearing left leg with walker (weakened tibia).

Daily aspirin for DVT prophylaxis if no contraindication (dose as per unit protocol).

Hb and CRP on POD 2. Culture report due POD 3 to 5. Date of second look and bead removal to be fixed by consultant after culture report and wound review.

Signature

Dr B., JR-2, Orthopaedics, for Dr A. Reg. no. ________. 26/08/2026, 12:40.

Must document for this operation

  • Number of beads on each chain and number of chains. Every bead must be found and removed at the next operation; the count is the only check.
  • Every culture and HPE specimen, where it came from, and whether antibiotics were stopped before. Antibiotic choice for weeks depends on these results, and culture from superficial swabs is unreliable.
  • End point of debridement (bleeding bone) and whether any dead bone was left. Retained dead bone is the usual reason for recurrence; the next surgeon needs to know what was left.
  • Size and shape of the cortical window or slot and bone stability after debridement. The weakened bone can fracture; this guides weight bearing and the need for protection or fixation.
  • Implants removed or left, with reasons. Retained implants affect cure; the decision must be clear to the treating team.
  • Cierny-Mader stage. It guides whether treatment is curative or palliative and makes results comparable in audit.

Common mistakes in these notes

  • Writing 'sequestrectomy done' with no size or number of sequestra.
  • Not recording the bead count or the antibiotic added to the cement.
  • Sending only one swab for culture instead of several deep tissue samples.
  • No note on bone stability and weight-bearing status.
  • No HPE of a long-standing sinus tract.

Indian practice and paperwork

  • Debrided tissue and sequestra not sent to the laboratory are human anatomical waste (yellow category). Removed metal implants go in the blue container. (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines)
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed. (2020), COP.14(e) and (f))

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 23, Osteomyelitis: chronic osteomyelitis, Technique 23.2 (sequestrectomy and curettage), Technique 23.3 (antibiotic bead pouch), pp. 810-815.
  • Chapman MW, James MA, eds. Chapman's Comprehensive Orthopaedic Surgery. 4th ed. Jaypee Brothers; 2019, Ch 54, Osteomyelitis (Sirkin M, Hwang JS), e-book PDF pp. 1063-1067.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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