The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used.

From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation.

29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test.

Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients.

Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction.

The use of antibiotic-spacer, it is essential to treat infections in orthopedics. They play a dual role, to fight the infection directly on the outbreak and keep the length or the articulation of the limbs thus facilitating the second operation. To date it is not known, the superiority of use of 3 antibiotics compared to two. Authors try to compare industrial preformed spacers with two antibiotics with custom made spacers with three antibiotics to assess (a) the control of infection, (b) complications, (c) quality of life, (d) pain and (e) patient satisfaction.

137 patients treated at the Institute Codivilla-Putti from January 2010 to December 2012 were considered: 68 patients treated with antibiotic preformed spacer (clindamycin + gentamicin) or (Erythromycin + Colistin), 69 patients treated with antibiotic spacer added with 3 antibiotics (clindamycin + gentamicin + vancomycin) or (Erythromycin Vancomycin + Colistin).

Demographic data were collected:

type and site of infection (classified by Cerny-Mader)

Primary outcome of infection control or relapse after at least 12 months of follow-up were assessed. Complications were recorded. Each patient completed a test on the quality of life and a satisfaction scale self-referenced.

After a mean follow-up of 33.82 months (SD 14:50), at the end of the treatment, at last follow up 15/133 were infected. 4 died from other causes not correlated with infection, whit a 11.3% rate of reinfection.

Up to our knowledge, there is only one study using the procedure in two steps comparing the use of spacers loaded with 2 or 3 antibiotics. Our results show that a revision protocol in two steps with 3 antibiotic loaded spacers have a high success rate in the treatment of chronic osteomyelitis. We can observe that patients treated with custom-made cements are 4 percentage points lower than those treated with preformed cements, but there are no statistically significant differences in the rate of recurrence of infection. Our results suggest that a two stages procedure with three antibiotic loaded spacers should be considered in selected patients to avoid rescue procedures, such as amputation and arthrodesis. We think is important to do more randomized trials, controlled, prospective study with a larger group to detect statistically significant differences.

Introduction: SCC is a rare but well-known complication of chronic osteomyelitis since 1835, with an incidence from 0.5 to 2.3%. Amputation has generally been the treatment of choice; in selected Patients, Limb-salvage procedures have been employed 28 cases are presented here.

Materials and Methods: From 1975 to 2000, 4089 Patients with ostemyelitis were admitted to our service. SCC was present or arising in 28 cases: they were all middle aged males, except one woman. Mean age was 56.6 yrs, range 40–72. Clinical data were pointed out, and in all of them single or multiple biopsy was performed.

Results: All the cases were affected by SCC in the lower limb: tibia was the main site 20, followed by hip (2), foot (2), femur (4). Bone infection was born over 40 yrs. before (range 21–57). Patients were painfree up to 51 years. From worsening symptoms to admission, time was about 9 months (1–24). 19/28 cases came with wide leg ulcers, the rest with one discharging sinus or more (up to 8). In 6 cases pathological fracture was observed. Microbiological yields were not significant.

13 cases were transferred to Bone Tumors Centers: 10 of them were lost at F.U. Among those who underwent amputation: in two of them, local recurrence was observed, and one deceased after two years. Another Patient deceased for non-related heart problems.

Conclusions: In chronic osteomyelitis relapses are frequent, malignancy rare. If clinical changes in lower limb are observed, (pain, increased discharge, fethor, enlarging ulcer), SCC must be suspected. Early diagnosis is vital: biopsy should be wide, deep, multifocal, including the marrow space. Amputation is the treatment of choice. Metastases occur in 18 months; prognosis after 3 yrs from surgery is good.

Aetiology is still unknown: there is no evidence for an initiating factor. About favouring conditions ( inflammation, lower limb,) data are not clear enough.

In limb preserving surgery, our experience suggests one-stage procedures, avoiding to re-create chronic inflammation near the site of cancer.

Introduction: Treatment of infected non union of the lower limb has many possibilities. A new one, the Expandable Nailing System (ENS), already employed in traumatology, is presented here.

Materials and Methods: Between June 2001 and Dec.2003, 119 Patients with an infected non union of the long bones of the lower limbs (98 tibias, 21 femurs) were treated in our osteomyelitis centre. Most of the cases were men (87%), mean age was 38.4 years. Follow-up was min 5 months, max 23 (8.7 ave.)

ENS was used for 28 cases (25.4%). Other surgical techniques, were the Ilizarov apparatus (41 cases, 34.4%), the Grosse-Kempf locked nail (18.4%), fibular osteotomy (11%) the retrograde nail (5%), others (6%). ENS is indicated in:

3 – non unions with focuses at least 5cm. From epiphysis.

2)- serious soft tissue and bone cortical damage.

3)- failure of previous treatment.

3 – hypertrophie non unions where infection is reduced /absent and ESR is negative.

ENS is not indicated in the following conditions:

focus near the epiphysis;

3 – active stage of the infection.

In spite of point 4, the Authors used it in 5 cases with active osteomyelitis that could not be treated otherwise.

Results: Many cases are still undergoing treatment. Recovery times are generally shorter compared to traditional Grosse-Kempff Nails and Ilizarov. Bone healing is physiological and refractures after removal have not occurred in the few nails removed. Two Patients underwent re-operation, one for a nail failure, the second for a wrong choice in the first operation. Nail breakages occurred in 4 cases (3 tibias, 1 femur). There were 3 re-infections, all among the 6 patients operated with an active form.

Conclusions: ENS is a more sophisticated nailing system, less aggressive, that reduces X-ray exposure, blood loss, surgical time. This nail offers the advantage of a dynamic GKN, controlling torsion with longitudinal bars, but with a relative weakness especially for femurs. The learning curve is brief, but without a guide-wire more care is needed. The cost is high.