Chronic Osteomyelitis Research Articles

Clinical Outcome following Management of Severe Osteomyelitis due to Pin Site Infection.

This study has investigated cases of pin site infection (PSI) which required surgery for persistent osteomyelitis (OM) despite pin removal. Patients requiring surgery for OM after PSI between 2011 and 2021 were included in this retrospective cohort study. Single-stage surgery was performed in accordance with a protocol at one institution. This involved deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. A successful outcome was defined as an infection-free interval of at least 24 months following surgery. Twenty-seven patients were identified (the sites were 22 tibias, 2 humeri, 2 calcanei, 1 radius); about 85% of them were males with a median age of 53.9 years. The majority of infections (21/27) followed fracture treatment. Fifteen patients were classified as BACH uncomplicated and 12 were BACH complex. Staphylococci were the most common pathogens, polymicrobial infections were detected in five cases (19%). Seven patients required flap coverage which was performed in the same operation.After a median of 3.99 years (2.00-8.05) follow-up, all patients remained infection free at the site of the former OM. Wound leakage after local antibiotic treatment was seen in 3/27 (11.1%) cases but did not require further treatment. Osteomyelitis after PSI is uncommon but has major implications for the patient as 7 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections were treated in accordance with a protocol and were not managed simply by curettage. All patients treated in this manner remained infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective. Pin site infection is a very common complication in external fixation. The sequela of a chronic pin site OM is rare but the implications to the patient are huge. In this series, more than a quarter of patients required flap coverage as part of the treatment of the deep infection. Frank FA, Pomeroy E, Hotchen AJ, et al. Clinical Outcome following Management of Severe Osteomyelitis due to Pin Site Infection. Strategies Trauma Limb Reconstr 2024;19(1):21-25.

Critical Bone Defect Affecting the Outcome of Management in Anatomical Type IV Chronic Osteomyelitis.

The Cierny and Mader classification assists with decision-making by stratifying host status and the pathoanatomy of the disease. However, the anatomical type IV represents a heterogenous group with regard to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Risk factors for the presence of a critical bone defect were female patients [OR 3.1 (95% CI, 1.08-8.92)] and requirement for soft tissue reconstruction [OR 3.35 (95% CI, 1.35-8.31)]; osteomyelitis of the femur was negatively associated with the presence of a critical bone defect [OR 0.13 (95% CI, 0.03-0.66)]. There was no statistically significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to the bone union was ten months (95% CI, 7.9-12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect [12.0 months (95% CI, 10.2-13.7 months)] and those without [6.0 months (95% CI, 4.8-7.1 months)]. This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time. Tsang STJ, Epstein GZ, Ferreira N. Critical Bone Defect Affecting the Outcome of Management in Anatomical Type IV Chronic Osteomyelitis. Strategies Trauma Limb Reconstr 2024;19(1):26-31.

РОЛЬ МОЛЕКУЛЯРНО-ГЕНЕТИЧЕСКИХ МЕТОДОВ ИССЛЕДОВАНИЙ В ЭТИОПАТОГЕНЕЗЕ ОСТЕОМИЕЛИТА ЧЕЛЮСТЕЙ

The subject of the study is the importance of molecular genetic research methods in the study of the etiopathogenesis of osteomyelitis of the jaws. The purpose of the work is to provide up-to-date information to researchers, dental surgeons, and maxillofacial surgeons on the possibilities of molecular genetic research in identifying bacterial pathogens in osteomyelitis of the jaws, as well as to reflect genetic markers of pathogenicity factors for a number of the main causative agents of the disease. Methodology. International scientific databases PubMed, ScienceDirect, Scopus, Cochrane Collaboration, Elsevier, as well as electronic catalogs eLIBRARY.RU and CyberLeninka.ru were used. Results. A review of publications demonstrated that S. aureus and S. Epidermidis dominate the etiological spectrum of causative agents of bone tissue infections. The participation of these microorganisms is determined by a whole range of pathogenicity factors. Toxins and Panton-Valentine leukocidin (PVL) genes play a major role in the pathogenesis of osteomyelitis and disease progression. It has been shown that the pathogenic bacteria Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans are capable of inducing differentiated production of cytokines. The most attention has been attracted to E. faecium, which exhibits multidrug resistance to a wide range of antibiotics. The proportion of infections mediated by S. epidermidis and S. Saprophyticus is, on average, about 25% of cases. The proportion of representatives of gram-negative flora Escherichia, Klebsiella, Enterobacter, Citrobacter, Proteus, Providencia, Serratia reaches 23% of cases. Pathogenic nosocomial strains of P. aeruginosa are also involved in the formation of chronic inflammation in osteomyelitis. According to the results of published studies, more than a third of cases of chronic osteomyelitis are mediated by microbial associations, which are dominated by S. aureus, S. epidermidis and, less commonly, E. faecalis. Conclusions. The use of PCR analysis to identify the causative agents of osteomyelitis and gene amplification using specific primers has a huge advantage over routine microbiological tests, being an informative method for studying the pathogenicity factors of the main pathogens. The high importance of molecular genetic methods in the study of the etiopathogenesis of osteomyelitis of the jaws requires their widespread use in the clinic of surgical dentistry and maxillofacial surgery to successfully solve complex problems in the rehabilitation of patients with this disease.

Surgical Management of Extensive Chronic Suppurative Maxillary Osteomyelitis in an Uncontrolled Diabetic Patient – A Comprehensive Case Report

Surgical Management of Extensive Chronic Suppurative Maxillary Osteomyelitis in an Uncontrolled Diabetic Patient – A Comprehensive Case Report

Defining the role of PSTPIP2 in neutrophil inflammatory function

Abstract Our lab and others have found that neutrophils isolated from Pstpip2cmo mice, that are deficient in proline-serine-threonine phosphatase-interacting protein 2 (PSTPIP2), display a hyperinflammatory phenotype with increased IL-1b and ROS secretion following stimulation. The hyperactive neutrophil phenotype is critical to the spontaneous development of an autoinflammatory disorder called chronic multifocal osteomyelitis. However, there are gaps in our understanding of the underlying mechanism that leads to the observed phenotype in Pstpip2cmo mice which could further our understanding of neutrophil biology. We first infected WT and Pstpip2cmo mice with P. aeruginosa to elucidate the importance of PSTPIP2 in vivo. 24-hours post infection, Pstpip2cmo mice had significantly lower bacterial burden compared to WT mice. We found increased neutrophils and monocytes in the bronchial alveolar fluid (BAL) of infected Pstpip2cmo mice, and these neutrophils are lower in side-scatter measured by flow cytometry. Under homeostatic conditions, we observed higher numbers of neutrophils in the bone marrow, blood, and spleen of Pstpip2cmo mice, and more granulocyte progenitors. In addition to elevated cell numbers, we found increased IL-1β secretion NETosis compared to WT mice. Together these data suggest that PSTPIP2 plays a critical role in restraining neutrophilic inflammatory response to bacterial infection and affects granulopoiesis in naïve mice.

Role of STIMULAN in chronic osteomyelitis-A randomised blinded study on 95 patients comparing 3 antibiotic compositions, bead quality, forming & absorption time

IntroductionChronic Osteomyelitis is a well-known clinical entity affecting patients holistically and presents with multiple treatment challenges. Local antibiotic delivery with biodegradable drug carriers has shown promising results. Materials and methodsProspective multicenter study performed at 2 centers from November 2021 to January 2023 on 95 osteomyelitis patients treated with surgical debridement & STIMULAN™ for local antibiotic delivery. Patients were randomized into 3 groups. Authors compared antibiotic combinations, bead quality, bead setting, and resorption time for calcium sulfate beads- STIMULAN™. Additionally, organisms isolated, WBC Turnover time, Hypersensitivity Reactions, Recurrence, and Revision Rates were documented. Results95 patients underwent surgical debridement and STIMULAN™ bead application for chronic osteomyelitis. The proximal 1/3rd tibia was commonly affected. The most common symptoms were sinus and pus discharge in 96.84 % & 86.31 % of patients respectively (p < 0.001). Staphylococcus aureus & MRSA were isolated in 37.8 % & 29.4 % of the patient's wound culture respectively. Bead setting time in Descending order was Group 3 > Group 2 > Group 1 (p < 0.001). Bead setting first in Group 1 followed by Group 3 & 2. On compression, Group-1 beads withstood maximum compression forces & had smooth even bead surfaces. On radiographs, 1/3rd bead volume in ascending order was Group 3 > Group 2 > Group 1 (p < 0.001). 2/3rd reduction in ascending order was Group 3 > Group 2 > Group 1. Complete bead absorption was earliest seen in Group 3 followed by Group 2 & Group 1 (p < 0.001). Recurrence in 2 patients (Group 2) at 6 weeks. Revision rate: 2.10 %. There were no incidences of hypersensitivity. Suture removal was done at 16 ± 2 days. ConclusionSTIMULAN™ combination with tobramycin, vancomycin, and gentamycin is stable, and forms uniform beads with predictable drug elution & bead resorption with negligible side effects. A mixture with higher liquid content sets later, forms softer beads, and resorbs earlier.

Chronic non-bacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO) with a focus on pamidronate therapy.

Chronic recurrent multifocal osteomyelitis (CRMO), also called chronic nonbacterial osteomyelitis (CNO) or nonbacterial osteomyelitis (NBO), is a rare autoinflammatory bone disease of unknown etiology. However, the number of patients properly diagnosed would increase with better knowledge of the disease. In this regard, whole-body magnetic resonance imaging (WB MRI) has been found to be a better predictor of active lesions than clinical examination. Importantly, the RINBO index (radiologic index for NBO) quantifies the involvement based on the WB MRI. Further, a chronic nonbacterial osteomyelitis MRI scoring (CROMRIS) has been developed as an online tool for assessing WB MRI. The therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates (pamidronate, zoledronate, etc.) and other drugs, including biologics. Pamidronate is an appropriate and safe therapy. The first pilot prospective randomised controlled trial (RCT) on pamidronate vs. placebo was carried out in adults. No RCT has been done in children yet. Besides RCTs, there are a number of issues to be explored in future, i.e. predictors of therapy effect, optimal therapy duration, predictors of therapy discontinuation and evaluation of optimal therapy protocol. Recently, the CNO clinical disease activity score (CDAS) was constructed and validated but the classification criteria are still being developed. As collaboration on this rare disease is essential, a prospective Chronic Nonbacterial Osteomyelitis International Registry (CHOIR) was established to generate future comparative effectiveness research data.

P019 Comparison of newly proposed chronic nonbacterial osteomyelitis classification criteria to previous diagnostic criteria

Abstract Background/Aims Chronic nonbacterial osteomyelitis (CNO) is an aseptic autoinflammatory bone disease of unknown etiology. This diagnosis can be delayed due to the non-specific nature of symptoms and normal imaging studies. New classification criteria were proposed in 2022. This study seeks to validate these new classification criteria by comparing them to previous diagnostic criteria in a cohort of known CNO patients. Methods This is a retrospective case-series of pediatric patients diagnosed with CNO (n = 39) between 2012 and 2023 in Virginia, USA. The newly proposed classification criteria (Table 1) was applied to this cohort. The entry criteria of chronic bone pain, age &amp;lt;18 years, abnormal radiograph and/or MRI were used prior to applying the newly proposed classification criteria. The 2008 Jansson diagnostic criteria and 2016 Bristol diagnostic criteria were also applied to the cohort for comparison and further validation. The clinical manifestations, laboratory results, and imaging studies that lead to a diagnosis of CNO were reviewed. Results The average age of diagnosis was 10 (range 2-17) years-old with the average time between onset of symptoms to confirmed clinical diagnosis being 24 (range 1-120) months. The most common presenting symptoms were bone pain (100%) and arthritis (49%). Evidence of radiographic abnormalities leading to CNO diagnosis was found with regional MRI (64%), bone scan (44%) with some requiring full body MRI (31%). Only one patient did not meet the new classification criteria (1/39; 3%) because of age &amp;lt;3 years, fever and elevated ESR which together gave less than the required 55 points for criteria fulfillment. One different patient (1/39; 3%) did not meet both the Bristol and Jansson criteria because of unifocal disease and lack of bone biopsy. Conclusion This retrospective chart review validates the newly proposed classification criteria for CNO. Older diagnostic criteria (Jansson and Bristol) both require advanced imaging and at times bone biopsy for fulfillment. We conclude that the newly proposed criteria is easy to apply even in the absence of a bone biopsy or advanced imaging studies. The newly proposed criteria will aid in the development of a homogeneous cohort for future studies about CNO. Disclosure A.M. Patel: Member of speakers’ bureau; ABBVIE, AMGEN, SANOFI. K.S. Lee: None. A.J. Kim: None.

Whole-body cryotherapy in orthopaedics: current concepts.

The use of whole-body cryotherapy (WBC) for musculoskeletal ailments is growing. WBC, involving brief exposure to extremely low temperatures, is increasingly used for its analgesic, anti-inflammatory, and antioxidant effects. The paper examines the physiological impacts of WBC on cardiovascular, musculoskeletal, hematologic, hormonal, and metabolic systems. Specific orthopaedic applications discussed include its role in the management of fractures, osteoarthritis, osteonecrosis of the femoral head, osteomyelitis, adhesive capsulitis, tendinopathies, rheumatic pathologies, chronic pain syndromes, and fibromyalgia. The study also highlights the benefits and drawbacks of WBC, including its potential to improve athletic performance, recovery, mood, and well-being, while noting risks like frostbite and impaired muscle strength. Clinical evidence from various studies is evaluated, revealing a spectrum of outcomes. For instance, WBC shows promise in enhancing bone health in athletes and providing relief in osteoarthritis and fibromyalgia patients. However, evidence for its efficacy in conditions like chronic pain syndromes and osteomyelitis is less robust. The paper underscores the need for further research to establish standardised protocols and understand long-term effects. While WBC offers significant benefits in orthopaedics, understanding its limitations and potential risks is crucial for its safe and effective clinical application.

A rare condition underlying childhood back pain: chronic nonbacterial osteomyelitis

A rare condition underlying childhood back pain: chronic nonbacterial osteomyelitis

Chronic Ankle Osteomyelitis Complicated by Robinsoniella peoriensis Infection

Chronic Ankle Osteomyelitis Complicated by Robinsoniella peoriensis Infection

Diagnostic Role of FDG PET/CT in Pediatric Patients With Chronic Recurrent Multifocal Osteomyelitis.

Chronic recurrent multifocal osteomyelitis (CRMO), or chronic nonbacterial osteomyelitis, is difficult to diagnose. The accurate diagnosis of CRMO relies on comprehensive imaging examinations because of its multifocal nature. In this regard, 18 F-FDG PET/CT has demonstrated significant utility in inflammatory diseases. This study tries to determine the value of FDG PET/CT in the evaluation of CRMO. We retrospectively collected imaging data from pediatric CRMO patients who underwent FDG PET/CT scans. Lesions exhibiting abnormal metabolism with/without structural abnormalities on FDG PET/CT were identified as CRMO lesions, and their location and SUV max were recorded. A total of 21 pediatric patients with CRMO were included in this study. The median age at diagnosis was 9.4 years. Total 131 foci of abnormal activity were identified using FDG PET/CT imaging. The distribution pattern showed a higher prevalence of lower limbs and pelvis involvement. Among all identified lesions, abnormalities were detected on both PET and CT images of 93 lesions, whereas exclusively positive findings on 18 F-FDG PET alone were observed for 38 of them. Our study findings suggest a higher prevalence of lesions in the bones of the lower limbs and pelvis among children with CRMO. Compared with CT scans, FDG PET exhibits superior sensitivity in detecting these lesions.

Chronic Nonspinal Osteomyelitis in Adults: Consensus Recommendations on Percutaneous Bone Biopsies from the Society of Academic Bone Radiologists.

The diagnosis and management of chronic nonspinal osteomyelitis can be challenging, and guidelines regarding the appropriateness of performing percutaneous image-guided biopsies to acquire bone samples for microbiological analysis remain limited. An expert panel convened by the Society of Academic Bone Radiologists developed and endorsed consensus statements on the various indications for percutaneous image-guided biopsies to standardize care and eliminate inconsistencies across institutions. The issued statements pertain to several commonly encountered clinical presentations of chronic osteomyelitis and were supported by a literature review. For most patients, MRI can help guide management and effectively rule out osteomyelitis when performed soon after presentation. Additionally, in the appropriate clinical setting, open wounds such as sinus tracts and ulcers, as well as joint fluid aspirates, can be used for microbiological culture to determine the causative microorganism. If MRI findings are positive, surgery is not needed, and alternative sites for microbiological culture are not available, then percutaneous image-guided biopsies can be performed. The expert panel recommends that antibiotics be avoided or discontinued for an optimal period of 2 weeks prior to a biopsy whenever possible. Patients with extensive necrotic decubitus ulcers or other surgical emergencies should not undergo percutaneous image-guided biopsies but rather should be admitted for surgical debridement and intraoperative cultures. Multidisciplinary discussion and approach are crucial to ensure optimal diagnosis and care of patients diagnosed with chronic osteomyelitis.

Aesthetic Mandibular Angloplasty to Improve Patient Quality of Life in Chronic Recurrent Multifocal Osteomyelitis

Summary: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoimmune disease that typically develops during adolescence and primarily affects women. CRMO primarily targets the bone in arms and legs, with sporadic occurrences in the mandible. CRMO is typically managed with medical treatment, and the efficacy of surgery remains controversial. Complications of surgery include massive bleeding and potential flare-up of CRMO symptoms. Herein, we report a patient with CRMO who had lesions in the bilateral rami of the mandible treated with aesthetic mandibular angloplasty. This is the first case of aesthetic mandibular angloplasty in a patient with CRMO who had bilateral rami involvement of the mandible. The patient began experiencing jaw pain accompanied by swelling and throbbing discomfort beneath the jawline at the age of 10. A pediatrician diagnosed CRMO, and the symptoms were controlled with nonsteroidal antiinflammatory drugs and immunosuppressants (infliximab, adalimumab). Aesthetic mandibular angloplasty was performed at our center because of mandibular hypertrophy. This procedure necessitated considerable removal of the spongy bone, raising concerns about potential massive intraoperative bleeding. Approximately 1.5 cm of the mandibular body was excised to reveal the cortical bone. Bleeding during surgery was not severe, rendering blood transfusions unnecessary. The patient was satisfied with the surgical results. This case indicates the feasibility of angloplasty for such cases.

The Concept of Treatment for Surgical Infection in the Hindfoot.

Chronic osteomyelitis of the calcaneus (OC) and open infected calcaneal fractures, especially when complicated by infected soft tissue defects, present significant surgical challenges. Accepted recommendations for the surgical treatment of this pathology are yet to be established. Drawing from our experience and the consensus among experts, we have developed a concept for selecting optimal, well-known surgical approaches based on the specific pathologic presentation. This concept distinguishes 4 main forms of hindfoot infection: infected wounds, open infected fractures, OC, and their mixed forms. Patients with conditions that could confound the treatment outcomes, such as diabetes mellitus and neurotrophic diseases, were excluded from this analysis. We present a retrospective analysis of the treatment outcomes for 44 patients (4 women and 40 men) treated between 2009 and 2022 using some refined surgical techniques. Treatment success was evaluated based on the absence of disease recurrence within a 2-year follow-up, the avoidance of below-knee amputations, and the restoration of weightbearing function. The treatment results were considered through the prism of our proposed concept and according to the Cierny-Mader classification. There were 4 instances of disease recurrence, necessitating 6 additional surgeries, 2 of which (4.5% of the patient cohort) resulted in amputations. In the remaining cases, we were able to restore weightbearing function and eliminate the infection through reconstructive surgeries, employing skin grafts when necessary. Surgical infections of the hindfoot area remain a significant challenge. The strategic concept we propose for surgical decision making, tailored to the specific pathology, represents a potential advancement in addressing this challenge. This framework could provide valuable guidance for orthopaedic surgeons in their clinical decision-making process. Level IV, case series.

Fusion Rates in Tibiotalocalcaneal Arthrodesis with Tantalum Coated Metal Cup Augmentation

Introduction/Purpose: Tantalum coated metal spacers (TCMS) have recently been utilized to fill and provide structure to large bony defects in the hindfoot. Tantalum is an appealing material due to its biocompatibility, lack of immune response generation, and structural integrity. Compared to custom printed spacers and bulk allografts, TCMS are readily available off-the-shelf implants with significantly less cost. There is currently a paucity of literature assessing the use and outcomes of TCMS in foot and ankle surgery, specifically in tibiotalocalcaneal (TTC) arthrodesis. This study serves to assess clinical outcomes and fusion rates of patients who underwent TTC arthrodesis utilizing intramedullary nailing with TCMS augmentation for large bony defects. Methods: We retrospectively identified all patients &gt; 18 years of age who underwent TTC arthrodesis with TCMS augmentation at our tertiary care center between 2015-2021. We also identified all patients who underwent TTC arthrodesis without augmentation within that time frame. The computed tomography (CT) scans at the six-month postoperative point were reviewed by one board-certified orthopaedic foot and ankle surgeon to determine fusion status, which was defined as having at least 50% fusion mass. Patient-reported outcomes measures (PROMs) including the modified foot function index (FFI) and PROMIS Global Mental Health Score were collected for patients in both groups. Patient demographics, clinical outcomes, and PROMs were compared between groups. A multivariate logistic regression model measured the effect of TCMS augmentation on the likelihood of achieving fusion. Results: Of the 65 patients included, 21 patients (32.3%) underwent TTC with TCMS augmentation. There were no significant differences in demographics between the two groups. Patients in the TCMS group had significantly higher modified FFI (91.1 + 47.6 vs 26.3 + 48.8, p&lt; 0.001) and PROMIS Global Mental Health (12.2 + 4.82 vs. 5.59 + 6.76, p&lt; 0.001) scores in the postoperative period. Overall, the fusion rate was higher for the TCMS group, however the difference was not significant between groups (90.5% vs. 80.5%, p=0.472). Multivariate logistic regression identified that TCMS augmentation was a nonsignificant predictor of increased odds of fusion at the six-month postoperative point (OR=2.87, p=0.232). Conclusion: This study is the largest to date to present 6-month postoperative CT scans demonstrating successful TTC fusion with TCMS augmentation, contributing to our understanding of its utility. Given the severity of disease and bone loss in the TCMS group, it is not surprising that post-operative patient reported outcome scores differed significantly compared to the control group. TCMS augmentation can be utilized as cost effective spacers to fill large defects in TTC arthrodesis with successful union rates. Further studies are needed to evaluate the efficacy of TCMS augmented fusions as a viable substitute to custom printed cages. Figure 1: Weight-bearing anteroposterior and lateral ankle radiographs of a patient with post-traumatic ankle arthritis and previously treated chronic osteomyelitis with valgus malalignment (A). Anteroposterior and lateral ankle radiographs status post TCMS augmented TTC arthrodesis (B). Coronal and sagittal CT scans demonstrating bony union through the TCMS augment (C).

PLANTAR CARCINOMA CUNICULATUM: A RARE PRESENTATION IN THE FOOT REGION

Carcinoma cuniculatum is a rare variant of squamous cell carcinoma. The clinical presentation is usually a non-verrucous exophytic plaque or tumor of the plantar region with a penetration in the deep tissues. Histological examination shows a proliferation of well-differentiated keratinocytes. We describe a patient affected by a slowly enlarging tumoral lesion overlying the fifth metatarsum of the left foot. Clinical examination and radiological investigations suggested a chronic osteomyelitis and a first histological examination of a punch biopsy was suggestive of a pseudo-epitheliomatous hyperplasia. The patient underwent several cycles with systemic antibiotics without improvement. Finally, the fifth metatarso was amputated and the skin lesion was completely removed. The histological examination of the whole operatory mass allowed a diagnosis of carcinoma cuniculatum invading the bone.

Current application and future perspectives of antimicrobial degradable bone substitutes for chronic osteomyelitis.

Chronic osteomyelitis remains a persistent challenge for the surgeons due to its refractory nature. Generally, treatment involves extensive debridement of necrotic bone, filling of dead space, adequate antimicrobial therapy, bone reconstruction, and rehabilitation. However, the optimal choice of bone substitute to manage the bone defect remains debatable. This paper reviewed the clinical evidence for antimicrobial biodegradable bone substitutes in the treatment of osteomyelitis in recent years. Indeed, this combination was proved to eradicate infection and facilitate bone reconstruction, which might reduce the cost and hospital stay. Handling was associated with increased risk of unwanted side effect to affect bone healing. The study provides some valuable insights into the clinical evaluation of treatment outcomes in the aspects of infection eradication, bone reconstruction, and complications caused by materials. However, achieving complete infection eradication and subsequently perfect bone reconstruction remains challenging in compromised conditions, hence advanced innovative bone substitutes are imperative. In this review, we mainly focus on the desired functional effects of advanced bone substitutes on infection eradication and bone reconstruction from the future perspective. Handling property was optimized to simplify surgery process. It is expected that this review will provide an important opportunity to enhance the understanding of the design and application of innovative biomaterials to synergistically eradicate infection and restore integrity and function of bone.

Intercalary Resection of the Tibia for Primary Bone Tumors: Are Vascularized Fibula Autografts With or Without Allografts a Durable Reconstruction?

Intercalary Resection of the Tibia for Primary Bone Tumors: Are Vascularized Fibula Autografts With or Without Allografts a Durable Reconstruction?

Geriatric chronic recurrent multifocal osteomyelitis (CRMO) mimicking multifocal multiple myeloma: a first in an octogenarian

Chronic recurrent multifocal osteomyelitis (CRMO), an autoinflammatory bone disorder characterized by non-bacterial osteomyelitis causing recurrent multifocal bone lesions, is a well-known, yet uncommon pediatric condition that rarely affects adults; to date, it has never been diagnosed over the age of 75. The following report will discuss the first octogenarian diagnosed with CRMO and therefore represents an exceptionally rare presentation of a rare disease. An 83-year-old woman presented with progressive right shoulder, forearm, and hip pain, with associated weight loss and global weakness, requiring a wheelchair for mobility. Imaging revealed a pathologic right ulna fracture in addition to lytic lesions of the right proximal humerus and proximal femur. The clinical picture was thus that of a patient with probable multiple myeloma versus metastatic disease. After an extensive workup, however, the lesions were not malignant; histologic findings were instead suggestive of chronic osteomyelitis with negative cultures. Given the multifocal nature of this condition, combined with a lack of clinical symptoms of infection, a diagnosis of CRMO was rendered. The patient underwent intramedullary nailing of the right femur and splinting of the ulna, with a subsequent remarkable recovery to painless ambulation, complete union of the right ulna fracture, and resolution of the lytic lesions without receiving any targeted medical treatment. This case highlights the importance of maintaining CRMO on the differential for multifocal skeletal lesions, regardless of age. Performing a thorough workup with necessary imaging, biopsy, and culture are critical to establishing this diagnosis, which can only made as a diagnosis of exclusion.