Pathological Fracture with Squamous Cell Carcinoma Arising from Chronic Osteomyelitis—A Case Report

Osteomyelitis had been treated and managed in an organized manner since past decade, and yet, still creates a substantial burden to entire healthcare system as a whole as its complications are exasperating. Although rare, squamous cell carcinoma could be one of the complications of chronic osteomyelitis. The aim of the work was to outline the presentation of illness and depict the carcinomatous transformation of chronic wound, based on literature review and patients operated on in the authors’ department. In this case report, we would like to present a case of moderately differentiated squamous cell carcinoma in a 67 years old gentleman with 20 years history of chronic osteomyelitis. For our patient, option of amputation was chosen and no complications had been observed with the patient being fully satisfied and daily function restored after prosthesis fitting.

Surgical management of chronic osteomyelitis:Organisms,recurrence and treatment outcome

Purpose:The study aimed to identify the risk factors of recurrence in chronic osteomyelitis(COM)and to document the microbiological patterns pre-and intra-operatively and at recurrence,if any.Methods:We performed retrospective review on COM patients treated with surgical debridement and a 6-week course of antibiotics.The patients with symptoms of osteomyelitis for at least 6 weeks,present or past episodes of discharging sinus,documentation of bone sequestration in operative notes or preop-erative images were included in the study.Patients with symptoms of osteomyelitis<6 weeks,lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded.Logistic regression models were used to assess the impact of risk factors of recurrence.Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence.Results:Totally,147 COM patients(115 males and 32 females,mean age(33±19)years)were included in this study.Recurrence was noted in 28 patients(19.0%).Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence.Cierny-Mader stage-1,hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence.Concordance between pre-operative and intra-operative cultures was 59.85%(Kappa score 0.526,p<0.001)and between index surgery and at recurrence was 23.81%(Kappa score 0.155,p<0.001).Lack of knowledge of causative organism preoperatively did not affect outcome.At mean follow-up(42±15)months,all patients were apparently infection free for at least 1 year.Conclusion:Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM.Patients'age,gender,diabetes mellitus,previous failed treatment,duration of symptoms,hae-moglobin,white cell count,C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection.Pre-operative isolation of organism is of questionable value.Recurrences of infections do occur and are more of re-infections than relapses.Diligent isolation of organism must be attempted even in re-debridements.Even patients with recurrences do well with appropriate debridement and antibiotic therapy.

Protective effects of Wuwei Xiaodu Drink against chronic osteomyelitis through Foxp3^(+)CD25^(+)CD4^(+) Treg cells via the IL-2/STAT5 signaling pathway

To explore the effectiveness and safety of a Chinese medicinal decoction Wuwei Xiaodu Drink(WWXDD)in inhibiting chronic osteomyelitis via regulatory T cells signaling.The effective constitutes of WWXDD and osteomyelitis related genes were screened.Target proteins were cross-validated using the Venny database.GO function and KEGG pathway analysis were performed for target proteins,while pharmacological network was constructed.The bone properties were analyzed by HE staining and the concentrations of immune factors were measured by ELISA.The expression of CTLA-4 and Foxp3 mRNA and STAT5,p-STAT5,CTLA-4 and Foxp3 protein were detected using Real-time PCR and Western blot,respectively.FACS was used to analyze the percentages of cells.A total of 117 genes overlapped between 785 target genes of the active compounds of WWXDD and 912 osteomyelitis related genes.Inflammation-related genes,including IL-6,TNFα,IL-1βand IL-2 showed high connection degree in the drug-compound-disease-target network.GO function and KEGG pathway analysis revealed that 117 intersection genes mainly enriched in virus infection related pathways,immune related pathways and chemokine signaling pathway.Furthermore,the development of chronic osteomyelitis was suppressed in model rats after treatment with WWXDD.Meanwhile,the concentrations of IL-2 and CD4^(+)CD25^(+)Foxp3 Treg perr centages together with the levels of p-STAT5,CTLA-4 and Foxp3 were also down-regulated.Furthermore,IL-2 and WWXDD drug-containing serum exhibited opposite effects on regulating IL-2,IL-10,TGF-β1,Foxp3,CTLA4 and STAT5.In addition,a STAT5 phosphorylation inhibitor suppressed the expression of Foxp3 and CTLA-4.WWXDD can treat chronic osteomyelitis through suppressing the main regulating factors of Tregs and interfere its immunodepression.Our results bring a new solution for chronic osteomyelitis.

A Rare Case of Chronic Recurrent Multifocal Osteomyelitis with Undifferentiated Juvenile Idiopathic Arthritis, Uveitis, and Psoriasis

We report here a 17-year-old boy with a complicated presentation of undifferentiated juvenile idiopathic arthritis, vision-threatening uveitis and chronic recurrent multifocal osteomyelitis (CRMO) in the pelvis. His severe iritis needed subtenon injections and only responded to infliximab after failing multiple biologics. Unfortunately he later developed infliximab-associated psoriasis. A combination of infliximab and ustekinumab induced remission of his arthritis, osteomyelitis, uveitis and psoriasis without experiencing severe infections.

Osteomyelitis in Children with Sickle Cell Disease: A Challenging Diagnosis: Case Report from Cameroon

Introduction: Sickle Cell Disease (SCD) is the most prevalent genetic disease in the world predominantly in the African population with Sickle Cell Anaemia (SCA) being its dominant form. One of the most frequent complications of SCD is osteomyelitis. SCA is due to a point mutation in the beta globin chain of haemoglobin. This is responsible for the sickled shape of RBCs under low oxygen tension conditions leading to obstruction in the microcirculation. This leads to vaso-occlusive crises (VOC) which has a similar clinical presentation to that of osteomyelitis, another complication of SCD. Case Presentation: We present the case of a three-year-old girl with SCA who presented with an inability to bear weight in a febrile context. A diagnosis of VOC was initially made, which was later on changed to both a left chronic tibial and right distal femoral osteomyelitis following a series of biological, and imaging investigations. Surgical debridement and drainage were performed, resulting 9 weeks later in the involution of fever and leg pain. Conclusion: Osteomyelitis when associated with SCD is a dreadful and deathly disease in low income countries as it also presents like VOC therefore higher suspicion index is recommended. It is therefore important to take this into consideration at an early stage in patients with homozygous sickle cell disease so as to rapidly initiate multidisciplinary care. Appropriate investigations, appropriate antibiotic therapy, and timely surgical intervention would help to greatly reduce morbidity and mortality.

Right Ulnar Reconstruction after Sequestrectomy by Non-Vascularized Fibular Transfer in a Girl of Three Years

Chronic osteomyelitis is serious because of the orthopedic sequels that they could cause. Extended diaphyseal sequestrations could cause bone loss and their management is delicate. Here we report a case of right ulnar diaphyseal reconstruction by non-vascularized fibula transfer. This was a three-year-old girl, non-sickle cell, who had chronic osteomyelitis of the right ulna. The evolution was towards an almost total ulnar diaphyseal sequestration with externalization of the distal extremity. The removal of this large sequestrum occurred almost spontaneously, leaving a significant bone loss over a length of about 6 cm. Secondarily, we reconstructed the right ulnar diaphysis by transfer of a free non-vascularized graft of the left fibula, maintained by a pin. The follow up was favorable with almost complete recovery of prono-supination. Fibular ossification has evolved as well and we did not notice any complications at the graft collection site. Non-vascularized fibula graft transfer is a useful therapeutic option in the management of significant bone defects secondary to chronic osteomyelitis of one of the two forearm bones.

Biosafety of the Novel Vancomycin-loaded Bone-like Hydroxyapatite/Poly-amino Acid Bony Scaffold

Background： Recently, local sustained-release antibiotics systems have been developed because they can increase local loci of concentrated antibiotics without increasing the plasma concentration, and thereby effectively decrease any systemic toxicity and side effects. A vancomycin-loaded bone-like hydroxyapatite/poly-amino acid （V-BHA/PAA） bony scaffold was successfully fabricated with vancomycin-loaded poly lactic-co-glycolic acid microspheres and BHA/PAA, which was demonstrated to exhibit both porosity and perfect biodegradability. The aim of this study was to systematically evaluate the biosafety of this novel scaffold by conducting toxicity tests in vitro and in vivo. Methods： According to the ISO rules for medical implant biosafety, for in vitro tests, the scaffold was incubated with L929 fibroblasts or rabbit noncoagulant blood, with simultaneous creation of positive control and negative control groups. The growth condition ofL929 cells and hemolytic ratio were respectively evaluated after various incubation periods. For in vivo tests, a chronic osteomyelitis model involving the right proximal tibia of New Zealand white rabbits was established. After bacterial identification, the drug-loaded scaffold, drug-unloaded BHA/PAA, and poly （methyl methacrylate） were implanted, and a blank control group was also set up. Subsequently, the in vivo blood drug concentrations were measured, and the kidney and liver functions were evaluated. Results： In the in vitro tests, the cytotoxicity grades of V-BHA/PAA and BHA/PAA-based on the relative growth rate were all below 1. The hemolysis ratios of V-BHA/PAA and BHA/PAA were 2.27% and 1.42%, respectively, both below 5%. In the in vivo tests, the blood concentration of vancomycin after implantation of V-BHA/PAA was measured at far below its toxic concentration （60 mg/L）, and the function and histomorphology of the liver and kidney were all normal. Conclusion： According to ISO standards, the V-BHA/PAA scaffold is considered to have sufficient safety for clinical utilization.