Posttraumatic osteomyelitis (PTO) is a complex condition that results in considerable morbidity. Tibia is one of the most common sites of PTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Developments in surgery have greatly improved the ability to treat this condition. However, some authors defend that functional outcome is often poorer after successful limb reconstruction than after treatment with amputation below the knee, especially in patients with systemic factors that might significantly compromise reconstructive treatment. Limb salvage is associated with a longer convalescence time and a higher risk of complications, additional surgeries, and rehospitalisation. We present a case report of a patient with PTO requiring amputation of the leg despite aggressive surgical treatment.

The authors present a case of an 86-year-old woman with past medical history significant for diabetes, hypertension, severe peripheral artery disease and congestive heart failure. In March 2013 the patient sustained a tibia and fibula fracture (42-C1 AO Classification). Closed reduction and intramedullary nailing were performed. Osteomyelitis was diagnosed 1 month later. Implant removal, debridement, stabilization with external fixator and a vascularized skin graft were performed. Graft necrosis with bone exposure occurred after 1 month. Cultures were positive for multiple pathogens, including methicillin-sensitive Staphylococcus aureus. Several surgical debridement, vacuum-assisted closure therapy (VAC) and specific antibiotic therapy were performed for 8 weeks. Clinical deterioration with persistent bacteremia and infectious process led to the amputation below the knee in October 2014. Symptomatic relieve was achieved and C-reactive protein returned to her normal values.

Minimal stump necrosis was detected. Seven months postoperatively the patient is doing well with assisted gaitpilaa and few limitations in her daily life and there are no signs of systemic or local infection.

Management of posttraumatic osteomyelitis remains a challenge.

Amputation may prove to be the most appropriate way of restoring function and improving patient's quality of live, if there is failure to achieve bone healing and restore function. The decision to amputate should be considered carefully and individually, involving both patient and family.

Pyogenic spondylodiscitis is an uncommon but clinically relevant infection that represents 3 to 5% of all cases or osteomyelitis. In Europe, it has an estimated incidence of 0.4 to 2.4/100.000 people/year. Mortality is less than 5%, increasing with a delay in diagnosis greater than 2 month. Patients with renal failure have greater predisposition to infections, consequence of the chronic uremic state. Infection rates in Polytetrafluoroethylene (PTFE) hemodialysis grafts in end-stage renal disease (ESRD) range from 3 to 35%. We present a rare case of concurrent spondylodiscitis and PTFE graft infection in a patient with ESRD and recurrent urinary tract infections (RUTI).

The authors present a case of an 80-year-old man with past medical history significant for abdominal aortic aneurysm, bilateral ureter-hydronephrosis, Pseudomonas aeruginosa RUTI and ESRD. Three months after a dialysis PTFE graft hemoaccess was performed a Pseudomonas graft infection was diagnosed and the PTFE graft was removed. One week later, the patient was observed in the author's Department due to an insidious dorsal-lumbar mechanic back pain without neurologic deficits, with progressive deterioration over the past 6 months. A T12-L1 and L1-L2 spondylodiscitis with dural compression was diagnosed and vertebral instability was documented on MRI and TC, demanding surgical treatment. Instrumented fusion with a screw and rod construct was performed from T9 to L5, along with somatic L1 and L2 debridement, and T12-L1 interbody fusion with autograft. Microbiology results were positive for Pseudomonas aeruginosa. Antibotic therapy with ceftazidime (6 weeks) and ciprofloxacin (12 weeks) was performed. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values.

No complications were documented. Four months post-surgery, the patient was asymptomatic (Visual Analogue Scale=0), with no significant limitation in his daily life activity (Disability Rating Index=85) and the vertebral body height was sustained, with imagiological signs of spinal fusion.

ESRD patients are more susceptive to infections. Failure in early diagnosis and treatment may lead to disease progression and subsequent functional limitations, deformity and increase in mortality. An aggressive approach, despite delay on diagnosis, is the key factor for a worthy outcome.

Despite the good results, recrudescence of spondylodiscitis is known to occur even years after the original offense is treated.

To report a rare case of successfully treated synchronous shoulder septic arthritis, total knee replacement infection and lumbar spondylodiscitis in a patient with rheumatoid arthritis.

Fifty-six year old woman, with a history of rheumatoid arthritis diagnosed at twenty-five year old, and total knee replacement at fifty-four. Recently treated with etanercept, presented with acute inflammatory signs of the right shoulder in addition to right knee and lumbar back pain for 6 months. After a shoulder and knee arthrocentesis the diagnosis suspicion of shoulder septic arthritis and total knee replacement infection was confirmed. Therefore it was performed shoulder arthroscopic irrigation and debridement and the first of two stages knee revision, with implantation of antibiotic cement on cement articulating spacer. It was also diagnosed a L1–L2 and L4–L5 spondylodiscitis with dural compression documented on MRI, which determined surgical treatment. By a posterior approach it was performed instrumentation from T11 to L5, followed by L1–L2 and L4–L5 discectomy and interbody fusion with autograft. Shoulder and knee synovial fluid cultures where positive for Methicillin Sensible Staphylococcus aureus narrowing the broad-spectrum combination therapy to levofloxacin for six weeks, with symptomatic relieve and C-reactive protein and white blood cell count returning to normal values.

Almost one year down the line the patient remained with no sign of infection, even under the influence of immunosuppressive therapeutic. She returned to her previous status concerning the rheumatologic disease and the second stage knee revision is being planned to happen on the short run.

Rheumatoid arthritis patients are a high-risk group for septic arthritis considering, among others, the immunosuppressive therapeutics and the frequent history of arthroplasty. The presented case illustrates three different type of septic complication in the same patient. The timely and aggressive approach was the key factor for a good outcome.

Chronic posttraumatic osteomyelitis (CPTO) is a complex condition that results in considerable morbidity and may be limb threatening. Tibia is the most common site of CPTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Adequate soft-tissue coverage is one of the cornerstones in chronic osteomyelitis management. Vacuum-assisted closure (VAC) is frequently used for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. Free muscle flaps are recommended in distal third tibial defects. We present our experience with two case reports.

The authors present two cases of type IIIA osteomyelitis according to Cierny-Mader classification, following previous distal third tibial open fractures.

Both patients presented with limb deformity, insidious local pain and chronic purulent discharge (without significant local inflammatory signs) after 11 and 24 years of trauma. They were treated with radical debridement of all nonviable and infected tissue, VAC instillation therapy for 3 weeks and transverse rectus abdominis muscle (TRAM) flap defect coverage. Intra-operative cultures were positive for multiple pathogens. Specific antibiotic therapy was performed for each case for 8 weeks.

Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values.

No complications were documented. 1 year post-surgery, both patients remain asymptomatic, with no signs of infection, with full flap integrity and gait without assistance.

Despite the challenging management of chronic posttraumatic osteomyelitis of the tibia, infection control and a satisfactory functional outcome can be achieved. The cornerstones of management include infection control with surgical debridement, microbial-specific antibiotic administration and soft tissue coverage. VAC instillation therapy has an important role promoting granulation tissue formation and infection eradication. The aggressive approach, even with delay on diagnosis, is the key factor for a worthy outcome.

Despite the good results, recrudescence of osteomyelitis is known to occur even years after the original offense is treated.