In acute haematogenous multifocal osteomyelitis, infectious foci occur in several bones simultaneously due to haematogenous bacterial spread.

Acute haematogenous multifocal osteomyelitis should be distinguished from chronic recurrent multifocal osteomyelitis (CRMO).

We reviewed the medical records of three male adolescents of 15 years (range 13–16 years) with acute multifocal haematogenous osteomyelitis. All patients were athletes (soccer player, water polo player, practicing rowing).

The mean duration of painful symptoms before seeking medical attention was 3 days. Osteomyelitis was confirmed by magnetic resonance imaging (MRI) and bone three phase scintigraphy. The lesions were at level of spine plus left femur in the first case, bilateral tibia and lumbosacral column in the second one, right foot plus left femur were interested in the third case. Two of the patients exhibited a spinal osteomyelitis, which is described as a common spinal affection in athletes.

Blood cultures (in all patients) and culture of abscess drainage (in one case) were positive for Staphylococcus aureus (MSSA). Inflammatory indices were increased in all patients (mean values: WBC 15.130/mmc, CRP 19 mg/dl, and ESR 63,6 mm/h).

Intravenous antibiotic therapy was prescribed for 19 days (range 13–33 days), followed by oral antibiotic therapy for a median of 18 days. After a median of 11 days, all patients clinically improved with resolution of fever and reduction of pain. Patients were discharged with oral antibiotic therapy after a median of 22 days hospitalization, and underwent a 16 months follow up. No patient reported sequelae.

Differential diagnosis among multifocal acute osteomyelitis, septic arthritis, CRMO, juvenile idiopathic arthritis and/or reactive arthritis may be difficult.

Previous studies reported that athletes are more at risk for osteomyelitis, but, to our knowledge, no case series of acute haematogenous multifocal infectious have been reported in competitive athletes. Staphylococcal outbreaks have been reported in sport players, as position, artificial grass abrasion, and body shaving are the main portal of bacterial entry.

In conclusion, a diagnosis of acute multifocal osteomyelitis must be considered in a patient with fever and pain of several bones. A prompt hospitalization and an appropriate therapy reduce the morbidities and can help to avoid surgery.

Daptomycin is a novel lipopetide antibiotic against gram-positive organisms, including multi-resistant strains. It effectively penetrates bone and has bactericidal activity within biofilms. In adults it has been demonstrated active against Staphylococcus Aureus Methicillin Sensible (MSSA) and Resistant (MRSA) bacteremia. The main side effect is a transitory myopathy that appears to be dose and frequency related. There are limited dates on daptomycin in pediatric patients.

We reviewed the medical records of four children (3 males and 1 female), with a median age of 11.2 years (range 7–13 years), who received daptomycin therapy for a complicated osteomyelitis. Osteomyelitis was clinically suspected and confirmed by magnetic resonance imaging at left ankle, left tibia, left calcaneum, lumbar column.

The pathogen isolated was a MSSA in all four cases. All patients received prior antibiotic treatment. Therapy was swiched to Daptomycin for first line treatment failure (in three cases) and for an adverse reaction to first line treatment (in one case). Daptomycin was prescribed at the mean dosage of 9 mg/kg/day (range 8–10 mg/kg/day) for a median time of 15 days. After 4 days therapy, all patients clinically and laboratory improved with resolution of fever and pain and decreased inflammatory indexes. No patient underwent surgery. After a median of 20 days of hospitalization, patients were discharged with oral antibiotic therapy. They received follow-up clinical evaluation for 8 months (range 6–10 months) with no sequelae.

With the limits of a small population and of a retrospective and unblended study, daptomycin therapy may be useful in complicated osteomyelitis and allowed the avoidance of surgery. The good outcome of the patients was probably due to daptomycin bactericidal activity against bacteria and to its ability to penetrate into bone and synovial fluid. Daptomycin therapy has been well tolerated in all patients, even if administered at a higher dose. No side effect was reported during therapy and at a 30 days follow-up evaluation.

Torsional changes in the lower limbs represent a serious clinical problem. The evaluation of the physiological development of the relationship between femur and tibia in the axial plane is necessary for final assessment.

The authors observed 940 patients aged from 4 to 15 years to identify the most important modifications of torsion of the lower limbs during paediatric age. Clinical examination includes assessment in the standing and supine position and observation of the gait features so that the physiological-pathological borderline can be defined, along with peculiar aspects of single and combined deformities, in order to identify indications for osteotomy.

The types of torsion are classified as: (1) isolated augmentation of femoral anteversion; (2) isolated reduction of femoral anteversion; (3) isolated medial tibial torsion; (4) isolated lateral tibial torsion; and (5) combined torsion (femoral anteversion combined with lateral tibial torsion).

The anatomy and the natural progression of femoral and tibial torsion can be assessed by clinical methods. Radiographic methods such as axial CT views are indicated in cases in which clinical examination does not provide clear information and, in particular, if qualitative and quantitative diagnosis is required in order to establish the therapeutic protocol.

The authors conclude by suggesting that the physiological development of torsion should be followed up to skeletal maturity in order to make a general evaluation and to decide on treatment.