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.