Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis. A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM. We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples. Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance. Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an above knee amputation and one underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at time of diagnosis. This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all identified incidentally after routine histological sampling, demonstrating the importance of this practice.
Chronic osteomyelitis is a challenging clinical problem. Aggressive debridement, bony fixation, obliteration of dead space and vascularised soft tissue coverage with appropriate antimicrobial therapy are essential to successful management of this condition. The gracilis muscle flap is the workhorse flap in our unit for reconstruction of limb osteomyelitis. We describe the experience and use of this flap in our unit over a 3 year period. Clinical records were reviewed from a prospectively-maintained Oxford Free Flap Database and patient notes. All patients who received a free gracilis flap reconstruction as part of the treatment of osteomyelitis between 2011 and 2014 were included in the study. 40 patients received free gracilis flaps; 38/40 for lower limb and 2/40 for upper limb osteomyelitis. Two were myocutaneous flaps, and the remainder were muscle only. The return to theatre rate was 12.5% with a total flap loss rate of 5%. Other flap-specific complications include partial flap loss (2.5%), flap site haematoma (2.5%), donor site haematoma (2.5%) and seroma (2.5%). General complications included pulmonary embolism (2.5%) and death from sepsis (2.5%). All but 2 patients were treated successfully and remain disease free following their initial surgery, with a mean follow up of 12.4 months (range 1–23 months). We have found that the free gracilis muscle flap is effective in the successful treatment of osteomyelitis, with a low complication rate.
