Cat-scratch disease: a rare cause of osteomyelitis.

Cat-scratch disease is a zoonosis caused by Bartonella henselae, characterised by regional lymphadenopathy. Rarer presentations, such as osteomyelitis, can occur.We present an adolescent girl with severe right lumbar pain and fever, without animal contacts or recent travels. On examination, pain on flexion of torso, movement limitation and marked lordosis were noted, but there were no inflammatory signs, palpable masses or lymph nodes. Serological investigations revealed elevated inflammatory markers. Imaging revealed a paravertebral abscess with bone erosion. Several microbiological agents were ruled out. After a second CT-guided biopsy, PCR for Bartonella spp was positive. At this point, the family recalled having a young cat some time before. Cat-scratch disease was diagnosed, and complete recovery achieved after treatment with doxycycline and rifampicin.Cat-scratch disease is a challenging diagnosis in the absence of typical features. However, B. henselae must be investigated if common pathogens are ruled out and response to therapy is poor.

Infection After Lower-Limb Osseointegration: A Single-Center Retrospective Evaluation of Pathogens, Management, and Outcomes.

PURPOSE: Osseointegration (OI) is a novel alternative to traditional socket-suspended prostheses for lower-limb amputees, eliminating the socket-skin interface and allowing for weight bearing directly on the skeletal system. However, the stoma through which the implant attaches to the external prosthesis creates an ingress route for bacteria, and infection rates as high as 66% have been reported. The aims of this study are to classify infection management and long-term outcomes in this patient population to maximize implant salvage. METHODS: An institutional review board-approved retrospective analysis was performed on all patients who underwent lower-limb OI at our institution between 2017 and 2022. Demographic, operative, and outcome data were collected for all patients. Patients were stratified by the presence and severity of infection. Chi-square and t tests were performed on categorical and continuous data, respectively, using an alpha of 0.05. RESULTS: One hundred two patients met our study criteria; 62 had transfemoral OI and 40 had transtibial OI. Patients were followed for 23.8 months on average (range, 3.5-63.7). Osteomyelitis was more likely than soft tissue infection to be polymicrobial in nature (71% vs 23%, P < 0.05). Infections at the stoma were mostly (96%) managed with oral antibiotics alone, whereas deeper soft tissue infections also required intravenous antibiotics (75%) or operative washout (19%). Osteomyelitis was managed with intravenous antibiotics and required operative attention; 5 (71%) underwent washout and 2 (29%) underwent explantation. Both implants were replaced an average of 3.5 months after explantation. There was no correlation between history of soft tissue infection and development of osteomyelitis (P > 0.05). The overall implant salvage rate after infection was 96%. CONCLUSIONS: This study describes our institution's experience managing infection after OI and soft tissue reconstruction. Although infections do occur, they are easily treatable and rarely require operative intervention. Explantation due to infection is rare and can be followed up with reimplantation, reaffirming that OI is a safe and effective treatment modality.

Recurrent skin opening induced by chronic sternal osteomyelitis caused by a bite wound in a cat: A case report.

BACKGROUND: Chronic sternal osteomyelitis is a rare condition in felines, with limited reported cases to date. OBJECTIVES: We report the case of a 2-year-old castrated male, domestic shorthair cat, weighing 4.68 kg, that presented with skin openings every 3-4 months, despite skin debridement and reconstruction. METHODS: A subcutaneous dead space larger than the skin defect was detected. Haematological analysis revealed elevated levels of inflammatory markers. Thoracic radiography revealed sternal deformation and suspected osteomyelitis. Computed tomography revealed a fistula extending from the third to the fourth sternebrae. RESULTS: Bone and soft tissue debridement and abscess flushing were performed along with long-term antibiotic therapy. The cat remained recurrence-free throughout an 18-month post-surgery follow-up period. CONCLUSION: To the best of our knowledge, this is the first report of chronic osteomyelitis occurring in a cat's sternebrae and represents the first successful case of its treatment. This case showcases the potential for improved treatment outcomes in similar cases. Understanding and successful treatment of such cases can pave the way for better management of feline osteomyelitis.

Imaging spectrum and complications of otogenic infections: insights into delayed diagnosis.

Skull base osteomyelitis (SBO) is a late manifestation of complicated otogenic infections that presents a diagnostic challenge. Delayed or missed diagnoses lead to high morbidity and mortality and can be attributed to non-specific symptoms, subtle early radiologic findings, radiologic mimicry of nasopharyngeal carcinoma (NPC), and under-recognition from clinician and radiologists. This pictorial review aims to emphasize on early imaging recognition and distinction between SBO and NPC.

Tibial fractures treated with mono-lateral fixation: Principles of design and application.

This paper presents the outcome of a data review of patients treated with the IOS external fixation system at the Royal Stoke University Hospital: a fixation designed to meet four requirements for external fixation proposed in this paper. Demographic data and outcome were collected and assessed. From 69 initial patients, 64 patients (55 males and 9 females) had an average age of 35.9 years. The mean time to union was 127 days. There were no incidences of malunion, or refracture post fixation removal attributable to the treatment method. In addition, in this cohort, there was no incidence of pin tract infection resulting in osteomyelitis. Of all the factors assessed the only factor to have any significant effect on healing was smoking: an average delay of 31 days. An examination of RUST (radiographic union score tibia) and modified RUST scores illustrated a potential false negative of up to 80%. Hence, this study cannot support the use of either scoring system to diagnose fracture healing. IOS external fixation was shown to be an effective method for the treatment of unstable tibial fractures. The reduction at fixation removal was shown to be very good. There was no incidence of osteomyelitis. It is, therefore, suggested that appropriately used external fixation is a viable alternative to intramedullary nailing if designed and surgically applied using four design principles outlined in this paper. Furthermore, it is proposed that external fixation be designed and applied to meet these four principles.

Effect of Antibiotic Prophylaxis on Infection Rates in Pediatric Supracondylar Humerus Fractures Treated with Closed Reduction and Percutaneous Pinning: A Prospective Double-Blinded Randomized Controlled Trial.

BACKGROUND: Supracondylar humerus fractures (SCHFs) are the most common elbow fracture in the pediatric population. In the case of displaced fractures, closed reduction and percutaneous Kirschner wire pinning (CRPP) is commonly performed. Infection rates are between 0 and 7%; however, retrospective studies have shown no benefit of preoperative antibiotics. There continues to be notable variability in antibiotic usage based on surgeon preference and local institutional policy. We conducted a double-blinded, randomized controlled trial to evaluate whether antibiotic prophylaxis reduces the risk of infection in pediatric SCHF patients treated with CRPP. METHODS: Pediatric patients with displaced SCHF who presented to a pediatric hospital were enrolled and randomized into two groups. Group I received one dose of prophylactic antibiotics (25 mg/kg cefazolin IV up to 1g or clindamycin 10 mg/kg up to 600 mg/kg IV in the case of cefazolin allergy). Group II received placebo (10-mL prefilled syringe of normal saline). All patients underwent CRPP and casting followed by pin removal 3 to 6 weeks after the initial procedure. The presence of pin-site infection, erythema, drainage, septic arthritis, and osteomyelitis was recorded. RESULTS: One hundred sixty patients were enrolled in the study. Eighty-two patients were randomized to receive antibiotics, and 78 patients were randomized to placebo. No difference was seen in the rate of infection between the treatment groups (1.2% in the antibiotic group versus 1.3% in the placebo group; P = 1.00). Presence of purulent drainage (0.0% versus 1.3%; P = 0.49), septic arthritis (0.0% versus 0.0%; P = 1.00), and osteomyelitis (1.2% versus 0.0%; P = 1.00) was similar in both groups. No difference in the need for additional antibiotics (1.2% versus 1.3%; P = 1.00) or additional surgery (1.2% versus 0.0%; P = 1.00) was found between groups. DISCUSSION: The use of antibiotic prophylaxis did not affect the risk of infection in pediatric patients who underwent CRPP for displaced SCHF. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT03261830. LEVEL OF EVIDENCE: Therapeutic Level I.

[Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects].

Objective: To investigate the perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy, and to evaluate its clinical effects. Methods: This study was a retrospective observational study. From January 2017 to December 2022, 36 patients with wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy who were conformed to the inclusion criteria were admitted to the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University, including 23 males and 13 females, aged 25 to 81 years. Preparation for surgery was made. For patients with suspected retrosternal mediastinal abscess cavity, all cancellous bone of the unhealed sternum was bitten off to fully expose the retrosternal mediastinum, remove the source of infection and granulation tissue, and to fill the sternum defect with flipped unilateral pectoralis major muscle. For patients who had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, the necrotic tissue and a small amount of necrotic sternum were palliatively removed, and bilateral pectoralis major muscles were advanced and abutted to cover the sternal defect. After the skin in the donor area was closed by tension-relieving suture, continuous vacuum sealing drainage was performed, and continuous even infusion and lavage were added 24 hours later. The thorax was fixed with an armor-like chest strap, the patients were guided to breathe abdominally, with both upper limbs fixed to the lateral chest wall using a surgical restraint strap. The bacterial culture results of wound exudation specimens on admission were recorded. The wound condition observed during operation, debridement method, muscle flap covering method, intraoperative bleeding volume, days of postoperative infusion and lavage, lavage solution volume and changes on each day, and postoperative complications and wound healing time were recorded. After discharge, the wound healing quality, thorax shape, and mobility functions of thorax and both upper limbs were evaluated during follow-up. The stability and closure of sternum were observed by computed tomography (CT) reexamination. Results: On admission, among 36 patients, 33 cases were positive and 3 cases were negative in bacterial culture results of wound exudation specimens. Intraoperative observation showed that 26 patients had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, palliative debridement was performed and bilateral pectoralis major muscles were advanced and abutted to cover the defect. In 10 patients with suspected retrosternal mediastinal abscess cavity, the local sternum was completely removed by bite and the defect was covered using flipped unilateral pectoralis major muscle. During the operation, one patient experienced an innominate vein rupture and bleeding of approximately 3 000 mL during mediastinal exploration, and the remaining patients experienced bleeding of 100-1 000 mL. Postoperative infusion and lavage were performed for 4-7 days, with a lavage solution volume of 3 500-4 500 mL/d. The lavage solution gradually changed from dark red to light red and finally clear. Except for 1 patient who had suture rupture caused by lifting the patient under the armpit during nursing on the 3rd day after surgery, the wounds of the other patients healed smoothly after surgery, and the wound healing time of all patients was 7-21 days. Follow-up for 3 to 9 months after discharge showed that the patient who had suture rupture caused by armpit lifting died due to multiple organ failure. In 1 patient, the armor-like chest strap was removed 2 weeks after surgery, and the shoulder joint movement was not restricted, resulting in local rupture of the suture, which healed after dressing change. The wounds of the remaining patients healed well, and they resumed their daily life. The local skin of patient's pectoralis major muscle defect was slightly sunken and lower than that of the contralateral thorax in the patients undergoing treatment of pectoralis major muscle inversion, while no obvious thoracic deformity was observed in patients undergoing treatment with pectoralis major muscle propulsion and abutment. The chest and upper limb movement in all patients were slightly limited or normal. CT reexamination results of 10 patients showed that the sternum was stable, the local sternum was closed or covered completely with no lacuna or defects. Conclusions: Once the wound associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy is formed, individualized and precise debridement should be performed as soon as possible, different transfer ways of pectoralis major muscle flap should be chosen to cover the defect, and postoperative continuous infusion and lavage together with strict thorax and shoulder joint restraint and immobilization should be performed. This treatment strategy can ensure good wound healing without affecting the shape and function of the donor area.

Retention of Antibiotic Cement Delivery Implants in Orthopedic Infection Associated With United Fractures Does Not Increase Recurrence Risk.

OBJECTIVES: To evaluate whether retention of antibiotic cement delivery devices after resolution of orthopaedic infection is associated with recurrence. DESIGN: Retrospective cohort. SETTING: Academic medical center. PATIENT SELECTION CRITERIA: Patients with a fracture definitively treated with internal fixation that went on to unite and develop a confirmed fracture-related infection or osteomyelitis after a remote fracture surgery and had implantation of antibiotic-impregnated cement for infection management. OUTCOME MEASURES AND COMPARISONS: Patients were divided into whom the antibiotic implants were retained (Retained Cohort) and whom the antibiotic implants were removed (Removed Cohort). Outcome measures included clinical infection resolution, infection recurrence, time to resolution of infection signs, symptoms and laboratory values, reoperation and readmission rates, and need for soft tissue coverage (local flap vs. free tissue transfer) because of recurrence. RESULTS: Of 98 patients treated for fracture-related infection in united fractures or osteomyelitis after a remote fracture surgery, 39 (39.8%) underwent implantation of antibiotic-impregnated cement delivery devices: 21 (21.4%) beads, 7 (7.1%) rods, and 11 (11.2%) blocks. Twenty patients (51.3%) comprised the Retained Cohort and 19 patients (48.7%) comprised the Removed Cohort. There were few differences in demographics ([American Society of Anesthesiology Score, P = 0.026] and [diabetes, P = 0.047]), infection location, and pathogenic profiles. The cohorts demonstrated no difference in eventual resolution of infection (100% in the Retained Cohort, 95% in the Removed Cohort, P = 0.487) and experienced similar time to clinical infection resolution, based on signs, symptoms, and laboratory values ( P = 0.360). There was no difference in incidence of subsequent infection recurrence after clinical infection resolution (1 recurrence Retained vs. 2 recurrences Removed, P = 0.605) for those considered "cured." Compared with the Retained Cohort, the Removed Cohort underwent more reoperations (0.40 vs. 1.84 reoperations, P < 0.001) and admissions after implantation ( P < 0.001). CONCLUSIONS: Retention of antibiotic-impregnated cement delivery devices in patients with orthopaedic infection after fractured bones that have healed was not associated with infection recurrence. Additional surgical intervention with the sole purpose of removing antibiotic delivery devices may not be warranted. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Antibiotic Prophylaxis for Grade 3 Open Fractures: A Retrospective Comparison of Ceftriaxone Plus Vancomycin Versus Cefazolin Plus Gentamicin.

Background: Because of the established path of bacterial entry and contamination-associated mechanisms, grade 3 open orthopedic fractures represent a substantial infection risk. The Eastern Association for the Surgery of Trauma (EAST) guidelines recommended covering Staphylococcus aureus and adding aminoglycoside gram-negative coverage. Local institutional guidelines rely on ceftriaxone for gram negative coverage and add methicillin-resistant Staphylococcus aureus coverage with vancomycin. Patients and Methods: The electronic health records of adults admitted for a grade 3 open fracture between January 1, 2016, and October 31, 2021, were retrospectively reviewed. Patients who received cefazolin and gentamicin (CZ+GM) or ceftriaxone and vancomycin (CRO+VA) as prophylaxis were included. We recorded the rate of a composite treatment failure outcome of receipt of antibiotic agents, infection-related hospitalization, or subsequent debridement for injury-site skin and soft tissue infection or osteomyelitis. The presence of acute kidney injury (AKI) was also evaluated. Results: There were 65 patients included in the CZ+GM group and 53 patients in the CRO+VA group. Patients in the CZ+GM group were younger (mean 42.6 compared with 50.6 years; p = 0.02). Otherwise, there were no significant differences between groups' demographics, mechanism and site of injury, timeline of care, or surgical interventions. More patients in the CZ+GM arm met the composite treatment failure outcome, but it was not statistically significant (45% vs. 32%; p = 0.2). There were similar rates of treatment failure at 30 days (21% vs. 26%; p = 0.5) and for only osteomyelitis (8% vs. 9%; p = 1). Conclusions: The trend in numerically lower treatment failure rates in the CRO+VA group across outcomes provides sufficient evidence to continue the current local recommendations. Given our sample size, type 2 error may have occurred, and studies with greater power should analyze this question.

Surgical Options for Diabetic Toe Ulcers and Osteomyelitis Technical Tips and a Decision-Making Algorithm.

INTRODUCTION: Diabetic foot ulcers (DFUs) reflect a pivotal event that could lead to serious complications such as amputation and death. Although conservative surgery was reported to have better outcomes when compared to nonsurgical standard of care of forefoot wounds, the surgical management of diabetic toe ulcers (DTUs) is hardly researched. METHODS: The aim of this study is to describe the types and techniques of surgical procedures that could be needed when managing DTU. The proposed surgical techniques were based on their outcomes following an evidence-based search of the literature. RESULTS: Six major types of procedures could be used to treat DTUs; (1) interphalangeal joint resection arthroplasty, (2) phalangectomy or internal pedal amputation, (3) distal Syme amputation, (4) percutaneous toe flexor tenotomy, (5) toe fillet flap, and (6) toe amputation. Details on technical tips are described. CONCLUSION: Based on the location, ulcer grade of the ulcer and the status of the surrounding soft tissue, a surgical decision-making algorithm is proposed to assist surgeons when managing such prevalent conditions.Levels of Evidence: Level V: Expert review.

Pharyngo-cervicospinal fistula with destructive osteomyelitis after laryngopharyngectomy and radiotherapy, managed successfully with a vascularized fibula free flap.

Total laryngectomy is an operation mainly employed in recurrent laryngeal and hypopharyngeal carcinoma after previous radiotherapy. The most feared complication after this procedure is a pharyngocutaneous fistula. An extremely rare complication is the development of osteomyelitis of the cervical spine, which is associated with high rates of neurological impairment and epidural empyema, often requiring surgical treatment. This report describes the case of a patient with neck and shoulder pain and progressive motor weakness of the left deltoid and biceps muscle, caused by a pharyngo-cervicospinal fistula with spinal empyema. This condition resulted in destructive osteomyelitis of the cervical spine. A successful reconstruction of the cervical spine and neopharynx was performed using a free vascularized fibula bone and skin graft in a complex area because of previous treatments. It appears that no similar case has been described previously.

Rifampicin does not reduce moxifloxacin concentrations at the site of infection and may not improve treatment outcome of a one-stage exchange surgery protocol of implant-associated osteomyelitis lesions in a porcine model.

We aimed to evaluate moxifloxacin steady-state concentrations in infected bone and soft tissue and to explore the additive microbiological and pathological treatment effect of rifampicin to standard moxifloxacin treatment of implant-associated osteomyelitis (IAO). 16 pigs were included. On Day 0, IAO was induced in the proximal tibia using a susceptible Staphylococcus aureus strain. On Day 7, the pigs underwent one-stage exchange surgery of the IAO lesions and were randomized to receive seven days of intravenous antibiotic treatment of either rifampicin combined with moxifloxacin or moxifloxacin monotherapy. On Day 14, microdialysis was applied for continuous sampling (8 h) of moxifloxacin concentrations. Microbiological, macroscopical pathology, and histopathological analyses were performed postmortem. Steady-state moxifloxacin area under the concentration-time curve was lower in the combination therapy group in plasma (total) and subcutaneous tissue compartments (infected and noninfected) (p < 0.04), while no differences were found in bone compartments. No additional treatment effect of rifampicin to moxifloxacin treatment was found (p = 0.57). Conclusive, additive rifampicin treatment does not reduce moxifloxacin concentrations at the infection site. Rifampicin treatment may not be necessary in a one-stage exchange treatment of IAO. However, our sample size and treatment period may have been too small and short to reveal true clinical differences.

Frontal Osteomyelitis and Sinusitis Complication After Type III Frontal Bone Cranioplasty for Facial Feminization.

Background: Forehead contouring can be a component of facial feminization surgery (FFS). Its complications have been rarely reported on and are often described as "hypothetical." Methods: A case report of complications from forehead contouring resulting in frontal osteomyelitis and sinusitis. Results: A female patient presented with frontal osteomyelitis, sinusitis, and forehead contour deformity after a type III forehead contouring surgery. She had failed prior treatment including oral antibiotics, IV antibiotics, revision sinus surgery, and revision nasal surgery. For definitive treatment, she underwent an anterior table resection, sinus obliteration with bony contouring, and pericranial flap. Conclusions: Forehead contouring represents a recent significant advancement in FFS and gender-affirming therapy. Descriptions of complications and their management are important when novel therapies such as FFS are introduced. This case demonstrates complications from type III forehead contouring including osteomyelitis, frontal sinusitis, and forehead deformity.

Commentary on: "Frontal Osteomyelitis and Sinusitis Complication After Type III Frontal Bone Cranioplasty for Facial Feminization" by Brown et al.

We present a complementary report of a 38-year-old XY intersex female with frontal mucopyocele developing 5 years after frontal setback for gender-affirming surgery to supplement recent report by Brown et al: Frontal Osteomyelitis and Sinusitis Complication After Type III Frontal Bone Cranioplasty for Facial Feminization by Brown et al.

Cervical Osteomyelitis and Diskitis as a Complication of Neopharyngeal Breakdown: A Multisite Case Series Review.

Laryngectomy and pharyngectomy are surgical options for advanced laryngeal or pharyngeal squamous cell carcinoma. Cervical osteomyelitis-diskitis, occurring when there is dehiscence of the posterior neopharyngeal wall, is an uncommon complication of laryngopharyngectomy. This case series describes imaging findings of pharyngoesophageal wall breakdown with subsequent cervical spine infection and demonstrates that most of these patients had undergone prior esophageal or neopharyngeal dilations for benign posttreatment stricture. Neck pain, fever, or serologic evidence of infection should prompt careful evaluation for osteomyelitis-diskitis and assessment for neopharyngeal breakdown and sinus tract formation, especially in the postdilation setting.

Diagnostic, clinical management, and outcome of bone flap-related osteomyelitis after cranioplasty.

OBJECTIVES: We aimed to describe diagnostic, management, and outcome of bone flap-related osteomyelitis after cranioplasty. METHODS: Patients followed up in our tertiary care hospital for bone flap-related osteomyelitis after cranioplasty were included in a retrospective cohort (2008-2021). Determinants of treatment failure were assessed using logistic regression and Kaplan-Meier curves analysis. RESULTS: The 144 included patients (81 [56.3%] males; median age 53.4 [interquartile range [IQR], 42.6-62.5] years) mostly presented wound abnormalities (n = 115, 79.9%). All infections were documented, the main pathogens being Staphylococcus aureus (n = 64, 44.4%), Cutibacterium acnes (n = 57, 39.6%), gram-negative bacilli (n = 40, 27.8%) and/or non-aureus staphylococci (n = 34, 23.6%). Surgery was performed in 140 (97.2%) cases, for bone flap removal (n = 102, 72.9%) or debridement with flap retention (n = 31, 22.1%), along with 12.7 (IQR, 8.0-14.0) weeks of antimicrobial therapy. After a follow-up of 117.1 (IQR, 62.5-235.5) weeks, 37 (26.1%) failures were observed: 16 (43.2%) infection persistence, three (8.1%) relapses, 22 (59.5%) superinfections and/or two (1.7%) infection-related deaths. Excluding superinfections, determinants of the 19 (13.4%) specific failures were an index craniectomy for brain tumor (odds ratio = 4.038, P = 0.033) and curettage of bone edges (odds ratio = 0.342, P = 0.048). CONCLUSION: Post-craniectomy bone flap osteomyelitis are difficult-to-treat infection, necessitating prolonged antimicrobial therapy with appropriate surgical debridement, and advocating for multidisciplinary management in dedicated reference centers.

Osteomyelitis and Septic Arthritis of the Foot and Ankle: Imaging Update.

Radiography is considered the first-line screening exam for clinically suspected osteomyelitis. However, additional evaluation is generally needed. MRI is the definitive diagnostic exam with high sensitivity and specificity combined with excellent anatomic definition. Gadolinium contrast can be useful to detect areas of devitalization before surgery. Bone marrow edema on fluid-sensitive images and low signal intensity on T1-weighted images in the presence of secondary MRI findings, including ulcer, sinus tract, and cellulitis with or without abscess are typical findings of osteomyelitis. If MRI is contraindicated, three phase bone scan can be used. Early diagnosis and treatment is essential.

Simultaneous Free Fibula and Anterolateral Thigh Flap in Lower Extremity Reconstruction Following Osteomyelitis in a Trauma Patient: A Case Report.

This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient's return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation.

Radiologic findings of osteonecrosis, osteoradionecrosis, osteomyelitis and jaw metastatic disease with cone beam CT.

PURPOSE: The purpose of this study was to assess CBCT scans of patients with medication related osteonecrosis of the jaws (MRONJ), osteoradionecrosis (ORN), osteomyelitis (OM) and jaw metastatic disease (JM), evaluate the presence and extent of radiologic findings, identify radiologic parameters that may distinguish the four entities and last, introduce a new modified radiographic index (CRIm), in order to contribute to the diagnosis of these conditions. METHODS: Τwo major databases were retrospectively searched for fully documented and diagnosed CBCT scans of MRONJ, ORN, OM and JM from 2006 to 2019. 335 CBCT scans met the inclusion criteria and were assessed under standardized viewing conditions blindly by 2 observers. The CRIm index proposed in this study evaluates: lytic changes, sclerosis, periosteal bone formation, sequestration, non-healing extraction sockets and other findings which included: sinus implication, inferior alveolar canal implication and jaw fracture. Lytic changes, sclerosis, periosteal bone formation, sequestration and non-healing extraction sockets were scored as: absent (0), localized/single (1) and extensive/multiple (2). Each one of other findings were scored individually as: absent (0) and present (1). For statistical analysis t-test, Pearson's r correlation coefficient, one-way ANOVA and Bonferonni were performed. RESULTS: Extensive lytic changes were the most common finding, especially for ORN, where it occurred in all CBCT scans (100%). The mean value of the CRIm index differs significantly between CBCT scans with MRONJ and JM, as well as between those with OM and JM (Bonferroni p < 0.001). CONCLUSIONS: The new modified Composite Radiographic Index introduced in this study, appears to have improved an objective approach to the previously used Composite Radiographic Index by means of cumulative radiologic features. Τhe predominance of certain radiologic features in one or more of these entities may lead the diagnostician towards the correct diagnosis.