**14. The casuistry**

The casuistic is based on 50 patients with hematogenous osteomyelitis, all less than 16 years old, age at which the growth cartilage knit, and 117 post-traumatic infective pseudoarthroses, where this term has been adopted for cases who showed a lack of non-solidification at 6 months after trauma.

We expressly made a distinction between hematogenic and post-traumatic forms, as the relations bacterial count vs. host response do differ. Let us first consider the hematogenic form with all patients infected by coagulase positive *Staphylococcus aureus*.

Males were infected most often (78%); the prevailing age were between 10 and 16 years old.

Lower limbs were involved three times more than arms, while there was no difference between proximal diaphyseal and distal diaphyseal localisation. In 30% of cases the lesion involved the whole bone segment (panostytis), while the remaining 70% showed a localisation at the diaphysis half (42%) or at the diaphysis (28%).

In males diffused forms are more frequent, while in females the same applies to localised forms.

Patients have been checked with a following-up lasting from 1 till 10 years after healing (where healing has already been defined).

With the depicted criteria we obtained 86% of healing (88.5% when considering localisation), of which 74% already from the first treatment, and only 12% after possible recurrences. Of these relapses only the half involved a bone, while in the other cases they were the periodical opening of abscesses and fistulae, without any bone involvement. 50% of the patients healed by adopting only immunotherapy; in 38% immunotherapy complemented a surgical intervention, and remaining 11.5% did not heal.

#### *Infections and Sepsis Development*

As far as time elapsed from treatment beginning till healing is concerned, we observed 46% healing within 6 months, 30% between 6 months and 1 year, and 24% between 1 and 5 years with an average duration of 9.6 months.

With reference to radiographic belated evidences 20 patients showed the damaged bone segments fully leaked, whereas in later checks 33 patients showed a bone rearrangement (residual osteosclerosis without periostal reaction or osteolytic area).

In 7 cases there were still traces of active infection.

In 3 cases the later checks showed growth disturbs higher than 2.5 cm (in 2 cases there had been a contraction owing to growth cartilage lesions and in 1 case there was a lengthening). In 5 further cases, that initially showed limb lengthening, such dysmetrias disappeared afterwards.

In 5 cases the later checks showed a limitation in movements concerning the articulation near the focus; in 4 cases such limitation was already ascertained at the first control and imputable to the treatment with plaster. The joint limitation has never been imputable to joint involvement by the inflammation process (osteoarthritis).

In 3 cases there were deformities of the bone segments (coxa varia, femur procurvation).

We discuss now the data concerning the 147 cases of post-traumatic infective pseudoarthrosis.

The higher percentage of 75.5% concerns pseudoarthrosis subsequent to osteosynthesis.

In this percentage there were 118 males (83.3%) and 29 female patients (19.7%). Mean age has been 32 years and 5 months; the youngest patient was 18 years old, whereas the oldest was 68 years old. The most frequently interested bone has been the shinbone with 99 cases and secondarily the femur with 35 cases.

25 cases were a two bone fractures and there were exactly 19 tibia and fibula and 6 radius and ulna fractures.

We had 7 cases concerning radius and ulna, 3 cases collar bone, 1 case humerus and 1 case hand. The time elapsed between trauma and infection beginning has been in the male 30 days with 7 days in the shortest case and 5 months in the most belated.

The tome between infection initial and our therapy start has been on an average 8 months, varying from minimal 6 months till maximal 4 years. Our treatment allowed almost always precocious weight bearing; as a matter of fact only the most serious cases had to wait 6 months before being in condition to use the sick limb.

At first hospitalisation already 89.1% of the patients showed a fistula.

In all cases therapy has been immunotherapy+antibioticotherapy. In 11 cases immunotherapy has been repeated and in 5 cases it has been administered 3 times.

We carried out 98 surgical toilets and sequestrectomies, of which 22 cases were more than once. In 4 cases we carried out Paltrinieri parafocal osteotomy (all tibial). In 45 cases the Ilizarof system has been adopted with resection of the focus and compactotomy. We had to amputate only in 1 case. Solidification rimes vary according to the involved bone. On the tibiae they vary from at least 3 till maximal 36 months, on average 9.9 months.

More frequently (76.8% of cases) healing was attained within 1 year from therapy start, 26 cases (equalling 26%) did not attain solidification, of which 18 cases are still under treatment.

Very similar times have been observed on femurs, from 3 till 35 months with 9.2 months average duration.

Also for the femur the 84% of cases heals after 12 months therapy, whereas the non consolidated cases are 10 equalling 28.6%, of which 6 cases are still under treatment.

The forearm does not show substantial differences concerning ulna and radius; the same results indeed have been obtained for both bone segments; in 2 cases on 7 we observed a lack of solidification with bone material loss/this happened in the pre-microsurgical period of our experience).

Fistulae closed fairly fast 6 months in 53.48 of cases. The main check control has been 15 months, varying from 4 months at least up to 7 years.

Belated consequences have been:

Articular rigidity. Patients who have been treated with immunotherapy and submitted to plaster casts, both cylinder or valve casts, and precocious walking showed significant articular functional limitations only in 26 cases, equalling 17.6%. 14 cases concerned the talocrural articulation, 8 cases the knee and 4 cases on 7 concerned the elbow.

Shortenings have been significant (more than 4 cm) only in 2% of cases, whereas there have been 30.5% with less than 4 cm. In the whole 102 cases showed shortenings, that were compatible with a good functionality of the sick limb with good walking.

Axial deviations appeared in 18.3% of cases: 15 cases in varus dislocation, 12 in valgus dislocation, 17 in recordation and 10 in procurvation. Calcification of soft parts have been only 3.4%, whereas they were very frequent before systematically introducing immunotherapy.

Relapses concern 26.5% of our patients, i.e. about 39 cases. In 15 cases (10.2%) it was a simple reopening of the fistula that healed soon, in 13 cases the restart of the infective focus was associated with a new relaxation of the fracture. Afterwards 9 cases healed and these have been the precocious relapses (within 1 year from healing), the belated ones have been 11 cases (7.5%) with 10 healings.
