PMC7210920_01
Anteroposterior radiograph of the right knee at the time of presentation (a) demonstrating heterotopic bone formation and increased density along the medial side of the proximal tibia indicative of osteomyelitis. Lateral radiograph of the right knee at the time of presentation (b) demonstrates increased density of the proximal tibia with a lucent area in the center consistent with osteomyelitis.
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F1
At that time, a plain radiograph demonstrated concerns of chronic osteomyelitis of the right proximal tibia although tumor or subacute fracture was also considered (Fig. 1).
T2 sagittal magnetic resonance imaging (MRI) of the right knee at the time of presentation (a). Signal change posterior to the proximal tibia can be seen indicating the location of infection and surrounding inflammation. T2 axial MRI of the right knee at the time of presentation (b). The same signal change is seen posterior to the proximal tibia showing the location of the infection.
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F2
Contrasted magnetic resonance imaging (MRI)demonstrated findings consistent with chronic osteomyelitis along the medial aspect of the proximal tibial epiphysis and metaphysis, however, with a cloaca extending from a cortical disruption of the posteromedial tibial metaphyseal cortex (Fig. 2).
Anteroposterior radiograph of the right knee at the time of recurrence (a). There are 3 lucent areas on the medial side of the proximal tibia, and the physes are now closed, likely due to infectious involvement. Lateral radiograph of the right knee at the time of recurrence (b). One of the lucent areas can be seen in the posterior aspect of the proximal tibia, likely a nidus of infection. There is possible erosion through the posterior aspect of the tibia. No involucrum, sequestrum, or periosteal abnormalities were noted.
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F3
Plain radiographs demonstrated concern of recrudescent chronic osteomyelitis in the proximal tibia, with worsening sclerotic changes compared with his most recent radiograph (Fig. 3).
T2 axial magnetic resonance imaging (MRI) of the right knee at the time of recurrence. These axial images demonstrate recurrent infection posterior as well as new signs of infection anterior on the proximal tibia. There is edema that can be seen posteriorly as well as a fluid collection posteromedial. The MRI further demonstrates likely erosion through the posteromedial proximal tibial cortex with some signal change subperiosteal. No signal change within the medial head of the gastrocnemius. The neurovascular structures are not involved.
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F4
A contrasted MRI demonstrated abnormal signal intensity in the proximal tibial metaphysis and epiphysis, with an abscess connected to a nidus of presumed chronic osteomyelitis througha fistula tract running inferior to the physis (Fig. 4 and 5).
T2 coronal magnetic resonance imaging of the right knee at the time of recurrence. There is signal change throughout the proximal tibia and likely a collection of infection on the medial aspect of the proximal tibia (seen as a white fluid collection, marked by arrow).
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F5
A contrasted MRI demonstrated abnormal signal intensity in the proximal tibial metaphysis and epiphysis, with an abscess connected to a nidus of presumed chronic osteomyelitis througha fistula tract running inferior to the physis (Fig. 4 and 5).
Final anteroposterior radiograph of the right knee taken 3 months after surgery (a) showing no signs of recurrence, closed physes, and the empty area of resected infected bone.Final lateral radiograph of the right knee (b) showing no signs of recurrence, closed physes, and the empty area of resected infected bone (in brackets).
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F6
A contrasted MRI performed 7 weeks and plain radiographs performed 3 months into treatment demonstrated no recrudescence of disease (Fig. 6).