Marjolin's ulcer in chronic osteomyelitis: seven cases and a review of the literature

Purpose of the study Malignant degeneration of chronic wound inflammation is a rare complication which almost always develops late. Unstable wounds and scar tissue related to chronic osteitis can degenerate after along period of chronic inflammation. We report seven cases. Case reports Seven patients presented squamous-cell carcinoma of the skin which had developed on wounds related to deep bone infections. Three patients had chronic bone infections subsequent to posttraumatic osteitis, two after hematogenous osteomyelitis, one after osteitis which developed on a zone of radiation-induced necrosis, and one after a deep burn was complicated by osteitis. The skin lesions developed over a period of 43 years on average before the diagnosis of malignant degeneration was established. Most of the lesions presented as budding malodorous ulcers. The pathological diagnosis was spinocellular squamous-cell carcinoma in five cases and verrucous squamous-cell carcinoma in two. Conservative treatment with wide resection and flap cover was attempted in all seven patients. Results Treatment failed in four patients and three required amputation. One patient died two years after amputation with local recurrence and metastatic dissemination to the brain. Discussion The diagnosis of malignant degeneration requires pathological proof. Biopsy material should be obtained whenever there is a modification leading to the development of a fistula or the formation of a scar tissue over a focus of chronic osteitis. Prevention requires adapted treatment of chronic bone infections, avoiding directed wound healing which can lead to fragile unstable scar tissue subject to degeneration.