Neoplasms as a result of chronic insults were described as early as during the Roman Empire. Aulus Cornelius Celsius told of tumoral neoformations in correspondence to chronic wounds [
2]. During the mid-19th century, Hawkins and Marjolin correlated these skin diseases with osteomyelitis [
3]. In a Mayo Clinic study in which investigators analyzed about 4000 cases of chronic osteomyelitis, malignant lesions were noted in 23 % of the patients [
4]. The incidence of skin lesions ranges between 0.2 % and 1.7 % of all patients affected by osteomyelitis [
5,
6]. In developing countries, the percentages increase with delayed diagnosis and inadequate treatments [
7]. Nowadays, trauma is the most common cause of osteomyelitis [
5]: Infection rates range from 4 % to 64 % in open long bone fractures, and the incidence is increasing [
8]. The occurrence of hematogenous osteomyelitis is declining, with the incidence dropping from 87 to 42 cases per 10,000 [
8]. The duration of osteomyelitis appears to be the principal factor related to carcinogenesis onset, with a minimum latency period of 20 years or more [
9]. Males are affected more often than women, with a predominance of 85 %, and patients’ are typically aged between 50 and 60 years old [
5]. The tibia, femur, and foot are the most frequent locations [
5,
10]. Clinical signs that should alert the clinician about malignant transformation include increased pain, blood, or foul release from the sinus; progressive bone destruction and erosion; and a growing mass in the area of the wound [
2]. To prevent local invasion and metastatic spread, treatment should not be delayed. The pathogenesis of this neoformation is still under debate, but the most widely accepted theory is focused on the chronic inflammatory state [
7,
11]. In these conditions, the immune system is dysregulated: Inflammatory mediators and cytokines expressed by the immune system modulate the genic expression of various proteins, including p53 [
11]. Furthermore, avascular areas and lymphatic duct obliteration [
7] are conditions that discourage antigen presentation. Polymicrobial infection sites are also characterized by horizontal gene transfer and consequent latent mutations that interfere with the immune response [
12]. There is evidence that carcinomatous transformation can follow a shift in bacterial flora. Gram-positive flora can be replaced by predominant gram-negative flora that produce endotoxins associated with cancer [
12].
The diagnosis can be made with the use of a primary and secondary imaging medical device. Magnetic resonance imaging can be useful to differentiate squamous cell carcinoma from other soft tissue neoplasms [
15]. Whole-body positron emission tomography-CT can clarify a suspicion of metastasis, especially in the lungs, the most common site. Shave biopsy, incisional biopsy, excisional biopsy, and punch biopsy are the settling examinations [
14]. They should include portions of the entire lesion: ulcer, sinus, and the marrow space.
Patients affected by chronic osteomyelitis with recurrent exacerbations undergo frequent hospital admissions, pharmacological therapies, and surgical procedures during their lifetimes. Several authors have suggested that amputation is the definitive treatment [
5,
10,
16,
17]. Body image anxiety, social discomfort, and depression are frequent consequences of lower limb amputation [
18,
19]. It is a tough choice that involves both physical and psychological issues, but in our experience it can guarantee better quality of life. In some selected cases and in the absence of metastasis, it is possible to evaluate a wide excision of the lesion, making use of Mohs micrographic surgery to resect at least 2 cm of tumor-free margins. Our patient at first did not accept the amputation. In his opinion, it would have prevented him from riding motorbikes, his preferred sport activity, and it would have altered his social role. Different authors have reported that persons with lower limb amputation can restore patients’ life habits [
19] and riding and/or driving capabilities [
20], but barriers such as family understanding, inadequate legislation, and confusion over various driving adaptations can slow the return to the community [
19] and to the activities conducted before the amputation [
20]. Our patient underwent a toilet of the osteomyelitic hotbed. The bone substitute we used is BonAlive S53P4 bioglass (BonAlive Biomaterials, Turku, Finland). Bone graft substitutes are widely used in orthopaedics since several decades with good outcomes whenever there is a need of a matrix capable to bridge regenerative or reparative biological effects. In most cases bone substitutes have just an osteoconductive effect and their efficacy is restricted only to certain conditions [
21,
22]. Autologous or heterologous bone transplants, in addition to being a substitute, have an osteostimulative effect. Unfortunately, the autologous effects are related to the adverse effects and comorbidities associated with a second surgical procedure, while the heterologous effects are related to infective risks and immune intolerance. Bioglass is a material with both osteoconductive and osteostimulative effects, as well as having antibacterial properties [
21,
22].