BackgroundWith the advent of bacterial resistance, it is important now more than ever to evaluate use of antibiotic chemoprophylaxis in foot and ankle surgery. Within this area of the body there may be less dissection, surgery time with smaller incisions and importantly smaller sizes of implanted fixation as compared to other bone and joint procedures. Our objective was to systematically evaluate the quality of evidence behind existing guidelines.MethodologyA systematic literature search was performed: MEDLINE, CINHAL, EMBASE and the Cochrane library from 1990 up to March 2018. To avoid omitting any studies on the subject, Google Scholar was also used. The inclusion criterion were studies exploring perioperative antibiotic use, postoperative infection rates in elective foot and ankle surgery and studies associated with this subject evaluating antibiotic use in clean elective foot and ankle surgery. The exclusion criterion being studies upon contaminated or dirty surgery or those which were inclusive of procedures proximal to the foot and ankle.ResultsOverall 11 studies met the inclusion criteria. From the grading of evidence, 2 level one and 4 level two studies were recognised. These studies ranked relatively highly in comparison to 5 studies that were graded as level three and level four tiers of evidence. Results of SSI rates found within this systematic review ranged from 0% to 9.4% of overall postoperative infections encountered after foot and ankle surgery in the studies analysed.ConclusionWhilst fragmented, aspects of antibiotic chemoprophylaxis are established fields in elective surgery with a growing body of evidence. Evidence for antibiotic use however, specifically within elective foot and ankle surgery, is lacking. This systematic review is a seminal paper which delivers an impression of the most influential literature within the field of foot and ankle surgery, with the aim being to entice conclusions and guide future research.

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Introduction Antibiotic loaded calcium sulphate hydroxyapatite (Cerament®) is being used increasingly to treat infections of the lower limb, in particular those associated with diabetes mellitus. Cerament® readily integrates and is replaced by new bone, whilst allowing for continued new bone integration. When impregnated with antibiotics, it also provides antimicrobial action and closure of dead space. Methodology This single centre, retrospective case series presents 16 patients who underwent pedal resection of amputation for the management of diabetic foot osteomyelitis. Primary outcomes measured include infection eradication, healing time, antibiotic duration with secondary measures including complication rate and duration of hospital admission. Results The average age of the cohort was 58.88 years (SD 10.09) and 87.5% of patients were male with type 2 diabetes mellitus. A paired t-test was conducted to examine whether the duration of infected ulceration and post-operative resolution time was statistically significant t(16) = 4.86, p = .0002, df = 15. Two tailed independent t-tests demonstrated no significant difference between reulceration rate in patients treated with Cerament® V and G (t(14) = 0.71, p = .491). Fishers exact tests demonstrated there was no significant correlation between treatment with Cerament® and complication rates, neurovascular status, preoperative antibiotic duration, post operative antibiotic durations, Texas wound classification, suggesting that these could be independent of one another. 100% of ulcers healed post intervention. Discussion This study demonstrates that earlier intervention and the use of Cerament® reduces the need for extended antibiotic treatment and may contribute to the prevention of widespread antibiotic resistance associated with antibiotics. Furthermore, use of antibiotic combinations in bone cement is thought to improve antibiotic efficacy and minimise failure relating to resistance, whilst resolving chronic osteomyelitis at an improved rate. Conclusion Cerament® provides an easy to use, safe and effective medium for bone substitution and local antibiotic delivery, in the case of patients undergoing pedal amputations for diabetic foot osteomyelitis. There was a low rate of complications and minimal re-infection rate. The limitations of this study include the small sample size, short term follow up and lack of control group, therefore further prospective study would be beneficial.

Several groups of antibiotics are known to interact with warfarin, presenting a challenge to the prescriber trying to manage underlying clinical infection, whilst mitigating the risk of coagulopathy. The authors present a case report of a 64-year old warfarinised patient who underwent forefoot surgery and developed a subsequent post-operative infection with combinations of antibiotics, leading to excessive anticoagulation and an adverse drug event. From reviewing both local and national guidance, careful monitoring is mandatory, dosing adjustments and pre-emptive dose reduction might also be needed. Consultation within the wider multi-disciplinary network will be central to decision making and implementing safety netting measures.