Combination therapy with vancomycin-loaded calcium sulfate and vancomycin-loaded PMMA in the treatment of chronic osteomyelitis

Abstract

Background: Chronic post-traumatic and postoperative osteomyelitis is a refractory disease which results in significant morbidity and mortality. The effect of combination therapy with vancomycin-loaded calcium sulfate and vancomycin-loaded polymethyl methacrylate (PMMA) was unknown. Methods: Fifty-one patients suffering from chronic post-traumatic or postoperative osteomyelitis of the lower extremities were included in the retrospective investigation. The patients were assigned to the study group of the combination therapy with antibiotic-loaded calcium sulfate and antibiotic-loaded PMMA or the control group of the antibiotic-loaded PMMA. Hematological parameters, eradication of infection, rate of infection recurrence and reoperation rate were evaluated during the follow-up. Results: The cases were followed up for an average of 24 months (range, 15-48 months) after the first-stage surgical operation. In the study group, all the patients revealed complete calcium sulfate resorption at an average of 6 weeks (range, 30-60 days). In the study group, infection was primarily eradicated in 92.31% (24 of 26) of patients and re-operation rate of 7.69% (2 of 26) after the first-stage surgery. Two patients underwent further surgical operation in the study group. One case achieved infection eradication in the recurrent two cases, with a secondary infection eradication rate of 96.15% (25 of 26). There was no persistent infection in the study group. In the control group, infection was eradicated in 64.00% (16 of 25) of patients and re-operation rate was 36.00% (9 of 25) after the first-stage surgery. Nine patients in the control group underwent further surgical operation. Two case achieved infection eradication in these cases who suffered from persistent or recurrent infection, with a secondary infection eradication rate of 72.00% (18 of 25). There was more re-operation rate in the control group (PMMA group, 9 vs combination therapy group, 2; P = 0.034).

A dual PMMA/calcium sulfate carrier of vancomycin is more effective than PMMA‐vancomycin at inhibiting Staphylococcus aureus growth in vitro

“…Chronic osteomyelitis, especially resulting from multidrug‐resistant bacteria, is still a refractory disease and one of the major challenges for orthopedic surgeons, even though great progress has been made in surgical treatment and antibiotics for chronic osteomyelitis [1]. Local antibiotic‐loaded delivery systems are commonly adapted as effective vehicles for chronic osteomyelitis, to maintain antibiotics at a high level at the local site of osteomyelitis [2,3]. Antibiotics‐loaded poly(methyl acrylate, methyl methacrylate) (PMMA) was the effective antibiotic carrier system to control chronic osteomyelitis, because it can provide the following advantages: a high releasing level of antibiotics at the local site of infection, synchronously eliminating the surgically debridement‐derived dead space, low toxicity and less in serum [3–4].…”

Treatment of chronic osteomyelitis with locally made calcium sulfate bone cement pellets impregnated with antibiotics at University Teaching Hospital of Butare (CHUB), Rwanda

“…Calcium sulfate absorbs plenty of water, which subsequently promotes seroma formation and increases the risk of secondary infection. 2 Our experience also showed that the calcium sulfate might not be completely degraded, causing a foreign body reaction in a small number of cases.…”

“…Antibiotic-impregnated bone cement was introduced in the 1970s to treat infected arthroplasties, and antibiotic-impregnated beads have since been developed to treat local soft tissue and bone infections. 1,2 The advantage of antibiotic-containing beads is that they fill the dead space produced by sequestrectomy and bone curettage and the resulting local antibiotic concentrations vastly exceed the minimum inhibitory concentrations for most pathogens isolated in orthopaedic infections. 1,2,[6][7][8][9][10][11][12] Calcium sulfate can be loaded with antibiotics and used as a biodegradable medication delivery device.…”

“…With the biodegradation, they do not need to be surgically removed. 2,6,8,11 Commercially manufactured bone cement is too expensive for the Rwandan population and probably for most of the African population. Additionally, it is not readily available in our market.…”

“…1 Antibiotic-impregnated calcium sulfate beads have been demonstrated to provide an adequate local antibiotic concentration at the site of COM for 2 to 3 weeks. 2 In this paper, we present the experience of locally made antibiotic-impregnated calcium sulfate pellets as local antibiotic therapy for COM at University Teaching Hospital of Butare (CHUB), Rwanda.…”