Infected bone resection plus adjuvant antibiotic-impregnated calcium sulfate versus infected bone resection alone in the treatment of diabetic forefoot osteomyelitis

Abstract

Background Managing with diabetic foot osteomyelitis (DFO) is challenging. Even after infective bone resection and thorough debridement, DFO is still difficult to cure and has a high recurrence rate. This retrospective study aims to compare the outcomes of two treatment methods, infected bone resection combined with adjuvant antibiotic-impregnated calcium sulfate and infected bone resection alone, for the treatment of diabetic foot osteomyelitis. Methods Between 2015 to 2017, 48 limbs (46 patients) with DFO met the criteria were included for assessment. 20 limbs (18 patients) were included in the calcium sulfate group (the CS group) in which vancomycin and/or gentamicin-impregnated calcium sulfate was used as an adjuvant after infected bone resection while 28 limbs (28 patients) as the control group were undergone infected bone resection only. Systemic antibiotics, postoperative wound care and offloading were continued to be applied following surgery in both groups. The time to healing, healing rate, recurrence rate and amputation rate were compared between the two groups. Results In total, 90% (18/20) limbs in the CS group as compared to 78.6% (22/28) infected limbs in the control group went to heal ( P = 0.513). The Mean time to healing was 13.3 weeks in the CS group and 11.2 weeks in control group ( P = 0.132). Osteomyelitis recurrence rate was 0% (0/18) in the CS group and 36.4% (8/22) in the control group ( P = 0.014). Postoperative leakage in calcium sulfate group was 30.0% (6/20) with a mean duration of 8.5 weeks. Amputation rate in the control group was 7.1% (2/28) compared to 0% (0/20) in the CS group ( P = 0.153). Conclusions Antibiotic-impregnated calcium sulfate as an adjuvant prevents the recurrence of DFO but cannot improve the healing rate, reduce the postoperative amputation rate or shorten the time to healing. Prolonged postoperative leakage as the most common complication can be managed with regular dressing. Level of Evidence III, Retrospective Comparative Study.

Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update

“…Although local antibiotic treatments are widely used for DFO, there is little high-quality evidence on the appropriate indications, best techniques, proper dosages, types of antibiotics, elution properties or pharmacokinetics [ 63 ]. The most recent published report on this topic is a retrospective review of patients with forefoot DFO who did or did not have perioperative antibiotic-impregnated calcium sulphate implanted [ 64 ]. They found that the antibiotic implant did not improve the rate of, or shorten the time to, healing, nor reduce the postoperative amputation rate.…”

“…They found that the antibiotic implant did not improve the rate of, or shorten the time to, healing, nor reduce the postoperative amputation rate. It did, however, reduce recurrences of DFO, but at the price of about a third of the patients having wound leakage that lasted for a couple of months [ 64 ].…”

Stimulan® Antibiotic Impregnated Beads for the Treatment of Diabetic Foot Infection

“…There was no recurrence recorded after 12 months. [12] A retrospective study by Noman et al reviewed the effectiveness of using adjuvant calcium sulfate antibiotic impregnated beads and debridement on seventy patients with diabetic foot osteomyelitis showed a 90% infection eradication rate and 81% healing rate after a follow-up of 10 months. [4] The result of high healing rates recorded in these studies could be explained by more residual microorganisms being eradicated by the delivery of a higher concentration of antibiotics directly to the wound.…”

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“…Approximately 40-80% of all diabetic foot ulcers (DFU) lead to diabetic foot infections, [1][2][3][4] 20% of these DFUs go on to develop diabetic foot osteomyelitis (DFO). [1][2][3][4][5] Patients with DFO often require hospitalization for surgical excisional debridement of infected bone and at times the discharge process is delayed as patients await antibiotic sensitivities for long term intravenous (IV) antibiotics.…”

“…Approximately 40-80% of all diabetic foot ulcers (DFU) lead to diabetic foot infections, [1][2][3][4] 20% of these DFUs go on to develop diabetic foot osteomyelitis (DFO). [1][2][3][4][5] Patients with DFO often require hospitalization for surgical excisional debridement of infected bone and at times the discharge process is delayed as patients await antibiotic sensitivities for long term intravenous (IV) antibiotics. 6 Prior studies have demonstrated a correlation between increased patient length of stay with an increased susceptibility to acquiring hospital related illnesses and iatrogenic complications, [7][8][9][10][11] as well as creating bottlenecks in the emergency department (ED) for patients awaiting hospital beds.…”