Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite

Local release of antibiotic has advantages in the treatment of chronic osteomyelitis and infected fractures. The adequacy of surgical debridement is still key to successful clearance of infection but local antibiotic carriers seem to afford greater success rates by targeting the residual organisms present after debridement and delivering much higher local antibiotic concentrations compared with systemic antibiotics alone. Biodegradable ceramic carriers can be used to fill osseous defects, which reduces the dead space and provides the potential for subsequent repair of the osseous defect as they dissolve away. A dissolving ceramic antibiotic carrier also raises the possibility of single stage surgery with definitive closure and avoids the need for subsequent surgery for spacer removal.In this article we provide an overview of the properties of various biodegradable ceramics, including calcium sulphate, the calcium orthophosphate ceramics, calcium phosphate cement and polyphasic carriers. We summarise the antibiotic elution properties as investigated in previous animal studies as well as the clinical outcomes from clinical research investigating their use in the surgical management of chronic osteomyelitis.Calcium sulphate pellets have been shown to be effective in treating local infection, although newer polyphasic carriers may support greater osseous repair and reduce the risk of further fracture or the need for secondary reconstructive surgery. The use of ceramic biocomposites to deliver antibiotics together with BMPs, bisphosphonates, growth factors or living cells is under investigation and merits further study.We propose a treatment protocol, based on the Cierny-Mader classification, to help guide the appropriate selection of a suitable ceramic antibiotic carrier in the surgical treatment of chronic osteomyelitis.

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“…Eight of the 10 cases healed with a single operation and all 10 remained infection-free at final review 65.…”

Section: Oxford Protocol For Dead Space Management With Ceramic Biocomentioning

confidence: 95%

“…The only study investigating a commercially available biphasic cement showed a lower infection recurrence rate of 4% 65. This large study included patients with poor Cierny & Mader (C-M) hosts and Type III and IV chronic osteomyelitis, infected non-union and concomitant septic arthritis.…”

Section: Outcomes In the Use Of Ceramic Antibiotic Carriersmentioning

confidence: 99%

Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections

Ferguson

Diefenbeck

McNally

2017

J. Bone Joint Infect.

130

153

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“…The use of RBGS mixed with vancomycin has been shown to be a successful outcome in the management of chronic osteomyelitis and non-union in adults [28, 29]. McNally MA et al described effective results in the treatment of deep bone infection using a new antibiotic-loaded biocomposite in the eradication of infection from bone defects [30]. Also, a systematic review of 15 studies to access the utility of anti-infective bone graft substitutes in osteomyelitis treatment suggested that such treatment could be a good option [25].…”

Section: Discussionmentioning

confidence: 99%

Clinical experience of debridement combined with resorbable bone graft substitute mixed with antibiotic in the treatment for infants with osteomyelitis

Zhang¹,

Li²,

Li³

et al. 2018

J Orthop Surg Res

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BackgroundOsteomyelitis (OM) is an uncommon disease that originates from many different mechanisms in children. Treatment often involves a combination of surgical debridement combined and antibiotic therapy. The purpose of this article is to evaluate the effect of debridement combined with a new resorbable bone graft substitute (RBGS) mixed with antibiotics in the treatment of infants with OM.MethodsTwenty-two patients diagnosed with OM at our institution underwent debridement combined with implantation of RBGS mixed with vancomycin within 48 h after admission. Clinical and epidemiological factors, preoperative and postoperative radiographs, and laboratory parameters, including white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and neutrophil percentage (NEU%), were documented. The function of the involved extremity was evaluated at the final follow-up.ResultsThe mean age was 6.3 ± 4.8 months (range, 0.5 to 12 months). The mean duration of the symptoms was 14.5 ± 8.4 days (range, 2 to 30 days). The average length of hospitalization was 13.7 ± 6.2 days (range, 6 to 28 days). 13.64% (3/22) had positive results of purulent material obtained at the time of open biopsy and 18.18% (4/22) had positive blood cultures. The most common sites were located in the proximal femur (12), the distal femur (3), and the proximal humerus (3). Ten patients presented with concurrent pyogenic arthritis, while another 12 infants suffered from simple isolated hematogenous OM. The mean follow-up time was 3.0 ± 1.6 years (range, 1.0 to 6.0 years). Seven of 22 patients (31.82%) had complications such as limb length deformity (LLD), avascular necrosis (AVN), and pathologic subluxation of the hip. Fifteen out of 22 (68.18%) patients achieved good results. Additionally, patients who had concomitant pyogenic arthritis were more likely to develop complications than those with isolated OM (p = 0.02).ConclusionsEarly debridement combined with implantation of RBGS mixed with vancomycin in the treatment of infants with OM achieved acceptable results in this series. Compared to those with simple isolated OM, patients with secondary pyogenic arthritis had a more virulent course.

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“…Therefore, the combination of a calcium sulfate/hydroxyapatite composite with local antibiotic gentamicin (CERAMENT™ G, Bonesupport, Lund, Sweden) seemed to be a reasonable alternative. So far, the applied BGS in our case has been used in bone reconstruction after osteomyelitis [20], but not in spine surgery. The composite enabled us to combine posterior debridement, posterior stabilization, and filling of the intervertebral space in a one-stage procedure.…”

Section: Discussionmentioning

confidence: 99%

First report on treating spontaneous infectious spondylodiscitis of lumbar spine with posterior debridement, posterior instrumentation and an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin: a case report

2016

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BackgroundSpontaneous infectious spondylodiscitis is a rare, but serious disease with the risk of progressive neurological impairment. The surgical approach to spontaneous infectious spondylodiscitis is in most cases an anterior debridement and fusion, often in staged surgeries. Here we report a case of single-stage posterior debridement and posterior instrumented fusion in combination with an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin.Case presentationA 59-year-old Caucasian man presented with a 6-week history of lumbar pain without sensory or motor disorders of his lower extremities. A magnetic resonance imaging scan of his lumbar spine in T2-weighted sequences showed a high signal of the intervertebral disc L4/L5 and in T1-weighted sequences an epidural abscess at the posterior wall of L4. Additional computed tomography imaging revealed osteolytic destruction of the base plate of L4 and the upper plate of L5. Antibiotic therapy was started with intravenous ciprofloxacin and clindamycin. We performed a posterior debridement via a minimally invasive approach, a posterior percutaneous stabilization using transpedicular screw-rod instrumentation and filled the intervertebral space with an injectable calcium sulfate/hydroxyapatite composite which elutes a high concentration of gentamicin. The patient’s lower back pain improved quickly after surgery and no recurrence of infection has been noticed during the 1-year follow-up. Computed tomography at 11 months shows complete bony fusion of L4 and L5.ConclusionsAn injectable calcium sulfate/hydroxyapatite composite releasing a high level of gentamicin can support the surgical treatment of spondylodiscitis in combination with posterior debridement and transpedicular screw-rod instrumentation.

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Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite

Abstract: This single-stage protocol, facilitated by the absorbable local antibiotic, is effective in the treatment of chronic osteomyelitis. It offers a more patient-friendly treatment compared with other published treatment options. Cite this article: Bone Joint J 2016;98-B:1289-96.

Cited by 199 publications

References 41 publications

Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections

Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections

Clinical experience of debridement combined with resorbable bone graft substitute mixed with antibiotic in the treatment for infants with osteomyelitis

First report on treating spontaneous infectious spondylodiscitis of lumbar spine with posterior debridement, posterior instrumentation and an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin: a case report

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