Surgical Management of Diabetic Foot Osteomyelitis using the end-capping technique with Antibiotic Loaded Calcium Sulphate Hydroxyapatite (Cerament®)

Abstract

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.