Vancomycin Three Ways: Multimodal Utilization of Intraoperative Antibiosis in Complex Foot and Ankle Infection

Abstract

Osteomyelitis of the foot and ankle is an unfortunate, albeit pervasive, complication faced by orthopedic surgeons and their patients. Chronic osteomyelitis confers a great risk of amputation and protracted hospital admission in patients with diabetes, existing orthopedic hardware, and/or compromised tissue perfusion. The current standard of practice in the treatment of osteomyelitis is the initiation of broad antibiotic coverage followed by subsequent narrowing informed by culture data and sensitivities. While mild to moderate infections are treated with oral antibiotics, more severe infections are often treated using intravenous (IV) antibiotics. Vancomycin, in its IV form, is frequently administered intraoperatively for patients with osteomyelitis as it confers adequate coverage of common causative organisms, including staphylococcus aureus. However, given the diminished blood flow to distal extremities commonly seen in patients experiencing this complication, inadequate distribution of oral or IV antibiotics may occur. This is especially problematic, as it leads to an increased risk of recurrent infection and the ultimate need for amputation. Here, we present an alternate method of intraoperative vancomycin administration for patients with chronic osteomyelitis in the form of paste, powder, and injectable slurry. Postoperatively, oral or IV antibiotics are continued based on OR culture susceptibility. We found this to be an effective way to administer intraoperative antibiotics to ensure adequate osseous and soft tissue penetration in patients with complicated osteomyelitis of the foot and ankle. Level of Evidence: III.