Antibiotic-loaded Cement Beads Research Articles

Bioactive glass S53P4 to fill-up large cavitary bone defect after acute and chronic osteomyelitis treated with antibiotic-loaded cement beads: A prospective case series with a minimum 2-year follow-up

Introduction: Bioactive glass S53P4 (BAG-S53P4) has been used in the treatment of osteomyelitis with excellent results. The aim of this study was to evaluate the clinical and radiographic results of patients treated with use of antibiotic-loaded cement beads, followed by bone defects filling using bioglass. Methods: We treated a prospective series of patients presenting with acute or chronic osteomyelitis of a long bone of the upper or lower limb. The first-stage procedure involved debridement and filling of cavitary defects with antibiotic-loaded polymethylmethacrylate (PMMA) beads. When signs of infection subsided, the defects were filled with BAG-S53P4. The main outcomes assessed were the reinfection rate, need for reoperation, radiographic and functional evaluations (DASH and Lysholm scores). Results: Ten patients were included, aged between 4 and 66 years (mean 25.4 years). The source of infection was hematogenic in five cases and post-traumatic in the other five. Hematogenic infections required two debridements before filling with bioglass, whereas post-traumatic cases required only one. The time between the first debridement and the application of bioglass varied from 1 to 63 weeks (average of 17 weeks). All patients showed a favorable evolution after bioglass procedure, with no need for reoperation or relevant wound problems. The radiographic evaluation showed partial incorporation of the material and adequate bone formation, and functional scores were satisfactory in all cases. Conclusion: The treatment of osteomyelitis with surgical debridement and PMMA beads, followed by filling of bone defect with BAG-S53P4, was effective in all patients evaluated, with adequate infectious control and bone regeneration. No cases required reoperation after bioglass implantation. Patients with hematogenous osteomyelitis required a greater number of debridements before filling with bioglass.

Acute Delayed or Late Infection of Revision Total Hip Arthroplasty Treated with Debridement/Antibiotic-loaded Cement Beads and Retention of the Prosthesis.

PurposeThe treatment of infected revision total hip arthroplasty (THA) is very challenging due to retained revision prosthesis, poor bone stock and soft tissue condition derived from previous revision surgeries, and comorbidities. The purpose of this study was to investigate the effectiveness and short-term outcomes of aggressive debridement and use of antibiotic-loaded cement beads with retention of the prosthesis for acute delayed or late infection of revision THAs.Materials and MethodsTen consecutive patients with symptoms or signs of less than one-week evolution and well-fixed prostheses, were treated with this procedure and a postoperative course of organism-specific antibiotics for a minimum of 6 weeks. All hips presented with acute delayed or late infection of revision THAs. Patients with a mean age of 68.1 years (range, 59-78 years) underwent an average of 1.9 previous revision THAs (1-4) before the index surgery. The minimal follow-up was 2 years with a mean of 46.2 months (range, 24-64 months).ResultsThere were 8 cures (80.0%) and 2 failures with no mortality during the study period. The 2 failures involved the same and resistant bacteria implicated in the primary infection (methicillin-resistant Staphylococcus aureus and Prevotella oralis, respectively). The mean Harris hip score was 65.2 (range, 26-83) and the mean visual analogue scale was 2.6 (range, 1-4) at final follow-up.ConclusionWith a favorable success rate and no mortality, our procedure may be considered a safe and effective alternative for the treatment of acute delayed or late infection of revision THAs with well-fixed prostheses.

Effects of loading concentration, blood and synovial fluid on antibiotic release and anti-biofilm activity of bone cement beads

Antibiotic loaded cement beads are commonly used for the treatment of biofilm related orthopaedic periprosthetic infections; however the effects of antibiotic loading and exposure of beads to body fluids on release kinetics are unclear. The purpose of this study was to determine the effects of (i) antibiotic loading density (ii) loading amount (iii) material type and (iv) exposure to body fluids (blood or synovial fluid) on release kinetics and efficacy of antibiotics against planktonic and lawn biofilm bacteria. Short-term release into an agar gel was evaluated using a fluorescent tracer (fluorescein) incorporated in the carrier materials calcium sulfate (CaSO4) and poly methyl methacrylate (PMMA). Different fluorescein concentrations in CaSO4 beads were evaluated. Mechanical properties of fluorescein-incorporated beads were analyzed. Efficacy of the antibiotics vancomycin (VAN) or tobramycin (TOB) alone and in combination was evaluated against lawn biofilms of bioluminescent strains of Staphylococcus aureus and Pseudomonas aeruginosa. Zones of inhibition of cultures (ZOI) were measured visually and using an in-vivo imaging system (IVIS). The influence of body fluids on release was assessed using CaSO4 beads that contained fluorescein or antibiotics and were pre-coated with human blood or synovial fluid. The spread from the beads followed a square root of time relationship in all cases. The loading concentration had no influence on short-term fluorescein release and pre-coating of beads with body fluids did not affect short-term release or antibacterial activity. Compared to PMMA, CaSO4 had a more rapid short term rate of elution and activity against planktonic and lawn biofilms. This study highlights the importance of considering antibiotic loading and packing density when investigating the clinical application of bone cements for infection management.

The control of dead space with antibiotic loaded cement beads and nails in high energy trauma

The control of dead space with antibiotic loaded cement beads and nails in high energy trauma

Antibiotic Treatment and Timing of Reimplantation

PJI is traditionally treated with intravenous (IV) antibiotics in order to obtain the minimum inhibitory concentration in the shortest time possible. Once this goal is met and there is clinical evidence of improvement, some IV antibiotic regimens can be switched to oral regimens. There is scarce literature reporting on the use of oral (combined or single) antibiotic therapy for the treatment of PJIs without an initial IV regimen [1–5]. Most of these studies were conducted in cases where the prosthesis was retained. There is one study in which no oral or prolonged IV regimen was used after debridement and the use of an antibiotic-impregnated cement spacers led to a 87% eradication rate [6]. No literature conclusively supports the use of only oral (combined or single) antibiotic therapy prior to reimplantation. The recently-published guidelines of the Infectious Diseases Society of America (IDSA) [7] suggest that pathogen-specific, highly bioavailable oral therapy (e.g. linezolid or fluoroquinolones) may be an alternative as initial therapy for some cases of PJI. Concerns against the routine use of appropriate oral agents in the treatment of PJI largely comprise questions of patient medication compliance and the long-term use of medication therapy with less intensive efficacy and toxicity monitoring.

Infections after high tibial osteotomy

High tibial osteotomy is an established method in the treatment for knee osteoarthritis. Infections are a rare but severe complication that might endanger the clinical, radiological and functional outcome and might require several surgical revisions. A systematic literature review was performed through PubMed until November 2011. Search terms were "HTO" or "(high) tibial osteotomy", alone or in combination with "infection(s)", "infected" or "septic". Only articles focussing on the infection treatment or analysis of risk factors for emergence of infection after high tibial osteotomy were included. A total of 26 studies could be identified. Seven studies were published before and 19 in or after 2000. One study had a level of evidence II, five level of evidence III and 20 level of evidence IV. Superficial infections were found in 1-9% and deep infections in 0.5-4.7% of the cases. Pin tract infections occurred in 2-71% of the cases. One study reported on a secondary bacterial arthritis in 4.5% of the cases. An oblique skin incision, non-smokers and a one-day hospitalization were found to be risk factors for infection emergence. Depending on the type of infection, treatment consisted of oral or systemic antibiotic therapy, alone or in combination with surgical revision, debridement and hardware removal. In some cases, antibiotic-loaded cement beads were inserted for local antibiotic therapy. Infections after high tibial osteotomy are rare. Current data about infection rates, infection localization, risk factors for emergence of infection and treatment options allow not for a generalization of conclusions. A large multi-centre study is required to develop a diagnostic and therapeutic algorithm. IV.

Distraction over Nail Using Circular External Fixation for Septic Pseudarthrosis of the Tibia

We present a report of nine patients (eight women and one man; mean age 37 years) from 2010 to 2012 with septic pseudarthrosis of the tibia treated with bone transport over an intramedullary nail using a circular external fixator. The mean follow-up was 15 months (range: 10-21 months). A two stage approach was used. At the first stage, removal of the primary osteosynthesis and extensive bone debridement to healthy, bleeding bone margins was performed. The bone defect was packed with antibiotic loaded cement beads, and stabilization of the tibia was done with a unilateral external fixator or with a long leg posterior splint. The mean size of bone defect was 4 cm (range: 3.5-5.5 cm). At the second stage, two consecutive negative wound cultures and normal values of blood cell count, C-reactive protein (CRP), and estimated sedimentation rate (ESR) were obtained. Then we reamed and locked the intramedullary nailing of the tibia, applied a circular external fixator, and performed percutaneous corticotomy of the tibia opposite the site of the bone defect. Bone distraction over the nail was initiated at the eighth postoperative day at a rate of 1 mm/day. At the last follow-up, union was achieved in all cases without recurrence of bone infection. All patients experienced excellent (n=3) or good (n=6) knee and ankle function, as well as complete return to their daily activities. Two patients experienced pin-tract infection, and one patient experienced anterior knee pain at the entry point of the nail.

Antibiotic-Loaded Cement Beads for Charcot Ankle Osteomyelitis

The concomitant presence of osteomyelitis and diabetic Charcot neuroarthropathy of the foot and ankle places those patients affected at increased risk for limb loss. Antibiotic-loaded cement has been reported to be useful in the treatment of deep soft tissue and joint infections. The authors present an overview of this adjunctive treatment modality and present a case report using antibiotic-loaded cement beads in staged reconstruction for Charcot ankle osteomyelitis.

Reply to the comments on our article “Comparison of various surgical methods in the treatment of implant-related infection”

We are pleased to read the fruitful comments on our article and would like to explain some important issues raised by Cai et al. [1, 2]. First of all, in our opinion the statistical tests used in the study (Mann–Whitney U test) are appropriate for such a study and there seems no need for other analyses. Additionally, we also stated in the discussion section of the text that the main weakness of the study was the small number of animals. We are also surprised to read the authors interpretations of our study methodology. The aim of our study was to address solutions for deep infection developed soon after intramedullary fixation of long bone fractures; therefore, the setting of the study was not a chronic osteomyelitis model. We agree with the statement that lengthening the impregnation time would facilitate the antibiotic impregnation into bone and prolong the T > MIC. However, we tried to put forward clinically applicable solutions for early postoperative deep infection. One hour is an acceptable period for antibiotic impregnation allowing the procedure to be done during surgery. Studies in the related literature have shown that one hour antibiotic impregnation provides effective antibiotic impregnation to bone [3, 4]. Our model was the establishment of early deep implant related infection; thus, it is not prerequisite to remove a stable implant which would inevitably increase the morbidity in clinical applications. It is a well known fact that restoring the bony continuity takes priority over treatment of the infection in clinical situations. Some details concerning the fabrication of teicoplanin-loaded bone grafts and acrylic beads such as surface area and bulk volume may also affect the antimicrobial efficacy. We are in agreement with the pertinent interpretations. Finally, we disagree with the writers’ conclusions. Even though the use of antibiotic-loaded cement beads has associated complications, it should be the treatment of choice for resistant infections because of its effectiveness when the infection cannot be controlled with debridement and antibiotic treatment.

TWO-STAGE REVISION HIP ARTHROPLASTY FOR INFECTION

A two-stage revision is a well-accepted method for the treatment of a deep infection of a hip with a joint implant. In the present study, the results associated with the interim use of antibiotic-loaded cement beads were compared with those associated with the interim use of an antibiotic-loaded cement prosthesis. One hundred and twenty-eight consecutive patients who were managed with a two-stage revision hip arthroplasty for the treatment of an infection were followed clinically and radiographically for an average of 4.9 years. Cement beads were implanted following resection arthroplasty in the first seventy hips, and a custom cement prosthesis was implanted in the subsequent fifty-eight hips. There was no evidence of recurrent infection in 122 patients (95.3%); the infection-free rates in both groups were similar. The use of a spacer prosthesis was associated with a higher hip score, a shorter hospital stay, and better walking capacity in the interim period; a decreased operative time, less blood loss, and a lower transfusion requirement at the time of reimplantation; and fewer postoperative dislocations. The present study supports the safety and efficacy of the routine use of an antibiotic-loaded cement prosthesis in the interim between the stages of a two-stage revision procedure for the treatment of an infection at the site of a hip arthroplasty.