Bead Pouch Technique Research Articles

The antibiotic bead pouch - a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery.

Soft tissue defects resulting from trauma and musculoskeletal infections can complicate surgical treatment. Appropriate temporary coverage of these defects is essential to achieve the best outcomes for necessary plastic soft tissue defect reconstruction. The antibiotic bead pouch technique is a reasonable surgical approach for managing temporary soft tissue defects following adequate surgical debridement. This technique involves the use of small diameter antibiotic-loaded bone cement beads to fill the dead space created by debridement. By applying antibiotics to the bone cement and covering the beads with an artificial skin graft, high local dosages of antibiotics can be achieved, resulting in the creation of a sterile wound that offers the best starting position for soft tissue and bone defect reconstruction. This narrative review describes the rationale for using this technique, including its advantages and disadvantages, as well as pearls and pitfalls associated with its use in daily practice. In addition, the article provides a comprehensive overview of the literature that has been published since the technique was introduced in surgical practice.

Sequestrectomy in Primary Osteomyelitis of the Humerus

Surgical treatment for primary osteomyelitis of the humerus is not well standardized; guidelines come from the scientific literature on osteomyelitis of the femur and tibia. Commonly deltopectoral approach is used for the proximal humerus and posterior approach for the distal humerus. Sequestrectomy alone or the use of antibiotic cement (bead pouch technique) is advised in case of chronic osteomyelitis. Berger and Buckwalter described a posterior approach to the proximal part of the humerus for an excisional biopsy of an osteoid-osteoma. We found that this approach is also useful for sequestrectomy in primary osteomyelitis of the humerus. We describe the technique and make a review of the literature.

Negative Pressure Wound Therapy Reduces the Effectiveness of Traditional Local Antibiotic Depot in a Large Complex Musculoskeletal Wound Animal Model

Negative pressure wound therapy (NPWT) has been used to help manage open wounds. Surgeons also often use local antibiotic depot as adjunctive therapy in an effort to reduce infection rates. These 2 techniques have been reported to be used in conjunction, but there are little data to support this practice. We sought to compare the contamination levels of wounds treated with the commonly used antibiotic bead pouch technique to wounds that received both antibiotic beads and NWPT. The effectiveness of a bead pouch was compared with antibiotic beads with NPWT. The anterior compartment and proximal tibia of goats were injured and inoculated with Staphylococcus aureus. Six hours later, the wounds were debrided and the animals were assigned to a group; the bacteria level was quantified immediately before and after initial debridement and 2 days after treatment. The wounds in the antibiotic bead pouch group had 6-fold less bacteria than the augmented NPWT group, 11 ± 2% versus 67 ± 11% of baseline values, respectively (P = 0.01). As expected, high levels of the antibiotic were consistently recovered from the augmented NPWT effluent samples at all time points. NPWT reduces the effectiveness of local antibiotic depot. These results can provide surgeons with the information to personalize the adjunctive therapies to individual patients, with the degree of difficulty in managing the wound and concern for infection being the 2 variables dictating treatment.

Ankle and foot osteomyelitis: Treatment protocol and clinical results

Introduction A management protocol for ankle and foot osteomyelitis and the outcome in 84 patients treated in a unit with special interest in musculoskeletal infection, is presented. Patients and methods Patients’ mean age was 50.7 ± 16.5 years and mean follow-up 31.5 ± 18.2 months. Systemic antibiotics were administered initially empirically, and later according to cultures. Surgical treatment included surgical debridement and bead-pouch technique, minor amputation (ray or toe), below knee amputation, and joint fusion. “Second-look” procedures were performed after 48–72 h. Vascularised grafts or Ilizarov's technique were used for bone defect reconstruction. Soft tissues were managed according the ‘reconstructive ladder’ concept. Results Host-type (Cierny's classification) was A in 25, B in 53 and C in 6 patients. Seventy-six infections were chronic. Causes were: open trauma without fracture (45/84), open fractures (9/84), ORIF of closed fractures (25/84) and elective surgery (5/84). Patients underwent 3.0 ± 1.5 (range 1–10) operative procedures and spent 14.8 ± 12.2 (range 3–60) days in hospital. Two (host-C) patients died. Complications requiring reoperations occurred in 20/84 (2/25 host-A, 16/53 host-B, 2/6 host-C; significant difference between host-A versus host-B and -C patients, p < 0.001). Infection recurrence occurred in 12 (none host-A; significant difference between host-A versus host-B and -C patients, p < 0.001). Multiple organisms were isolated in 39/84. Ankle arthrodesis using external fixation was performed in 9 (fusion rate 8/9). The free vascularised fibula graft was used in 2 and distraction osteogenesis in 8 patients with a mean bone defect of 5.4 cm (range 3–13). Below knee amputations were performed in 5/84 (3/53 host-B, 2/6 host-C) and foot ray amputations in 8/84 (6/53 host-B, 2/6 host-C). Soft tissue coverage required: free muscle flap transfer in 6/84, reverse soleus flap in 1/84, local fasciocutaneous flaps in 7/84, split thickness skin grafts in 5/84, and vacuum assisted closure in 5/84 patients. Eighty-two surviving patients, including amputees, were able to mobilise independently and were satisfied with the result of treatment. Conclusions Host-B and -C patients had more complications and infection recurrences and occasionally required amputations. Reconstructive procedures were performed for limb salvage in patients with soft tissue and bone defects and restoration of a functional limb was achieved.

Management of Open Fractures and Subsequent Complications

Early, systemic, wide-spectrum antibiotic therapy is necessary for the treatment of open fractures. The bead pouch technique delivers antibiotics locally and prevents secondary wound contamination. The open fracture wound should be thoroughly débrided. To avoid the complication of gas gangrene, the wound should not be closed. Extensive soft-tissue damage may necessitate the use of local or free flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and the characteristics of the injury. Early bone grafting and supplemental procedures may be needed to achieve healing. Management of the infected open fracture is based on radical débridement, skeletal stabilization, microbial-specific antibiotics, soft-tissue coverage, and reconstruction of bone defects.

TIMING OF WOUND CLOSURE IN SEVERE COMPOUND FRACTURES

In a consecutive series of 1085 open fractures treated from May 1983 to July 1992, 381 severe compound fractures in 335 patients were managed with the antibiotic bead pouch technique. There were 27 grade I (marked swelling, compartment syndrome), 115 grade II, and 239 grade III open fractures (94 type IIIA, 114 type IIIB, and 31 type IIIC). These fractures were managed with early administration of broad spectrum antibiotics, copious wound irrigation, serial debridements, and external skeletal stabilization. Tobramycin-PMMA beads were placed in the wound, and porous plastic film (Opsite, Smith and Nephew Medical, Limited, Hall, England) covered the soft tissue defect. This dressing was changed every 48 to 72 hours until wound coverage/closure could be obtained. Infection rate, either on an acute or chronic basis, was 2.6% in grade II open fractures and 8.4% in grade III compound fractures. There was no infected wound or bone in the grade I category. Those fractures that did not develop an infection were closed at a mean time of 7.6 days; those that developed an infection were closed at a mean time of 17.9 days. The difference was statistically significant (P < 0.001). When severe open fractures are managed with the antibiotic bead pouch technique, wound closure should be obtained within 1 week to prevent infectious complications.

Optimal timing of wound closure in severe open fractures with temporary coverage by skin substitute

In a consecutive series of 1085 open fractures treated at the University of Louisville Level I Trauma Center from May 1983 to July 1992, 381 severe compound fractures in 335 patients were managed with the antibiotic bead pouch technique. There were 27 grade I (marked swelling, compartment syndrome), 115 grade II and 239 grade III open fractures (94 type IIIA, 114 type IIIB and 31 type IIIC). These fractures were managed with early administration of broad spectrum antibiotics, copious wound irrigation, serial debridements and external skeletal stabilization. Tobramycin-PMMA-beads were placed in the wound and porous plastic film (Opsite) covered the soft tissue defect. This dressing was changed every 48 to 72 hours until wound coverage/closure could be obtained. Infection rate either on an acute or chronic basis was 2.6% in grade II open fractures and 8.4% in grade III compound fractures. There was no infected wound or bone in the grade I category. Those fractures which did not develop an infection were closed at a mean time of 7.6 days; those which developed an infection were closed at a mean time of 17.9 days. The difference was statistically highly significant (p < 0.001). When severe open fractures are managed with the antibiotic bead pouch technique, wound closure should be obtained within one week to prevent infectious complications.

The Antibiotic Bead Pouch Technique

In a consecutive series of 704 compound fractures, 227 open fractures in 204 patients were managed with the antibiotic bead pouch technique. There were 16 Grade I compound fractures, 83 Grade II fractures, and 128 Grade III open fractures. The mean patient age was 35.25 years (range, 14-87). The Injury Severity Score (ISS) ranged from 9 to 57, with a mean of 15. Porous plastic film is placed over the soft-tissue defect to establish a "closed" bead-hematoma-fracture environment containing high local levels of antibiotic at the fracture site. All patients had serial wound debridements and parenteral systemic antibiotics (cefazolin, tobramycin, penicillin). Bead pouch changes ranged from one to seven per patient (mean, two). During these changes, 1248 cultures were taken, 78 (6.25%) of which were positive in 34 patients. Seventeen patients developed clinical signs consistent with an infection. The wound infection rate was 0% in Grade I open fractures, 1.2% in Grade II compound fractures, and 8.6% in Grade III open fractures. The osteomyelitis rate was 0% in Grade I compound fractures, 2.4% in Grade II open fractures, and 5.5% in Grade III compound fractures. Wound closure was obtained in 134 fractures with delayed primary closure of the skin, in 53 fractures with flap coverage, and in 23 fractures with split-thickness skin graft. Coverage was not completed in 17 wounds, at which time an amputation was performed or death occurred. Time of closure ranged from one to 32 days (mean, 7.1 days).(ABSTRACT TRUNCATED AT 250 WORDS)

Value of adjuvant local antibiotic administration in therapy of open fractures. A comparative analysis of 704 consecutive cases

Seven hundred and four compound fractures--198 (28%) grade I, 259 (37%) grade II, 247 (35%) grade III (86 IIIA, 119 IIIB, 42 IIIC)--were treated in 590 patients between May 1983 and May 1989 at the University of Louisville. Of these fractures, 157 (22%, group 1) received systemic antibiotic prophylaxis only, whereas 547 (78%, group 2) were treated with additional local application of aminoglycoside beads (tobramycin). Comparison of factors (fracture grades, age, sex, fracture location, follow up) revealed no significant differences between the two groups. All fractures underwent timely irrigation, debridement and skeletal stabilization. In group 1, 52 wounds were primarily closed, 53 underwent delayed primary closure and 52 were left open. In group 2 283 wounds were primarily closed, 229 were managed with the bead pouch technique and 35 were adapted loosely (delayed closure). Forty-nine (6.96%) of the 704 compound fractures became infected (acute wound infection and/or chronic osteomyelitis). Group 1 showed an infection rate of 16.6% (26/157), group 2 a rate of 4.2% (23/547). The difference was statistically highly significant (P < 0.001). Comparison of the infection rates, whether on an acute or a chronic basis, showed that infection rates were lower in group 2 than in group 1 for all fracture grades. A statistically significant difference was established only for type IIIB fractures, where the wound infection rate was 39.1% (9/23) in group 1 and 7.3% (7/96) in group 2 (P < 0.001). The rate of chronic osteomyelitis was 26.1% (6/23) in group 1 and 6.3% (6/96) in group 2 (P < 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of bone defects with staged bone grafting and antibiotic impregnated beads

Antibiotic impregnated bead chains in conjunction with staged bone grafting is effective in contributing to the union of bone defects resulting from serious fractures. In addition to eluting high concentrations of antibiotics in the closed wound environment, the antibiotic bead chains function as soft tissue spacers to allow bone grafting at a later date. Because some wounds are not immediately able to be closed, the bead pouch technique, in which antibiotic bead chains are implanted in an open wound and covered by an OpSite dressing, allows sterilization of the bone dead space prior to grafting.

The Prophylactic Use of Antibiotic Impregnated Beads in Open Fractures

Four hundred four compound fractures were reviewed in 339 patients treated between August 1983 and November 1987. The 252 males and 87 females had a mean age of 33 years (range, 14-86). One hundred twenty-seven (31.4%) fractures were classified as Grade I, 153 (38.9%) as Grade II, and 124 (30.7%) as Grade III by Gustilo's classification. The mean Injury Severity Score was 15 (range, 9-57). Three hundred thirty-four of the open fractures (82.7%) were managed with antibiotic-impregnated bead chains (tobramycin) and systemic antibiotic prophylaxis (cefazolin, tobramycin, and penicillin). Seventy open fractures (17.3%) received systemic antibiotic prophylaxis (cefazolin, tobramycin, and penicillin) without supplemental use of the antibiotic beads. All open fractures underwent acute irrigation and debridement. In the 404 fractures 46.5% of wounds were closed primarily, 12.9% underwent delayed primary closure, 7.9% were left open, and 32.7% were temporized by the antibiotic bead pouch technique until definitive flap coverage and skin grafting were performed. Of the 404 fractures evaluated, 17 (4.2%) developed an acute wound infection. Of these wound infections, eight (11.4%) were in the group managed with systemic antibiotics alone. By comparison, nine (2.7%) of open fractures treated with combined systemic antibiotics and antibiotic-impregnated beads developed an infection. Chronic osteomyelitis developed in 18 of 404 open fractures (4.5%). Ten (14.3%) open fractures which developed osteomyelitis were managed with systemic antibiotics whereas eight (2.4%) fractures managed with systemic antibiotics and antibiotic-impregnated beads developed a chronic infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylactic Management of Open Fractures with the Antibiotic Bead Pouch Technique

Prophylactic Management of Open Fractures with the Antibiotic Bead Pouch Technique