Antibiotic cement beads allow for salvage in diabetic osteomyelitis cases of the foot

Surgeon has used cement beads successfully along with debridement in 15 salvage cases.

Issue: November 2007

TORONTO – Israeli surgeons from Rambam Medical Center in Haifa treat diabetic osteomyelitis cases in the foot with a cement antibiotic spacer. So far, only one patient out of 15 patients treated with the salvage method has required an amputation.

Eyal Melamed, MD, presented the results of eight of these patients as a poster presentation at the American Orthopaedic Foot and Ankle Society 23rd Annual Summer Meeting.

Surgeons have used cement beads to prevent and treat infections with open fractures, osteomyelitis and septic joint replacement, but this marks the first time that a surgeon has used this method in diabetic patients, according to Melamed.

54-year-old man with deep ulcer
This 54-year-old man had a deep ulcer over the interphalangeal joint of the hallux, as a result of thermal burn. In this image, osteomyelitis and septic arthritis are apparent.

In the first stage of surgery, Melamed shortened the toe to compensate for missing skin. He also resected the joint and debrided the bone and soft tissue.

Images: Melamed E

“I use this method when there is osteomyelitis and it seems that the toe is salvageable and we just need to resect the infected piece of bone … and later perform a reconstruction using bone graft,” Melamed told Orthopedics Today. “The advantage is we get a very high, local concentration of antibiotic.”

Using this technique as an adjunct to debridement, patients have better load distribution with the functionality of the remaining toe or ray, he said.

At 1 week postoperatively, the patient’s swelling and infection have calmed down.

Here, the cement is apparent in the resected joint space. Because the cement was inserted and compressed before it hardened sufficiently, the cement is now too prominent.

Melamed retrospectively reviewed eight diabetic foot patients with osteomyelitis who were being considered for toe amputation. He treated the patients with the salvage method, using methacrylate polymethyl with gentamicin. He added a supplementation of vancomycin in six patients.

One patient had arthritis and osteomyelitis of the big toe interphalangeal (IP) joint. Melamed treated this patient with staged resection of the joint surfaces, implantation of antibiotic cement for 6 weeks and arthrodesis of the IP joint after 6 weeks.

In three patients with osteomyelitis of the metatarsophalangeal (MP) joint of the big toe, Melamed said he performed a wide resection of the first metatarsal head and base of the proximal phalanx, and then placed a cement spacer.

“One of them had a later bone block arthrodesis, while in the other two, the wound was allowed to shrink and granulate, creating a semi-stiff pseudo joint, which participates in weight-bearing,” Melamed wrote in the poster abstract.

Four of the eight patients presented with ulcers under the second, third or fifth metatarsal heads, as well as osteomyelitis of the metatarsal head. “All were treated with debridement, irrigation and placement of the antibiotic bead, which was carried out through the ulcer with minimal or no skin cut,” Melamed wrote.

At an average of 11 months follow-up, these eight patients have healed and are clear of infection, Melamed said. In addition, none of them use supplemented antibiotic and none have any evidence of new ulcers. “In two of them the cement was left in the lesser MP joint and contributes to weight bearing by that metatarsal,” Melamed said.

At six weeks after the initial surgery, the cement was removed and the interphalangeal joint fused.

At 1-year follow-up, the patient achieved solid fusion, as seen in this radiographic image.

For more information:
Eyal Melamed, MD, can be reached at Rambam Medical Center, P.O. Box 9602, Haifa, Israel 31096; 972-4-854-2932; e-mail: emelamed@rambam.health.gov.il. He has no direct financial interest in any product or company mentioned in this article.
Reference:

Melamed E. Salman S. Peled E. Zinman C. Cement antibiotic spacer for the salvage of diabetic osteomyelitis. Poster #220. Presented at the American Orthopaedic Foot and Ankle Society 23rd Annual Summer Meeting. July 13-15, 2007. Toronto.