SLR - September 2019 - Nader Ghobrial
Reference: Cheng-He Qin, Chun-Hao Zhou, Hui-Juan Song, Guo-Yun Cheng, Hong-An Zhang, Jia Fang, and Rui Tao. Infected Bone Resection Plus Adjuvant Antibiotic-Impregnated Calcium Sulfate Versus Infected Bone Resection Alone in the Treatment of Diabetic Forefoot Osteomyelitis. BMC Musculoskelet Disorders. 2019 May; 20 (1): 246
Scientific Literature Review
Reviewed By: Nader Ghobrial, DPM
Residency Program: Hoboken University Medical Center – Hoboken, NJ
Podiatric Relevance: Diabetic foot infection with underlying osteomyelitis (DFO) is one of the most common complications of DM. Multiple approaches either used alone or combined with each other for treatment of DFO. Prolonged IV antibiotics, surgeries (Debridement and amputation) and local application of antibiotics; which provides higher concentration and better delivery of the antibiotics to the infection site. This study designated to compare between different outcomes of surgeries alone vs surgeries combined with antibiotic impregnated calcium sulphate application.
Methods: This is a level III retrospective comparative study for operatively treated DFO between 2015 and 2017 done by the same two surgeons. Inclusion criteria were that all patients underwent bone resection either alone or with application of antibiotic-impregnated calcium sulfate (CS) and persisted to follow up for at least 12 months after the surgery. Forty-six patients with 48 infected limbs included divided into a CS group 18 patients (20 limbs) which had the surgery with application of antibiotic-impregnated calcium sulfate and control group 20 patients (20 limbs) which had the surgery only. All patient underwent bone biopsy to confirm the diagnosis, started empirical IV antibiotic therapy adjusted to more specific one after the result of the biopsy came out. Two weeks of IV antibiotics followed by four weeks of PO antibiotics according to IWDGF recommendations. All patients followed the same postoperative protocol (offloading and wound dressing). Mean hospital stay, healing rate, recurrence rate, amputation rate and complications rate were compared between the two groups. Data collected with Microsoft excel, Multiple tests used for analysis SPSS, Independent-Samples T Test, Mann–Whitney U test. Pearson χ2, Continuity Correction Chi-square Test and Fisher Exact Test.
Results: Staph aureus was the most common species isolated in both groups. Mean hospital stay in the CS group was 24.8 compared to 28.3 in the control group. Postoperative healing rate in the CS group was 90 percent compared to 78.6 percent in the control group. The mean healing duration in weeks in the CS group was 13.3 compared to 11.2 of the control group. Recurrence rate was 0.0 percent in the CS group compared to 36.8 percent in the control group. Amputation rate was 0.0 percent in the CS group compared to 7.1 percent in the control group. Prolonged postoperative leakage was the most common complication of the CS group.
Conclusions: The authors conclude that the use of antibiotic-impregnated calcium sulfate as adjuvant to surgical debridement of DFO vs surgery alone is effective for preventing the recurrence. No evidence found that it improves the healing rate, shorten the duration of healing or decrease the amputation rate. It was noted also that the most common complication of the antibiotic-impregnated calcium sulfate is prolonged wound leakage. Overall, this article shows the importance of applying antibiotic-impregnated calcium sulfate as adjuvant to surgery for patient with DFO who have increased risk of recurrence after surgery. However, It should be cautiously used in patients with increased drainage.