Chronic osteomyelitis of calcaneus is not rare but is very hard to treat. Irrigation-suction and antibiotic-impregnated calcium sulfate following debridement are commonly used in managing chronic osteomyelitis, but their effects have rarely been compared. We aimed to compare the effectiveness of antibiotic-impregnated calcium sulfate with irrigation-suction in the treatment of patients with chronic calcaneal osteomyelitis.
Methods:
From January 2011 to June 2018, adult patients at our institute with chronic osteomyelitis receiving treatment of either antibiotic-impregnated calcium sulfate (CS group) or irrigation-suction (IS group) following thorough debridement were screened and selected according to the inclusion and exclusion criteria. The clinical presentation, laboratory tests, complications, and the ultimate single-staged cure rate and recurrence were compared.
Results:
A total of 61 patients, including 41 in the CS group and 20 in the IS group, were included in our study. Of the patients, 85.4% in the CS group and 60.0% in the IS group (P = .006) were successfully cured in the single stage, respectively, without infection recurrence. Lower infection recurrence rates with shorter hospital stay were found in the CS group than the IS group. Inflammatory biomarkers after surgery with both treatments were slightly decreased and not significantly different from preoperative or between-groups postoperative. Exudate from incision was found primarily in the CS group.
Conclusion:
This study demonstrates that both antibiotic-impregnated calcium sulfate and irrigation-suction after careful and thorough surgical debridement are generally effective in treating chronic calcaneal osteomyelitis. Antibiotic-impregnated calcium sulfate achieved a higher single-staged cure rate but was associated with an increased postoperative wound exudate.
AhlmannEPatzakisMRoidisNShepherdLHoltomP.Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Joint Surg Am. 2002;84(5):716-720.
2.
AikenSSCooperJJFloranceHRobinsonMTMichellS.Local release of antibiotics for surgical site infection management using high-purity calcium sulfate: an in vitro elution study. Surg Infect. 2015;16(1):54-61.
3.
al RuhaimiKA. Effect of calcium sulphate on the rate of osteogenesis in distracted bone. Int J Oral Maxillofac Surg. 2001;30(3):228-33.
4.
AlbrektssonTJohanssonC.Osteoinduction, osteoconduction and osseointegration. Eur Spine J. 2001;10(suppl 2):S96-S101.
5.
BajadaSHarrisonPEAshtonBACassar-PullicinoVNAshammakhiNRichardsonJB.Successful treatment of refractory tibial nonunion using calcium sulphate and bone marrow stromal cell implantation. J Bone Joint Surg Br. 2007;89(10):1382-1386.
6.
BansalVPHarmitS.Management of chronic osteomyelitis using an irrigation suction technique. Int Orthop. 1988;12(4):265-268.
7.
BelooseskyYGrinblatJPirotskyAWeissAHendelD.Different C-reactive protein kinetics in post-operative hip-fractured geriatric patients with and without complications. Gerontology. 2004;50(4):216-222.
8.
BeuerleinMJMcKeeMD.Calcium sulfates: what is the evidence?J Orthop Trauma. 2010;24:S46-S51.
9.
BillowDKhlopasAChughtaiM, et al. The reamer-irrigator-aspirator system: a review. Surg Technol Int. 2016;29:287-294.
10.
BollingerMThordarsonDB.Partial calcanectomy: an alternative to below knee amputation. Foot Ankle Int. 2002;23(10):927-932.
11.
BorrelliJJrPrickettWDRicciWM. Treatment of nonunions and osseous defects with bone graft and calcium sulfate. Clin Orthop Relat Res. 2003(411):245-254.
12.
BrodellJDJrKozakiewiczLNHoffmanSLOhI.Intraoperative site vancomycin powder application in infected diabetic heel ulcers with calcaneal osteomyelitis. Foot Ankle Int. 2021;42(3):356-362.
13.
CaesarBCMorgan-JonesRLWarrenREWadeRHRobertsPJRichardsonJB.Closed double-lumen suction irrigation in the management of chronic diaphyseal osteomyelitis: long-term follow-up. J Bone Joint Surg Br. 2009;91(9):1243-1248.
14.
CiernyGIII. Infected tibial nonunions (1981-1995). The evolution of change. Clin Orthop Relat Res. 1999;360:97-105.
15.
CiernyGIIIDiPasqualeD. Treatment of chronic infection. J Am Acad Orthop Surg. 2006;14(10):S105-S110.
16.
ClawsonDKDavisFJHansenST.Treatment of chronic osteomyelitis with emphasis on closed suction-irrigation technic. Clin Orthop Relat Res. 1973;96:88-97.
17.
CooperJJFloranceHMcKinnonJLLaycockPAAikenSS.Elution profiles of tobramycin and vancomycin from high-purity calcium sulphate beads incubated in a range of simulated body fluids. J Biomater Appl. 2016;31(3):357-365.
18.
DrampalosEMohammadHRKosmidisCBalalMWongJPillaiA.Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: the Silo technique. Foot (Edinb). 2018;34:40-44.
19.
FergusonJDiefenbeckMMcNallyM.Ceramic biocomposites as biodegradable antibiotic carriers in the treatment of bone infections. J Bone Joint Infect. 2017;2(1):38.
20.
FergusonJDudarevaMRileyNStubbsDAtkinsBMcNallyM.The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases. Bone Joint J. 2014;96(6):829-836.
21.
French Intensive Care Society. International congress—reanimation 2016. Ann Intensive Care. 2016;6(suppl 1):50.
GaulandC.Managing lower-extremity osteomyelitis locally with surgical debridement and synthetic calcium sulfate antibiotic tablets. Adv Skin Wound Care. 2011;24(11):515-523.
24.
GoldmanM. A new approach to chronic osteomyelitis. Orthopedics. 1960;2:63-65.
25.
GrammaticoLBaronSRuschE, et al. Epidemiology of vertebral osteomyelitis (VO) in France: analysis of hospital-discharge data 2002-2003. Epidemiol Infect. 2008;136(5):653-660.
26.
GrüneboomAHawwariIWeidnerD, et al. A network of trans-cortical capillaries as mainstay for blood circulation in long bones. Nat Metab. 2019;1(2):236-250.
27.
JiangNQinCHMaYFWangLYuB.Possibility of one-stage surgery to reconstruct bone defects using the modified Masquelet technique with degradable calcium sulfate as a cement spacer: a case report and hypothesis. Biomed Rep. 2016;4(3):374-378.
28.
KanellakopoulouKGalanopoulosISoranoglouV, et al. Treatment of experimental osteomyelitis caused by methicillin-resistant Staphylococcus aureus with a synthetic carrier of calcium sulphate (Stimulan) releasing moxifloxacin. Int J Antimicrob Agents. 2009;33(4):354-359.
29.
KennedyJE.Local Delivery of Antibiotics in a Calcium Sulfate Vehicle: In Vitro Results. University of Kentucky; 2000.
30.
KingCMCastellucci-GarzaFMLyonLDoyleMDNimickCWilliamsML.Microorganisms associated with osteomyelitis of the foot and ankle. J Foot Ankle Surg. 2020;59(3):491-494.
31.
KinikHKaradumanM.Cierny-Mader Type III chronic osteomyelitis: the results of patients treated with debridement, irrigation, vancomycin beads and systemic antibiotics. Int Orthop. 2008;32(4):551-558.
32.
KitaokaHBAlexanderIJAdelaarRSNunleyJAMyersonMSSandersM.Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-353.
33.
KooHAllanRNHowlinRPStoodleyPHall-StoodleyL.Targeting microbial biofilms: current and prospective therapeutic strategies. Nat Rev Microbiol. 2017;15(12):740-755.
34.
KoyonosLZmistowskiBDella ValleCJParviziJ.Infection control rate of irrigation and debridement for periprosthetic joint infection. Clin Orthop Relat Res. 2011;469(11):3043.
LiLXuLZhuRSongJWangX.Effect of prior receipt of antibiotics on the pathogen distribution: a retrospective observational cohort study on 27,792 patients. BMC Infect Dis. 2020;20(1):8.
37.
LipskyBABerendtAREmbilJde LallaF.Diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev. 2004;20(suppl 1):S56-S64.
38.
MansellJPBaileyAJ.Abnormal cancellous bone collagen metabolism in osteoarthritis. J Clin Invest. 1998;101(8):1596-1603.
39.
McKeeMDLi-BlandEAWildLMSchemitschEH.A prospective, randomized clinical trial comparing an antibiotic-impregnated bioabsorbable bone substitute with standard antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis and infected nonunion. J Orthop Trauma. 2010;24(8):483-490.
40.
McNallyMFergusonJLauA, et al. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016;98(9):1289-1296.
41.
MerletACazanaveCDauchyF-A, et al. Prognostic factors of calcaneal osteomyelitis. Scand J Infect Dis. 2014;46(8):555-560.
42.
MetsemakersWJMorgensternMMcNallyMA, et al. Fracture-related infection: a consensus on definition from an international expert group. Injury. 2018;49(3):505-510.
43.
MorelliIDragoLGeorgeDAGallazziEScarponiSRomanòCL.Masquelet technique: myth or reality? A systematic review and meta-analysis. Injury. 2016;47(suppl 6):S68-s76.
44.
MottolaCMatiasCSMendesJJ, et al. Susceptibility patterns of Staphylococcus aureus biofilms in diabetic foot infections. BMC Microbiol. 2016;16(1):119.
45.
MuthukrishnanGMastersEADaissJLSchwarzEM.Mechanisms of immune evasion and bone tissue colonization that make Staphylococcus aureus the primary pathogen in osteomyelitis. Curr Osteoporosis Rep. 2019;17(6):395-404.
46.
NandiSKBandyopadhyaySDasP, et al. Understanding osteomyelitis and its treatment through local drug delivery system. Biotechnol Adv. 2016;34(8):1305-1317.
47.
NilssonMZhengMHTägilM.The composite of hydroxyapatite and calcium sulphate: a review of preclinical evaluation and clinical applications. Exp Rev Med Devices. 2013;10(5):675-684.
48.
PaakkonenMKallioMJKallioPEPeltolaH.Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections. Clin Orthop Relat Res. 2010;468(3):861-866.
49.
PapagelopoulosPJMavrogenisAFTsiodrasSVlastouCGiamarellouHSoucacosPN.Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis. J Int Med Res. 2006;34(6):704-712.
50.
PooleK.Pseudomonas aeruginosa: resistance to the max. Front Microbiol. 2011;2:65.
51.
QinCXuLLiaoJFangJHuY.Management of osteomyelitis-induced massive tibial bone defect by monolateral external fixator combined with antibiotics-impregnated calcium sulphate: a retrospective study. Biomed Res Int. 2018;2018:9070216.
52.
QinCHZhangHACheeYHPitariniAAdem AliA.Comparison of the use of antibiotic-loaded calcium sulphate and wound irrigation-suction in the treatment of lower limb chronic osteomyelitis. Injury. 2019;50(2):508-514.
RomanòCLogolusoNMeaniE, et al. A comparative study of the use of bioactive glass S53P4 and antibiotic-loaded calcium-based bone substitutes in the treatment of chronic osteomyelitis: a retrospective comparative study. Bone Joint J. 2014;96(6):845-850.
55.
SantonocitoCDe LoeckerIDonadelloK, et al. C-reactive protein kinetics after major surgery. Anesth Analg. 2014;119(3):624-629.
56.
ScaranoAOrsiniGPecoraGIezziGPerrottiVPiattelliA.Peri-implant bone regeneration with calcium sulfate: a light and transmission electron microscopy case report. Implant Dent. 2007;16(2):195-203.
57.
StuckenCOlszewskiDCCreevyWRMurakamiAMTornettaP.Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am. 2013;95(15):1409-1412.
58.
ThanniLO.Bacterial osteomyelitis in major sickling haemoglobinopathies: geographic difference in pathogen prevalence. Afr Health Sci. 2006;6(4):236-239.
59.
ThomasMVPuleoDA.Calcium sulfate: properties and clinical applications. J Biomed Mater Res B Appl Biomater. 2009;88(2):597-610.
60.
WalshTPYatesBJ.Calcanectomy: avoiding major amputation in the presence of calcaneal osteomyelitis—a case series. Foot. 2013;23(4):130-135.
61.
WangEHSimpsonSBennetGC.Osteomyelitis of the calcaneum. Bone Joint J. 1992;74(6):906-909.
62.
YahavAKurtzmanGMKatzapMDudekDBaranesD.Bone regeneration: properties and clinical applications of biphasic calcium sulfate. Dent Clin North Am. 2020;64(2):453-472.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
