Bioactive glass as dead space management following debridement of type 3 chronic osteomyelitis

Single versus two-stage management of long-bone chronic osteomyelitis in adults: a systematic review and meta-analysis

BACKGROUND

Chronic osteomyelitis is a debilitating bone infection, characterized by a persistent infection over months to years, poses diagnostic and therapeutic challenges due to its insidious nature and potential for severe bone and soft tissue destruction. This systematic review and meta-analysis aims to review the literature on the treatment of chronic osteomyelitis in long bones and assess cure rates in single versus two-stage surgery.

METHODS

Following the PRISMA guidelines and registered with PROSPERO (ID: CRD42021231237), this review included studies that reported on the management of chronic osteomyelitis in long bones using either a planned one-stage or two-stage surgical approach in adult patients. Databases searched included Medline, Embase, Web of Science, CINAHL, HMIC, and AMED, using keywords related to osteomyelitis, long bones, and surgical management. Eligibility criteria focused on adults with chronic osteomyelitis in long bones, with outcomes reported after a minimum follow-up of 12 months. The meta-analysis utilized the random-effects model to pool cure rates.

RESULTS

The analysis included 42 studies with a total of 1605 patients. The overall pooled cure rate was 91% (CI 95%) with no significant difference observed between single-stage and two-stage surgeries (X2 = 0.76, P > 0.05). Complications were reported in 26.6% of cases in single-stage procedures and 27.6% in two-stage procedures, with prolonged wound drainage noted as a common issue. Dead space management techniques varied across studies, with antibiotic-loaded calcium sulphate beads used in 30.4% of cases.

CONCLUSION

This meta-analysis reveals no significant difference in cure rates between single and two-stage surgical treatments for chronic osteomyelitis in long bones, supporting the efficacy of both approaches. The current treatment strategy should include a combination of debridement, dead space management using local and systematic antibiotics and soft tissue reconstruction if necessary.

Clinical outcomes and complications of S53P4 bioactive glass in chronic osteomyelitis and septic non-unions: a retrospective single-center study

INTRODUCTION

Dead space management following debridement surgery in chronic osteomyelitis or septic non-unions is one of the most crucial and discussed steps for the success of the surgical treatment of these conditions. In this retrospective clinical study, we described the efficacy and safety profile of surgical debridement and local application of S53P4 bioactive glass (S53P4 BAG) in the treatment of bone infections.

METHODS

A consecutive single-center series of 38 patients with chronic osteomyelitis (24) and septic non-unions (14), treated with bioactive glass S53P4 as dead space management following surgical debridement between May 2015 and November 2020, were identified and evaluated retrospectively.

RESULTS

Infection eradication was reached in 22 out of 24 patients (91.7%) with chronic osteomyelitis. Eleven out of 14 patients (78.6%) with septic non-union achieved both fracture healing and infection healing in 9.1 ± 4.9 months. Three patients (7.9%) developed prolonged serous discharge with wound dehiscence but healed within 2 months with no further surgical intervention. Average patient follow-up time was 19.8 months ± 7.6 months.

CONCLUSION

S53P4 bioactive glass is an effective and safe therapeutic option in the treatment of chronic osteomyelitis and septic non-unions because of its unique antibacterial properties, but also for its ability to generate a growth response in the remaining healthy bone at the bone-glass interface.

Prosthetic Joint Infections: Biofilm Formation, Management, and the Potential of Mesoporous Bioactive Glass as a New Treatment Option

Infection of prosthetic joints is one of the biggest challenges to a successful replacement of the joint after a total joint arthroplasty. Such infections are caused by bacterial colonies that are difficult to treat by systemic delivery of antibiotics. Local delivery of antibiotics can prove to be the solution to such a devastating outcome that impacts patients' health and ability to regain function in their joints as well as costs the healthcare system millions of dollars every year. This review will discuss prosthetic joint infections in detail with a focus on the development, management, and diagnosis of the infections. Surgeons often opt to use polymethacrylate cement locally to deliver antibiotics; however, due to the rapid release of antibiotics, non-biodegradability, and high chance of reinfection, the search for alternatives is in high demand. One of the most researched alternatives to current treatments is the use of biodegradable and highly compatible bioactive glass. The novelty of this review lies in its focus on mesoporous bioactive glass as a potential alternative to current treatments for prosthetic joint infection. Mesoporous bioactive glass is the focus of this review because it has a higher capacity to deliver biomolecules, stimulate bone growth, and treat infections after prosthetic joint replacement surgeries. The review also examines different synthesis methods, compositions, and properties of mesoporous bioactive glass, highlighting its potential as a biomaterial for the treatment of joint infections.

Dead space management strategies in the treatment of chronic osteomyelitis: a retrospective review

PURPOSE

Dead space management is critically important during the treatment of chronic osteomyelitis. Many dead space management strategies are available, each with their respective advantages and shortcomings. This study aims to present the outcomes and complications of dead space management strategies employed in the treatment of chronic osteomyelitis at a single tertiary level musculoskeletal unit.

METHODS

A retrospective review of dead space management strategies employed at a tertiary-level musculoskeletal infection unit was conducted. Patients of any age treated for chronic osteomyelitis of the appendicular skeleton with a minimum follow-up of 6 months were included in the study. Data were collected regarding patient demographics, aetiology and site of infection, dead space management strategy employed, follow-up period and outcome in terms of resolution of infection.

RESULTS

A final cohort of 132 patients underwent surgical treatment with a dedicated dead space management strategy for chronic osteomyelitis of the appendicular skeleton. Eleven patients (8%) experienced a recurrence of infection. Seven patients (63%) with recurrence were type B hosts, while four patients (37%) were type A hosts.

CONCLUSION

Dead space management is an integral part of treating chronic osteomyelitis; however, no guidelines currently exist regarding the most appropriate strategy. Favourable results are achievable in low to middle-income countries, and it is evident that no dead space management strategy is superior to another. The pursuit for the ideal void filler is ongoing.

LEVEL OF EVIDENCE

III.

Current Concepts of Fracture-Related Infection

Currently, fracture-related infection (FRI) still represents great challenges in front of orthopaedic surgeons, despite great advances that have been achieved regarding its diagnosis and treatment. Although both FRI and prosthetic joint infection (PJI) belong to osteoarticular infections and share similarities, FRI displays unique characteristics. Diagnosis of FRI is sometimes difficult owing to the nonspecific symptoms, and treatment is usually tricky, with a high risk of infection recurrence. In addition, the long disease course is associated with a significantly elevated risk of disability, both physically and psychologically. Moreover, such a disorder still poses heavy economic burdens to the patients, both personally and socially. Therefore, early diagnosis and reasonable treatment are the key issues for increasing the cure rate, decreasing the risks of infection relapse and disability, and improving the life quality and prognosis of the patients. In this review, we summarized the present concepts regarding the definition, epidemiology, diagnosis, and treatment of FRI.

Bioactive glass in the treatment of chronic osteomyelitis in children: Description of four consecutive cases and literature review

INTRODUCTION

Chronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management.

METHODS

Four consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated.

RESULTS

All patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years.

CONCLUSIONS

Bioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children.

Mid-term clinical results of chronic cavitary long bone osteomyelitis treatment using S53P4 bioactive glass: a multi-center study

Introduction: Chronic osteomyelitis is a challenging condition in the orthopedic practice and traditionally treated using local and systemic antibiotics in a two-stage surgical procedure. With the introduction of the antimicrobial biomaterial S53P4 bioactive glass (Bonalive^®), chronic osteomyelitis can be treated in a one-stage procedure. This study evaluated the mid-term clinical results of patients treated with S53P4 bioactive glass for long bone chronic osteomyelitis. Methods: In this prospective multi-center study, patients from two different university medical centers in the Netherlands were included. One-stage treatment consisted of debridement surgery, implantation of S53P4 bioactive glass, and treatment with culture-based systemic antibiotics. If required, wound closure by a plastic surgeon was performed. The primary outcome was the eradication of infection, and a secondary statistical analysis was performed on probable risk factors for treatment failure. Results: In total, 78 patients with chronic cavitary long bone osteomyelitis were included. Follow-up was at least 12 months (mean 46; standard deviation, SD, 20), and 69 patients were treated in a one-stage procedure. Overall infection eradication was 85 %, and 1-year infection-free survival was 89 %. Primary closure versus local/muscular flap coverage is the only risk factor for treatment failure. Conclusion: With 85 % eradication of infection, S53P4 bioactive glass is an effective biomaterial in the treatment of chronic osteomyelitis in a one-stage procedure. A major risk factor for treatment failure is the necessity for local/free muscle flap coverage. These results confirm earlier published data, and together with the fundamentally different antimicrobial pathways without antibiotic resistance, S53P4 bioactive glass is a recommendable biomaterial for chronic osteomyelitis treatment and might be beneficial over other biomaterials.

Bioactive glass S53P4 vs. autologous bone graft for filling defects in patients with chronic osteomyelitis and infected non-unions - a single center experience

Introduction: The goals of osteomyelitis therapy are successful control of infection and reconstruction of the bone. The gold standard for filling defects is the autologous bone graft. Bioactive glass S53P4 is an inorganic bone substitute. We compared the outcome of using bioactive glass (BAG) versus autologous bone graft (AB) in patients with infected non-union. Methods: Patients with chronic osteomyelitis and infected non-union who received either bioactive glass or autologous bone grafts between 2013 and 2017 were analyzed retrospectively. The primary endpoint was successful control of infection during follow-up. Secondary endpoints were bone healing, functional outcome, and occurrence of complications. Results: Eighty-three patients were analyzed (BAG n=51, AB n=32). Twenty-one patients experienced reinfection (BAG n=15, 29 %; AB n=6, 19 %). Seventy-eight patients achieved full weight bearing (BAG n=47, 92 %; AB n=31, 97 %). Sixty-four patients had complete bone healing at the end of the follow-up period (BAG n=39, 77 %; AB n=25, 78 %). There were no significant differences between the groups with respect to the primary or secondary endpoints. Patients with multidrug-resistant pathogens had a significantly higher rate of incomplete bone healing (p=0.033) and a 3-fold higher risk of complications in both groups. Conclusions: Bioactive glass appears to be a suitable bone substitute not only for successful control of infection and defect filling but also for bone healing in cases of infected non-union. In our study, bioactive glass was neither superior nor inferior to autologous bone graft with regard to the primary and secondary endpoints. Further studies with larger numbers of patients are required.