Management of calcaneal osteomyelitis

Tricalcium phosphate-loaded injectable hydrogel as a promising osteogenic and bactericidal teicoplanin-delivery system for osteomyelitis treatment: An in vitro and in vivo investigation

Osteomyelitis is an inflammation of bone tissue usually caused by pyogenic bacteria. The most recurrent clinical approach consists of bone debridement followed by parenteral administration of antibiotics. However, systemic antibiotic treatment has limitations regarding absorption rate and bioavailability over time. The main challenge of osteomyelitis treatment consists of coupling the persistent infection treatment with the regeneration of the bone debrided. In this work, we developed an injectable drug delivery system based on poloxamer 407 hydrogel containing undoped Mg, Zn-doped tricalcium phosphate (β-TCP), and teicoplanin, a broad-spectrum antibiotic. We evaluated how the addition of teicoplanin and β-TCP affected the micellization, gelation, particle size, and surface charge of the hydrogel. Later, we studied the hydrogel degradation and drug delivery kinetics. Finally, the bactericidal, biocompatibility, and osteogenic properties were evaluated through in vitro studies and confirmed by in vivo Wistar rat models. Teicoplanin was found to be encapsulated in the corona portions of the hydrogel micelles, yielding a bigger hydrodynamics radius. The encapsulated teicoplanin showed a sustained release over the evaluated period, enough to trigger antibacterial properties against Gram-positive bacteria. Besides, the formulations were biocompatible and showed bone healing ability and osteogenic properties. Finally, in vivo studies confirmed that the proposed locally injected formulations yielded osteomyelitis treatment with superior outcomes than parenteral administration while promoting bone regeneration. In conclusion, the presented formulations are promising drug delivery systems for osteomyelitis treatment and deserve further technological improvements.

[Total calcanectomy in osteomyelitis and soft tissue defect with complex secondary reconstruction of the hindfoot : Case report and literature comparison]

The clinical picture and surgical treatment of implant-associated osteomyelitis of the calcaneus with soft tissue defect are presented based on this case study. Due to the fulminant infection, complete resection of the calcaneus and a two-stage complex reconstruction of the hindfoot were performed. As necrosis developed in the surgical access route, coverage with a free ALT flap became necessary.

Pediatric calcaneal osteomyelitis: an analysis of literature-reported 128 cases

BACKGROUND

Calcaneal osteomyelitis (CO) poses a formidable challenge in treatment due to the distinct anatomical structure and functional properties of the calcaneus. The present study endeavors to furnish a thorough and comprehensive understanding of the clinical manifestations, therapeutic strategies, and therapeutic outcomes pertaining to pediatric calcaneal osteomyelitis (PCO) by conducting a meticulous synthesis and analysis of cases reported in the literature.

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted to identify English-language studies analyzing PCO between 2000 and 2021. The quality of the included studies was assessed using the National Institutes of Health (NIH) assessment scale. Effective data were extracted and analyzed.

RESULTS

A total of 42 studies, encompassing 128 patients, fulfilled the established inclusion criteria. The gender distribution revealed a male-to-female ratio of 2:1 (81 boys and 40 girls). The median age at the time of diagnosis was 8 years, while the median duration of symptoms was 0.6 month. Trauma emerged as the primary etiology (41 cases, 54%), and limited activity was the most prevalent symptom (68 cases). The positive rate for pathogen culture was 75.4% (49/65), with Staphylococcus aureus being the most commonly isolated pathogen (28 cases, 57.1%). Surgical intervention was performed in 51% (64/126) of the patients, with debridement serving as the primary surgical strategy. The rate of infection recurrence was 6.8% (8/118), and the risk of below-knee amputation was 0.8% (1/124).

CONCLUSIONS

PCO occurred more frequently in male patients, with trauma being the primary underlying cause and Staphylococcus aureus being the most prevalent bacterial pathogen isolated. Over half of the patients underwent surgical intervention. Nonetheless, it is imperative that treatment strategies undergo further refinement, as approximately 7% of patients experienced infection recurrence.

Clinical characteristics, treatment and efficacy of calcaneal osteomyelitis: A systematic review with synthesis analysis 1118 reported cases

BACKGROUND

Calcaneal osteomyelitis (CO) still poses great challenges to orthopaedic surgeons due to unique anatomic and functional features of the calcaneus. This study summarized the current data regarding clinical characteristics, treatment and efficacy of CO, based on an analysis of literature-reported cases.

MATERIALS AND METHODS

We searched the PubMed, Embase, and Cochrane Library databases to find English and Chinese studies reporting on CO patients between 2000 and 2021, with available data for synthesis analysis. The quality of the included studies was evaluated by the National Institutes of Health (NIH) assessment scale. Effective data were extracted and pooled for analysis.

RESULTS

Altogether 198 studies involving 1118 patients were included, with a male-to-female ratio of 2.3 (724 males and 310 females). The median age at CO diagnosis was 46 years, with a median symptom duration of 3 months. Injury-related infections (524 cases) and diabetic foot infections (336 cases) were the two most common causes, with ulcer (468 cases) and wound sinus or exudation (209 cases) being the predominant symptoms. The overall positive culture rate was 80.2%, with polymicrobial infections accounting for 18.1%. Staphylococcus aureus was the most frequently detected pathogen (42.7%), with fungal-related infections isolated in 17 cases. Although most patients received surgical interventions (96.9%), the recurrence rate was 20.1%. The incidence of infection relapse following partial calcanectomy, total calcanectomy, debridement with implantation of local antibiotics, and debridement with or without flap or skin coverage were 31.7%, 45.0%, 16.8%, and 15.1%, respectively. The overall incidence of limb amputation was 12.4%, with all-cause and CO-related mortalities of 2.8% and 0.2%, separately.

CONCLUSIONS

CO shared similar characteristics with extremity chronic osteomyelitis, primarily affecting young males, with trauma and diabetic foot as the leading causes and Staphylococcus aureus as the most frequently detected pathogen. Despite surgery being the primary treatment modality, clinical outcomes remained unsatisfactory, marked by high rates of infection recurrence and limb amputation.

Long-term limb salvage and functional outcomes for patients undergoing partial calcanectomy

INTRODUCTION

Partial calcanectomy (PC) can be performed to treat chronic heel ulcers in patients with calcaneal osteomyelitis. Patients undergoing PC often have multiple comorbidities, limited mobility, and face high risk of major limb amputation. This study examined the extent of vascular diagnostic testing and interventions as well as long-term outcomes in patients undergoing PC.

METHODS

A retrospective analysis was performed on patients who underwent PC for non-healing calcaneal ulcer over a ten-year period. Demographics, comorbidities, vascular testing, and procedural data were recorded. Additional subgroup analysis was performed according to presence or absence of peripheral arterial disease (PAD). Primary outcomes were major limb amputation (above or below the knee) and mortality. Secondary outcomes included successful wound healing, time to complete wound healing, re-interventions, and change in ambulatory status.

RESULTS

A total of 157 patients underwent partial calcanectomies on 162 limbs. 78.3% of patients had diabetes mellitus and 47.8% were diagnosed with PAD. Ankle brachial index with pulse volume recording (ABI/PVR) was performed for 46.5% (73/157) of patients, arterial duplex in 44.6% (70/157), and 19.7% (31/157) had a computed tomography angiogram. Lower extremity revascularization was performed in 28.4% of limbs (46/162). Independent ambulatory status was reported in 40.1% prior to PC and decreased to 17.9% by the time of last recorded follow-up (p < .00001). Long-term amputation-free survival was significantly higher in patients without PAD at 7 years (78.4% vs 57.1%, p = .02). Multivariate logistic regression analysis demonstrated that PAD and end-stage renal disease (ESRD) increased the odds of major limb amputation (OR 3.5 and 2.8, respectively), whereas ESRD and adjuvant podiatric procedures were associated with increased mortality (OR 4.8 and 4.8, respectively).

CONCLUSION

Non-invasive vascular testing should be obtained in all patients undergoing PC, in order to stratify risk of amputation and identify candidates for revascularization. Over the long-term, patients undergoing PC face significant risk of prolonged wound healing, decline in ambulatory status, and major limb amputation.

Using 3D printing-assisted shaping titanium cages and Masquelet techniques to reconstruct calcaneal osteomyelitis complicated by extensive soft tissue and uncontrolled defects

OBJECTIVE

To investigate the clinical efficacy of three-dimensional (3D) printing-assisted shaping titanium cage combined with Masquelet technology in the treatment of calcaneal infectious defects.

METHODS

A retrospective analysis was performed of the data from nine patients with chronic calcaneal infection defects treated with distal gastronal flap coverage and one patient with free anterolateral thigh flap coverage, also using a 3D printing-assisted shaping titanium cage combined with both mask technology and rib autografting from January 2017 to January 2019. There were seven males and three females, with a mean age of 37 years (range, 17-52 years). The injury mechanism of the 10 patients included four motor vehicle incidents, four high fall injuries, and two rolling compactions. All patients were treated by two⁃stage procedures. The first stage included debridement, polymethyl methacrylate (PMMA) filling, and regional flap coverage. The soft tissue defect of the 10 cases included 80 cm2 in four cases and 56 cm2, 40 cm2, and 15 cm2 in each of two cases. The bone defect was 24 cm3 and 18 cm3 in each of four cases and 3 cm3 in two cases. The second stage was the mask technology of 3D printing-assisted shaping titanium cage combined with rib autografting. Time of bone union, calcaneus morphology, implant position, and the Maryland and AOFAS hind foot scores were recorded to evaluate the clinical outcome.

RESULTS

All 10 patients were followed up for a mean of 18.5 months (range, 12-30 months). Infection occurred in two patients 2 months after the first stage operation and were successfully treated by debridement and PMMA replacement. The incision of the other eight cases all healed successfully. Cultures from the 10 cases included five cases of methicillin-resistant Staphylococcus aureus, three cases of S. aureus, and one case each of Escherichia coli and Pseudomonas aeruginosa. All 10 patients exhibited calcaneus bone union after the second stage operation. The mean time for bone union was 4.32 (range, 3-8) months. Bone trabeculae were observed in a CT scan 13 (range, 10-22) months post-operation. The mean Maryland score at 12 months post-operation was 92 (range, 86-98) and the mean AOFAS ankle hind foot score was 89.8 (range, 83-100).

CONCLUSION

Three-dimensional printing-assisted shaping titanium cages and Masquelet technology may be effective methods for the treatment of infectious calcaneal defects.

Gentamicin-permeated cement to sustain mechanical support for the treatment of a chronic calcaneal abscess. A case report

INTRODUCTION AND IMPORTANCE

Chronic calcaneal osteomyelitis is a challenging condition associated with high relapse rates, requiring a multidisciplinary approach and various therapeutic options for effective management. We report a very rare case of a pyogenic osteomyelitis of the os calcis presented as a bone abscess.

CASE PRESENTATION

A diabetic male patient presented with chronic osteomyelitis of the calcaneus in the form of bone abscess with a cavity of 6*5 cm. After pus evacuation and debridement of the cavity, gentamycin-impregnated polymethylmethacrylate cement was used to locally assist in controlling the infection and to assure mechanical support. Antibiogram-based oral antibiotic was administrated for 6 weeks. At final follow-up, the patient could walk without any assistance and was able to raise his body on the operated heel, with no signs of infection.

CLINICAL DISCUSSION

This case illustrates successful conservative surgical treatment of calcaneal abscess using antibiotic-impregnated cement for mechanical support and local infection control.

CONCLUSION

Incorporating antibiotic-impregnated cement into conservative foot surgeries for deeply embedded calcaneal abscesses provides effective infection control, mechanical support, and functional preservation, leading to successful treatment outcomes.

Inflammatory response in confirmed non-diabetic foot and ankle infections: A case series with normal inflammatory markers

BACKGROUND

The distinction between foot and ankle wound healing complications as opposed to infection is crucial for the appropriate and efficacious allocation of antibiotic therapy. Multiple reports have focused on the diagnostic accuracy of different inflammatory markers, however, mainly in the diabetic population.

AIM

To evaluate the diagnostic accuracy of white cell count (WCC) and C-reactive protein (CRP) as diagnostic tools for this distinction in the non-diabetic cohort.

METHODS

Data was reviewed from a prospectively maintained Infectious Diseases Unit database of 216 patients admitted at Leicester University Hospitals–United Kingdom with musculoskeletal infections over the period between July 2014 and February 2020 (68 mo). All patients with confirmed diagnosis of diabetes were excluded while only those with confirmed microbiological or clinical diagnosis of foot or ankle infection were included in our study. For the included patients, we retrospectively retrieved the inflammatory markers (WCCs and CRP) at the time of presentation. Values of CRP 0-10 mg/L and WCC 4.0-11.0 × 10⁹/L were considered normal.

RESULTS

After exclusion of patients with confirmed diabetes, 25 patients with confirmed foot or ankle infections were included. All infections were confirmed microbiologically with positive intra-operative culture results. 7 (28%) patients with osteomyelitis (OM) of the foot, 11 (44%) with OM of the ankle, 5 (20%) with ankle septic arthritis and 2 (8%) patients with post-surgical wound infection were identified. Previous bony surgery was identified in 13 (52%) patients, either a corrective osteotomy or an open reduction and internal fixation for a foot or ankle fracture with the infection developing on top of the existing metalwork. 21 (84%) patients did have raised inflammatory markers while 4 (16%) patients failed to mount an inflammatory response even with subsequent debridement and removal of metal work. CRP sensitivity was 84%, while WCC sensitivity was only 28%.

CONCLUSION

CRP has a relatively good sensitivity in the diagnosis of foot and ankle infections in non-diabetic patients, whereas WCC is a poor inflammatory marker in the detection of such cases. In presence of clinically high level of suspicion of foot or ankle infection, a normal CRP should not rule out the diagnosis of OM.

Total calcanectomy in calcaneal osteomyelitis: An alternative to major amputation

BACKGROUND

Hindfoot ulcers associated with chronic calcaneus osteomyelitis are very difficult to manage and many patients need a limb amputation for resolution. Total calcanectomy can be a salvage procedure for these patients. The purpose of this study is to present our results of total calcanectomy.

METHODS

Retrospective analysis of six patients undergoing total calcanectomy at our institution between 2008 and 2019. Patient data and ambulatory status were analyzed.

RESULTS

In 4 of the 6 patients, infection control and wound closure was achieved with total calcanectomy with follow-up ranging from 1 to 12 years. The 4 patients maintain walking ability. Two major complications: an early death caused by a respiratory infection and a below the knee amputation due to recurrence of the foot infection.

CONCLUSION

Total calcanectomy is an useful procedure for limb salvage in foot ulcers with chronic calcaneus osteomyelitis.

An Effective Technique for Managing the Calcaneus Osteomyelitis Combined with Soft-Tissue Defect

The treatment of the Cierny-Mader (C-M) type III-IV calcaneus osteomyelitis combining with the soft-tissue defect is sophisticated and difficult. The aim of this study is to introduce the application and availability of the modified distally based sural flap with an adipofascial extension to reconstruct these defects. We retrospectively reviewed the data of 37 patients with C-M type III-IV calcaneus osteomyelitis accompanied with soft-tissue defect between December 2004 and December 2019. A modified distally based sural flap with an adipofascial extension was conducted to reconstruct the defect. The patient's demographics, duration of the diseases, etiology, reconstruction outcomes, infection control rate, recurrence rate, amputation rate, and follow-up data were collected to evaluate the effectiveness and reliability of the modification. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale was applied to assess the function of the ankle and hindfoot. Thirty-four flaps survived uneventfully, 1 flap displayed marginal necrosis and 2 flaps (5.41%) developed partial necrosis. Using this modified flap alone or combining with some simple salvage methods reconstructed all of the defects successfully. The calcaneus osteomyelitis was cured successfully, and no recurrences were observed during the follow-up period. The AOFAS ankle and hindfoot scores were excellent in 27 patients and good in 8 patients. The distally based sural flap with an adipofacial extension is a simple and effective technique to reconstruct the calcaneus osteomyelitis combined with soft-tissue defect in 1 stage. Applications of the adipofacial extension to obliterate the dead space and the well-vascularized skin island to cover the defect are the guarantee of achieving good ankle and foot functions. However, this technique is not appropriate for the patients with calcaneum less than half weight-bearing area.

Extensive eggshell-like debridement technique plus antibiotic-loaded calcium sulphate for one-stage treatment of chronic calcaneal osteomyelitis

BACKGROUND

Management of chronic calcaneal osteomyelitis is challenging. At present, there is still no widely accepted, simple, and effective surgical method to eradicate the infection and prevent osteomyelitis recurrence. The objective of this study was to assess the outcomes of one-stage treatment of chronic calcaneal osteomyelitis with a shape-preserving debridement technique combined with antibiotic-loaded calcium sulphate.

METHODS

Between 2012 and 2018, 33 patients (33 limbs) with chronic calcaneal osteomyelitis were treated with a novel debridement technique, named "eggshell-like debridement", plus antibiotic-impregnated calcium sulphate. The infection remission rate, recurrence rate, and amputation rate were analyzed. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess postoperative hindfoot function.

RESULTS

26 patients (81.8%) achieved infection remission without recurrence. In the patients with osteomyelitis remission, pain, limitation of movement, sinus tracts, and typical redness and swelling were generally eliminated. Most of the patients could tolerate full weight-bearing without pain. The average AOFAS ankle and hindfoot score was 88 points (range, 67-100 points), implying the foot function was mostly restored. 6 patients (18.2%) had osteomyelitis recurrence but no amputation was required to elimilate the infection.

CONCLUSIONS

Eggshell-like debridement combined with antibiotic-loaded calcium sulphate is an effective method for one-stage management of chronic calcaneal osteomyelitis. With the application of this technique, secondary autogenous bone or muscle flap grafts are unnecessary. The surgical procedure can be simplified whlie the hindfoot function is well preserved.

Treatment of chronic osteomyelitis with multidose oritavancin: A case series and literature review

Osteomyelitis remains difficult to treat, typically requiring a prolonged course of intravenous (i.v.) antibiotics. The optimal route and duration of antibiotics remains ill-defined due to limited prospective clinical trials. Oritavancin is a long-acting, semisynthetic lipoglycopeptide antibiotic with rapid concentration-dependent bactericidal activity against many Gram-positive organisms. Favourable pharmacokinetics makes oritavancin an appealing alternative to currently available antibiotics requiring daily infusion to decrease the risk of vascular access complications associated with outpatient antimicrobial therapy. The purpose of this study was to report the outcomes of nine patients with chronic osteomyelitis receiving multidose oritavancin. Using electronic medical records, patients aged ≥18 years treated with i.v. oritavancin between September 2015 and April 2018 at Downtown Dublin Wound Center, a hospital-owned outpatient wound care clinic and infusion centre affiliated with Meadows Regional Health System in Dublin, GA, were identified. Of 12 cases reviewed, 9 patients received at least two doses of i.v. oritavancin for the treatment of chronic osteomyelitis. All nine patients experienced clinical cure at 6-month follow-up after the last dose of oritavancin. Multidose oritavancin was found to be a safe and efficacious option for chronic osteomyelitis when treatment options are limited by patient complexities or barriers in their ability to access healthcare services.

Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis

Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy.

LEVEL OF EVIDENCE

V.

Free intra-osseous muscle transfer for treatment of chronic osteomyelitis

BACKGROUND

Chronic osteomyelitis is still a big reconstructive challenge. Even with standard care, therapeutic failures and recurrences are common. Multiple techniques of tissue transfer have increased the success rate. This study recommends free muscle transfers into the intramedullary bone cavities for treatment of chronic osteomyelitis.

PATIENTS AND METHODS

The review included 29 patients that were treated for chronic osteomyelitis. Osteomyelitis was located at the femur in four patients, the tibia in 22 patients, and the foot in three patients. Dead bone and scar tissue were replaced with durable free muscle flap with special attention to fill the dead space.

RESULTS

The average age of these patients was 48.5 years old (range = 23-70 years old). The average duration of osteomyelitis was 8.2 years (range = 1-45 years). Gracilis was applied in 20 cases (69%), latissimus dorsi was used in five cases (17.2%), and rectus abdominis was performed in four cases (13.8%). There was one flap failure, one partial superficial flap necrosis, two arterial thrombosis, and one venous thrombosis. All the remaining 28 muscle flaps survived. From 1-10 years follow-up, there was one recurrence of the osteomyelitis in the distal end of the intra-medullary cavity of a femur after reconstructing using the gracilis flap.

CONCLUSION

The present study demonstrated that free intramedullary muscle transfers are effective in providing a high rate of success in the treatment of chronic osteomyelitis. The secondary filling of the intramedullary cavity after extensive removal of all infected bony sequesters has proven to give a long-term arrest of chronic osteomyelitis.

Gentamycin-impregnated calcium phosphate cement for calcaneal osteomyelitis: a case report

We report a case of chronic calcaneal osteomyelitis in a diabetic patient who was successfully treated with radical debridement and gentamycin-impregnated calcium phosphate cement. At 1.5-year follow-up, the patient could walk without any assistance. Calcium phosphate cement is an effective local antibiotic delivery system and a biocompatible material for filling the debrided space to facilitate bone formation.

De-epithelialized fasciocutaneous turnover flap for recurrent calcaneal wound with osteomyelitis

Recurrent ulcerations of the foot and ankle almost always present a challenge to lower extremity surgeons. Recalcitrant heel ulcerations with osteomyelitis are especially difficult to treat because of the lack of soft tissue coverage. The turnover flap is a simple, fast, and effective treatment method for lower extremity wounds. It is a de-epithelialized fasciocutaneous flap harvested from the adjacent area of the wound. We believe it is an underused technique for advanced wound closure in the lower extremity. It offers several advantages compared with traditional, more difficult to perform, flaps. We have seen an excellent result 18 months after using the turnover flap in a patient with recurrent posterior heel ulceration with calcaneal osteomyelitis.

Adult calcaneal osteitis: incidence, etiology, diagnostics and therapy

Calcaneal osteomyelitis presents a complicated situation. The specific anatomy of the os calcis and its surrounding soft tissues plays an important role in the planning and realization of the procedures needed in order to eradicate the osteomyelitic focus. The calcaneus represents a spongious bone; a fact that supports the developement of an osteomyelitis. It is the strongest bone of the foot and is highly important for the biomechanical features of physiological walking. The surrounding soft tissues are thin and contain various important anatomical structures. These might be damaged during the treatment of the osteomyelitis. In addition the vascularization of the os calcis is delicate and may be compromized during the surgical osteomyelitis treatment. Calcaneus osteomyelitis may be classified based on the routes of infection into exogenous and endogenous forms. Additionally from the clinical point of view acute and chronic forms may be distinguished from an early and a late infection. Exogenous calcaneal osteomyelitis mostly is the result of an infection with S. aureus. The treatment is equal to the therapy in other locations and based on: Eradication of the bone infectionSanitation of the soft tissue infectionReconstruction of bone and soft tissue Especially the preservation and restoration of the soft tissue is important. Thus plastic surgical procedures play an essential role. The main object of treatment is the preservation of a biomechanical functioning foot. This may be impossible due to the local situation. Calcanectomy or even below knee amputation may be needed in those cases.