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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the recent guidelines and literature regarding the diagnosis and the treatment of common pediatric musculoskeletal infections: septic arthritis, osteomyelitis, pyomyositis, and Lyme disease. RECENT FINDINGS In the last decade, a better understanding of the causative organisms of common bacterial infections, including Kingella , leads to prompt targeted antimicrobial coverage in all musculoskeletal infections. Prompt diagnosis and treatment continues to be the mainstay in the treatment of children with osteoarticular infections. Efforts to improve early detection have lead to improving rapid lab diagnostic testing; however, more advanced diagnostics such as arthrocentesis for septic arthritis and MRI for osteomyelitis and pyomyositis, remain the gold standard. Shorter and narrowed antibiotic courses, with appropriate transition to outpatient oral treatment provide effective infection clearance and reduction in complications of disease. SUMMARY Advances in diagnostics, including pathogen identification as well as imaging continues to improve our ability to diagnose and treat these infections, although still lack ability to provide definitive diagnosis without more invasive nor advanced techniques.
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Affiliation(s)
- Megan Hannon
- Division of Emergency Medicine
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Chiang CY, Chang WC, Chang WM, Shih YC, Lin FH, Wu CC, Yang KC. An assessment of physical properties and the viability of osteoblast-like cells of cefazolin-impregnated calcium sulfate bone-void filler. J Biomed Mater Res B Appl Biomater 2023; 111:382-391. [PMID: 36053824 DOI: 10.1002/jbm.b.35157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022]
Abstract
Calcium sulfate, an injectable and biodegradable bone-void filler, is widely used in orthopedic surgery. Based on clinical experience, bone-defect substitutes can also serve as vehicles for the delivery of drugs, for example, antibiotics, to prevent or to treat infections such as osteomyelitis. However, antibiotic additions change the characteristics of calcium sulfate cement. Moreover, high-dose antibiotics may also be toxic to bony tissues. Accordingly, cefazolin at varying weight ratios was added to calcium sulfate samples and characterized in vitro. The results revealed that cefazolin changed the hydration reaction and prolonged the initial setting times of calcium sulfate bone cement. For the crystalline structure identification, X-ray diffractometer revealed that cefazolin additive resulted in the decrease of peak intensity corresponding to calcium sulfate dihydrate which implying incomplete phase conversion of calcium sulfate hemihydrate. In addition, scanning electron microscope inspection exhibited cefazolin changed the morphology and size of the crystals greatly. A relatively higher amount of cefazolin additive caused a faster degradation and a lower compressive strength of calcium sulfate compared with those of uploaded samples. Furthermore, the extract of cefazolin-impregnated calcium sulfate impaired cell viability, and caused the death of osteoblast-like cells. The results of this study revealed that the cefazolin additives prolonged setting time, impaired mechanical strength, accelerated degradation, and caused cytotoxicity of the calcium sulfate bone-void filler. The aforementioned concerns should be considered during intra-operative applications.
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Affiliation(s)
- Chih-Yung Chiang
- Department of Biomedical Engineering, College of Engineering and College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Orthopedics, En Chu Kong Hospital, New Taipei City, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chia Chang
- School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wei-Min Chang
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yin-Chuan Shih
- Department of Orthopedics, En Chu Kong Hospital, New Taipei City, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Feng-Huei Lin
- Department of Biomedical Engineering, College of Engineering and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chang-Chin Wu
- Department of Orthopedics, En Chu Kong Hospital, New Taipei City, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan
| | - Kai-Chiang Yang
- School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
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He SY, Yu B, Jiang N. Current Concepts of Fracture-Related Infection. Int J Clin Pract 2023; 2023:4839701. [PMID: 37153693 PMCID: PMC10154639 DOI: 10.1155/2023/4839701] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/24/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023] Open
Abstract
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.
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Affiliation(s)
- Si-ying He
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
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Efficacy and safety of vancomycin-loaded calcium sulfate versus conventional surgical debridement for pediatric acute osteomyelitis: a retrospective study. BMC Musculoskelet Disord 2022; 23:1124. [PMID: 36564738 PMCID: PMC9784290 DOI: 10.1186/s12891-022-06105-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the safety and efficacy of vancomycin-loaded calcium sulfate beads and negative-pressure wound therapy (NPWT) in treating children with acute hematogenous osteomyelitis (AHOM). METHODS A retrospective cohort study was conducted from January 2017 to January 2020 examining children (n = 60) with AHOM who were treated with surgical debridement followed by vancomycin-loaded calcium sulfate beads and NPWT (n = 32) and compared to treatment by conventional surgical debridement (n = 28) followed by NPWT. Conventional surgical treatment consisted of fenestration of necrotic infected bone, debridement of surrounding soft tissue, and washing of the medullary canal before the application of NPWT. In the vancomycin group, the antibiotic-loaded beads were implanted after washing the medullary canal and before the application of NPWT. Epidemiological factors, complications during the procedure, outcomes at last follow-up (30.0 ± 11.7 months, range 13-58 months), and laboratory parameters were documented and compared between the two groups. RESULTS Good outcomes were achieved at last follow-up in 71.4% of the conventional treatment group and 75% of the vancomycin group. In the vancomycin group, it took a mean of 4.8 ± 2.5 days for CRP levels to decrease to 50% of initial inflammatory levels compared to 13 ± 9.6 days for the conventional treatment group (p = 0.001, t-test). The conventional group also had seven patients who underwent four or more surgeries whereas no patients in the vancomycin group underwent more than three surgeries (p = 0.013, chi-square test). CONCLUSION Localized vancomycin delivery with NPWT effective for treating cases of AHOM that required. No perioperative adverse reactions or complications occurred from this treatment method. Based on the shortened recovery period of CRP levels, prolonged administration of post-operational parenteral antibiotics can possibly be reduced with this treatment method.
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Tao R, Wu JQ, Luo JW, Hong L, Zhou CH, Cheng GY, Qin CH. Antibiotic-impregnated calcium sulfate for the treatment of pediatric hematogenous osteomyelitis. BMC Pediatr 2022; 22:732. [PMID: 36564727 PMCID: PMC9783740 DOI: 10.1186/s12887-022-03791-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antibiotic-impregnated calcium sulfate has excellent curative efficacy in chronic osteomyelitis. However, its curative efficacy in pediatric hematogenous osteomyelitis has not been sufficiently studied. The purpose of this study was to evaluate the curative effects of antibiotic-impregnated calcium sulfate in the treatment of pediatric hematogenous osteomyelitis. METHODS Overall, twenty-one pediatric patients with hematogenous osteomyelitis treated at our hospital between 2013 and 2018 were included for assessment. The clinical history, clinical manifestation, infection recurrence rate, sinus leakage, incision leakage, pathological fractures, bone growth and surgical procedures were analyzed. RESULTS The infection recurrence rate was 0% (0/21) at a minimum of 31 months (range 31 to 91 months) of follow-up. Postoperative incision leakage was found in one pediatric patient. Osteolysis was found in one pediatric patient. Acceleration of bone growth occurred in one pediatric patient. Retardation of bone growth occurred in one pediatric patient. Genu valgus deformity occurred in one pediatric patient. CONCLUSIONS Although noninfectious complications occurred, the curative effect of antibiotic-impregnated calcium sulfate in pediatric hematogenous osteomyelitis was satisfactory.
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Affiliation(s)
- Rui Tao
- grid.284723.80000 0000 8877 7471Department of Orthopaedics, Southern Medical University Zengcheng Branch of Nanfang Hospital, No. 28 Chuangxin Avenue Yongning Street, Zengcheng District Guangzhou, 511340 People’s Republic of China
| | - Jian-qun Wu
- grid.263817.90000 0004 1773 1790Department of Bone and Joint, School ofMedicine, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, 518055 People’s Republic of China
| | - Ji-wei Luo
- grid.284723.80000 0000 8877 7471Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, No. 1838, Guangzhou Ave. North, Guangzhou, Guangdong 510515 People’s Republic of China
| | - Liang Hong
- grid.284723.80000 0000 8877 7471Department of Orthopaedics, Southern Medical University Zengcheng Branch of Nanfang Hospital, No. 28 Chuangxin Avenue Yongning Street, Zengcheng District Guangzhou, 511340 People’s Republic of China
| | - Chun-hao Zhou
- grid.284723.80000 0000 8877 7471Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, No. 1838, Guangzhou Ave. North, Guangzhou, Guangdong 510515 People’s Republic of China
| | - Guo-yun Cheng
- Department of Orthopaedics and Traumatology, Second Clinical Medical School, Guangdong Second Provincial General Hospital, Southern Medical University, Guangzhou, 510317 People’s Republic of China
| | - Cheng-he Qin
- grid.284723.80000 0000 8877 7471Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, No. 1838, Guangzhou Ave. North, Guangzhou, Guangdong 510515 People’s Republic of China
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Lazzeri S, Montagnani C, Zanardi A, Beltrami G, Galli L. Bioactive glass in the treatment of chronic osteomyelitis in children: Description of four consecutive cases and literature review. Injury 2022; 53:3317-3321. [PMID: 35817607 DOI: 10.1016/j.injury.2022.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/20/2022] [Accepted: 07/02/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Simone Lazzeri
- Department of Orthopaedics and Traumatology, Meyer Children's Hospital, Viale Pieraccini, 24, Firenze, Italy.
| | | | - Alessandro Zanardi
- Department of Orthopaedics and Traumatology, Meyer Children's Hospital, Viale Pieraccini, 24, Firenze, Italy
| | - Giovanni Beltrami
- Department of Orthopaedics and Traumatology, Meyer Children's Hospital, Viale Pieraccini, 24, Firenze, Italy
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children's Hospital, Firenze, Italy
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Elhessy AH, Rivera JC, Shu HT, Andrews TJ, Herzenberg JE, Conway JD. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022; 17:123-130. [PMID: 35990181 PMCID: PMC9357795 DOI: 10.5005/jp-journals-10080-1554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS). Background Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal. Technique Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones. Conclusion Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication. Clinical significance The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS. How to cite this article Elhessy AH, Rivera JC, Shu HT, et al. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022;17(2):123–130.
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Affiliation(s)
- Ahmed H Elhessy
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
| | - Jessica C Rivera
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America; Louisiana State University Health Science Center, New Orleans, Louisiana, United States of America
| | - Henry T Shu
- Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States of America
| | - Taj-Jamal Andrews
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
| | - John E Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
- Janet D Conway, International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America, Phone: +410 6019562, e-mail:
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McPherson E, Jennings J, Yunis O, Harris M, Dipane M, Curtin N, Chowdhry M, Wassef A, Bumgardner J, Noel S. Simulated large joint fluid model for evaluating intra-articular antibiotic delivery systems: initial evaluation using antibiotic-loaded calcium sulfate beads. J Bone Jt Infect 2022; 7:117-125. [PMID: 35620590 PMCID: PMC9128367 DOI: 10.5194/jbji-7-117-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: Local antimicrobial delivery via calcium sulfate
(CaSO4) beads is used as an adjunctive treatment for periprosthetic
joint infection. There is limited clinical information describing the
performance of antimicrobial-loaded CaSO4 (ALCS) in large-scale applications. We developed a simulated large joint model to study properties
of eluting ALCS. Methods: The in vitro testing platform was an adapted
standardized model for tribological testing of prosthetic total hips and
total knees (ASTM F732). The model was 70 mL total fluid volume, 25 % bovine serum, and 75 % phosphate-buffered saline, using ISO standard 14242-1 for human synovial fluid simulation. Four brands of CaSO4 were
evaluated. Each 10 mL of CaSO4 was loaded with 1.2 grams (g) of tobramycin and 1 g of vancomycin powders. A 35 mL bead volume, equaling 175 beads, of each product was placed in incubated flasks. The test period was 6 weeks with scheduled interval fluid exchanges. Fluid samples were tested
for antibiotic and calcium concentrations and pH. Results: Antibiotic elution showed an initial burst on Day 1, followed by a logarithmic
reduction over 1 week. Tobramycin fully eluted within 2.5 weeks. Vancomycin showed sustained release over 6 weeks. Calcium ion concentrations were high, with gradual decrease after 3 weeks. All four CaSO4 products
were inherently acidic. Fluid became more acidic with the addition of
antibiotics primarily driven by vancomycin. Discussion: Clinicians should be
cognizant of tobramycin elution burst with ALCS in large loads. The main
driver of acidic pH levels was vancomycin. We propose that joint
complications may result from lowered fluid acidity, and we suggest clinical study of synovial pH.
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Affiliation(s)
- Edward J. McPherson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at
UCLA, Santa Monica, 90404, USA
| | - Jessica A. Jennings
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
| | - Omar Yunis
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
| | - Michael A. Harris
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
| | - Matthew V. Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine at
UCLA, Santa Monica, 90404, USA
| | - Nora L. Curtin
- Department of Orthopaedic Surgery, David Geffen School of Medicine at
UCLA, Santa Monica, 90404, USA
| | - Madhav Chowdhry
- Nuffield Department of Primary Care Health Sciences, Kellogg College,
University of Oxford, Oxford, OX1 2JD, UK
| | - Andrew J. Wassef
- Long Beach Lakewood Orthopedic Institute, Long Beach, 90808, USA
| | - Joel D. Bumgardner
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
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Outcome Analysis of the Use of Cerament® in Patients with Chronic Osteomyelitis and Corticomedullary Defects. Diagnostics (Basel) 2022; 12:diagnostics12051207. [PMID: 35626362 PMCID: PMC9139791 DOI: 10.3390/diagnostics12051207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic osteomyelitis (OM) is a progressive but mostly low-grade infection of the bones. The management of this disease is highly challenging for physicians. Despite systematic treatment approaches, recurrence rates are high. Further, functional and patient-reported outcome data are lacking, especially after osseous defects are filled with bioresorbable antibiotic carriers. Objective: To assess functional and patient-reported outcome measures (PROM) following the administration of Cerament® G or V due to corticomedullary defects in chronic OM. Methods: We conducted a retrospective study from 2015 to 2020, including all patients who received Cerament® for the aforementioned reason. Patients were diagnosed and treated in accordance with globally valid recommendations, and corticomedullary defects were filled with Cerament® G or V, depending on the expected germ spectrum. Patients were systematically followed up, and outcome measures were collected during outpatient clinic visits. Results: Twenty patients with Cierny and Mader type III OM were included in this study and followed up for 20.2 ± 17.2 months (95%CI 12.1–28.3). Ten of these patients needed at least one revision (2.0 ± 1.3 revisions per patient (95%CI 1.1–2.9) during the study period due to OM persistence or local wound complications. There were no statistically significant differences in functional scores or PROMs between groups. Conclusion: The use of Cerament® G and V in chronic OM patients with corticomedullary defects appears to have good functional outcomes and satisfactory PROMs. However, the observed rate of local wound complications and the OM persistence rate may be higher when compared to previously published data.
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Liu Y, Liang A, Li X, Ma Z, Zhang D. Efficacy Evaluation of Ciprofloxacin-Loaded Poly (Trimethylene Carbonate) Implants in the Treatment of Chronic Osteomyelitis. Front Bioeng Biotechnol 2022; 10:864041. [PMID: 35464725 PMCID: PMC9024176 DOI: 10.3389/fbioe.2022.864041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/24/2022] [Indexed: 11/24/2022] Open
Abstract
In this study, poly (trimethylene carbonate) (PTMC) with excellent biocompatibility was synthesized via ring-opening of TMC to prepare the Ciprofloxacin-loaded PTMC implants, and antibacterial effects in vitro or in vivo of the resulting implants were investigated to evaluate the potential for treating chronic osteomyelitis. The in vitro results showed the Ciprofloxacin-loaded PTMC implants could sustain release ciprofloxacin at a release amount of about 90 μg/d for 28 days and possessed excellent antibacterial effect, as evidenced by the smaller size of the antibacterial ring of 32.6 ± 0.64 mm and the biofilm inhibition of 60% after 28 days of release. The in vivo results showed that after 28 days of treatment, the body weight and the white blood cell counts of chronic-osteomyelitis-model rats in the treatment group reached 381.6 ± 16.8 g and (7.86 ± 0.91) ×109/L, respectively, returning to normal rapidly compared with the control and blank group, indicating the remarkable antibacterial effect of the Ciprofloxacin-loaded PTMC implants. X-ray images and HE staining results also confirmed that most of the proximal and middle parts of the tibia returned to typical structures and new and trabecular bone had been formed for the rats in the treatment group, and no inflammatory cells were found as compared to the control and blank groups, after 28 days of treatment. The significant lower number of colonies of (9.92 ± 1.56) × 10 CFU/g in the treatment group also suggests that the Ciprofloxacin-loaded PTMC implants achieve a practical antibacterial effect through a local application.
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Affiliation(s)
- Yixiu Liu
- Department of Orthopaedics, The Central Hospital Affiliated to Shenyang Medical College, Shenyang, China
- Shenyang Clinical Research Center for Hand and Foot, Shenyang, China
- *Correspondence: Yixiu Liu, ; Dan Zhang,
| | - A. Liang
- Department of Orthopaedics, The Central Hospital Affiliated to Shenyang Medical College, Shenyang, China
- Shenyang Clinical Research Center for Hand and Foot, Shenyang, China
| | - Xu Li
- Department of Orthopaedics, The Central Hospital Affiliated to Shenyang Medical College, Shenyang, China
- Shenyang Clinical Research Center for Hand and Foot, Shenyang, China
| | - Zhihe Ma
- The First People’s Hospital of Shenyang, Shenyang, China
| | - Dan Zhang
- Liaoning Provincial Key Laboratory of Oral Diseases, School and Hospital of Stomatology, China Medical University, Shenyang, China
- *Correspondence: Yixiu Liu, ; Dan Zhang,
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Shi X, Wu Y, Ni H, Li M, Zhang C, Qi B, Wei M, Wang T, Xu Y. Antibiotic-loaded calcium sulfate in clinical treatment of chronic osteomyelitis: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:104. [PMID: 35183215 PMCID: PMC8858512 DOI: 10.1186/s13018-022-02980-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/27/2022] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Present work was aimed to gather accessible evidence on the eradication rates and related postoperative complications of antibiotic-loaded calcium sulfate (CS) as an implant in the treatment of chronic osteomyelitis (COM).
Methods
Databases including PubMed, EMBASE, Medline, Ovid and Cochrane library were searched from their dates of initiation until November 2021. Two independent authors scrutinized the relevant studies based on the effectiveness of radical debridement combined with antibiotic-loaded CS for COM; data extraction and quality assessment of the Methodological Index for Non-Randomized Studies (MINORS) criteria were also performed by the authors. In addition, clinical efficacy mainly depended on the evaluation of eradication rates and complications, and all the extracted data are pooled and analyzed by STATA 16.0.
Results
A total of 16 studies with 917 patients (920 locations) were recruited, with an overall eradication rate of 92%. Moreover, the overall reoperation rate, overall refracture rate, overall delayed wound healing rate, and the rate of aseptic wound leakage were 9.0%, 2.0%, 20.0%, and 12.0%, respectively. Moreover, the choice of tobramycin-loaded CS or vancomycin combined with gentamicin-loaded CS did not affect the eradication rate, and the incidence of postoperative complications in COM patients (all $$P>0.05$$
P
>
0.05
). The general quality of the included studies was fair.
Conclusions
Our meta-analysis indicated that the overall eradication rate of COM treated with antibiotic-loaded CS was 92%. Delayed healing is the most common postoperative complication. The choice of tobramycin-loaded CS or vancomycin combined with gentamicin-loaded CS did not affect the eradication rate and the incidence of postoperative complications in COM patients.
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13
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Bor N, Dujovny E, Rinat B, Rozen N, Rubin G. Treatment of chronic osteomyelitis with antibiotic-impregnated polymethyl methacrylate (PMMA) - the Cierny approach: is the second stage necessary? BMC Musculoskelet Disord 2022; 23:38. [PMID: 34991574 PMCID: PMC8740499 DOI: 10.1186/s12891-021-04979-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Chronic osteomyelitis is a challenge for orthopedic surgeons. Most patients with osteomyelitis receive two-stage management according to Cierny-Mader. The first stage includes radical debridement and insertion of an antibiotic-impregnated cement spacer (ACS) (beads, rods, nails, or blocks) into the bone defect. The second stage is performed 6–8 weeks later, when the spacer is removed and a cancellous autograft is placed within the bone defect. The possibility of ACS as definitive management for osteomyelitis, avoiding the second stage, is presented. Methods Sixteen patients with osteomyelitis received radical debridement and insertion of an ACS in all forms into the bone defect as a definitive management. In 8 patients, the tibia was infected, 4 had femur infection, 2 humerus, 1 fibula, and 1 ankle. The mean age at the time of the first stage of reconstruction was 49 years (range, 13–71 years). According to the Cierny-Mader classification, 1 patient was C-M IA, another was IB, 7 IIIA, 6 IIIB, and 1 was 4A. All B hosts had systemic illnesses. The mean follow-up period was 6 years (1.5–16 years). Results No patient exhibited radiographic evidence of excessive bone loss. Signs of recurrence of osteomyelitis were not noted in any of the patients, and no fractures had occurred by the last follow-up. Conclusion Our study suggests that a proportion of patients with planned retention of ACS appear to function well without requiring further surgical intervention, especially in elderly or vulnerable patients.
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Affiliation(s)
- Noam Bor
- Orthopedic Department, Emek Medical Center, Afula, Israel. .,Faculty of Medicine, Technion, Haifa, Israel.
| | - Eytan Dujovny
- Orthopedic Department, Emek Medical Center, Afula, Israel
| | - Barak Rinat
- Orthopedic Department, Emek Medical Center, Afula, Israel
| | - Nimrod Rozen
- Orthopedic Department, Emek Medical Center, Afula, Israel.,Faculty of Medicine, Technion, Haifa, Israel
| | - Guy Rubin
- Orthopedic Department, Emek Medical Center, Afula, Israel.,Faculty of Medicine, Technion, Haifa, Israel
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Hua H, Wang X, Guo J, Zhang L, Guo Z, Chen J. A comparison of the vancomycin calcium sulfate implantation versus fenestration decompression for the treatment of sclerosing osteomyelitis. BMC Musculoskelet Disord 2021; 22:993. [PMID: 34844579 PMCID: PMC8630894 DOI: 10.1186/s12891-021-04881-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/16/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To compare the clinical efficacy of vancomycin calcium sulfate implantation and fenestration decompression in the treatment of sclerosing osteomyelitis. METHOD A retrospective analysis for 46 cases of sclerosing osteomyelitis were admitted to our department between June 2010 to June 2020. Twenty-one patients were treated with fenestration decompression, twenty-five patients were treated with vancomycin calcium sulfate implantation. The postoperative hospital stay, days of drainage tube placement, visual analogue scale scores, C-reactive protein and erythrocyte sedimentation rate were compared between the two groups. RESULTS The visual analogue scale scores of both groups were significantly lower than before treatment (p < 0.05), but the difference between them was not statistically significant. Patients treated by vancomycin calcium sulfate implantation had shorter postoperative hospital stay and days of drainage tube placement compared to those treated by fenestration decompression (p < 0.05). C-reactive protein and erythrocyte sedimentation rate in both groups were significantly lower than before treatment, but the improvement effect of vancomycin calcium sulfate implantation was better (p < 0.05). CONCLUSION Both treatment methods can relieve pain effectively. Compared with fenestration decompression, vancomycin calcium sulfate implantation can shorten the treatment time effectively, control the infection better.
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Affiliation(s)
- Haotian Hua
- Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Xinwei Wang
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China.
| | - Jiangang Guo
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
| | - Lei Zhang
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
| | - Zairan Guo
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
| | - Jiangfei Chen
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
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15
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Woods CR, Bradley JS, Chatterjee A, Copley LA, Robinson J, Kronman MP, Arrieta A, Fowler SL, Harrison C, Carrillo-Marquez MA, Arnold SR, Eppes SC, Stadler LP, Allen CH, Mazur LJ, Creech CB, Shah SS, Zaoutis T, Feldman DS, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:801-844. [PMID: 34350458 DOI: 10.1093/jpids/piab027] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 01/08/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee College of Medicine, Chattanooga, Tennessee, USA
| | - John S Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine, and Rady Children's Hospital, San Diego, California, USA
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew P Kronman
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington, USA
| | - Antonio Arrieta
- University of California Irvine School of Medicine and Children's Hospital of Orange County, Irvine, California, USA
| | - Sandra L Fowler
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stephen C Eppes
- Department of Pediatrics, ChristianaCare, Newark, Delaware, USA
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, USA
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas, USA
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Feldman
- New York University Langone Medical Center, New York, New York, USA
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of Montreal Research Center, Montreal, Quebec, Canada
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Qin CH, Tao R, Luo JW, Hong L, Xu L, Fang J, Zhou CH. Culture-negative chronic hematogenous osteomyelitis in a two months old girl: a case report. BMC Musculoskelet Disord 2021; 22:679. [PMID: 34380448 PMCID: PMC8359591 DOI: 10.1186/s12891-021-04547-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background Previous articles have focused on the diagnosis and treatment of acute hematogenous osteomyelitis. Here, we present a case of chronic hematogenous osteomyelitis in a 2-month-old girl. The diagnostic procedure was unusual and difficult due to negative culture results. Case presentation A girl aged 2 months and 23 days had fever and swelling in her right lower leg for 7 days. On the basis of her medical history, physical, and histological examination results; and radiologic and magnetic resonance imaging findings, a diagnosis of chronic osteomyelitis was made. The patient underwent surgical treatment and was discharged successfully. The patient showed good recovery and no sequelae at the 12-month follow-up. Conclusion Hematogenous osteomyelitis in babyhood is different from that at any other age. Hematogenous osteomyelitis-related bone destruction in babyhood is more serious and occurs faster. The transition from acute hematogenous osteomyelitis to chronic hematogenous osteomyelitis takes only 7 days. To the best of our knowledge, this chronic hematogenous osteomyelitis patient is the youngest ever reported.
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Affiliation(s)
- Cheng-He Qin
- Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, No. 1838, Guangzhou Ave. North, Guangzhou, Guangdong, 510515, People's Republic of China.
| | - Rui Tao
- Department of Orthopaedics, Southern Medical University Zengcheng branch of Nanfang Hospital, No. 28, Chuangxin avenue, Yongning Street, Zengcheng District, Guangzhou, 511340, People's Republic of China
| | - Ji-Wei Luo
- Department of Orthopaedics, Southern Medical University Zengcheng branch of Nanfang Hospital, No. 28, Chuangxin avenue, Yongning Street, Zengcheng District, Guangzhou, 511340, People's Republic of China
| | - Liang Hong
- Department of Orthopaedics, Southern Medical University Zengcheng branch of Nanfang Hospital, No. 28, Chuangxin avenue, Yongning Street, Zengcheng District, Guangzhou, 511340, People's Republic of China
| | - Lei Xu
- Department of Orthopaedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, Guangzhou, 510317, People's Republic of China
| | - Jia Fang
- Department of Orthopaedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, Guangzhou, 510317, People's Republic of China
| | - Chun-Hao Zhou
- Department of Orthopaedics and Traumatology, Southern Medical University Nanfang Hospital, No. 1838, Guangzhou Ave. North, Guangzhou, Guangdong, 510515, People's Republic of China
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17
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Treatment of Chronic Hematogenous Osteomyelitis in Children With Antibiotic Impregnated Calcium Sulphate. J Pediatr Orthop 2021; 41:127-131. [PMID: 33284138 DOI: 10.1097/bpo.0000000000001723] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical and radiologic outcome of chronic hematogenous osteomyelitis (CHOM) in children, treated with single-stage debridement and dead space management using antibiotic impregnated calcium sulphate pellets. METHODS The authors retrospectively evaluated a consecutive series of 34 patients who presented with CHOM from 2011 to 2017. In each case, CHOM was classified according to the Beit CURE classification. Following thorough surgical debridement, the resulting dead space in the bone was filled with the antibiotic impregnated beads before primary closure. RESULTS Of the 31 patients available for follow up, effective regeneration of bone was confirmed in all cases, with radiographic bone healing typically observed at around 12 weeks. None of the children required reoperation for infection and none had recurrence of infection at the time of final review. The beads were completely absorbed within 3 months. No systemic adverse reactions to the local delivery of antibiotics were observed in this study. CONCLUSIONS The authors found that single-stage debridement in conjunction with antibiotic impregnated calcium sulphate was an effective means of treating CHOM in children, with effective eradication of infection in every case. LEVEL OF EVIDENCE Level IV-Retrospective case series. See instructions for authors for a complete description of levels of evidence.
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Jiang N, Zhao XQ, Wang L, Lin QR, Hu YJ, Yu B. Single-stage debridement with implantation of antibiotic-loaded calcium sulphate in 34 cases of localized calcaneal osteomyelitis. Acta Orthop 2020; 91:353-359. [PMID: 32237934 PMCID: PMC8023923 DOI: 10.1080/17453674.2020.1745423] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - The successful eradication of calcaneus infection with limb salvage remains a challenge. We describe the outcomes of cortical bone windowing followed by eggshell-like debridement and implantation of antibiotic-loaded calcium sulphate (CS) for localized (Cierny-Mader type III) calcaneal osteomyelitis (CO).Patients and methods - We report a retrospective study of 34 patients. Infection followed trauma or orthopedic surgery in 30 patients and hematogenous spread in 4 patients. 31 patients had a sinus tract, accompanied by a soft tissue defect in 3 patients. All patients received cortical bone windowing, debridement, multiple sampling, local implantation of vancomycin- and gentamicin-loaded CS, skin closure or flap coverage, and culture-specific systematic antibiotic treatment in a single-stage procedure. Patients were followed up for a median of 26 months.Results - Infection was eradicated in 29 patients after the single-stage surgery, and all of the 5 recurrent infections were cleared by repeated surgery without amputation. Other adverse events included 11 patients with aseptic wound leakage and 1 unrelated death. Compared with those before surgery, the median postoperative scores of the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale (65 vs. 86 vs. 89) and the visual analog scale (VAS) for pain (6 vs. 3 vs. 1) improved at the 1-year and 2-year follow-up.Interpretation - This single-stage protocol, cortical bone windowing, and eggshell-like debridement combined with local implantation of antibiotic-loaded CS is effective in treating type III CO. However, the incidence of aseptic wound leakage is high.
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Affiliation(s)
- Nan Jiang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou; ,Guangdong Provincial Key Laboratory of Bone & Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, P R China
| | - Xing-qi Zhao
- Guangdong Provincial Key Laboratory of Bone & Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, P R China
| | - Lei Wang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou;
| | - Qing-rong Lin
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou;
| | - Yan-jun Hu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou;
| | - Bin Yu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou; ,Guangdong Provincial Key Laboratory of Bone & Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, P R China,Correspondence:
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Ishida W, Perdomo-Pantoja A, Elder BD, Locke J, Holmes C, Witham TF, Lo SFL. Effects of Intraoperative Intrawound Antibiotic Administration on Spinal Fusion: A Comparison of Vancomycin and Tobramycin in a Rat Model. J Bone Joint Surg Am 2019; 101:1741-1749. [PMID: 31577679 DOI: 10.2106/jbjs.18.00988] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Local, intrawound use of antibiotic powder, such as vancomycin and tobramycin, in spinal fusion surgery has become an increasingly common prophylactic measure in an attempt to reduce rates of postsurgical infection. However, the effects of localized antibiotic delivery on fusion remain unclear. The objective of this study was to examine the in vivo effects of intraoperative local delivery of 2 antibiotics commonly used in bone-grafting surgery on spinal fusion outcomes in a rat model. METHODS Single-level (L4-L5), bilateral posterolateral intertransverse process lumbar fusion surgery was performed on 60 female Lewis rats (6 to 8 weeks of age) using syngeneic iliac crest allograft mixed with clinical bone-graft substitute and varying concentrations of antibiotics (n = 12 each): (1) control without any antibiotics, (2) low-dose vancomycin (14.3 mg/kg), (3) high-dose vancomycin (71.5 mg/kg), (4) low-dose tobramycin (28.6 mg/kg), and (5) high-dose tobramycin (143 mg/kg). Eight weeks postoperatively, fusion was evaluated via micro-computed tomography (µCT), manual palpation, and histological analysis, with blinding to treatment group. In the µCT analysis, fusion-mass volumes were measured for each rat. Each spine specimen (L4-L5) was rated (manual palpation score) on a scale of 2 to 0 (2 = fused, 1 = partially fused, and 0 = non-fused). RESULTS The mean fusion-mass volume on µCT (mm) was as follows: control, 29.3 ± 6.2; low-dose vancomycin, 26.3 ± 8.9; high-dose vancomycin, 18.8 ± 7.9; low-dose tobramycin, 32.7 ± 9.0; and high-dose tobramycin, 43.8 ± 11.9 (control versus high-dose vancomycin, p < 0.05; and control versus high-dose tobramycin, p < 0.05). The mean manual palpation score for each group was as follows: control, 1.46 ± 0.58; low-dose vancomycin, 0.86 ± 0.87; high-dose vancomycin, 0.68 ± 0.62; low-dose tobramycin, 1.25 ± 0.71; and high-dose tobramycin, 1.32 ± 0.72 (control versus high-dose vancomycin, p < 0.05). The histological analyses demonstrated a similar trend with regard to spinal fusion volume. CONCLUSIONS Intraoperative local application of vancomycin, particularly at a supraphysiological dosage, may have detrimental effects on fusion-mass formation. No inhibitory effect of tobramycin on fusion-mass formation was observed. CLINICAL RELEVANCE When spine surgeons decide to use intraoperative intrawound antibiotics in spinal fusion surgery, they should weigh the reduction in surgical site infection against a possible inhibitory effect on fusion.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - John Locke
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christina Holmes
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng-Fu L Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents: is the rationale of antibiotics use appropriate? J Pediatr Orthop B 2019; 28:415-416. [PMID: 31135689 DOI: 10.1097/bpb.0000000000000630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Response to 'Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents: is the rationale of antibiotics use appropriate?' by Rajnish et al. J Pediatr Orthop B 2019; 28:416-417. [PMID: 31135690 DOI: 10.1097/bpb.0000000000000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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