J Korean Foot Ankle Soc.  2019 Jun;23(2):58-66. 10.14193/jkfas.2019.23.2.58.

Risk Factors for the Treatment Failure of Antibiotic-Loaded Cement Spacer Insertion in Diabetic Foot Infection

• Park SJ
• Song S

• KMID: 2449673
• DOI: http://doi.org/10.14193/jkfas.2019.23.2.58

Abstract

PURPOSE
To evaluate the efficacy of antibiotic-loaded cement spacers (ALCSs) for the treatment of diabetic foot infections with osteomyelitis as a salvage procedure and to analyze the risk factors of treatment failure.
MATERIALS AND METHODS
This study reviewed retrospectively 39 cases of diabetic foot infections with osteomyelitis who underwent surgical treatment from 2009 to 2017. The mean age and follow-up period were 62±13 years and 19.2±23.3 months, respectively. Wounds were graded using the Wagner and Strauss classification. X-ray, magnetic resonance imaging (or bone scan) and deep tissue cultures were taken preoperatively to diagnose osteomyelitis. The ankle-brachial index, toe-brachial index (TBI), and current perception threshold were checked. Lower extremity angiography was performed and if necessary, percutaneous transluminal angioplasty was conducted preoperatively. As a surgical treatment, meticulous debridement, bone curettage, and ALCS placement were employed in all cases. Between six and eight weeks after surgery, ALCS removal and autogenous iliac bone graft were performed. The treatment was considered successful if the wounds had healed completely within three months without signs of infection and no additional amputation within six months.
RESULTS
The treatment success rate was 82.1% (n=32); 12.8% (n=5) required additional amputation and 5.1% (n=2) showed delayed wound healing. Bacterial growth was confirmed in 82.1% (n=32) with methicillin-resistant Staphylococcus aureus being the most commonly identified strain (23.1%, n=9). The lesions were divided anatomically into four groups; the largest number was the toes: (1) toes (41.0%, n=16), (2) metatarsals (35.9%, n=14), (3) midfoot (5.1%, n=2), and (4) hindfoot (17.9%, n=7). A significant difference in the Strauss wound score and TBI was observed between the treatment success group and failure group.
CONCLUSION
The insertion of ALCSs can be a useful treatment option in diabetic foot infections with osteomyelitis. Low scores in the Strauss classification and low TBI are risk factors of treatment failure.

Keyword

Diabetic foot; Osteomyelitis; Antibiotic-loaded cement spacer; Risk factor

MeSH Terms

Amputation
Angiography
Angioplasty
Ankle Brachial Index
Classification
Curettage
Debridement
Diabetic Foot*
Follow-Up Studies
Lower Extremity
Magnetic Resonance Imaging
Metatarsal Bones
Methicillin-Resistant Staphylococcus aureus
Osteomyelitis
Retrospective Studies
Risk Factors*
Toes
Transplants
Treatment Failure*
Wound Healing
Wounds and Injuries

Figure

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  Figure 1. Right foot anteroposterior (A) and lateral (B) radiographs show mild osteolytic lesion on the 1st distal phalanx. T2-weighted axial magnetic resonance imaging (C) shows hypersignal intensity on the 1st distal phalanx and suspicious of abscess formation around it, compatible with osteomyelitis.

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  Figure 2. Right 1st toe anteroposterior (A) and lateral (B) radiographs after debridement, bone curettage and antibiotic cement spacer insertion.

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  Figure 3. Right 1st toe anteroposterior (A) and lateral (B) radiographs after antibiotic cement spacer removal and autogenous iliac bone graft.

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  Figure 4. Right 1st toe anteroposterior (A) and lateral (B) radiographs after 4 months of antibiotic cement spacer removal and autogenous iliac bone graft. The 1st distal phalanx healed nearly as normal, and we could prevent amputation.

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