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

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.

Artificial Fusion of Infected Total Knee Arthroplasty Using a Flexible Intramedullary Rod Bundle and an Antibiotic-Loaded Cement Spacer / 대한정형외과학회잡지

Multiple total knee arthroplasty (TKA) failure resulting from a recurrent infection is a challenging problem. Knee arthrodesis is one treatment option that normally involves the application of an external fixator, plate fixation, and intramedullary nailing. However, these approaches are not always successful, and a reinfection is a risk, particularly in older, medically compromised patients. This paper reports a new arthrodesis technique that uses a bundle of flexible intramedullary rods and an antibiotic-loaded cement spacer. This technique was used in two cases of multiple TKA failure that resulted from a recurrent infection. The procedure was successful in both cases with no evidence of rod or cement failure. Two advantages of this procedure are infection eradication and mechanical strength. However, this procedure should only be used for medically compromised elderly patients at high risk of rerevision TKA failure resulting from persistent periprosthetic infection because rod fracture or loosening can occur with time.

Staged Revision of Infected Hip Arthroplasty Using an Antibiotics-Loaded Intra-Articular Cement Spacer with Retention of the Stem

PURPOSE: When the femoral stem was well fixed in patients with a deep prosthetic hip infection, the authors performed a two-stage revision procedure using antibiotic-loaded cement spacers (ALCS) without removal of the stem, and the efficacy of this treatment was assessed. MATERIALS AND METHODS: For 12 cases of infected hip arthroplasties, a two-stage procedure was performed, and the patients were followed up for over 2 years. After the acetabular component and head was removed, debridement was done. The molded ALCS was inserted. Revision was then performed after eradication of the infection. The results were analyzed, including the changes in the clinical manifestation, the radiologic findings, the laboratory results, the functional score and the complications. RESULTS: Of all 12 cases, the two-stage revision arthroplasty using an ALCS with retention of the stem was performed in 11 cases (92%), on an average of 66 days (range: 40~152 days). In the 11 revised cases, there was no evidence of recurrence of infection. In the 11 cases, the mean Harris hip score improved from 40.1 points preoperatively to 91.8 points at last the follow-up. The mean WOMAC score improved from 41.8 points preoperatively to 81 points at the last follow-up. The mean Harris hip score was 85.3 points and the WOMAC score was 72.4 points during the ALCS insertion-period. CONCLUSION: For the case of a perioprosthetic hip infection with a well-fixed femoral stem, two-staged revision using an ALCS without stem removal could be an alternative method in terms of effective infection control and preservation of the joint function.