Local release of antibiotic has advantages in the treatment of chronic osteomyelitis and infected fractures. The adequacy of surgical debridement is still key to successful clearance of infection but local antibiotic carriers seem to afford greater success rates by targeting the residual organisms present after debridement and delivering much higher local antibiotic concentrations compared with systemic antibiotics alone. Biodegradable ceramic carriers can be used to fill osseous defects, which reduces the dead space and provides the potential for subsequent repair of the osseous defect as they dissolve away. A dissolving ceramic antibiotic carrier also raises the possibility of single stage surgery with definitive closure and avoids the need for subsequent surgery for spacer removal.In this article we provide an overview of the properties of various biodegradable ceramics, including calcium sulphate, the calcium orthophosphate ceramics, calcium phosphate cement and polyphasic carriers. We summarise the antibiotic elution properties as investigated in previous animal studies as well as the clinical outcomes from clinical research investigating their use in the surgical management of chronic osteomyelitis.Calcium sulphate pellets have been shown to be effective in treating local infection, although newer polyphasic carriers may support greater osseous repair and reduce the risk of further fracture or the need for secondary reconstructive surgery. The use of ceramic biocomposites to deliver antibiotics together with BMPs, bisphosphonates, growth factors or living cells is under investigation and merits further study.We propose a treatment protocol, based on the Cierny-Mader classification, to help guide the appropriate selection of a suitable ceramic antibiotic carrier in the surgical treatment of chronic osteomyelitis.

Aims: Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. Methods: A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). Results: At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). Conclusion: We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion. Cite this article: Bone Joint J 2022;104-B(9):1095–1100.

This prospective study compared bifocal acute shortening and relengthening (ASR) with bone transport (BT) in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at the surgical resection of the infection. Patients with an infected tibial segmental defect (>2 cm) were eligible for inclusion. Patients were allocated to ASR or BT, using a standardized protocol, depending on defect size, the condition of soft tissues and the state of the fibula (intact or divided). We recorded the Weber–Cech classification, previous operations, external fixation time, external fixation index (EFI), follow-up duration, time to union, ASAMI bone and functional scores and complications. A total of 47 patients (ASR: 20 patients, BT: 27 patients) with a median follow-up of 37.9 months (range 16–128) were included. In the ASR group, the mean bone defect size measured 4.0 cm, and the mean frame time was 8.8 months. In the BT group, the mean bone defect size measured 5.9cm, and the mean frame time was 10.3 months. There was no statistically significant difference in the EFI between ASR and BT (2.0 and 1.8 months/cm, respectively) (p = 0.223). A total of 3/20 patients of the ASR and 15/27 of the BT group needed further unplanned surgery during Ilizarov treatment (p = 0.006). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.0% (p < 0.0001). The infection eradication rate was 100% in both groups at final follow-up. Final ASAMI functional rating scores and bone scores were similar in both groups. Segmental resection with the Ilizarov method is effective and safe for reconstruction of infected tibial defects, allowing the eradication of infection and high union rates. However, BT demonstrated a higher rate of unplanned surgeries, especially docking site revisions. Acute shortening and relengthening does not reduce the fixator index. Both techniques deliver good functional outcome after completion of treatment.

Background and Purpose: A case series review of chronic pelvic osteomyelitis treated with combined medical and surgical treatment by a multidisciplinary team.Methods: All patients treated with surgical excision of pelvic osteomyelitis at our tertiary referral centre between 2002 and 2014 were included. All received combined care from a clinical microbiologist, an orthopaedic surgeon and a plastic surgeon. The rate of recurrent infection, wound healing problems and post-operative mortality was determined in all. Treatment failure was defined as reoperation involving further bone debridement, a requirement for the use of long-term suppressive antibiotics or sinus recurrence.Results: Sixty-one adults (mean age 50.2 years, range 16.8-80.6) underwent surgery. According to the Cierny-Mader classification of osteomyelitis there were 19 type II, 35 type III and 7 type IV cases. The ischium was the most common site of infection. Osteomyelitis was usually the result of contiguous focus infection associated with decubitus ulcers, predominantly in patients with spinal or cerebral disorders. Most patients with positive microbiology had polymicrobial infection (52.5%). Thirty patients required soft tissue reconstruction with muscle or myocutaneous flaps.Twelve deaths occurred a mean of 2.8 years following surgery (range 7 days-7.4 years). Excluding these deaths the mean follow-up was 4.6 years (range 1.5-12.2 years). Recurrent infection occurred in seven (11.5%) a mean of 1.5 years post-operatively (92 days - 5.3 years). After further treatment 58 cases (95.1%) were infection free at final follow-up.Interpretation: Patients in this series have many comorbidities and risk factors for poor surgical outcome. Nevertheless, the multidisciplinary approach allows successful treatment in the majority of cases.

Aims: Dead-space management, following dead bone resection, is an important element of successful chronic osteomyelitis treatment. This study compared two different biodegradable antibiotic carriers used for dead-space management, and reviewed clinical and radiological outcomes. All cases underwent single-stage surgery and had a minimum one-year follow-up.Methods: A total of 179 patients received preformed calcium sulphate pellets containing 4% tobramycin (Group OT), and 180 patients had an injectable calcium sulphate/nanocrystalline hydroxyapatite ceramic containing gentamicin (Group CG). Outcome measures were infection recurrence, wound leakage, and subsequent fracture involving the treated segment. Bone-void filling was assessed radiologically at a minimum of six months post-surgery.Results: The median follow-up was 4.6 years (interquartile range (IQR) 3.2 to 5.4; range 1.3 to 10.5) in Group OT compared to 4.9 years (IQR 2.1 to 6.0; range 1.0 to 8.3) in Group CG. The groups had similar defect sizes following excision (both mean 10.9 cm³ (1 to 30)). Infection recurrence was higher in Group OT (20/179 (11.2%) vs 8/180 (4.4%), p = 0.019) than Group CG, as was early wound leakage (33/179 (18.4%) vs 18/180 (10.0%), p = 0.024) and subsequent fracture (11/179 (6.1%) vs 1.7% (3/180), p = 0.032). Group OT cases had an odds ratio 2.9-times higher of developing any one of these complications, compared to Group CG (95% confidence interval 1.74 to 4.81, p < 0.001). The mean bone-void healing in Group CG was better than in Group OT, in those with ≥ six-month radiological follow-up (73.9% vs 40.0%, p < 0.001).Conclusion: Local antibiotic carrier choice affects outcome in chronic osteomyelitis surgery. A biphasic injectable carrier with a slower dissolution time was associated with better radiological and clinical outcomes compared to a preformed calcium sulphate pellet carrier.Cite this article: Bone Joint Res 2023;12(7):412–422.

Aims: An investigation of the impact of a multidisciplinary bone infection unit (BIU) undertaking osteomyelitis surgery with a single-stage protocol on clinical outcomes and healthcare utilisation compared to national outcomes in England. Patients and Methods: A tertiary referral multidisciplinary BIU was compared to the rest of England (ROE) and a subset of the 10 next busiest centres based on osteomyelitis treatment episode volume (Top Ten), using the Hospital Episodes Statistics database (HES). A total of 25 006 patients undergoing osteomyelitis surgery between April 2013 and March 2017 were included. Data on secondary healthcare resource utilisation and clinical indicators were extracted for 24 months before and after surgery. Results: Patients treated at the BIU had higher orthopaedic healthcare utilisation in the 2 years prior to their index procedure, with more admissions (p< 0.001) and a mean length of stay (LOS) over 4 times longer than other groups (10.99 d, compared to 2.79 d for Top Ten and 2.46 d for the ROE, p< 0.001). During the index inpatient period, the BIU had fewer mean theatre visits (1.25) compared to the TT (1.98, p< 0.001) and the ROE (1.64, p= 0.001). The index inpatient period was shorter in the BIU (11.84 d), 33.6 % less than the Top Ten (17.83 d, p< 0.001) and 29.9 % shorter than the ROE (16.88 d, p< 0.001). During follow-up, BIU patients underwent fewer osteomyelitis-related reoperations than Top Ten centres (p= 0.0139) and the ROE (p= 0.0137). Mortality was lower (4.71 %) compared to the Top Ten (20.06 %, p< 0.001) and the ROE (22.63 %, p< 0.001). The cumulative BIU total amputation rate was lower (6.47 %) compared to the Top Ten (15.96 %, p< 0.001) and the ROE (12.71 %, p< 0.001). Overall healthcare utilisation was lower in the BIU for all inpatient admissions, LOS, and Accident and Emergency (A&E) attendances. Conclusion: The benefits of managing osteomyelitis in a multi-disciplinary team (MDT) specialist setting included reduced hospital stays, lower reoperation rates for infection recurrence, improved survival, lower amputation rates, and lower overall healthcare utilisation. These results support the establishment of centrally funded multidisciplinary bone infection units that will improve patient outcomes and reduce healthcare utilisation.