Diabetic Foot Osteomyelitis

Review

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Rev Diabet Stud, 2021, 17(2):75-81 DOI 10.1900/RDS.2021.17.75

Local Antibiotic Delivery Systems in Diabetic Foot Osteomyelitis: A Brief Review

Christos Chatzipapas1, Makrina Karaglani1, Nikolaos Papanas2, Konstantinos Tilkeridis1, Georgios I. Drosos1

1Department of Orthopaedic Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
2Diabetes Centre - Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
Address correspondence to: Nikolaos Papanas, e-mail: papanasnikos@yahoo.gr

Manuscript submitted February 9, 2021; resubmitted March 22, 2021; accepted September 14, 2021.

Keywords: diabetic foot osteomyelitis, local antibiotic delivery, PMMA, calcium sulfate

Abstract

Diabetic foot osteomyelitis (DFO) is a severe, difficult to treat infection. Local antibiotic delivery has been studied as a potential therapeutic adjunct following surgery for DFO. This review aims to summarize the evidence on local antibiotic delivery systems in DFO. PubMed database was searched up to March 2020. Overall, 16 studies were identified and included: 3 randomized controlled trials (RCTs), 3 retrospective studies (RSs), and 10 case series. In the RCTs, gentamicin-impregnated collagen sponges significantly improved clinical healing rates and slightly improved duration of hospitalization. In the RSs, antibiotic-impregnated calcium sulfate beads non-significantly improved all healing parameters, but did not reduce post-operative amputation rates or time of healing. The majority of case series used calcium sulfate beads, achieving adequate rates of healing and eradication of infection. In conclusion, evidence for add-on local antibiotic delivery in DFO is still limited; more data are needed to assess this therapeutic measure.

1. Introduction

Diabetes mellitus increases the risk of foot infections, some cases of which progress to diabetic foot osteomyelitis (DFO) [1, 2]. Foot deformity, peripheral neuropathy, peripheral arterial disease, and minor injury increase the risk of diabetic foot lesions [2-5]. The development of biofilms in chronic wounds represents an additional challenge, since they protect pathogens from removal by host immunity and systemically administered antibiotics [6].

Management of DFO may be surgical or medical, depending on patient characteristics [7]. Surgery is especially useful in the event of pus, sequestrum, gangrene, or antibiotic-resistant bacteria [8]. Instead of amputation, debridement offers the advantage of removing necrotic while preserving healthy bones and tissues [9]. This approach is sometimes accompanied by local antibiotic delivery [3].

Local antibiotics offer the following advantages: higher local antibiotic concentration, longer duration, and fewer side effects [3]. At the same time, they act as a bone substitute that fills the dead space caused by bone resection [10]. Polymethylmethacrylate (PMMA) beads are the major representative of non-biodegradable carriers [11]. Antibiotic release from PMMA beads is initially high during the first 48-72 hours, but quickly falls to lower levels, and may elute for weeks or even years [11]. Disadvantages include the high temperature it produces and the surgical removal of the beads required upon completion of drug release [12, 13].

During the last 2 decades, biodegradable carriers have been developed: proteins (collagen, gelatin, thrombin etc.), synthetic polymers, grafts, and substitutes (calcium sulfate or phosphate) [14]. These act as a matrix for new bone growth. During their degradation, additional release of antibiotics occurs, prolonging their action and preventing biofilm formation on their surface [15].

The aim of this brief review is to summarize the evidence on add-on local antibiotic delivery in the surgical management of DFO.

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