Skip to content
2000
image of Calcium Sulfate as a Local Antibiotic Delivery Vehicle in Chronic Osteomyelitis Following Internal Fixation: A Prospective Case Series

Abstract

Introduction

Chronic osteomyelitis is a complex and persistent orthopedic infection Antibiotic-loaded calcium sulfate (CS) has promoted the eradication of infection and bone regeneration. To evaluate the early and mid-term clinical outcomes of antibiotic-impregnated CS in the management of chronic osteomyelitis following internal fixation.

Methods

A prospective interventional case series included (=15) patients with chronic osteomyelitis treated at Al Yarmouk Teaching Hospital. The patient's medical, surgical history, and physical examination were recorded. Additionally, patients' inflammatory markers and microbiological culture from sinus discharge. Imaging was performed to classify the type of infection according to the Cierny and Mader classification. All patients underwent extensive surgical debridement and implantation of CS loaded with vancomycin or tobramycin, and systemic antibiotics were administered according to culture results. Patients were followed up for 1 year to assess functional scores and infection eradication.

Results

The mean age was 36.86±9.41 years, with 66.7% male and 33.3% female. Tibia was involved in (46.7%). Methicillin-Resistant Staphylococcus Aureus was isolated in (66.67%) of all cases. After a one-year follow-up, all cases achieved infection resolution. Functional scores improved significantly, from 26.8 to 64.2 ( < 0.001).

Discussion

Antibiotic-loaded CS as an adjuvant to surgical debridement and systemic antibiotics shows promising results with higher rates of infection eradication and significant functional improvement.

Conclusions

Using CS loaded with antibiotics as complementary therapy with systemic antibiotics demonstrated significant infection control and functional recovery in patients with chronic osteomyelitis following internal fixation during the early and mid-term follow up. Future studies need a larger sample and a longer follow up.

© 2025 Bentham Science Publishers
Loading

Article metrics loading...

/content/journals/rrct/10.2174/0115748871425903250909144103
2025-09-25
2025-10-31

  • From This Site

    /content/journals/rrct/10.2174/0115748871425903250909144103
    dcterms_title,dcterms_subject,pub_keyword
    -contentType:Contributor -contentType:Concept -contentType:Institution
    10
    5
Loading full text...

Full text loading...

References

  1. Pande K. Optimal management of chronic osteomyelitis: Current perspectives. Orthop. Res. Rev. 2015 7 71 81 10.2147/ORR.S50753
    [Google Scholar]
  2. Aiken K.T. Elliott L. Da Costa M. Acute osteomyelitis: How to recognize, diagnose, and treat - A narrative review. J. Nurse Pract. 2024 20 2 104899 10.1016/j.nurpra.2023.104899
    [Google Scholar]
  3. Davis W.T. Gilbert S.R. Comparison of methicillin-resistant versus susceptible Staphylococcus aureus pediatric osteomyelitis. J. Pediatr. Orthop. 2018 38 5 e285 e291 10.1097/BPO.0000000000001152 29462119
    [Google Scholar]
  4. Lee Y.J. Sadigh S. Mankad K. Kapse N. Rajeswaran G. The imaging of osteomyelitis. Quant. Imaging Med. Surg. 2016 6 2 184 198 10.21037/qims.2016.04.01 27190771
    [Google Scholar]
  5. Van Asten S.A.V. Nichols A. La Fontaine J. Bhavan K. Peters E.J.G. Lavery L.A. The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis. Int. Wound J. 2017 14 1 40 45 10.1111/iwj.12545 26634954
    [Google Scholar]
  6. Ertugrul M.B. Baktiroglu S. Salman S. The diagnosis of osteomyelitis of the foot in diabetes: microbiological examination vs. magnetic resonance imaging and labelled leucocyte scanning. Diabet. Med. 2006 23 6 649 653 10.1111/j.1464‑5491.2006.01887.x 16759307
    [Google Scholar]
  7. Kowalczyk N. Radiographic Pathology for Technologists. Elsevier Health Sciences 2017
    [Google Scholar]
  8. Moulopoulos L.A. Koutoulidis V. Bone marrow MRI. Milano Springer 2015 10.1007/978‑88‑470‑5316‑8
    [Google Scholar]
  9. Cierny G. A clinical staging system for adult osteomyelitis. Contemp. Orthop. 1985 10 17 37
    [Google Scholar]
  10. Panteli M. Giannoudis P.V. Chronic osteomyelitis: What the surgeon needs to know. EFORT Open Rev. 2016 1 5 128 135 10.1302/2058‑5241.1.000017 28461939
    [Google Scholar]
  11. Thahir A. Lim J.A. West C. Krkovic M. The use of calcium sulphate beads in the management of osteomyelitis of femur and tibia: A systematic review. Arch. Bone Jt. Surg. 2022 10 4 320 327 35721593
    [Google Scholar]
  12. Zhou C.H. Ren Y. Ali A. Single-stage treatment of chronic localized tibial osteomyelitis with local debridement and antibiotic-loaded calcium sulfate implantation: A retrospective study of 42 patients. J. Orthop. Surg. Res. 2020 15 1 201 10.1186/s13018‑020‑01721‑7 32487197
    [Google Scholar]
  13. Fernandes G. Abhyankar V.M. O’Dell J. Calcium sulfate as a scaffold for bone tissue engineering: A descriptive review. J. Dent. Health Oral Disord. Ther. 2021 9 1 1 22 10.15226/jdodt.2021.001124
    [Google Scholar]
  14. Binkley J.M. Stratford P.W. Lott S.A. Riddle D.L. The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. Phys. Ther. 1999 79 4 371 383 10201543
    [Google Scholar]
  15. Stratford P. Binkley J. Stratford D. Development and initial validation of the upper extremity functional index. Physiother. Can. 2001 53 4 259 267
    [Google Scholar]
  16. Callistus K.B. Alhassan A. Majeed S.F. Mogre V. Chronic osteomyelitis in a Ghanaian Specialist Hospital. Adv. Appl. Sci. Res. 2015 6 2 150 153
    [Google Scholar]
  17. Walter N. Baertl S. Alt V. Rupp M. What is the burden of osteomyelitis in Germany? An analysis of inpatient data from 2008 through 2018. BMC Infect. Dis. 2021 21 1 550 10.1186/s12879‑021‑06274‑6 34112102
    [Google Scholar]
  18. Mulualem B. Belay G. Bogale E.K. Magnitude of chronic osteomyelitis and its associated factors in children as diagnosed on X-ray visiting at Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia: A cross-sectional study. SAGE Open Med. 2023 11 20503121231161191 10.1177/20503121231161191 36949827
    [Google Scholar]
  19. Wang X. Yu S. Sun D. Current data on extremities chronic osteomyelitis in southwest China: Epidemiology, microbiology and therapeutic consequences. Sci. Rep. 2017 7 1 16251 10.1038/s41598‑017‑16337‑x 29176616
    [Google Scholar]
  20. Ma X. Han S. Ma J. Epidemiology, microbiology and therapeutic consequences of chronic osteomyelitis in northern China: A retrospective analysis of 255 Patients. Sci. Rep. 2018 8 1 14895 10.1038/s41598‑018‑33106‑6 30291260
    [Google Scholar]
  21. Roomi A.B. Mahdi Salih A.H. Noori S.D. Nori W. Tariq S. Evaluation of bone mineral density, serum osteocalcin, and osteopontin levels in postmenopausal women with type 2 diabetes mellitus, with/without osteoporosis. J. Osteoporos. 2022 2022 1 1 5 10.1155/2022/1437061 35198139
    [Google Scholar]
  22. Abdulqader S. Nori W. Akram N. Al-Kinani M. Radiological modalities for the assessment of fetal growth restriction: A comprehensive review. Al-Kindy Coll Med J 2024 20 1 4 13 10.47723/nz221421
    [Google Scholar]
  23. Litao M.K.S. Kamat D. Erythrocyte sedimentation rate and C-reactive protein: How best to use them in clinical practice. Pediatr. Ann. 2014 43 10 417 420 10.3928/00904481‑20140924‑10 25290132
    [Google Scholar]
  24. Jha V.K. Zacarias T.P. Bharali K. Dutta S. Functional outcome of chronic osteomyelitis treated by sequestrectomy & saucerisation with antibiotic bead implantation. Indian J. Orthop. Surg. 2024 10 2 101 107 10.18231/j.ijos.2024.017
    [Google Scholar]
  25. Selvaratnam V. Roche A. Narayan B. Effectiveness of an antibiotic-impregnated bioabsorbable carrier for the treatment of chronic intramedullary and diffuse osteomyelitis. Strateg. Trauma Limb Reconstr. 2023 18 3 148 154 38404569
    [Google Scholar]
  26. Shen L. Dong Y. Zhang C. Chronic osteomyelitis treatment: A clinical and pharmaco-kinetic study of vancomycin impregnated calcium sulphate. J. Med. Imaging Health Inform. 2015 5 1 36 42 10.1166/jmihi.2015.1362
    [Google Scholar]
  27. Lima A.L.L. Oliveira P.R. Carvalho V.C. Cimerman S. Savio E. Recommendations for the treatment of osteomyelitis. Braz. J. Infect. Dis. 2014 18 5 526 534 10.1016/j.bjid.2013.12.005 24698709
    [Google Scholar]
  28. Jiang C. Zhu G. Liu Q. Current application and future perspectives of antimicrobial degradable bone substitutes for chronic osteomyelitis. Front. Bioeng. Biotechnol. 2024 12 1375266 10.3389/fbioe.2024.1375266 38600942
    [Google Scholar]
  29. Metaoy S. Rusu I. Pillai A. Adjuvant local antibiotic therapy in the management of diabetic foot osteomyelitis. Clin. Diabetes Endocrinol. 2024 10 1 51 10.1186/s40842‑024‑00200‑w 39681930
    [Google Scholar]
  30. Shi X. Wu Y. Ni H. Antibiotic-loaded calcium sulfate in clinical treatment of chronic osteomyelitis: A systematic review and meta-analysis. J. Orthop. Surg. Res. 2022 17 1 104 10.1186/s13018‑022‑02980‑2 35183215
    [Google Scholar]
  31. Mills H. Donnelly L. Platt S. Platt S.R. Locally delivered antibiotics in fracture-related infection. Cureus 2024 16 11 e73210.[11] 39650921
    [Google Scholar]
  32. Zhong C. Wu Y. Lin H. Liu R. Advances in the antimicrobial treatment of osteomyelitis. Compos., Part B Eng. 2023 249 110428 10.1016/j.compositesb.2022.110428
    [Google Scholar]
  33. Sambri A. Cevolani L. Passarino V. Mid-term results of single-stage surgery for patients with chronic osteomyelitis using antibiotic-loaded resorbable PerOssal® beads. Microorganisms 2023 11 7 1623 10.3390/microorganisms11071623 37512796
    [Google Scholar]
  34. van Vugt T.A.G. Arts J.J. Geurts J.A.P. Antibiotic-loaded polymethylmethacrylate beads and spacers in treatment of orthopedic infections and the role of biofilm formation. Front. Microbiol. 2019 10 1626 10.3389/fmicb.2019.01626 31402901
    [Google Scholar]
  35. Lu L. Yu T. Wang H. Zhu X. Liao L. Zhu J. Wang X. Yang A. Yang C. Zhang Y. Zhang Y. Virulence arresting drugs discovery by strategies targeting bacterial virulence: mainly focusing on quorum-sensing interference and biofilm inhibition. J. Pharm. Anal. 2025 Apr 12 101310 10.1016/j.jpha.2025.101310
    [Google Scholar]
  36. Ali S. Asnani P. Odedra S. Pillai J. Jayasheel N. Yadav S. Histopathological Osteomyelitis Evaluation Score (HOES): Pioneering precision for diagnosing jaw osteomyelitis. J. Oral Maxillofac. Pathol. 2025 29 1 81 86 10.4103/jomfp.jomfp_160_24 40248617
    [Google Scholar]
  37. Singh K. Bauer J.M. LaChaud G.Y. Bible J.E. Mir H.R. Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: A retrospective pilot study. J. Orthop. Traumatol. 2015 16 4 287 291 10.1007/s10195‑015‑0352‑0 25957509
    [Google Scholar]
  38. Rupp M. Walter N. Szymski D. Taeger C. Langer M.F. Alt V. The antibiotic bead pouch – A useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery. J. Bone Jt. Infect. 2023 8 3 165 173 10.5194/jbji‑8‑165‑2023 37818255
    [Google Scholar]
  39. McConoughey S.J. Howlin R.P. Wiseman J. Stoodley P. Calhoun J.H. Comparing PMMA and calcium sulfate as carriers for the local delivery of antibiotics to infected surgical sites. J. Biomed. Mater. Res. B Appl. Biomater. 2015 103 4 870 877 10.1002/jbm.b.33247 25142105
    [Google Scholar]
  40. Eliaz N. Metoki N. Calcium phosphate bioceramics: A review of their history, structure, properties, coating technologies and biomedical applications. Materials 2017 10 4 334 10.3390/ma10040334 28772697
    [Google Scholar]
  41. Zhou H. Yang L. Gbureck U. Bhaduri S.B. Sikder P. Monetite, an important calcium phosphate compound-Its synthesis, properties and applications in orthopedics. Acta Biomater. 2021 127 41 55 10.1016/j.actbio.2021.03.050 33812072
    [Google Scholar]
  42. Morgenstern M. Vallejo A. McNally M.A. The effect of local antibiotic prophylaxis when treating open limb fractures. Bone Joint Res. 2018 7 7 447 456 10.1302/2046‑3758.77.BJR‑2018‑0043.R1 30123494
    [Google Scholar]
/content/journals/rrct/10.2174/0115748871425903250909144103
Loading
Calcium Sulfate as a Local Antibiotic Delivery Vehicle in Chronic Osteomyelitis Following Internal Fixation: A Prospective Case Series
Bentham Science Publishers ; https://doi.org/10.2174/0115748871425903250909144103
/content/journals/rrct/10.2174/0115748871425903250909144103
/content/journals/rrct/10.2174/0115748871425903250909144103
Loading

Data & Media loading...


  • Article Type:     Research Article
Keywords: vancomycin ; calcium sulfate ; tobramycin ; Chronic osteomyelitis ; antibiotics ; functional scores ; debridement

Most Cited Most Cited RSS feed

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error
Please enter a valid_number test