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

Se-Jin Park; Seungcheol Song

doi:10.14193/jkfas.2019.23.2.58

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

Original Article

J Korean Foot Ankle Soc 2019;23(2):58-66.

Published online: 14 January 2019

DOI: https://doi.org/10.14193/jkfas.2019.23.2.58

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

Se-Jin Park, Seungcheol Song

Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

Corresponding Author: Seungcheol Song Department of Orthopedic Surgery, Kangbuk Samsung Hospital, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea Tel: 82-2-2001-2168, Fax: 82-2-2001-2176, E-mail: s3g1@naver.com ORCID: https://orcid.org/0000-0002-1841-6683

Received 22 April 2019 Revised 28 May 2019 Accepted 7 June 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Diabetic foot, Osteomyelitis, Antibiotic-loaded cement spacer, Risk factor

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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.

Figure 2.

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

Figure 3.

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

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.

Table 1.

Strauss Wound Classification Scoring System

Criteria*	2 points	1 point	0 point
Appearance (wound base)	Red	Yellow or withe	Black
Size	Thumb tip or smaller	Between Thumb tip and fist	Larger than fist
Depth (maximum depth of probe)	Skin or subcutaneous	Muscle or tendon	Bone or joint
Infection (bioburden)	Colonized	Cellulitis	Septic^†
Perfusion	Palpable pulses	Biphasic or triphasic dopplerable pulses (cool, pale or dusky, capillary refill 2~5 sec)	Monophasic or imperceptible pulses (cold, black/cyanotic/purplish, capillary refill >5 sec)

Healthy wound: 7.5~10 points, Problem wound: 3.5~7 points, Futile wound: 0~3 points.

* Half points used for mixed or intermediate findings,

^† Findings associated with sepsis include unstable blood sugars, leukocytosis, positive blood cultures, fever, and chills.

Table 2.

Current Perception Threshold (CPT) by Neurometer

Grade*	Sensory classification
12	Completely anesthetic
9.9	Severe hypoesthesia
8.82	Moderate hypoesthesia
7.74	Mild hypoesthesia
6.62	Moderate hyperesthesia
5.54	Mid hyperesthesia
4.82	Mid dysfunction
3.9	Very mild dysfunction
2.78	Extremely mild dysfunction
1.66	Slight dysfunction
0	No abnormal measures

^* 11 grades, 1st toe examed.

Table 3.

Summary of Patient Data Showing Successful Treatment Outcome

No.	Age (yr)	Sex	FU (mo)	Location	Date of ALCS insertion	Date of ALCS removal	Interval (d)	Pathogens cultured	Wagner wound grade	Strauss wound score	ABI	TBI	CPT
1	37	Female	6.1	Lt. 5th toe MP&DP	2010-04-01	2010-05-13	42	MSSA	3	5	1.09	0.91	12
2	63	Male	6.2	Lt. 5th toe PP-DP	2017-02-20	2017-03-24	32	MSSA	3	5	1.07	0.59	9.9
3	73	Male	6.4	Rt. navicular, talus, calcaneus	2016-10-15	-	-	Citrobacter koseri	4	4.5	0.9	0.72	7.37
4	77	Male	12.0	Rt. 2nd toe DP	2016-12-09	2017-01-20	42	MRSA	4	6	0.78	0.49	12
5	39	Male	90.6	Rt. 1st toe PP-DP	2010-04-08	2010-05-20	42	No growth	3	5.5	1.18	0.77	12
6	61	Female	6.1	Rt. 1st toe PP-DP	2010-04-07	2010-10-07	71	MRSA	4	5	1.00	0.69	9.9
7	61	Female	9.7	Rt. 2nd toe PP-DP	2010-11-08	2010-12-30	52	Streptococcus agalactiae	3	5	0.99	0.66	10.9
8	74	Male	6.0	Rt. 1st toe DP	2015-04-20	-	-	No growth	4	5.5	1.08	0.59	7.3
9	52	Male	25.6	Rt. 1st metatarsal	2010-11-17	2010-12-15	28	MSSA	3	5	0.84	0.39	9.82
10	68	Male	6.3	Lt. 5th metatarsal	2016-11-15	2017-01-02	48	MSSA	3	5	0.95	0.54	12
11	47	Female	105.7	Lt. 1,2,3rd metatarsal	2009-03-19	2009-04-10	22	MSSA	3	5	1.15	0.62	11.5
12	80	Female	6.1	Rt. 1st toe DP	2015-03-11	2015-05-06	56	S. agalactiae	4	6	1.02	0.65	12
13	51	Male	26.6	Lt. 5th toe PP-DP	2012-01-27	2012-03-16	49	MSSA	4	5.5	1.22	0.72	10.9
14	61	Male	8.0	Rt. 1st toe PP-DP	2010-04-29	2010-06-17	49	MRSA	3	5.5	1.13	0.80	12
15	78	Male	7.0	Lt. 1st metatarsal-DP	2015-05-11	2015-07-01	51	No growth	3	5.5	0.54	0.74	10.9
16	59	Male	8.7	Rt. Calcaneus	2017-03-22	2017-05-16	55	Proteus vulgaris, Streptococcus equisimilis	3	4.5	0.98	0.82	12
17	73	Male	8.0	Lt. 5th metatarsal-DP	2010-07-26	2010-09-13	49	S. agalactiae	3	5	0.85	0.67	12
18	39	Male	6.5	Rt. 4th metatarsal	2011-03-04	2011-05-20	77	No growth	4	5	0.87	0.42	12
19	78	Male	14.5	Rt. Calcaneus	2015-01-28	2015-03-25	56	MRSA	3	5	1.02	0.55	9.9
20	70	Female	6.3	Lt. 1st toe PP-DP	2011-10-14	2011-12-10	57	Staphylococcus epidermidis	4	4.5	1.06	0.68	7.3
21	65	Male	17.5	Lt. 1st∼4th metatarsal	2015-03-25	2015-04-10	16	C. koseri, S. equisimilis	3	4.5	1.18	0.74	12
22	49	Male	8.1	Rt. 1st metatarsal-DP	2012-03-23	2012-05-26	64	Enterococcus faecalis, Pseudomonas aeruginosa	3	5	1.07	0.89	10.9
23	64	Male	34.7	Rt. 5th metatarsal-cuboid	2011-01-21	2011-03-11	49	MRSA	3	5	1.05	0.84	9.9
24	49	Female	12.7	Lt. 4th metatarsal-DP	2015-12-23	2016-02-24	63	MRSA	3	5.5	1.02	0.96	10.9
25	58	Male	28.4	Rt. 1st metatarsal-navicular	2010-05-27	2010-07-15	49	E. faecalis	3	5	1.1	0.36	9.78
26	76	Female	6.0	Lt. calcaneus	2017-11-29	2017-12-18	19	MRSA	3	4.5	1.14	0.42	10.9
27	51	Male	7.4	Rt. calcaneus	2016-03-23	2016-05-16	54	MRSA	3	5	1.12	0.75	12
28	73	Female	9.6	Lt. 1st toe PP-DP	2017-08-14	2017-09-25	42	No growth	3	5	1.04	0.91	7.3
29	79	Male	46.0	Lt. 5th toe-metatarsal	2009-04-13	2009-05-15	32	P. aeruginosa	4	5	1.24	0.77	9.9
30	65	Female	8.4	Lt. 5th metatarsal	2016-04-06	2016-05-04	28	S. agalactiae, S. equisimilis	3	5.5	0.59	0.42	12
31	49	Male	6.1	Rt. 2nd∼4th metatarsal	2017-04-08	2017-05-15	37	E. faecalis, MSSA	3	5	0.81	0.58	10.9
32	86	Female	46.7	Lt. 5th metatarsal	2013-10-11	2013-11-21	41	No growth	3	6	1.08	0.84	12

FU: follow-up, ALCS: antibiotic-loaded cement spacers, Interval: interval to secondary surgery, ABI: ankle-brachial index, TBI: Toe-brachial index, CPT: current perception threshold, Rt.: right, Lt.: left, MP: middle phalanx, DP: distal phalanx, PP: proximal phalanx, MSSA: Methicillin-sensitive Staphylococcus aureus, MRSA: Methicillin-resistant Staphylococcus aureus.

Table 4.

Summary of Patient Data Showing Non-Successful Treatment Outcome

No.	Age (yr)	Sex	Location	Date of ALCS insertion	Date of secondary amputation	Interval (wk)	Pathogens cultured	Wagner wound grade	Strauss wound scores	ABI	TBI	CPT
1	65	Male	Lt. 1st toe PP-DP	2017-01-16	2017-02-01	2.3	Enterococcus faecalis	4	2.5	0.8	0.35	9.9
2	75	Male	Lt. 3rd∼5th metatarsal	l 2010-10-25	2011-02-10	15.4	No growth	3	3	0.97	0.23	12
3	62	Male	Lt. 1st toe PP-DP	2016-11-02	2017-01-26	12.1	Citrobacter freundii, Enterobacter cloacae	3	3	1.2	0.65	9.9
4	63	Female	Lt. 1st toe-calcaneus	2017-06-18	2017-06-21	0.4	E. faecalis, Streptococcus mitis/Streptococcus o	oralis 4	2.5	0.7	0.47	12
5	39	Male	Rt. 1st toe PP-DP	2009-04-10	2009-08-02	16.3	Streptococcus agalactiae	3	3	1.08	0.64	12
6	53	Male	Rt. 1st toe PP-DP	2010-07-14	-	-	E. faecalis	3	3	1.1	0.68	12
7	40	Male	Lt. calcaneus	2010-05-12	-	-	MRSA	4	3	0.99	0.61	11.5

ALCS: antibiotic-loaded cement spacers, Interval: interval to secondary surgery, ABI: ankle-brachial index, TBI: Toe-brachial index, CPT: current perception threshold, Lt.: left, PP: proximal phalanx, DP: distal phalanx, Rt.: right, MRSA: Methicillin-resistant Staphylococcus aureus.

Table 5.

Distribution of Lesions by Location

Location	Number of patients (%)
Toes	16 (41.0)
Metatarsals	14 (35.9)
Midfoot	2 (5.1)
Hindfoot	7 (17.9)
Total	39 (100)

Table 6.

Comparing between Successful Group and Non-Successful Group

Variable	Successful group (n=32)	Non-successful group (n=7)	p-value*
Age (yr)	62.66+13.14	56.71+12.41	0.398
Wagner wound grade	3.28+0.45	3.43+0.49	0.554
Strauss wound score	5.13+0.41	2.86+0.23	<0.01
ABI	1.01+0.16	0.98+0.16	0.654
TBI	0.67+0.16	0.52+0.16	0.040
Neurometer	10.69+1.52	11.33+0.92	0.359

Values are presented as mean+standard deviation.

ABI: ankle-brachial index, TBI: toe-brachial index.

* Mann-Whitney U test.

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