Introduction. Cerament, a bioresorbable hydroxyapatite and calcium sulfate cement, is known to be used as a bone-graft substitute in traumatic bone defect cases. However, its use in open fractures has not previously been studied. Materials and Methods. Retrospective, single-centre review of cases between November 2016 and February 2021. Open fractures were categorised according to the Orthopaedic Trauma Society classification (OTS). Cases were assessed for union, time to union, and associated post-operative complications. Results. Twenty-four patients were identified. Fifteen cases were classified as OTS simple open fractures, and nine cases were complex open fractures requiring soft tissue reconstruction. Four cases were lost to follow-up. Four cases had limited follow-up beyond 6 months but showed evidence of progressive radiographic union. Of the remaining 16 cases, eight cases (50%) went on to union with a mean time to union of 6.7 months (5 to 12 months). Persistent non-union remained in six cases (38%). Two cases required return to theatre due to an infected skin graft and wound dehiscence respectively. One case had the complication of persistent weeping of Cerament from the wound. This self-resolved within two weeks. Limitations of this case series include the lack of complete follow-up in eight patients (33%) and the lack of patient reported outcome measures. Conclusions. Cerament can be a useful adjunct in managing open fractures. However, it should be noted there is a high rate of non-union which may be reflective of the significant morbidity associated with open fractures with structural bone defects

Aims

Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects.

To test the hypothesis that: CERAMENT[™]|G (C-G) would improve new bone growth and decrease infection rate after debridement as compared with 1) CERAMENT|BONE VOID FILLER (CBVF) and 2) no void filler in a rat osteomyelitis model.

72 Sprague Dawley rats were injected with 1.5 × 10∧6 CFU of S. aureus into a drill hole in the right tibia. After 3 weeks, the osteomyelitic defect was debrided, and filled with either: 1) C-G (n=32), 2) CBVF (n=20), or 3) nothing (n=20). 6 weeks after the second surgery, 20 rats from each group were sacrificed and the right tibias were harvested. A long-term group (n=12) of C-G treated rats were also sacrificed at 6 months after the second surgery. The tissues were sonicated and the colony forming units in the sonicate were quantified by serial dilutions and culture. MicroCT was used to quantify the new bone growth (BV/TV) in the debrided osteomyelitic void. Histological samples were analyzed for the presence of a neutrophil response by a blinded pathologist.

(*: p<0.05)

Positive cultures in:

○ 30% of animals treated with CBVF

Neutrophil reaction in:

○ 35% of animals treated with CBVF

The BV/TV in:

○ C-G treated rats was 24% greater than CBVF treated rats (*)

Animals sacrificed at 6 months which were treated with C-G did not have any evidence of infection by culture or histology. The bone mass of the implanted limb was higher than the contralateral (non-operated) side.

CERAMENT|G decreased the rate of infection and increased new bone growth as compared with both CBVF and no void filler in a debrided osteomyelitic environment. Animals treated with C-G at 6 months showed no evidence of infection and retained a higher bone mass relative to the contralateral (non-operated) side.

This study supports the use of CERAMENT|G as a readily available void filler which could be used in osteomyelitic environments after debridement.

Diabetic foot problems are a common cause for hospitalisation in this group and up to 25% of diabetic patients will be affected. Prevalence of diabetes is rising, currently affecting 680000000 people worldwide. The enormity of this problem mandates any strategy that shortens therapeutic period and enhances success rates. Cerament G has been used in our unit as a treatment adjunct in diabetic foot treatment. Successful treatment is viewed as eradication of infection and a functional foot. Retrospective review of 40 months practice with 115 patients. Inclusion: all diabetic feet requiring surgery Cerament G used, protocol driven Microbiology pathway. Exclusion: Primary closure not possible. Cerament G not used. Outcome assessed in three groups: Total failure (further surgery required); slow to heal (healing by secondary intention); healed without problems. Healed 99 (eradication of infection and return to function), failure to heal 16 (success rate: 86.1%). Infection was the cause of failure in only in 2.6% (13 failures due to patient noncompliance or poor vascularity). Accepted success rate in treating osteomyelitis in diabetic feet is 68% (medical treatment only), combination of surgery and medical is 86%. Eradication of infection is the only end point return to function is not addressed. This study shows Cerament G with surgery/systemic antibiotics provides a 97.4% success rate. Therapeutic drivers in this field have been determined traditionally by Physicians and Vascular Surgeons (resection rather than reconstructive surgery.) Our assertion is that eradicating infection in a functionally useless foot is a waste of health resources. Our strategy is always the delivery of an intact functional foot residuum. Cerament G as an adjunct allows this goal in a cost-effective manner

Surgical site infections following spinal surgery profoundly influence continued treatment, significantly impacting psychological and economic dimensions and clinical outcomes. Its reported incidence varies up to 20%, with the highest incidence amongst neuromuscular scoliosis and metastatic cord compression patients. We describe the first reported biphasic osteoconductive scaffold (Cerament G) with a logarithmic elution profile as a cumulative strategic treatment modality for adjacent spinal surgery infections. All patients who developed surgical site infections following instrumented fusion (May 2021-December 2021) had their demographics (age, sex), type and number of procedures, isolated organism, antibiotics given, comorbidities, and WHO performance status analysed. The infected wound was debrided to healthy planes, samples taken, and Cerament g applied. Thirteen patients were treated for deep SSI following spinal instrumentation and fusion procedures with intraoperative Cerament G application. There were four males and nine females with an average age of 40 ranging between 12 and 87. Nine patients underwent initial surgery for spinal deformity, and four were treated for fractures as index procedure. 77% of infections were attributable to MSSA and Cutibacteriousm acnes; others included Klebsiella, Pseudomonas and Streptococcus and targeted with multimodal cumulative therapy. A WHO performance score improved in 11 patients. In addition, there was no wound leak, and infection was eradicated successfully in 12/13 with a single procedure. This series shows the successful eradication of the infection and improved functional outcomes with Cerament G. However, the low numbers of patients in our series are an essential consideration for the broader applicability of this device

Aim. Antibiotic-eluting calcium compounds can be used to deliver antibiotics in the management of prosthetic joint infection (PJI). Described omplications include wound drainage, heterotopic ossification(HO) as well as hypercalcaemia which is potentially life threatening. The aim of this study is to assess the incidence of hypercalcaemia and other complications between two calcium based antibiotic delivery systems. Method. A retrospective study was performed. Thirty two patients treated with Stimulan or Cerament Calcium based antibiotic delivery system between August 2014 to January 2017 were included. Seven patients received Cerament, 21 cases received Stimulan and one patient received both. The volume used as well as pre- and post-operative serum calcium were recorded as well as any wound related complications and radiologic changes suggestive of heterotopic ossification. The postoperative serum adjusted Calcium were taken weekly during the initial post operative period. Patients with overactive parathyroid disease and pre-existing renal disease were excluded. Results. Stimulan group (n=22, Mean volume 39.2ml). Mean pre-operative serum calcium was 2.48mmol/l. At 1 and 2 weeks post-surgery mean levels were 2.51 and 2.47mmol/l (patients receiving <40ml), and 2.47 and 2.50mmol/l (patients receiving >40ml – 9 cases) respectively. There was no significant difference between pre/post-operative levels at 1 (p=0.97) or 2 weeks (p=0.91) and no difference between those treated with <40ml or >40ml of Stimulan at 1 or 2 weeks (p=0.91). Cerament group (n=8, Mean volume 9.4ml). Mean pre-operative serum calcium was 2.42mmol/l. Mean post-operative levels at 1 and 2 weeks post-surgery were 2.44mmol/l (p=0.92) and 2.37mmol/l (p=0.61) respectively. One patient had prolonged wound discharge and required re operation. No HO was encountered. Conclusions. Our results suggest that hypercalcaemia and other complications are uncommon with the use calcium based antibiotic delivery systems and that calcium based antibiotic delivery systems are safe in the treatment of PJI

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes

To evaluate the clinical outcome of three different local antibiotic delivery materials, used as bone defect fillers after excision of chronic osteomyelitis. We reviewed all patients receiving Collagen Fleece with Gentamicin (Septocoll E)(n=74), Calcium Sulphate with Tobramycin pellets (Osteoset T)(n=166) or Calcium Sulphate/Hydroxyapatite biocomposite with Gentamicin (Cerament G)(n=73) for dead space filling after resection of C-M Stage III and IV chronic osteomyelitis. Data was collected on patient comorbidities, operation details, microbiology, postop complications and need for plastic surgery or external fixation. All operations were performed by two surgeons. All patients had similar systemic antibiotic therapy and rehabilitation. Primary outcomes were recurrence rate, fracture rate and wound leakage rate. All three groups had very similar mean age and range, microbiological cultures, need for free muscle flaps or local flaps, proportion of femur, tibia and upper limb bones and use of external fixation. There were small differences in the proportion of C-M Class B hosts and anatomic Type IV cases, between the groups. All patients were followed up for at least one year. Mean follow-up was 1.75 years for Septocoll E, 1.96 years for Osteoset T and 1.78 years for Cerament G. After surgery, there were fewer prolonged wound leaks with Cerament G (leakage persisting for more than 2 weeks). Fracture rates and infection recurrence were twice as common with Osteoset T compared with Cerament G at between one and two years after operation (see Table). The use of a biocomposite material delivering local aminoglycoside was associated with lower recurrence rates and few wound problems, compared with collagen or calcium sulphate alone. This may reflect the higher levels of antibiotic in the defect and controlled release profile. The improved recurrence rate was despite a higher percentage of compromised Class B hosts

Aim. To evaluate the clinical outcome of a new absorbable, gentamycin loaded calcium sulfate/hydroxyapatite biocomposite (CERAMENT. ™. /G) as cavity filler after debridement and removal of infected metalwork in chronic osteomyelitis. Methods. We report the retrospective study of prospectively collected data from 36 patients with chronic osteomyelitis from implant infection. Treatment included a single stage protocol with removal of the metalwork, debridement augmented with application of CERAMENT. ™. /G, stabilization, culture-specific antibiotics and primary skin closure or flap. The biocomposite was used for dead space filling after resection of Cierny-Mader (C-M) stage III and IV chronic osteomyelitis. Data were collected on patient age, comorbidities, operation details, microbiology, postoperative complications and type of fixation or plastic surgery. Primary measure of outcome was recurrence rate. Results. According to the C-M classification 22 patients (63%) were defined as Type III and 13 (37%) as Type IV. A total of 26 (72%) patients were Class B hosts. In 9 cases (25%), there was an infected non-union and 1 patient had septic arthritis. Mean age was 52 years (range 22 to 81). Patients were followed for a mean of 20 months (range 6 to 36). Infection was eradicated in 32 patients. There were three (8.3%) recurrences (two cases of osteomyelitis and one of soft tissue/flap infection). Two of them were successfully managed with repeat surgery (one Class B and one Class A host) and one (Class B host) with suppressive antibiotic therapy as per patient's choice. In one infected nonunion the infection was eradicated but the nonunion persisted. Thirteen patients (36.6%) had a local or free fascio-cutaneus flap. Staphylococci (50%) and Enterococci (15%) were the most common microorganisms. Pseudomonas aeruginosa was more common in polymicrobial infection usually with Staphylococcus aureus. Conclusions. A multidisciplicary approach including augmented debridement with CERAMENT. ™. /G is effective for treatment of chronic osteomyelitis with infected metalwork

Introduction. The treatment of chronic bone infection often involves excision of dead bone and implantation of biomaterials which elute antibiotics. Gentamicin is a preferred drug for local delivery, but its systemic use carries a well-established risk of nephrotoxicity. We aim to establish the risk of renal injury with local delivery in a ceramic carrier. Materials and Methods. 163 consecutive patients with Cierny-Mader Type 3 or 4 chronic osteomyelitis were treated with a single-stage operation which included filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier containing gentamicin. The mean carrier volume used was 10.9mls, leading to a mean implanted gentamicin dose of 191.3mg (maximum 525mg). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Renal impairment was graded using the Chronic Kidney Disease (CKD) Staging system, and AKI was assessed using the RIFLE criteria. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. 7 patients had pre-existing renal disease. 70 patients (45.2%) had a temporary eGFR drop post-operatively, with the greatest decrease occurring a mean 3.06 days following surgery. Twenty cases had a >10% decline in eGFR, but 12 resolved within 7 days. 7 patients transiently fell into the “Risk” category according to RIFLE criteria, but no patient had a change consistent with “Injury”, “Failure” or “Loss” of renal function and none had clinical signs of new acute renal impairment post-operatively. Conclusions. The implantation of up to 525mg of gentamicin contained within Cerament G, as part of the surgical treatment of osteomyelitis, is safe and carries minimal risk of significant acute kidney injury. A small, transient increase in serum creatinine may be observed in the early post-operative period, and attention should be paid to limit patients exposure to other nephrotoxic agents. The majority of patients will return to their baseline renal function within 7 days following the operation. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

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.

Aim. The primary aim of multidisciplinary management of diabetic foot disease is limb savage. Difficulty in eradication of infection with systemic antibiotics and obliteration of dead space created by debridement, are two major stumbling blocks in achieving this. Antibiotic loaded bio composites help achieve both these objectives. The aim of this study is to report the early results of antibiotic loaded bio composites in diabetic foot disease. Method. We present early results of 16 patients with diabetic foot disease and osteomyelitis in whom we used antibiotic loaded bio composite (CERAMENT G Bone Support, Lund, Sweden) for local antibiotic delivery and dead space eradication. A multidisciplinary team managed all patients. We performed magnetic resonance and vascular imaging preoperatively and adhered to a strict protocol involving debridement, culture specific systemic antibiotics and dead space obliteration with antibiotic loaded bio composite. The wound was managed with negative pressure wound therapy and all patients were kept non-weight bearing with a plaster back slab or walking boot. Skin cover where required was undertaken by our plastic surgeons. Results. According to the Cierny –Mader Classification 1 patient was type 1, 4 were defined as type 2, 7 were type 3 and 4 were type 4. Seven patients were classed as type B hosts and 9 were type A hosts. At a mean follow up of 38 weeks (26–60) we achieved infection clearance in 14 patients (88%). 10 (63%)wounds healed by secondary intention, 2 had split skin graft, and 1 had primary closure. 2 patients were still on negative pressure wound therapy at final follow-up, one of which has got clearance of infection. One patient is having regular dressings in the community. We had 2 patients who had below knee amputation, one due to significant vascular disease and the other at patient request. Conclusions. A multidisciplinary approach and a strict protocol including augmented debridement and Cerament G injection are effective for treatment of chronic osteomyelitis in diabetic foot disease. The early results with this bio composite antibiotic combination are encouraging

Aims

Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below-knee amputation, particularly in the presence of severe soft-tissue destruction. This study assesses the outcomes of single-stage orthoplastic surgical treatment of calcaneal osteomyelitis with large soft-tissue defects.

Aims. Dead space management is an important element in the surgical management of chronic osteomyelitis and can be addressed with the use of a biodegradable local antibiotic carrier. We present the clinical and radiographic outcomes in two different biodegradable antibiotic carriers used in the management of chronic osteomyelitis. Method. A single centre series reviewed between 2006–2017. The initial cohort (2006–2010) of 180 cases (Group A) had a calcium sulphate carrier containing tobramycin (Osteoset. ®. T, Wright Medical). The second cohort (2013–1017) of 162 cases (Group B) had a biphasic calcium sulphate, nano-crystalline hydroxyapatite carrier containing gentamicin (Cerament. TM. G, Bonesupport AB). All cases were Cierny-Mader Grade III and IV and had a minimum of one-year clinical follow-up. Clinical outcomes reviewed included infection recurrence rate, wound leak, and subsequent fracture involving the treated segment. All cases with a minimum one-year radiographic follow-up were reviewed and bone void filling was assessed as percentage filling on the final follow-up radiograph to the nearest five percent increment. Results. Mean follow-up in Group A was 4.2 years (range 1.3–10.5 years) and in Group B it was 1.8 years (1–4.7 years). Group A had a significantly higher rate of infection recurrence (19/180 (10.6%) Vs. 7/163 (4.4%) p=0.030), wound leak (33/180 (18.3.%) Vs. 16/162 (9.9%) p=0.026) and subsequent fracture rate (11/180 (6.1%) Vs. 3/162 (1.9%) p=0.047) compared to Group B. Of the cases with a minimum of one-year radiographic follow-up Group A had 96 cases (mean follow-up 3.3 years, range 1.0–10.5 years) and Group B had 137 cases (mean follow-up 1.6 years, range 1.0–4.7 years). The mean bone void healing in Group B was significantly better than Group A (74.0% Vs. 41.7%, p <0.00001). Conclusions. Cerament. TM. G has significantly better bone healing compared to a calcium sulphate carrier and was associated with a lower rate of recurrent infection, wound leak and subsequent fracture risk

Aim. The current treatment concepts of acute and chronic osteomyelitis are associated with unsolved challenges and problems, underlining the need for ongoing medical research. The invention and prevalence of an absorbable, gentamicin-loaded ceramic bone graft, that is well injectable for orthopedic trauma and bone infections, enlarges the treatment scope regarding the rise of posttraumatic deep bony infections. This substance can be used either for infection, dead-space, or reconstruction management. The bone cement, eluting antibiotics continuously to the surrounding tissue, outperforms the intravenous antibiotic therapy and enhances the local concentration levels efficiently. This study aims to evaluate the power and practicability of bone cement in several locations of bony infections. Method. The occurrence of posttraumatic infections with acute or chronic osteomyelitis increases in trauma surgery along with progression of high impact injuries and consecutively high incidence of e.g. open fractures. We present a case-series of 33 patients (18w/15m; 56,8±19,4 years) with posttraumatic osteomyelitis at different anatomic sites, who were treated in our level I trauma center. All of these patients received antibiotic eluting bone cement (Cerement® G) for infection and reconstruction management. Results. With admission to our trauma-center all patients with obvious or suspected osteomyelitis undergo an interdisciplinary pre-work up, including thorough clinical examination and different measures of diagnostic imaging, ultimately leading to the definition of an individual treatment plan. We diagnosed 33 bone infections anatomically allocated to the proximal and distal femur (12x), the pelvis (2x), distal tibia (3x), tibial diaphysis (10x), the ankle joint (4x) and calcaneus (2x). According to Cierny-Mader we diagnosed grade I (6), II (7), III (13) and IV (7). These 33 patients were treated (1) with surgical debridement, (2) with Cerament G, (3) bone stabilisation (including nail osteosynthesis, arthrodesis nails, plates, or external ring fixation), (4) optionally VAC-conditioning, and (5) optionally soft tissue closure with local or free flaps. The overall number of surgery was 2.9±2.26. We observed very good clinical, functional and radiological results by using bone cement augmented with gentamicin. The overall recurrence rate of infection is low (12%, 4/33). “White fluid” secretion was observed in six cases. Conclusions. Current concepts for treatment of osteomyelitis include radical surgical debridement and additional antibiotic therapy. It could be demonstrated that the usage of an antibiotic biocement with osteoconductive characteristics enlarges the success rate in septic bone surgery. The treatment concepts, however, remain complex, time consuming, require a high patient compliance, and are highly individually

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.

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

To report our experience with the use of local antibiotic co-delivery with a synthetic bone graft substitute during a second stage re-implantation of an infected proximal humeral replacement. A 72 year old man was admitted to our department with a pathological fracture through an osteolytic lesion in the left proximal humerus, due to IgG Myelomatosis. He was initially treated with a cemented proximal humerus replacement hemiarthroplasty. Peri-prosthetic joint infection (PJI) with significant joint distention was evident three weeks post operatively. Revision surgery confirmed presence of a large collection of pus and revealed disruption of the soft tissue reattachment tube, as well as complete retraction of rotator cuff and residual capsule. All modular components were removed and an antibiotic-laden cement spacer (1.8g of Clindamycin and Gentamycin, respectively) was implanted onto the well-fixed cemented humeral stem. Initial treatment with i.v. Amoxicillin/Clavulanic acid was changed to Rifampicin and Fusidic Acid during a further 8 weeks after cultures revealed growth of S. epidermidis. During second stage revision, a hybrid inverse prosthesis with silver coating was implanted, with a total of 20 ml Cerament ™G (injected into the glenoid cavity prior to insertion of the base plate and around the humeral implant-bone interface) and again stabilized with a Trevira tube. Unfortunately, this prosthesis remained unstable, ultimately requiring re-revision to a completely new constrained reverse prosthesis with a custom glenoid shell and silver-coated proximal humeral component. 18 months postoperatively, the patient's shoulder remains pain free and stable, without signs of persistent or reinfection since the initial second stage revision. The function however, unfortunately remains poor. This case report illustrates the application of an antibiotic-eluting bone graft substitute in a specific clinical situation, where co-delivery of an antibiotic together with a bone remodeling agent may be beneficial to simultaneously address PJI as well as poor residual bone quality

Aim. Eradication of infection in chronic osteomyelitis requires effective dead space management after debridement. Residual bacteria in biofilm may be resistant to normal levels of systemic antibiotic penetrating bone and will contribute to recurrence of osteomyelitis. This study evaluated a new antibiotic-loaded biocomposite in the eradication of chronic infection from bone defects. Patients and Method. We report a prospective study of 100 patients with Cierny and Mader types III and IV chronic osteomyelitis, in 105 bones. Osteomyelitis followed open fracture or ORIF of closed fractures in 71%. Nine had concomitant septic arthritis. 80% had comorbidities (Cierny-Mader Class B hosts). Ten had infected non-unions. All patients were treated by a multidisciplinary team with a single-stage protocol including; debridement, multiple sampling, culture-specific systemic antibiotics, stabilisation, dead space filling with Cerament G™ and immediate primary skin closure. Stabilisation was required in 21 cases and 5 required joint fusion as part of the initial surgery. Plastic surgical skin closure was needed in 23 cases (18 free flaps). Patients were followed up for a minimum of one year (mean 19.5 months; 12–34). Results. Staphylococci were the commonest organism (41.8%), with MRSA in six patients. Proteus mirabilis and Pseudomonas spp were more common in polymicrobial infection, often with a gram-positive organism (usually Staphylococcus aureus). Sixteen patients cultured organisms which were shown to be gentamicin resistant using EUCAST breakpoints. Gentamicin resistance was just as likely to be present in patients with haematogenous infections (3/19; 15.8%) as in post-trauma (13/81; 16%) (Chi-square: p=0.978) Gentamicin resistant organisms were more likely to be found in polymicrobial infections (9/21; 42.8%) than in single isolates (7/79; 8.9%) (Chi-square: p<0.001). Infection was eradicated in 96% with a single procedure and all four recurrences were successfully managed with repeat surgery. All 5 fusions healed and 8/10 non-unions healed with the primary surgery alone. Adverse events were uncommon, with 3 fractures, 6 wound leaks and 3 deaths, unrelated to the infection or surgery. Outcome was not dependant on C-M host class, aetiology of infection, microbial culture, wound leakage or presence of non-union. Conclusions. This protocol, facilitated by the absorbable local antibiotic, was effective in the treatment of C-M types III and IV chronic osteomyelitis. The single-stage approach with high bioavailability local antibiotics is a robust management strategy, applicable across a wide range of patients, including those with significant co-morbidities. It offers a more patient-friendly treatment compared to other published treatment options

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.