Adjuvant antibiotic loaded bio composite in the management of diabetic foot osteomyelitis - A multicentre study.

BACKGROUND: Diabetic foot ulcers are associated with a high morbidity and are common cause of non-traumatic lower limb amputations. The effect of debridement and the use of an adjuvant local antibiotic carrier in the treatment of diabetic foot ulcers with osteomyelitis was evaluated. METHODS: A retrospective review of patients with diabetic foot ulceration and osteomyelitis treated by debridement with adjuvant local antibiotic was performed. Seventy patients with Texas Grade 3B & 3D lesions were included, with a mean age of 68 years. Cerament G, an antibiotic-loaded absorbable calcium sulphate/hydroxyapatite bio-composite was used along with intraoperative multiple bone sampling and culture-specific systemic antibiotics. RESULTS: Patients were followed up until infection eradication or ulcer healing. Mean follow up was 10 months (4-28months). Nine patients had Charcot foot deformity, 14 had peripheral vascular disease. 62% of patients had forefoot, 5% midfoot and 33% hind foot involvement. Fifty-three patients (87%) had polymicrobial infection. Staphylococcus aureus was the most common microorganism isolated. Infection was eradicated in 63 patients (90%) with mean time to ulcer healing of 12 weeks. Seven patients were not cured and required further treatment. Five patients had below knee amputation. CONCLUSIONS: Adjuvant, local antibiotic therapy with an absorbable bio-composite can help achieve up to 90% cure rates in diabetic foot ulceration with osteomyelitis. Cerament G can act as effective void filler allowing dead space management after excision and preventing reinfection and the need for multiple surgical procedures. LEVEL OF EVIDENCE: Level IV- case series.

Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: The Silo technique.

BACKGROUND: Chronic osteomyelitis necessities appropriate infected bone and soft tissue excision. The authors describe the Silo surgical technique for the treatment of calcaneal osteomyelitis using a new antibiotic-loaded absorbable calcium sulphate/hydroxyapatite biocomposite. METHODS: The Silo method involves debridement of the dead bone and local delivery of antibiotic in drilled tunnels using the biocomposite. It is combined with multiple sampling and culture-specific systemic antibiotic treatment guided by a multidisciplinary team. Twelve consecutive diabetic patients with heel ulcers and calcaneal osteomyelitis were treated with the above method. All had comorbidities (Cierny-Mader (C-M) Class B hosts). The mean age was 68 years (range 50-85). A retrospective review of radiographs and electronic medical records was conducted. RESULTS: Patients were followed up until clinical cure of the ulcer for a mean of 16 weeks (range 12-18). Infection was eradicated in all 12 patients with a single stage procedure following a bone preserving technique. One patient required a subsequent flap operation and six vacuum-assisted closure (V.A.C.). There was also one case of prolonged wound leakage and no calcaneal fractures. CONCLUSIONS: The Silo technique is an effective method of local delivery of antibiotics and can be effectively implemented into the single-stage treatment of calcaneal osteomyelitis offering increased bone preservation and local delivery of antibiotic, decreasing the need for a major amputation. LEVEL OF EVIDENCE: Level IV- case series.

The influence of theory on the formation of the infirmary during antiquity and the Middle Ages in the West.

The modern infirmary is the evolutional product of the dialectic interface between medical theories at each time and the outcome of their application in clinical practice. The infirmary as we know it today did not exist during antiquity, but the different precursors of the modern hospital emerged as a result of the interaction between medical theory and practice. During antiquity the Hippocratic work decisively contributed to the creation of the Asklipieion, an institution with predetermined structure created to heal diseases. Later in antiquity new types of infirmaries appeared along with the evolution of private practice for physicians. Establishment of the first modern hospitals was an outstanding contribution of Islamic medicine during reign of the Islamic Empire. Although there was little progress in the development of medical theory in medieval West, evolution of the infirmary continued and was mostly influenced by Christian religion and charity. In Constantinople large medieval infirmaries were built, but patient care was frequently offered in monasteries by clergymen. Later on medicine and treatment of diseases were taken over by physicians and taught in universities, and medical theory continued on its course of evolution. It is obvious that the modern infirmary is not only a place for treating diseases, but rather the upshot of a series of advancements in science, the relations between people or even countries, and the way humanity perceives its nature and the future. Our research is focused on the interactive relationship between the evolution of medical theory and the infirmary as an institution during antiquity and the Middle Ages with particular emphasis on the Western World.