J Korean Foot Ankle Soc.  2019 Jun;23(2):58-66. 10.14193/jkfas.2019.23.2.58.

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

  • 1Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea. s3g1@naver.com


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.
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.
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.
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.


Diabetic foot; Osteomyelitis; Antibiotic-loaded cement spacer; Risk factor
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