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I have used PMMA beads with either vancomycin or aminoglycosides for many years, successfully. However, there have been many times I have had pathogens that I needed to cover that the aforementioned antibiotics would not do the job.  Also using the PMMA beads required another surgery to remove them.  Recently I have been using Ceramant bone void filler with either vancomycin, timentin, fortaz, zosyn, primaxin, tobramyacin, and a vancomycin/tobramycin combo against MRSA and timentin, fortaz, zosyn, primaxin, tobramyacin, and a vancomycin/tobramycin combo against Pseudomonas with excellent results in 20+ patients thus far.  The elusion data and zone of inhibition data is very impressive.  The zone of inhibition data was presented at APMA in Toronto last month.  What I also like about this carrier vehicle for the antibiotics is that the Ceramant is biodegradable so I do not need remove the beads after implantation.

I am curious  what your thoughts on this carrier vehicle would be and why or why not would you use this in your practice?

  • Comments (30)
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  • I forgot my bad.....thanks for the reply.
    The impetus for my inquiry was a hallux amp, that did not heal.
    The patient was sent for an MRI which revealed osteo of the head and neck of the first met post hallux amp not Pre hallux amp.
    When one examines the wound, thre is no evidence of any necrotic bone. Since, nothing looks necrotic, I do not want to resect anything.
    I went back to the OR, used a versa jet to clean all tissue, examine for sinus tracts and then placed the antibiotic beads around the periphery off the head and neck. I also had a picc line placed and have him on IV antibiotics.
    (I did come across articles that used purely the beads without the IV meds but was not that ballsy to do anything like that.)
    Additionally, we put a wound vac on the patient and so far he seems to be doing well. (According to wound nurse, I see him Tuesday.)
    (Non compliant diabetic - so I realize things may change fast.)
    I ask about the beads as I am new to them......
  • Quote:

    Alex - (or whoever else would like to join in); 1) Did you ever or would you consider giving antibiotic impregnanted beads as your sole antibiotic treatment? 2) were you using it for mainly soft tissue infection? Osteo or both? 3) have you or to your knowledge can the impregnated beads have an effect on osteomyelitic bone without debriding the bone? Another words, if one wants to give bone a chance to heal and not be amputated could the beads reverse the infectious process or stagnate it so that it lays dormant? 4) it sounded from your initial comment you were speaking in past tense....do you still utilize the technique or have you abandoned it?



    Jeff, to answer your questions:

    1. I'd not consider using the antibiotic beads as sole treatments as I am confident this would be a significant deviation from "standard of care", regardless of how strongly I felt of the efficacy of this treatment.

    2. I have used the antibiotic beads for BOTH soft tissue and oseteomyeliitis. Again, I have a several photos and if I had time, I could probably come up with come case studies. I often resected frankly osteomyelitic bone (discolored / brittle bone) and ream out the medullary canal and then stuff it with the beads or even the bone cement paste before it had set. Again, excellent results. Was this result due to the resection of the infected bone, the oral/IV antibiosis, the implanted beads, or all of the above? I don't know, what I can say though is that I could sleep well at night knowing that I used everything in my armamentarium to prevent further spread of infection / amputation mitigation. Was this my standard approach? Certainly not, I only used the beads in severe enough / limb at risk cases.

    3. See #2. Furthermore, I believe that whatever bone appears non-viable, needs to be resected / debrided. Barring vascular compromise or some other co-morbidity which would preclude surgical management, this is "non-negotiable" in my opinion.

    4. I'd still use this technique if I were still in practice.  In the event you don't recall, I am in a year long training program and hence am not in a clinical setting at this juncture in time.

  • Alex - (or whoever else would like to join in);
    1) Did you ever or would you consider giving antibiotic impregnanted beads as your sole antibiotic treatment?
    2) were you using it for mainly soft tissue infection? Osteo or both?
    3) have you or to your knowledge can the impregnated beads have an effect on osteomyelitic bone without debriding the bone?
    Another words, if one wants to give bone a chance to heal and not be amputated could the beads reverse the infectious process or stagnate it so that it lays dormant?
    4) it sounded from your initial comment you were speaking in past tense....do you still utilize the technique or have you abandoned it?
  • Over my years of practice and experience in complex foot infections, I have used antibiotic impregnated beads on a plethora of occasions.

    The main purpose for using aminoglycocide antibiotics, especially with the non-resorbable PMMA beads, is not so much related to the broad spectrum of these antibiotics but more due to their stability to heat. If one recalls, when PMMA beads are mixed, this creates an exothermic reaction which will affect most other antibiotics (they are heat labile), whereas the amioglycocides (gentamycin, vancomycin, tobramycin, etc.) are heat stable.

    The issue of heat stability as well as antibiotic spectrum is addressed with the calcium based absorbable beads. With these products you also have the added benefit of not needing to retrieve the antibiotic beads in a subsequent procedure (bedside or otherwise).

    With the calcium based absorbable beads one can use whatever powdered or liquid antibiotic which may be indicated based on cultures or suspected organisms. One main drawback to these beads is increased drainage and associated risk of maceration and seroma formation. Personally, I mitigated these risks and rarely had an issue by simply packing the wund open and performing frequent packing / dressing changes.  Occasionally I painted the wound margins with gentian violet or betadine. I have allot of clinical cases and photos and i was a big advocate in using antibiotic beads in complex or deep / wide space infections.

  • This is an older blog that I came across. I was going to start a blog on the very topic but figured this one was an excellent start.
    I am curious to hear any feedback from anyone using the beads and their experiences....


  • Rick,

    That is a very good question.  I mostly use the injectable antibiotic cement (off-label use) for filling bone defects after removal of hardware.  The hardware removed and the defect to be filled can be as small as a screw or as large as an IM rod.  I have done both with success.  Success would be defined as no reoccurrence of osteomyeltis. 

    I also use flowable bone void filler without antibiotic (on-lable use) to fill cyst and and other bone voids.

    Here are some mixing instructions in regards to flowable antibiotic cement.  When preparing the cement you should be ready for placement of the flowable antibiotic cement at the time of mixing.  This is very important, as you should not prepare this ahead of time as you do with antibiotic beads, because the window for use of the flowable antibiotic cement is not very long and a delay before usage may allow the antibiotic cement to set in the chamber.  General guidelines for preparing the flowable antibiotic cement are as follows. Mix the 8 ml Iohexol solution 180 mg I/ml (CERAMENT™│C-TRU or Omnipaque™) with antibiotic powder in a small sterile plastic cup on the back table.  Redraw the Iohexal/antibiotic solution back into a 10 cc syringe.  Now add to the mixture to the 10 ml Cerament™| Bone Void Filler chamber and mix for one minute.  Attach a 11 or 8 gauge jamshidi needle with a lure lock, not all jamshidi needles have lure locks.  Because of the incorporation of the Omnipaque™, the placement of the antibiotic flowable cement can be verified in actual time with intra-operative fluoroscopy. The flowable times are in chart two.

    Table 2:  Recommended flowable antibiotic mixing guidelines

     

    Antibiotic

    Iohexol 180mg I/ml

    NaCl 14.6% vol.

    Mixing time of Cerament™ with Iohexol

    Flowable until

    Cefazolin 1g

    8 ml

    n/a

    1 minute

    3.5 min

    Timentin 1 g

    8 ml

    n/a

    1 minute

    15 min

    Vancomycin 2 g

    8 ml

    n/a

    1 minute

    13 min

     

     

     

  • Dr Karr
    Do you have experience with injectable antibiotic cement for the treatment of osteomyelitis?  If so, what have you used, for which organisms, and what are your outcomes?  Thank you. Dr. Weiner



  • 40% is the correct HA content by weight.  

    In my opinion, it is hard to see the HA at 12 months, but there is some increased density.   I believe that so much antibiotic is released in a zone that all bacterial are killed.  I also agree bonding would occur without infection but what about with infection? - a very good question indeed.

    I would theorize that bonding will be impeded  with bacteria or biofilm present.  However clinical cases to date are promising.  I am actually updating a lecture and here is some of the information from the lecture in regards to clinical cases:

    33 patients - follow-up 3 to 18 months involving:

       Metatarsal - 18     Phalanx - 2

       Mid-foot - 1 Fibula (ankle) - 3

       Tibia - 6

    Success in 30 of 33 patients, three failures from poor patient selection involving:

       Metatarsal - 1 Calcaneus   1  

       Tibia - 1

    The antibiotics used in the beads were:

    Vancomycin, vancomycin/tobramycin, timentin, fortaz, and zosyn.

    Bacteria treated successfully was:

    MRSA, MSSA, enterobacter, enterococcus, citrobacter, stenotrophomonas, and pseudomonas, E. coli, streptococcus


    Karr 






  • Thank you for your response, isn't Cerament 40% HA? On radiograph's I've seen in the product literature the cement is visible and denser than bone at 12 months, presumably the HA element? It is also worth bearing in mind that any infection inhibits bone formation so the bonding of HA and the apatite layer seen in standard fx scenarios wouldn't translate to an active infection site, that said your results seem impressive with over a 90% success,  presuming there's not a remanant biofilm!

  • I agree that colonizing bacteria/adherent colonies continues to be an important consideration in orthopedics in regard to implants and bone cement.  In a recent article:  

    Persistence of bacterial growth on antibiotic-loaded beads: Is it actually a problem?  
    Acta Orthopaedica 2008, Vol. 79, No. 2, Pages 302-307 , DOI 10.1080/17453670710015120 

     

    The authors examined PMMA non-absorbable antibiotic beads upon removal found a persistence of bacterial growth (biofilm) on the beads.  I would expect not to see this with bio-absorbable antibiotic beads as there is little product left  i.e. hydroxyapatite (HA) for the bacteria to adhere to.  

     

    I can understand a biofilm around PMMA as there is a fibrous capsule separating the PMMA from bone (probably initially created by the exotherm which kills bone around the implant).

     

    With respect to Cerament™ the HA has a carbonated apatite layer around it making it highly attractive for osteoblasts which progress the bone formation process. Therefore I see little opportunity for a biofilm to form.

    Proof is in the long term data that is collected.  To date I have managed 34 cases with 31 success and  3 failures.  Of the 31 success there have been no reoccurrence.  The longest follow-up is about 18 months.  The three failures were all poor patient selection that ended up with BKA's due to non-compliance and uncontrolled co-morbidities.

    I plan on submitting for publication next year multi-center data.

    Karr 


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