Thoracoscopic debridement and stabilization of pyogenic vertebral osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.     

Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages

There is no scientific consensus on the role of posterior instrumentation in vertebral osteomyelitis. No study has examined the use of titanium cages to reconstruct the anterior column of the spine with vertebral osteomyelitis. Here the authors evaluated the efficacy of using titanium mesh cages anteriorly and posterior instrumentation after anterior debridement in the surgical treatment of vertebral osteomyelitis. In one center, 21 consecutive patients had surgery for vertebral osteomyelitis. The mean follow-up time was 67 months (range, 24 to 120 months). Ten patients received supplemental posterior instrumentation. Five patients had reconstruction of the anterior column with titanium cages. Greater improvement in sagittal alignment was noted for patients with cages implanted (p = 0.0009) and for those with posterior instrumentation (p = 0.005). Patients who received cages had greater (p = 0.0006) correction of their coronal alignment than did those patients without cages. A trend toward fewer postoperative complications emerged for patients who had posterior stabilization or titanium cages. These results support the use of posterior stabilization and titanium cages in the surgical treatment of vertebral osteomyelitis.     

Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting

From 1971 to 1984 at the University of Rochester Medical Center, 23 adult patients underwent surgical treatment via an anterior approach for pyogenic vertebral osteomyelitis. Data from 21 patients with greater than 2-year follow-up is presented in this report. Surgical debridement via an anterior approach was performed in all 21 patients. Bone grafting with iliac crest or rib strut was done in 19 patients. Clinical follow-up averaged 4 years, with a range of 2 years to 9 years, 9 months. No patient had a recurrence of osteomyelitis. All patients with neurologic deficits recovered without functional motor or sensory deficits. Of the 19 patients grafted, 18 showed roentgenographic evidence of fusion, and one went on to a pseudarthrosis. The average increase in kyphosis at the infection site was 3 degrees. In selected patients with pyogenic vertebral osteomyelitis requiring surgical treatment, anterior debridement and primary bone grafting in conjunction with appropriate antibiotics is successful in treating the infection and promoting osseous fusion in a high percentage of cases.     

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36–74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84–100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.     

Vertebral osteomyelitis secondary to Pseudallescheria boydii

Because Pseudallescheria boydii vertebral osteomyelitis is rare and frequently resistant to available antifungal agents, the proper treatment of this lesion has not been defined. To better determine the best treatment of this lesion, the authors evaluated a case P. boydii vertebral osteomyelitis and reviewed the literature. A 48-year-old man had isolated thoracic vertebral osteomyelitis resulting from P. boydii and associated severe thoracic back pain and proximal lower extremity pain and weakness. Magnetic resonance imaging studies revealed continued collapse of the T6--T7 vertebrae despite previous posterior debridement and appropriate antifungal chemotherapy. On admission to the authors' institution, the patient underwent a right thoracotomy, anterior debridement with transthoracic T6--T7 corpectomies and strut grafting, followed by posterior fusion and stabilization with pedicle screws. After operation, the patient's pain, hyperalgesia, and lower extremity symptoms resolved. He was treated with a 12-month course of itraconazole. Imaging and laboratory studies show no evidence of recurrence. P. boydii vertebral osteomyelitis can have devastating neurologic sequelae if not treated properly. The frequent lack of response of this unusual fungal infection to systemic therapy requires frequent serial follow-up examinations. Patients with evidence of progression on imaging studies or neurologic findings should undergo early and aggressive surgical debridement.     

Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis.

BACKGROUND CONTEXT: Vertebral osteomyelitis can be successfully treated with spinal immobilization and parenteral antibiotics. Failure of medical therapy may necessitate surgical treatment consisting of anterior debridement and structural anterior column reconstruction. Autologous structural bone graft has traditionally been the gold standard in anterior column reconstruction. Because of the morbidity related to graft harvest, vertebral body replacement cages have emerged as a viable option for reconstructing a deficient anterior column. PURPOSE: To evaluate the efficacy of titanium mesh cages in the reconstruction of anterior column defects in the presence of active pyogenic infection. STUDY DESIGN: Prospective case series. METHODS: Eleven patients underwent operative treatment for osteomyelitis of the thoracolumbar spine using staged anterior debridement and reconstruction with cylindrical titanium mesh cages followed by delayed posterior spinal fusion with pedicle screw instrumentation during a 2-year period. Patients were postoperatively evaluated clinically and radiographically. RESULTS: Follow-up averaged 17+/-9 months. Average increase in kyphosis of 10+/-6 degrees corresponding to 4+/-4 mm loss in the height (subsidence) of the anterior construct. One patient died during revision surgery for hardware failure. Seven of the remaining 10 patients have not required antibiotics after the initial postoperative course of treatment. Three patients are maintained on chronic suppressive therapy as a precaution. There has been no evidence of recurrence or residual infection in any patient. Seven of the 10 patients were pain free at latest follow-up. There has been one case of pseudarthrosis. CONCLUSION: Cylindrical titanium mesh can be used with consistently good results for large anterior column defect reconstructions even in the face of active pyogenic infection. In our cohort of patients with pyogenic vertebral osteomyelitis, the use of titanium mesh cages has not been associated with early recurrence of infection.     

Surgical treatment of the spontaneous spinal epidural abscess.

Seven cases of spontaneous epidural abscess are reviewed. Three patients had posterior abscesses and no evidence of vertebral body osteomyelitis. These patients had excellent outcomes with laminectomies and antibiotics. Because of significant vertebral destruction, two patients with vertebral osteomyelitis required posterior fixation after laminectomy. Two other patients with vertebral osteomyelitis had complete destruction of the vertebral body and required anterior decompression and fusion in addition to posterior fixation. In the four patients with vertebral osteomyelitis, morbidity was high, reflecting their age and significant medical problems. This review supports the contention that medically stable patients with posterior epidural abscesses can be treated with laminectomy and antibiotics with little risk of progressive instability. The proper surgical treatment of anterior epidural abscesses secondary to osteomyelitis requires knowledge about the amount of destruction of the supporting columns, the amount of neural compression secondary to the purulence, and the patient's general medical condition.     

Successful treatment of extended epidural abscess and long segment osteomyelitis: a case report and review of the literature

BACKGROUND: Spinal osteomyelitis and epidural abscess are complicated medical conditions. Diagnosis is often delayed because of cormorbidity. The time of instrumentation is still controversial. However, there is no doubting the indication of spinal hardware implantation when spinal fusion is needed. Long segment osteomyelitis and extended epidural abscess are rare. The treatment is challenging for neurosurgeons. We report a case of extended epidural abscesses and long segments of osteomyelitis. METHODS: One-stage meticulous debridement, anterior cervical corpectomies, and spinal fusion with mesh cage and titanium plate were performed on the patient. Hyperbaric oxygenation and 6 weeks of intravenous antibiotics were prescribed as adjuvant therapy. RESULTS: Both clinical presentations and imaging studies showed a good response to the treatment. The patient returned to his life 3 months later. CONCLUSIONS: This case illustrates that spinal instrumentation is not an absolute contraindication in the presence of epidural abscesses and vertebral osteomyelitis. Combined surgical debridement at a critical level, with adjuvant antibiotics and hyperbaric oxygenation, is a safe and effective therapy in those with neurologic deficits, spinal instability, and extended epidural abscess.     

Vertebral osteomyelitis: an analysis of 38 surgically treated cases

The purpose of the study was to evaluate the characteristics of patients with vertebral osteomyelitis who were treated by anterior debridement and interbody fusion. Thirty-eight patients with vertebral osteomyelitis, who were treated between 1980 and 1993, were analyzed in terms of age at the occurrence of disease, duration of disease, type of onset symptoms, radiological type of vertebral destruction, species of pathogen, and surgical result. Thirty-one out of 38 patients (82%) were more than 40 years of age. The patients with severe vertebral destruction were significantly older than those with mild vertebral destruction. Vertebral destruction in the thoracic spine was significantly more severe than that in the lumbar spine. Staphylococcus aureus was identified in only six patients (32% of organism-determined cases). In the present patients who required anterior debridement and bone grafting for this disease, the prognosis was quite good after anterior interbody fusion in conjunction with antibiotics therapy. Received: 3 February 1997 Revised: 7 April 1997 Accepted: 30 July 1997     

Candida albicans osteomyelitis of the spine: progressive clinical and radiological features and surgical management in three cases

Candida albicans vertebral osteomyelitis is rare. Three cases are presented. Without antifungal treatment, they developed spinal collapse and neurological deterioration within 3–6 months from the onset of symptoms. There was a delay of 4.5 and 7.5 months between the onset of symptoms and surgery. All patients were managed with surgical debridement and reconstruction and 12-week fluconazole treatment. The neurological deficits resolved completely. The infection has not recurred clinically or radiologically at 5–6 years follow-up. Although rare, Candida should be suspected as a causative pathogen in cases of spinal osteomyelitis. Without treatment the disease is progressive. As soon as osteomyelitis is suspected, investigations with MRI and percutaneous biopsy should be performed followed by medical therapy. This may prevent the need for surgery. However, if vertebral collapse and spinal cord compression occurs, surgical debridement, fusion and stabilisation combined with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.     

Single-stage treatment of pyogenic spinal infection with titanium mesh cages

STUDY DESIGN: Single institution retrospective review. OBJECTIVES: To report a series of pyogenic spinal infections treated with single-stage debridement and reconstruction with titanium mesh cages. SUMMARY OF BACKGROUND DATA: Various studies have reported surgical results of pyogenic spinal osteomyelitis with anterior debridement, strut grafting and fusion, including delayed posterior spinal instrumentation. Additionally, various authors have recommended against the use of instrumentation because of the concern about glycocalyx formation on the metal and chronic infection. At our institution, we routinely treat chronic vertebral osteomyelitis with single-stage debridement, reconstruction with a titanium mesh cage filled with allograft chips and demineralized bone matrix, and posterior pedicle screw instrumentation. To our knowledge, this is the largest single series reporting single-stage debridement and instrumentation of pyogenic spinal infection with titanium mesh cages and posterior instrumentation. MATERIALS AND METHODS: We retrospectively reviewed the patient records and radiographs of 21 consecutive patients (average age 49.3 years, range 23 to 80 years) with pyogenic vertebral osteomyelitis, all treated with titanium mesh cages. Average follow-up was 44 months (range, 25 to 70 months). Spinal levels included 6 thoracic, 4 thoracolumbar, 9 lumbar, and 2 lumbosacral (L5-S1) lesions. All patients had preoperative serum evaluation, which usually included blood cultures, complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), in addition to plain radiographs and magnetic resonance imaging. A positive needle biopsy was available in only 2/7 patients (29%), and overall, preoperative pathogen identification was available in only 7/21 patients (33%). All patients were treated postoperatively with a minimum of 6 weeks of intravenous antibiotics, with a specific antibiotic regimen directed toward the postoperative pathogen when identified (17/21 cases). Extensive radiographic evaluation was also performed. RESULTS: ESR and CRP were routinely elevated (18/20 and 11/17 cases respectively), whereas the white blood count was elevated in only 8 out of 21 cases (38%). The average duration of symptoms to diagnosis was approximately 13.6 weeks (range 3 weeks to 10 months). The indications for surgery included neurologic compromise, significant vertebral body destruction with loss of sagittal alignment, failure of medical treatment, and/or epidural abscess. All patients had resolution of infection, as noted by normalization of the ESR and CRP. Further, 16 out of 21 patients also had a significant reduction of pain. There were no deaths or new postoperative neurologic compromise. The most common pathogen was Staphylococcus aureus. Two patients required a second surgery (posterior irrigation and debridement) during the same admission for persistent wound drainage. Radiographically, the average segmental kyphosis (or loss of lordosis) was 11.5 degrees (range, 0 to 24 degrees) preoperatively, and +0.8 degrees (range, -3 to +5 degrees) at latest postoperative follow-up. There was an average of 2.2 mm cage settling (range, 0 to 5 mm) on latest follow-up. There were no instrumentation failures, signs of chronic infection, or rejection. CONCLUSIONS: Titanium mesh cages present a viable option for single-stage anterior surgical debridement and reconstruction of vertebral osteomyelitis, without evidence of chronic infection or rejection. When used in conjunction with pedicle screw instrumentation, there is minimal cage settling without loss of sagittal alignment.     

Osteomyelitis of the cervical spine: a potentially dramatic disease

Osteomyelitis of the cervical spine is a rare disease, representing only 3% to 6% of all cases of vertebral osteomyelitis. In contrast with other locations of spinal infections, osteomyelitis of the cervical spine can be a much more dramatic and rapidly deteriorating process, leading to early neurologic deficit. Thus, the disease must be diagnosed quickly and appropriate therapy initiated as soon as possible. The clinical course, therapy, and outcome of 15 patients treated for osteomyelitis of the cervical spine are presented. Nine of 15 patients presented with a neurologic deficit at the time of diagnosis. Surgical treatment consisted of radical debridement of the infected bone and either immediate bone grafting and stabilization as a one-step procedure or interval antibiotic treatment before bone grafting and surgical stabilization as a second procedure. A favorable outcome was achieved by early and aggressive surgical intervention, including complete resolution of neurologic deficits in more than 50% of the patients and complete bony fusion in all but one patient. The authors prefer additional posterior rather than anterior stabilization alone to perform fusion over a shorter distance involving only the infected segments.     

Osteomyelitis of the cervical spine: a potentially dramatic disease

Osteomyelitis of the cervical spine is a rare disease, representing only 3% to 6% of all cases of vertebral osteomyelitis. In contrast with other locations of spinal infections, osteomyelitis of the cervical spine can be a much more dramatic and rapidly deteriorating process, leading to early neurologic deficit. Thus, the disease must be diagnosed quickly and appropriate therapy initiated as soon as possible. The clinical course, therapy, and outcome of 15 patients treated for osteomyelitis of the cervical spine are presented. Nine of 15 patients presented with a neurologic deficit at the time of diagnosis. Surgical treatment consisted of radical debridement of the infected bone and either immediate bone grafting and stabilization as a one-step procedure or interval antibiotic treatment before bone grafting and surgical stabilization as a second procedure. A favorable outcome was achieved by early and aggressive surgical intervention, including complete resolution of neurologic deficits in more than 50% of the patients and complete bony fusion in all but one patient. The authors prefer additional posterior rather than anterior stabilization alone to perform fusion over a shorter distance involving only the infected segments.     

Two-staged operation for thoracolumbar osteomyelitis following methicillin-resistant staphylococcus aureus infection of a craniectomy wound--case report.

A previously healthy 53-year-old woman developed pyogenic vertebral osteomyelitis (PVO) manifesting as progressive lumbago following wound infection of a decompressive craniectomy performed for brain contusion caused by a traffic accident. Magnetic resonance imaging disclosed vertebral osteomyelitis at T-12 and L-1 with paravertebral abscess. Anterior debridement and fusion using autografts were performed at the first operation. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from the abscess specimen. Antibiotic therapy resolved the infection. Pedicle screw fixation was performed at the second operation. The patient became free from back pain and no recurrence of infection was seen. The diagnosis of PVO is frequently observed or delayed because of the nonspecific symptomatic presentation in the early stage. Coexistent infection or trauma makes early diagnosis more difficult. Indications and timing of instrumentation for the spinal column infected with MRSA is difficult. Two-staged operation with anterior debridement and posterior instrumentation after eradication of the infection is a safe and effective procedure for MRSA vertebral osteomyelitis.     

Delayed reconstruction by titanium mesh-bone graft composite in pyogenic spinal infection: a long-term follow-up study

OBJECTIVE: Use of instrumentation in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. Particularly, limited information is available regarding the long-term follow-up of patients. We retrospectively reviewed the use of titanium mesh-bone graft composite after corpectomy in pyogenic spinal infection with a minimum 3-year follow-up outcome. METHODS: Four patients, two men and two women, with cervical and thoracic myelopathy caused by cervical (two cases) and thoracic (two cases) osteomyelitis and epidural abscess, were treated. Their age ranged from 49 to 74 years (mean age 58 years). In one case, the coexisting medical condition was diabetes. Neurologic deficits caused by direct spinal cord compression due to epidural abscess, segmental deformity, and instability were observed in all cases. After infection was clinically controlled by intravenous antibiotics, anterior debridement and fusion using titanium mesh cage along with anterior plate were performed. Two-stage treatment was performed in two cases. RESULTS: The postoperative course was uneventful; all patients experienced relief of symptoms. No evidence of recurrence or residual infection was observed in any patient during the average follow-up period of 42-56 months (average 49.0 months). CONCLUSIONS: Once infection is clinically controlled, a titanium mesh-bone graft composite and plate in combination with aggressive debridement might provide an effective therapy for spinal osteomyelitis requiring surgery. Despite studying a small number of patients, we can conclude that titanium mesh reconstruction can be useful as a surgical method in selected low-risk patients with vertebral osteomyelitis.     

成人血源性脊柱化脓性骨髓炎23例临床分析

目的 总结23例成人血源性脊柱化脓性骨髓炎(PDVO)的临床诊治经验.方法 对1999年7月至2006年10月收治的23例成人血源性PDVO患者的病史、临床表现、诊断、治疗及转归等进行回顾性分析.结果 本组23例,男15例,女8例;平均年龄55.4岁.诊治延误时间4周～11个月,平均4.4个月.其中患有或合并患有下述1种以上疾病的17例:糖尿病、泌尿系感染、酒精中毒、肝硬化、风湿性关节炎以及长期滥用糖皮质激素.全部23例实验室检查C反应蛋白和红细胞沉降率均有升高,而白细胞计数仅有9例升高.7例保守治疗;16例前路病灶清创植骨融合,其中11例脊柱不稳的选择适当的内固定,3例采用一期椎体侧前方钢板固定.7例采用二期后路融合椎弓根螺钉固定.本组23例全部获随访,随访时间6个月～7年,平均27个月.患者生活均能自理,无复发.手术治疗的患者,术后症状迅速缓解,植骨融合率达87.5%.结论 成人血源性PDVO好发于患有内科疾病的老年患者,血培养阳性有助于确诊.对于保守治疗失败的慢性PDVO的患者,手术清创植骨融合配合适当的内固定,能迅速缓解症状,安全有效.     

Pyogenic Vertebral Osteomyelitis after Acute Bacterial Prostatitis: A Case Report

A case of pyogenic vertebral osteomyelitis after acute bacterial prostatitis in a 78-year-old man is reported. The rarity and subtle clinical presentation of this condition, and the delayed appearance of radiologic signs of progression to destructive osteomyelitis, contributed to a significant delay in diagnosis. An arterial blood culture positive for bacterial growth during the episode of acute prostatitis suggested that bacteremia might result from hematogenous spread of the infection to the vertebral column via the venous system. Since intensive antimicrobial therapy proved ineffective, debridement of the first and second lumbar vertebral bodies, and anterior spinal fusion from the twelfth thoracic to the third lumbar vertebrae were performed. The patient's high fever and severe lumbago subsided immediately after the surgery. The possibility of development to pyogenic vertebral osteomyelitis should be kept in mind when treating a serious genitourinary tract infection.     

Anterior Column Reconstruction Using Titanium Ring Cages in Severe Vertebral Osteomyelitis

Abstract Background and Purpose: The use of instrumentation in spinal infections is still a controversial issue. The aim of the present study was to evaluate the efficiency of titanium cages in the surgical treatment of severe vertebral osteomyelitis (synonym spondylodiscitis) concerning eradication of the infection as well as biomechanical aspects. Materials and Methods: The peri- and postoperative data of 43 consecutive patients with vertebral osteomyelitis who underwent single-stage posterior stabilization, anterior debridement including decompression, and anterior column reconstruction using modular titanium ring cages filled with autologous bone were analyzed retrospectively. In 29 cases, a clinical and radiological follow-up of on average 2.5 years (median 2.2 years) was available. To assess the course of spinal alignment, a detailed radiometric analysis was performed. Results: The time of symptoms prior to surgery averaged 4.6 months. Preoperatively, 37% of the patients showed neurologic compromise with partial or complete recovery in 88% after surgery. In 25 patients (58%), a germ was isolated with Staphylococcus aureus being the most frequent pathogen (44%). Except for one patient with anterior revision and exchange of the cage for persistent infection, primary eradication of the infection was accomplished in all patients. At follow-up, all infections were eradicated, and all cages appeared radiographically fused. The present loss of correction in the sagittal plane amounted 1.5° at the affected segment(s) reconstructed by cage interposition and 4.4° at posterior fusion levels. Conclusion: Single-stage posterior instrumentation and fusion combined with anterior debridement and anterior column reconstruction using modular titanium ring cages represent a safe and efficient strategy in cases of severe vertebral osteomyelitis necessitating surgery. The use of titanium cages guarantees long-term maintenance of correction without increased risk of persistent or recurrent infection.     

Surgical therapy of unspecific and specific Spondylodiscitis

AIM: The aim of this study was to evaluate the clinical and radiological results of surgical treatment of thoracic and lumbar vertebral osteomyelitis by means of one-stage extrafocal posterior stabilisation, anterior debridement, and anterior column reconstruction. METHOD: A retrospective analysis of the peri- and postoperative parameters of 62 patients with a clinical and radiographic follow-up of 2.6 years that were available for 46 patients was performed. In 42 cases, the anterior column was restored with structural bone grafts, in 20 patients, expandable titanium cages filled with morsellised autologous bone and antibiotic collagen sponges were used. To assess the course of spinal alignment a radiometric analysis was undertaken. Furthermore, the Roland-Morris score (RMS) was applied to evaluate the back pain-related disability. RESULTS: The diagnosis was made no earlier than 2.7 months after the first symptoms. Preoperatively, 40 % of the patients presented with neurological impairment, of these 76 % improved after surgery. Staphylococcus aureus was the most common pathogen isolated (32 %), Mycobacterium tuberculosis was found in 11 % of the patients. Except for one patient with revision for persistent infection and consecutive failure of the bone graft, primary eradication of the infection was achieved in all cases. At follow-up, bony fusion was radiographically observed in all patients. When using cages, the segmental loss of correction was significantly lower than when using bone grafts (1.0 vs. 4.1 degrees ). At follow-up the RMS averaged 6.6. CONCLUSION: One-stage extrafocal posterior stabilisation combined with anterior debridement and anterior column reconstruction with bone grafts or titanium cages is a safe and effective strategy for patients with vertebral osteomyelitis in need of surgery. Titanium cages have proven to be biomechanically advantageous, especially in cases of extensive destruction and are not associated with higher rates of persistence or recurrence of infection compared to autologous bone grafts.     

Efficacy and Safety of Bioactive Glass S53P4 as a Treatment for Diabetic Foot Osteomyelitis

Osteomyelitis represents a challenging condition in the diabetic foot with an associated high risk of major amputation. S53P4 Bioactive Glass (BG) has bacterial inhibiting properties on the market and indicated to be used in osteomyelitis. The objective of the study was to test the efficacy and safety of BG in treating diabetic foot osteomyelitis. This was an observational, retrospective, single-centre study involving subjects with diabetes affected by osteomyelitis of the foot who underwent surgical debridement from 01/2016 to 10/2018. Overall, 44 diabetic patients (14 [31.8%] female, aged 68.0 ± 10.2 years, diabetes duration 26.8 ± 11.9 years) were studied: 22 (50%) treated with surgical debridement and a local application of BG; 22 (50%) treated by means of surgical debridement. The primary outcome was the osteomyelitis resolution. Revascularization was performed before surgical procedure in 31 (70.5%) of patients. Systemic antibiotics were used in both groups. The osteomyelitis resolution rate was significantly higher in subjects treated with BG than in subjects treated with traditional procedure (18 [90%] vs 13 [61.9%], respectively p = .03). The odds of BG to reach osteomyelitis resolution was 5.54 times greater than for traditional treatment (odds ratio 5.54, 95% confidence interval 1.10-30.5). The use of BG was associated with an 81% lower probability to need additional antibiotic therapy compared to subjects treated with traditional procedure (odds ratio 0.19, 95% confidence interval 0.04-0.87). The debridement of osteomyelitis followed by application of BG could be an effective and safe option in the treatment of osteomyelitis of the diabetic foot.