From the Guidelines
Managing a calcaneal sinus tract with antibiotic beads involves a multi-step surgical approach combined with antimicrobial therapy, prioritizing thorough debridement, antibiotic-impregnated bead placement, and concurrent systemic antibiotics to minimize morbidity, mortality, and improve quality of life. The procedure begins with thorough debridement of the sinus tract, removing all infected and necrotic tissue, as emphasized in the management of diabetic foot infections 1. After debridement, antibiotic-impregnated beads (typically PMMA beads loaded with antibiotics like gentamicin, tobramycin, or vancomycin at concentrations of 2-4g antibiotic per 40g of cement) are placed into the debrided cavity. The choice of antibiotic should be based on culture results or empiric coverage if cultures are pending, considering the potential for antibiotic-resistant organisms 1.
Key steps in the procedure include:
- Thorough debridement of the sinus tract
- Placement of antibiotic-impregnated beads into the debrided cavity
- Concurrent administration of systemic antibiotics for 4-6 weeks
- Monitoring of treatment response through serial imaging and inflammatory markers (ESR, CRP)
- Regular wound care and offloading of the affected heel
The use of antibiotic-impregnated beads provides high local antibiotic concentrations while minimizing systemic toxicity, as discussed in the context of topical antibiotic therapy for foot wounds 1. Although there is limited evidence to recommend topical antimicrobial therapy, including antibiotic-impregnated beads, for deep surgical wounds, this approach may be useful in supplying high local antibiotic concentrations and filling dead space 1. The beads are usually left in place for 2-4 weeks before removal in a second procedure, at which time bone grafting may be performed if there is a significant osseous defect. This approach is effective because it combines mechanical removal of infected tissue with sustained high-concentration local antibiotic delivery directly to the infection site, while the bead structure helps maintain dead space and facilitates drainage.
From the Research
Management of Calcaneal Sinus Tract with Antibiotic Beads
The management of a calcaneal sinus tract with antibiotic beads involves several steps, including:
- Debridement of the affected area to remove any dead tissue or debris
- Implantation of antibiotic-loaded beads, such as calcium sulphate, to deliver high concentrations of antibiotics directly to the site of infection 2
- Closure of the wound, either by primary closure or with the use of a flap
- Systemic antibiotic treatment, tailored to the specific causative organisms, to ensure complete eradication of the infection
Surgical Procedure
The surgical procedure for managing a calcaneal sinus tract with antibiotic beads typically involves:
- Cortical bone windowing to access the affected area
- Eggshell-like debridement to remove any infected tissue or bone
- Implantation of antibiotic-loaded calcium sulphate beads
- Closure of the wound, either by primary closure or with the use of a flap
- Systemic antibiotic treatment, as described above 2
Postoperative Care
Postoperative care for patients undergoing this procedure typically involves:
- Monitoring for signs of infection or wound complications
- Management of pain and discomfort
- Follow-up appointments to assess the healing progress and remove any implanted materials, such as antibiotic beads
- Physical therapy to promote mobility and prevent stiffness in the affected area
Considerations
It is essential to note that the management of a calcaneal sinus tract with antibiotic beads may involve a high incidence of aseptic wound leakage, as reported in some studies 2. Therefore, careful monitoring and management of the wound are crucial to prevent complications. Additionally, the choice of antibiotic beads and systemic antibiotic treatment should be tailored to the specific causative organisms to ensure effective eradication of the infection.