What are the steps for managing a calcaneum fracture with antibiotic beads?

From the Guidelines

Managing a calcaneum fracture with antibiotic beads requires a comprehensive approach that prioritizes infection control and fracture stabilization. The procedure involves several key steps, including surgical debridement to remove necrotic tissue, foreign material, and infected bone, as recommended by the AAOS clinical practice guideline summary 1. During surgery, antibiotic-impregnated polymethylmethacrylate (PMMA) beads, such as tobramycin-impregnated beads, are placed in the wound cavity to provide local antibiotic prophylaxis. The selection of antibiotics, such as vancomycin or tobramycin, is based on culture results or empiric coverage for common pathogens like Staphylococcus aureus, with the goal of achieving high-dose antibiotic concentrations locally while minimizing systemic toxicity.

The steps for managing a calcaneum fracture with antibiotic beads can be outlined as follows:

• Surgical debridement to remove all necrotic tissue, foreign material, and infected bone
• Placement of antibiotic-impregnated PMMA beads in the wound cavity
• Temporary closure of the wound or management with negative pressure wound therapy
• Administration of systemic antibiotics, typically for 4-6 weeks, as recommended by the AAOS guideline 1
• Removal of the antibiotic beads after 2-4 weeks during a second surgical procedure
• Definitive fracture fixation can be performed if infection is controlled

Throughout treatment, regular clinical assessment, laboratory monitoring (ESR, CRP), and radiographic evaluation are essential to track infection resolution and bone healing, as emphasized by the AAOS guideline 1. This approach allows for targeted antibiotic delivery directly to the infection site while providing temporary structural support to the fracture, ultimately prioritizing morbidity, mortality, and quality of life outcomes.

From the Research

Managing Calcaneum Fractures with Antibiotic Beads

The management of calcaneum fractures, particularly those complicated by infection or at high risk of infection, can be challenging. The use of antibiotic beads has emerged as a strategy to deliver high concentrations of antibiotics locally, aiming to prevent or treat infections in these cases.

Steps for Managing Calcaneum Fractures with Antibiotic Beads

• Surgical Debridement: The first step involves thorough surgical debridement of the infected area to remove any dead tissue or bone that may harbor bacteria 2.
• Application of Antibiotic Beads: After debridement, antibiotic-impregnated beads, such as those made from calcium sulfate, are applied to the affected area. These beads can be impregnated with various antibiotics, depending on the suspected or confirmed causative pathogens 3, 4.
• Wound Closure and Postoperative Care: The wound is then closed, and the patient is started on a regimen of systemic antibiotics, if not already on one. Postoperative care includes monitoring for signs of infection, managing pain, and follow-up appointments to assess healing and remove any beads or other implanted materials as necessary.
• Follow-Up and Potential Reoperation: Patients are closely followed up to monitor the healing process and to address any complications that may arise. In some cases, reoperation may be necessary to remove beads, address persistent infection, or further debride the wound.

Considerations and Evidence

• The effectiveness of antibiotic beads in managing calcaneum fractures and preventing infection has been studied, with evidence suggesting that they can be an effective adjunct to surgical debridement and systemic antibiotics 2, 3.
• The choice of antibiotic and the material of the beads can influence the outcome, with calcium sulfate beads being a common choice due to their ability to deliver high concentrations of antibiotics locally and their bioabsorbable nature 5, 6.
• While antibiotic beads can be beneficial, their use must be considered as part of a broader treatment strategy that includes thorough debridement, appropriate systemic antibiotic therapy, and careful postoperative monitoring and care.

Key Points

• Antibiotic beads can be an effective tool in the management of calcaneum fractures, especially in cases where infection is a concern.
• The procedure involves surgical debridement followed by the application of antibiotic-impregnated beads.
• Postoperative care is crucial and includes monitoring for infection, pain management, and follow-up to assess healing and remove implanted materials.
• The choice of antibiotic and bead material, as well as the overall treatment strategy, should be tailored to the individual patient's needs and circumstances.