OM and ABX

[DYK343]

This is only true if you use those silly “absorbable” beads. Staged amp with PMMA beads, which are removed upon DPC work great.

Yeah. They kinda just fall out of the wound though. Or are you closing over them then returning for rewash out and DPC?

If im planning a tendon transfer and I question infection I pack them around the tendon and let it stew for 5 days or more then go back in and remove beads/transfer. Thats really the only time I use them anymore - so not often.

About a month ago I tunneled and curettage the crap out of a calcaneus. I did pack vanco beads in there. The juicy kind because I had nothing else to offer. Plus I was vacing a decubitus ulcer/exposed bone so they could drain all they wanted.

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[JustAPedicurist]

Powder vs beads… why not just use powder?

 

[PeaJay]

Yeah. They kinda just fall out of the wound though. Or are you closing over them then returning for rewash out and DPC?

Typically going with a staged procedure if beads are in the equation.

Stage 1: aggressive tissue resection with clearance fragments and beads underneath flaps that are tacked together. If it is going to require some fancy closure suture in with Zeroform like a bolster dressing for skin grafts.

Stage 2: resect more based off of clearance frags, close with prior flaps or get fancy with some rotational thing and tendon balance.

 

[PeaJay]

Powder vs beads… why not just use powder?

You can bill for bead placement…

Edit: Also, powder is a one time blast and beads are drug eluding.

 

[diabeticfootdr]

We’ve been using Synthecure calcium sulfate which you can mix any number of abx (and combo) in it so you can be culture directed. The set times differ based on abx and if it’s powder or liquid abx.

Working on designing a trial with siloing into OM of the calc or in the metatarsal shafts of open TMAs.

 

[Pronation]

We’ve been using Synthecure calcium sulfate which you can mix any number of abx (and combo) in it so you can be culture directed. The set times differ based on abx and if it’s powder or liquid abx.


View attachment 375802

Working on designing a trial with siloing into OM of the calc or in the metatarsal shafts of open TMAs.

Thanks for this valuable information. I heard there was a new special product coming on the market and maybe this is it? But basically what the product does is you pack it into the wound so that it fixes infection but also it has special deodorizing properties so when podiatry calls vascular/ortho then it doesn’t smell as bad when the patient is getting a BKA. Thank you.

 

[wakaflocka88]

Why are we trying to over complicate this.

Vanco powder or your powder of choice mixed slowly with a little saline until it forms a putty. Shove it into bone, spread it over bone, etc. But academic centers will find new ways to re-invent something and continue to drive up costs.

 

[Pronation]

your powder of choice

This got me in trouble at my last job. Thank you.

 

[Feli]

I really dislike beads. They have their place in my practice but they drain and drain and drain. They can be detrimental to wound closure. I rarely use them.

I just put 500-1000mg vanco dry powder in any ray or TMA amps where there is not clearly clean margin (and you can't go further back without losing TA or pero brev).

All of the studies on beads or pellets show that the abx all leeches out right away anyways, so why mess with the drainage and wast cost and added material into infection area? Jmo.

Plus, it kinda looks like cocaine the OR... so that's cool too.

... powder is a one time blast and beads are drug eluding.

Do we really buy that? (for foot sized beads on the tiny plastic muffin pan)
Cement being time released? Yeah. Beads... not so much.

 

[PeaJay]

Do we really buy that? (for foot sized beads on the tiny plastic muffin pan)
Cement being time released? Yeah. Beads... not so much.

Most is gone over hours, some is there for days, almost negligible at weeks. Beads should be gone in days…when you go back and close. If you leave magic beads in the foot and are hoping for a cure…well…that’s a waste.

This generally summarizes my thoughts on the matter…

PMMA beads

Linked this instead of JFAS as it appears it has paper available without paywall

 

[deleted1020736]

Anti-biotic beads have had good outcomes. Have used them a lot in dorsal PIPJ ulcers with om... 2 years going strong no recurrence of om. In combination with good blood flow and iv abx.

 

[PeaJay]

Anti-biotic beads have had good outcomes. Have used them a lot in dorsal PIPJ ulcers with om... 2 years going strong no recurrence of om. In combination with good blood flow and iv abx.

Seems like it is working well for your practice.

I tend to give patients the option of amputation straight away. I find that patients choose amputation 100% of the time for pipj ulcers once they know it will be 2 weeks of recovery versus ?? weeks of abx and wound care. The other hurdle is telling them there will be no change in balance or walking with a lesser toe amp. Any balance it gave was lost when it became mangled enough to get an upcer.

Edit: this is in setting of clear osteo or direct extension to bone. If no clear bone infection they get an immediate tenotomy/caplsulotomy. Yes even in rigid toes… jut just need some physical persuasion (closed manipulation) to fall back in line.

 

[heybrother]

Anti-biotic beads have had good outcomes. Have used them a lot in dorsal PIPJ ulcers with om... 2 years going strong no recurrence of om. In combination with good blood flow and iv abx.

What are you actually doing? Resecting the joint and putting in an antibiotic spacer?

Some of the wound healing centers near me will debride bone through ulcers and keep the patients on long term IV antibiotics. They sometimes "remission" the osteomyelitis but they routinely produce new absurd ulcer forming lesions doing this. My experience is resections work best when they are distal resection.

 

[Pronation]

What are you actually doing? Resecting the joint and putting in an antibiotic spacer?

Some of the wound healing centers near me will debride bone through ulcers and keep the patients on long term IV antibiotics. They sometimes "remission" the osteomyelitis but they routinely produce new absurd ulcer forming lesions doing this. My experience is resections work best when they are distal resection.

I gave this comment some deep thought. I think he might be onto something here. After doing some research, I am confident in saying that a PIPJ arthroplasty + insertion drug eluting device is superior to amputating the toe by an additional 3 RVUs. Additionally, I can generate the toe amputation RVUs at a later date in the highly unlikely event that the remainder of the toe rots off.