{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T03:58:13Z","timestamp":1781236693015,"version":"3.54.1"},"reference-count":42,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2024,12,1]],"date-time":"2024-12-01T00:00:00Z","timestamp":1733011200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Antibiotics"],"abstract":"<jats:p>Introduction: Despite the rising global awareness and improvement of socioeconomic and living standards, the prevalence of diabetic osteomyelitis (DOM) and its complications has been increasing rapidly. This study aims to investigate the long-term prognosis of DOM of the foot treated using antibiotic-impregnated cement spacer (ACS) and the contributing risk factors for reoperation. Methods and Materials: We retrospectively reviewed the data of 55 diabetic patients with Meggitt-Wagner Grade IIB wounds diagnosed with osteomyelitis of the foot, treated in our institution with excessive debridement, excision of the infected tissue, and implantation of antibiotic-impregnated cement spacer fixed with a Kirschner wire. Descriptive statistics, including patient demographics, were analyzed. Statistical analysis was performed using point-biserial correlation and a Chi-square test with Cramer\u2019s V effect-size estimation to determine the relationship between reoperation and various parameters. Results: 55 patients (36 (65.45%) males and 19 (34.55%) females) with a median age of 64 (39\u201384) years were thoroughly analyzed throughout a median follow-up of 884 days (2\u20134671 days). Of the entire cohort, 29 (52.72%) patients achieved primary successful infection eradication without any further intervention, and 8 (14.54%) patients were successfully treated using a secondary procedure. More than half of the reoperated patients underwent the secondary intervention within less than a month after the primary ACS. When assessing correlation, age (r = 0.28, p = 0.04), gender (r = 0.31, p = 0.02), Staphylococcus aureus (r = \u22120.10, p = 0.04), and the use of gentamicin-only antibiotic cement spacer (r = 0.34, p = 0.01) demonstrated statistically significant correlation to reoperation. 89.18% of the patients who achieved infection eradication did not undergo cement removal. Conclusions: ACS has shown excellent results in eradicating bone infection with up to 7.23 years of follow-up, acting as a structural stabilizer, preventing soft tissue contractures, and delivering highly concentrated local antibiotic treatment both to soft tissue and bone. Regardless, specific factors should be thoroughly evaluated prior to surgery, as advancing age, gender, and the use of gentamicin-only antibiotics appear to be positively associated with a higher likelihood of reoperation. Conversely, infections caused by cultured Staphylococcus aureus seem to be inversely related to reoperation.<\/jats:p>","DOI":"10.3390\/antibiotics13121153","type":"journal-article","created":{"date-parts":[[2024,12,2]],"date-time":"2024-12-02T05:43:43Z","timestamp":1733118223000},"page":"1153","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Revisiting Antibiotic-Impregnated Cement Spacer for Diabetic Osteomyelitis of the Foot"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4882-209X","authenticated-orcid":false,"given":"Farouk","family":"Khury","sequence":"first","affiliation":[{"name":"Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3109601, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ihab","family":"Karkabi","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3109601, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7533-9779","authenticated-orcid":false,"given":"Elias","family":"Mazzawi","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3109601, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doron","family":"Norman","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3109601, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eyal A.","family":"Melamed","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3109601, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eli","family":"Peled","sequence":"additional","affiliation":[{"name":"Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa 3109601, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2400489","DOI":"10.1002\/adfm.202400489","article-title":"An Immunoregulation Hydrogel with Controlled Hyperthermia-Augmented Oxygenation and ROS Scavenging for Treating Diabetic Foot Ulcers","volume":"34","author":"Qi","year":"2024","journal-title":"Adv. Funct. Mater."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"11144","DOI":"10.1021\/acsami.1c25014","article-title":"Dendritic Hydrogels with Robust Inherent Antibacterial Properties for Promoting Bacteria-Infected Wound Healing","volume":"14","author":"Cheng","year":"2022","journal-title":"ACS Appl. Mater. Interfaces"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"209","DOI":"10.2337\/dci22-0043","article-title":"Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers","volume":"46","author":"McDermott","year":"2022","journal-title":"Diabetes Care"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1288","DOI":"10.2337\/dc05-2425","article-title":"Risk factors for foot infections in individuals with diabetes","volume":"29","author":"Lavery","year":"2006","journal-title":"Diabetes Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/j.ijid.2015.09.023","article-title":"Diabetic foot infections: What have we learned in the last 30 years?","volume":"40","author":"Lew","year":"2015","journal-title":"Int. J. Infect. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1080\/14787210.2020.1730177","article-title":"Management of diabetic foot infections in the light of recent literature and new international guidelines","volume":"18","author":"Lipsky","year":"2020","journal-title":"Expert. Rev. Anti Infect. Ther."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Lipsky, B.A., and U\u00e7kay, \u0130. (2021). Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. Medicina, 57.","DOI":"10.3390\/medicina57040339"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s40842-024-00193-6","article-title":"Microbial profile of diabetic foot osteomyelitis from the northwest of England","volume":"10","author":"Metaoy","year":"2024","journal-title":"Clin. Diabetes Endocrinol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"637","DOI":"10.2337\/dc07-1744","article-title":"Outcome of Diabetic Foot Osteomyelitis Treated Nonsurgically: A retrospective cohort study","volume":"31","author":"Senneville","year":"2008","journal-title":"Diabetes Care"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"423","DOI":"10.7547\/87507315-63-9-423","article-title":"Successful treatment of osteomyelitis and ulcer of patient with diabetes mellitus","volume":"63","author":"Rosen","year":"1973","journal-title":"J. Am. Podiatry Assoc."},{"key":"ref_11","first-page":"231","article-title":"The team approach in salvage of the diabetic foot","volume":"9","author":"Jacobs","year":"1977","journal-title":"Surg. Annu."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1177\/1534734614550686","article-title":"Conservative Surgery of Diabetic Forefoot Osteomyelitis: How Can I Operate on This Patient Without Amputation?","volume":"14","year":"2015","journal-title":"Int. J. Low. Extrem. Wounds"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"863","DOI":"10.3109\/17453678008990886","article-title":"Antibiotic containing bone cement beads in the treatment of deep muscle and skeletal infections","volume":"51","author":"Lidgren","year":"1980","journal-title":"Acta Orthop. Scand."},{"key":"ref_14","first-page":"709","article-title":"[Treatment of osteomyelitis with antibiotic cement]","volume":"53","author":"Buchholz","year":"1982","journal-title":"Chirurg"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"371","DOI":"10.2106\/00004623-198365030-00013","article-title":"Experimental osteomyelitis: Description of a canine model and the role of depot administration of antibiotics in the prevention and treatment of sepsis","volume":"65","author":"Fitzgerald","year":"1983","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Dong, T., Huang, Q., and Sun, Z. (2023). Antibiotic-laden bone cement for diabetic foot infected wounds: A systematic review and meta-analysis. Front. Endocrinol., 14.","DOI":"10.3389\/fendo.2023.1134318"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Soldevila-Boixader, L., Fern\u00e1ndez, A.P., Laguna, J.M., and U\u00e7kay, I. (2023). Local Antibiotics in the Treatment of Diabetic Foot Infections: A Narrative Review. Antibiotics, 12.","DOI":"10.3390\/antibiotics12010124"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1053\/j.jfas.2016.10.022","article-title":"Long-Term Outcomes of Permanent Cement Spacers in the Infected Foot","volume":"56","author":"Elmarsafi","year":"2017","journal-title":"J. Foot Ankle Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"58","DOI":"10.14193\/jkfas.2019.23.2.58","article-title":"Risk Factors for the Treatment Failure of Antibiotic-Loaded Cement Spacer Insertion in Diabetic Foot Infection","volume":"23","author":"Park","year":"2019","journal-title":"J. Korean Foot Ankle Soc."},{"key":"ref_20","first-page":"051","article-title":"Treatment of Foot and Ankle Infection with Antibiotic Cement Spacer","volume":"5","author":"Kim","year":"2021","journal-title":"Int. J. Foot Ankle"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Dai, J., Zhou, Y., Mei, S., and Chen, H. (2023). Application of antibiotic bone cement in the treatment of infected diabetic foot ulcers in type 2 diabetes. BMC Musculoskelet. Disord., 24.","DOI":"10.1186\/s12891-023-06244-w"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Woo, I., Park, J., Seok, H., Kim, T.G., Moon, J.S., Chung, S.M., and Park, C.H. (2022). The Fate of Antibiotic Impregnated Cement Space in Treatment for Forefoot Osteomyelitis. J. Clin. Med., 11.","DOI":"10.3390\/jcm11071976"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"213","DOI":"10.3113\/FAI.2012.0213","article-title":"Antibiotic impregnated cement spacer for salvage of diabetic osteomyelitis","volume":"33","author":"Melamed","year":"2012","journal-title":"Foot Ankle Int."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1177\/107110078100200202","article-title":"The dysvascular foot: A system for diagnosis and treatment","volume":"2","author":"Wagner","year":"1981","journal-title":"Foot Ankle"},{"key":"ref_25","first-page":"93","article-title":"Inflammation and neovascularization in diabetic atherosclerosis","volume":"45","author":"Purushothaman","year":"2007","journal-title":"Indian J. Exp. Biol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1016\/j.fcl.2010.04.006","article-title":"Risk and prevention of reulceration after partial foot amputation","volume":"15","author":"Sage","year":"2010","journal-title":"Foot Ankle Clin."},{"key":"ref_27","unstructured":"Armstrong, D.G., and Lavery, L.A. (1998). Plantar pressures are higher in diabetic patients following partial foot amputation. Ostomy Wound Manag., 44."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1111\/j.1464-5491.2004.01237.x","article-title":"Diabetic foot ulcer and multidrug-resistant organisms: Risk factors and impact","volume":"21","author":"Robert","year":"2004","journal-title":"Diabet. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1016\/j.jinf.2006.08.013","article-title":"Risk factors for infection of the diabetic foot with multi-antibiotic resistant microorganisms","volume":"54","author":"Kandemir","year":"2007","journal-title":"J. Infect."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1177\/107110070502601216","article-title":"Development of gentamicin resistance after gentamicin-PMMA beads for treatment of foot osteomyelitis: Report of two cases","volume":"26","author":"Wong","year":"2005","journal-title":"Foot Ankle Int."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"135","DOI":"10.4239\/wjd.v8.i4.135","article-title":"Osteomyelitis in diabetic foot: A comprehensive overview","volume":"8","author":"Giurato","year":"2017","journal-title":"World J. Diabetes"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1016\/S0140-6736(04)16727-5","article-title":"Osteomyelitis","volume":"364","author":"Lew","year":"2004","journal-title":"Lancet"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1111\/iwj.12545","article-title":"The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis","volume":"14","author":"Nichols","year":"2017","journal-title":"Int. Wound J."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Sharma, H., Sharma, S., Krishnan, A., Yuan, D., Vangaveti, V.N., Malabu, U.H., and Haleagrahara, N. (2022). The efficacy of inflammatory markers in diagnosing infected diabetic foot ulcers and diabetic foot osteomyelitis: Systematic review and meta-analysis. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0267412"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1177\/1534734613486152","article-title":"The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis","volume":"12","author":"Michail","year":"2013","journal-title":"Int. J. Low. Extrem. Wounds"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"425","DOI":"10.25270\/wnds\/082421.03","article-title":"Inflammatory markers in diabetic foot infection: A meta-analysis","volume":"35","author":"Wang","year":"2023","journal-title":"Wounds"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Khury, F., Oltmanns, M., Fuchs, M., Leiprecht, J., Reichel, H., and Faschingbauer, M. (2022). Against the Norm: Do Not Rely on Serum C-Reactive Protein and White Blood Cell Count Only When Assessing Eradication of Periprosthetic Joint Infection. Antibiotics, 11.","DOI":"10.3390\/antibiotics11091174"},{"key":"ref_38","first-page":"511","article-title":"[Depot effects of various antibiotics mixed with Palacos resins]","volume":"41","author":"Buchholz","year":"1970","journal-title":"Chirurg"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1016\/S1067-2516(00)80037-X","article-title":"Antibiotic beads in the treatment of diabetic pedal osteomyelitis","volume":"39","author":"Roeder","year":"2000","journal-title":"J. Foot Ankle Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1232","DOI":"10.1016\/j.arth.2007.10.010","article-title":"Biological and biomechanical effects of vancomycin and meropenem in acrylic bone cement","volume":"23","author":"Baleani","year":"2008","journal-title":"J. Arthroplast."},{"key":"ref_41","first-page":"290851","article-title":"Antibiotic-Loaded Cement in Orthopedic Surgery: A Review","volume":"2011","author":"Bistolfi","year":"2011","journal-title":"Int. Sch. Res. Not."},{"key":"ref_42","first-page":"317","article-title":"Versuche und uberledbeudem carcinomgewebe (methoden)","volume":"142","author":"Otto","year":"1923","journal-title":"Biochem. Zeitschr."}],"container-title":["Antibiotics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2079-6382\/13\/12\/1153\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:44:16Z","timestamp":1760114656000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2079-6382\/13\/12\/1153"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,1]]},"references-count":42,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["antibiotics13121153"],"URL":"https:\/\/doi.org\/10.3390\/antibiotics13121153","relation":{},"ISSN":["2079-6382"],"issn-type":[{"value":"2079-6382","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,1]]}}}