Single-stage surgical management of pediatric chronic osteomyelitis using antibiotic-loaded bone filler: A single center prospective case series

Carlo Ciccullo; Gabriele Franco Zanoli; Luca De Berardinis; Valentino Coppa; Mario Marinelli; Antonio Gigante

doi:10.23750/abm.2026.17188

Single-stage surgical management of pediatric chronic osteomyelitis using antibiotic-loaded bone filler: A single center prospective case series

Authors

Carlo Ciccullo Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy. https://orcid.org/0009-0008-4552-9596
Gabriele Franco Zanoli Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.
Luca De Berardinis IRCCS Ospedale San Raffaele, Milan, Italy.
Valentino Coppa Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.
Mario Marinelli Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.
Antonio Gigante Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy. https://orcid.org/0000-0003-0772-563X

Keywords:

Osteomyelitis, Cemented antibiotic-loaded filler, Pediatric orthopedics, Orthopedics

Abstract

Osteomyelitis in children presents a significant clinical and surgical challenge. It is an acute or chronic infection of the bone. It predominantly affects preschool-aged children, with an estimated incidence of 8 per 100,000 children annually in high-income countries, with a male-to-female ratio of 2:1. Traditional treatments often involve multiple surgeries and prolonged systemic antibiotic use. Recent interest has focused on resorbable antibiotic-loaded bone fillers to minimize surgical interventions. The aim of this study was to evaluate the outcomes of single-stage surgical treatment for pediatric chronic osteomyelitis using local debridement and antibiotic-loaded bone filler. Twenty patients with Cierny-Mader type III chronic osteomyelitis were treated between March 2016 and March 2022. Clinical, radiological, and laboratory data were collected pre- and postoperatively, with a follow-up of up to 24 months. The cohort included 12 males and 8 females with a mean age of 11.1 years. The most commonly affected sites were the distal tibia, fibula, and femur. Staphylococcus aureus was the predominant pathogen (65%). All patients underwent successful single-stage procedures without need for further surgical intervention. Inflammatory markers normalized postoperatively, and all patients were infection-free at 1- and 2-year follow-up. No complications, wound issues, or growth disturbances were observed. A one-stage surgical protocol using local debridement and cemented antibiotic-loaded bone filler appears to be a safe and effective treatment for pediatric chronic osteomyelitis.

References

Peltola H, Pääkkönen M. Acute osteomyelitis in children. N Engl J Med. 2014 Jan 23;370(4):352-60. doi: 10.1056/NEJMra1213956.

2. Riise ØR, Kirkhus E, Handeland KS, et al. Childhood osteomyelitis-incidence and differentiation from other acute onset musculoskeletal features in a population-based study. BMC Pediatr. 2008 Oct 20;8:45. doi: 10.1186/1471-2431-8-45.

3. Thakolkaran N, Shetty AK. Acute Hematogenous Osteomyelitis in Children. Ochsner J. 2019 Summer;19(2):116-122. doi: 10.31486/toj.18.0138.

4. Congedi S, Minotti C, Giaquinto C, Da Dalt L, Donà D. Acute infectious osteomyelitis in children: new treatment strategies for an old enemy. World J Pediatr. 2020 Oct;16(5):446-455. doi: 10.1007/s12519-020-00359-z.

5. Cierny, George III M.D. Surgical Treatment of Osteomyelitis. Plastic and Reconstructive Surgery 127(): p 190S-204S, January 2011. | DOI: 10.1097/PRS.0b013e3182025070

6. Cierny G 3rd. Chronic osteomyelitis: results of treatment. Instr Course Lect. 1990;39:495-508. PMID: 2186142.

7. Sambri A, Cevolani L, Passarino V, et al. Mid-Term Results of Single-Stage Surgery for Patients with Chronic Osteomyelitis Using Antibiotic-Loaded Resorbable PerOssal® Beads. Microorganisms. 2023 Jun 21;11(7):1623. doi: 10.3390/microorganisms11071623.

8. McNally MA, Ferguson JY, Scarborough M, Ramsden A, Stubbs DA, Atkins BL. Mid- to long-term results of single-stage surgery for patients with chronic osteomyelitis using a bioabsorbable gentamicin-loaded ceramic carrier. Bone Joint J. 2022 Sep;104-B (9):1095-1100. doi: 10.1302/0301-620X.104B9.BJJ-2022-0396.R1.

9. Romanò CL, Logoluso N, Meani E, et al. A comparative study of the use of bioactive glass S53P4 and antibiotic-loaded calcium-based bone substitutes in the treatment of chronic osteomyelitis: a retrospective comparative study. Bone Joint J. 2014 Jun;96-B(6):845-50. doi: 10.1302/0301-620X.96B6.33014.

10. Kinik H, Karaduman M. Cierny-Mader Type III chronic osteomyelitis: the results of patients treated with debridement, irrigation, vancomycin beads and systemic antibiotics. Int Orthop. 2008 Aug;32(4):551-8. doi: 10.1007/s00264-007-0342-9.

11. McKee MD, Li-Bland EA, Wild LM, Schemitsch EH. A prospective, randomized clinical trial comparing an antibiotic-impregnated bioabsorbable bone substitute with standard antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis and infected nonunion. J Orthop Trauma. 2010 Aug;24(8):483-90. doi: 10.1097/BOT.0b013e3181df91d9.

12. Rand BC, Penn-Barwell JG, Wenke JC. Combined local and systemic antibiotic delivery improves eradication of wound contamination: An animal experimental model of contaminated fracture. Bone Joint J. 2015 Oct;97-B(10):1423-7. doi: 10.1302/0301-620X.97B10.35651.

13. Lidgren L, Raina D., Gupta A ,et al. (2015). A biphasic bone substitute with gentamycin regenerates bone in osteomyelitis with muscle acting as an osteoinductive niche. 10.1302/1358-992x.97bsupp_16.ebjis2015-024.

14. Nilsson M, Wang JS, Wielanek L, Tanner KE, Lidgren L. Biodegradation and biocompatability of a calcium sulphate-hydroxyapatite bone substitute. J Bone Joint Surg Br. 2004 Jan;86(1):120-5. PMID: 14765879.

15. Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003 Sep;(414):7-24. doi: 10.1097/01.blo.0000088564.81746.62.

16. Matzkin EG, Dabbs DN, Fillman RR, Kyono WT, Yandow SM. Chronic osteomyelitis in children: Shriners Hospital Honolulu experience. J Pediatr Orthop B. 2005 Sep;14(5):362-6. doi: 10.1097/01202412-200509000-00009.

17. Tao R, Wu JQ, Luo JW, et al. Antibiotic-impregnated calcium sulfate for the treatment of pediatric hematogenous osteomyelitis. BMC Pediatr. 2022 Dec 23;22(1):732. doi: 10.1186/s12887-022-03791-4.

18. Bar-On E, Weigl DM, Bor N, et al. Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic-impregnated cement rods. J Pediatr Orthop. 2010 Jul-Aug;30(5):508-13. doi: 10.1097/BPO.0b013e3181e00e34.

19. Rosenbaum DM, Blumhagen JD. Acute epiphyseal osteomyelitis in children. Radiology. 1985 Jul;156(1):89-92. doi: 10.1148/radiology.156.1.3159044.

20. Yoo WJ, Choi IH, Yun YH, et al. Primary epiphyseal osteomyelitis caused by mycobacterium species in otherwise healthy toddlers. J Bone Joint Surg Am. 2014 Sep 3;96(17):e145. doi: 10.2106/JBJS.M.01186.

21. Bouchoucha S, Benghachame F, Trifa M, et al. Deep venous thrombosis associated with acute hematogenous osteomyelitis in children. Orthop Traumatol Surg Res. 2010 Dec;96(8):890-3. doi: 10.1016/j.otsr.2010.05.006.

22. Wang X, Wei F, Luo F, Huang K, Xie Z. Induction of granulation tissue for the secretion of growth factors and the promotion of bone defect repair. J Orthop Surg Res. 2015 Sep 17;10:147. doi: 10.1186/s13018-015-0287-4.

23. Rafferty BA, Thakrar P. Chronic Recurrent Multifocal Osteomyelitis. Med Clin North Am. 2024 Jan;108(1):227-239. doi: 10.1016/j.mcna.2023.05.022.

24. Vij N, Singleton I, Kang P, Esparza M, Burns J, Belthur MV. Clinical Scores Predict Acute and Chronic Complications in Pediatric Osteomyelitis: An External Validation. J Pediatr Orthop. 2022 Jul 1;42(6):341-346. doi: 10.1097/BPO.0000000000002159.

25. Porat S, Goitien K, Saperia BS, Liebergall M, Abu-Dalu K, Katz S. Complications of suppurative arthritis and osteomyelitis in children. Int Orthop. 1991;15(3):205-8. doi: 10.1007/BF00192295.

26. Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health. 2005 Jan-Feb;41(1-2):59-62. doi: 10.1111/j.1440-1754.2005.00538.x.

27. Li HK, Rombach I, Zambellas R, et al.; OVIVA Trial Collaborators. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med. 2019 Jan 31;380(5):425-436. doi: 10.1056/NEJMoa1710926.

28. Dudareva M, Kümin M, Vach W, et al. Short or Long Antibiotic Regimes in Orthopaedics (SOLARIO): a randomised controlled open-label non-inferiority trial of duration of systemic antibiotics in adults with orthopaedic infection treated operatively with local antibiotic therapy. Trials. 2019 Dec 9;20(1):693. doi: 10.1186/s13063-019-3832-3. PMID: 31815653; PMCID: PMC6902346.

29. Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am. 2007 Jul;89(7):1517-23. doi: 10.2106/JBJS.F.01102. PMID: 17606791.

30. Andreacchio A, Alberghina F, Paonessa M, Cravino M, De Rosa V, Canavese F. Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents. J Pediatr Orthop B. 2019 May;28(3):189-195. doi: 10.1097/BPB.0000000000000517. PMID: 29851713.

31. Kucukkaya M, Kabukcuoglu Y, Tezer M, Kuzgun U. Management of childhood chronic tibial osteomyelitis with the Ilizarov method. J Pediatr Orthop. 2002 Sep-Oct;22(5):632-7. PMID: 12198466.

32. Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res. 2004 Oct;(427):86-93. doi: 10.1097/01.blo.0000143571.18892.8d.

33. Walenkamp GH, Kleijn LL, de Leeuw M. Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1-12 years. Acta Orthop Scand. 1998 Oct;69(5):518-22. doi: 10.3109/17453679808997790.

34. Cho SH, Song HR, Koo KH, Jeong ST, Park YJ. Antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis. Bull Hosp Jt Dis. 1997;56(3):140-4. PMID: 9361913.

35. Shi X, Wu Y, Ni H, et al. Antibiotic-loaded calcium sulfate in clinical treatment of chronic osteomyelitis: a systematic review and meta-analysis. J Orthop Surg Res. 2022 Feb 19;17(1):104. doi: 10.1186/s13018-022-02980-2.

36. Canavese F, Corradin M, Khan A, Mansour M, Rousset M, Samba A. Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute. Eur J Orthop Surg Traumatol. 2017 Feb;27(2):221-228. doi: 10.1007/s00590-016-1859-7.

37. Pugmire BS, Shailam R, Gee MS. Role of MRI in the diagnosis and treatment of osteomyelitis in pediatric patients. World J Radiol. 2014 Aug 28;6(8):530-7. doi: 10.4329/wjr.v6.i8.530.

38. Okubo Y, Nochioka K, Testa M. Nationwide survey of pediatric acute osteomyelitis in the USA. J Pediatr Orthop B. 2017 Nov;26(6):501-506. doi: 10.1097/BPB.0000000000000441.

39. Walter N, Bärtl S, Alt V, Rupp M. The Epidemiology of Osteomyelitis in Children. Children (Basel). 2021 Nov 3;8(11):1000. doi: 10.3390/children8111000.