The logic behind antibiotic-loaded bone cement (ALBC) in the infected diabetic foot gets more attractive the longer you stare at it. Pack a debrided, infected wound with PMMA carrying vancomycin or gentamicin and you buy three things at once: a local antibiotic depot eluting at concentrations no IV line could safely deliver, obliteration of dead space, and — by way of a Masquelet-style induced membrane — a vascularized, growth-factor-rich bed primed for closure. It’s a tidy bit of borrowed orthopedic biology, repurposed for limb salvage.
So does the evidence keep pace with the elegance? A trio of studies says the signal is real and reasonably consistent across levels of evidence.
The meta-analysis. Dong and colleagues pooled nine randomized studies (n = 532) and found ALBC beat conventional care on essentially every endpoint that matters: time to wound healing (MD −7.30 days), length of stay (MD −6.32 days), time to bacterial conversion (MD −5.15 days), and number of procedures (MD −2.35). It’s PROSPERO-registered, and the authors — appropriately — call for larger trials. DOI
The randomized trial. Mendame Ehya et al. randomized 36 patients with neuropathic DFUs complicated by osteomyelitis to ALBC versus vacuum sealing drainage. The cement arm came out ahead on baseline pathogen eradication, pain, healing time, length of stay and cost, with lower complication and recurrence rates across 12 months of follow-up. DOI
The real-world cohort. Dai and colleagues retrospectively compared 22 PMMA-treated infected DFUs against 30 managed with debridement alone. The cement group healed faster (35.3 vs 44.4 days, p < 0.001), needed fewer debridements, and — most relevant to those of us who think in terms of remission — lost no limbs, against two major amputations in the control arm. DOI
The usual caveats apply: single-center designs, modest samples, heterogeneous endpoints, and a literature heavily weighted toward one region. None of this is the multicenter RCT we keep asking for. But across a meta-analysis, a randomized trial, and a pragmatic cohort, the arrow points the same way — faster healing, fewer trips to the OR, better limb salvage. For the infected, osteomyelitic foot with dead space to fill, ALBC reads less like a niche trick and more like a tool that earns its place on the bench.
More support for use? On this evidence, yes — cautiously, and pending the bigger trials.
References
Dai J, Zhou Y, Mei S, Chen H. Application of antibiotic bone cement in the treatment of infected diabetic foot ulcers in type 2 diabetes. BMC Musculoskelet Disord. 2023;24(1):135. https://doi.org/10.1186/s12891-023-06244-w
Dong T, Huang Q, Sun Z. Antibiotic-laden bone cement for diabetic foot infected wounds: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2023;14:1134318. https://doi.org/10.3389/fendo.2023.1134318
Mendame Ehya RE, Zhang H, Qi B, Yu A. Application and clinical effectiveness of antibiotic-loaded bone cement to promote soft tissue granulation in the treatment of neuropathic diabetic foot ulcers complicated by osteomyelitis: a randomized controlled trial. J Diabetes Res. 2021;2021:9911072. https://doi.org/10.1155/2021/9911072
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