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Received Sep 25, 2017; Accepted Jan 16, 2018
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1. Introduction
The importance of effective surgical management of dead space as a result of debridement in procedures to treat periprosthetic joint infection and osteomyelitis cannot be underestimated and is an essential aspect of clinical practice in septic surgery [1]. The use of muscle flaps to minimise soft tissue dead space is effective [2–4], but residual dead space can remain which can fill with hematoma, an ideal environment for bacterial growth. This can increase the chance of infection reoccurrence. Also, the use of local tissue flaps and free flaps may not be possible if there has been extensive debridement.
Antibiotic impregnated PMMA beads have been used as a dead space filler for over 30 years [5] and PMMA is frequently applied as a spacer in joint revision surgery [6, 7], or as beads on a wire or in a pouch to facilitate their removal [8]. PMMA requires surgical removal to prevent it becoming a potential nidus for future infection [9, 10].
The use of CS as a material for management of residual dead space offers important advantages as it is resorbed in vivo [11, 12] and does not require subsequent surgical removal. CS can also be combined with antibiotics to treat infections [13]. CS has historically been used as a bone void filler [14, 15]. However, literature has reported that CS, by itself, does not stimulate bone formation. New bone formation occurs when periosteum or bone is also present [16]. Biocompatibility was evaluated by implantation of CS into the proximal epiphysis of the rabbit tibia [17]. The authors found that CS did not induce an inflammatory reaction and was quickly resorbed. It did not support bone formation unless in contact with bone tissue supporting an osteoconductive mechanism. Another animal study concluded that when implanted into subcutaneous sites, CS resorbed too rapidly to be effective in inducing bone replacement [18].
Despite the data available, there remain some concerns regarding the risk of heterotopic ossification (HO) when CS is implanted in soft tissue [19, 20], which could complicate its...