Abstract / Summary
Abstract Background Wagner grade 4 diabetic foot ulcers (DFUs) represent a limb-threatening condition where achieving a wound bed suitable for skin grafting often necessitates a protracted course of multiple surgeries. This retrospective cohort study evaluated whether the antibiotic bone cement-induced membrane technique is associated with a reduced surgical burden and improved grafting outcomes compared to conventional vacuum-assisted drainage (VSD) alone. Methods This retrospective cohort study included 126 patients with Wagner grade 4 DFUs (2020–2024). All underwent initial debridement and toe amputation with VSD. Treatment allocation was based on surgeon preference and patient choice rather than randomization. At the second operation, the cement + VSD group (n = 62) received antibiotic-loaded PMMA cement followed by VSD, while the VSD-alone group (n = 64) received VSD alone. After 14 days, wound beds were assessed. The primary outcome was the number of operations to achieve a graft-ready wound bed. Secondary outcomes included hospitalization duration, costs, graft survival, and 1-year scar quality (Vancouver Scar Scale). Results The study group required significantly fewer operations to achieve a graft-ready wound bed (median 3 vs. 5, P < 0.001). At day 21, granulation tissue coverage was markedly higher in the study group (82.3 ± 8.1% vs. 45.6 ± 10.2%, P < 0.001). This translated into shorter hospital stays (28.4 ± 5.2 vs. 42.6 ± 7.8 days, P < 0.001) and lower costs (P = 0.002). Graft survival was superior (94.7% vs. 78.1%, P = 0.003), and at 1 year, the study group exhibited significantly better scar quality (VSS: 4.2 ± 1.3 vs. 6.8 ± 1.9, P < 0.001). Conclusions In this retrospective cohort, the antibiotic bone cement-induced membrane technique was associated with fewer surgeries, shorter hospitalization, lower costs, and improved graft and scar outcomes compared to VSD alone. However, due to the non-randomized design and potential confounding, these findings should be considered hypothesis-generating. Prospective randomized trials are warranted to confirm these associations and establish causality.