- Discussion:
    - discussion of addition of antibiotics to cement and osteomyelitis / vancomycin in ca sulfate
    - after fracture stabilization has been completed, osseous defects may be filled w/ antibiotic-PMMA beads; 
              - these beads provide local depot administration of antibiotic and maintain space for subsequent bone graft; 
    - as noted by Keating, et al (1996), bead pouches help reduce the infection rate in open tibia fractures from 16% to 4%; 
             - Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate? 
  - other considerations:
           - wound vac
           - structural support: 
                    - reference:  Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. 
    - considerations for individual antibiotics:
           - vancomycin properties in cement:
                    - typically add 4 gm of Vancomycin per batch of cement;
           - gentamicin and tobramycin properties in cement
                    - add 2.4 gm of tobramycin per cement package, and fashion small beads attached to a O silk suture; 
                    - references:
                           - The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. 
                           - The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. 
                           - Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis.. 

    - technique considerations:
           - once cement no longer sticks to fingers, roll cement into small spheres and thread over 18 gauge wire or #2 Ethibond; 
           - counting the beads and adding methylene blue helps ensure that none of the beads will be left behind at removal 

- references:
             - Antibiotic bead chains.
             - The antibiotic bead pouch technique. The management of severe compound fractures.
             - Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. 
             - Septopal beads and autogenous bone grafting for bone defects in patients with chronic osteomyelitis. 
             - In vitro characteristics of tobramycin PMMA beads: compressive strength and leaching.  
             - Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. 
             - The role of local antibiotic therapy in the management of compound fractures.
             - Comparison of Vacuum-assisted Closure to the Antibiotic Bead Pouch for the Treatment of Blast Injury of the Extremity
             - Commentary: Comparison of Vacuum-assisted Closure to the Antibiotic Bead Pouch for the Treatment of Blast Injury of the Extremity
             - Antibiotic-leaching from polymethylmethacrylate beads.