Evaluation of the Efficiency of the Bone Substitute Cerament-G Locally Delivering Gentamicin in the Treatment of Chronic Osteomyelitis of Long Bones (CONVICTION)

Evaluation of the Efficiency of the Bone Substitute Cerament-G Locally Delivering Gentamicin in the Treatment of Chronic Osteomyelitis of Long Bones: Randomized Multicentre Study in the CRIOAc Network - CONVICTION Study

Chronic osteomyelitis is a serious osteoarticular infection that most often occurs in the long bones (tibia, femur, humerus), responsible for significant morbidity with risk of fracture and amputation. It is due to the presence of bacteria in the bone marrow, sometimes responsible for an intraosseous abscess.

Chronic osteomyelitis can have a hematogenous or more often exogenous origin, after trauma or surgery. The bacteria involved have the ability to modify their metabolism and involve persistence mechanisms (such as biofilm) making them difficult to eradicate. The treatment of chronic osteomyelitis requires surgery, i.e. corticotomy, which means opening of the bone cortex to perform an endomedullary curettage to identify the bacteria, remove any sequestration (bone fragments to which the bacteria adhere as biofilm) and reduce the bacterial inoculum. At the same time, or at a second stage, a skin and soft tissue/muscle flap may be required, especially in patients with long-standing disease with embrittlement and adhesion of the skin and soft tissue to the underlying bone.

Post-operatively, the patient receives a probabilistic systemic antibiotic therapy and then a systemic antibiotic therapy targeted on the identified germ, for a period of 3 months. The effectiveness of these antibiotics is based on their ability to penetrate bone tissue. Despite the progress made in both antibiotics and surgical treatments, the probability of failure (recurrence of infection) is around 20%, and has unfortunately remained stable for more than 20 years.

Cerament-G (BONESUPPORT AB Laboratory, Sweden), a synthetic bone substitute composed of hydroxyapatite, calcium sulphate, and gentamicin, fills the "dead space" formed during surgery, prevents infection of this blood-filled cavity, and promotes bone regeneration within this space (limiting the risk of fracture in the medium and long term). Cerament-G also delivers locally very high doses of gentamicin (concentration of 17.5 mg/mL in the device) for several weeks. Gentamicine is a broad-spectrum bactericidal antibiotic effective against the vast majority of bacteria involved in osteoarticular infections. It provides effective local antibiotic therapy through wide exposure and prolonged concentrations during several weeks.

To date, there is no other bone substitute with antibiotics available in France. Two prospective studies have shown that Cerament-G reduces the number of infectious recurrences (about 5%).

This innovation is available in France but at a high price (between 2,500 and 4,000 euros) and is not currently reimbursed. However, the use of this product would make it possible to improve the health and quality of life of patients while avoiding certain consumption of resources.

Study Overview

• Status: Recruiting
• Conditions: Osteomyelitis Chronic
• Intervention / Treatment: Procedure: Corticotomy and use of the bone substitute : Cerament-G device.; Procedure: Corticotomy

• Study Type: Interventional
• Enrollment (Estimated): 220
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Tristan FERRY; Phone Number: +33 4 72 07 24 81; Email: tristan.ferry@chu-lyon.fr

Study Locations

• France
  • Amiens, France, 80054
    • Recruiting
    • CHU Amiens-Picardie
    • Contact: Benoit BRUNSCHWEILER
    • Principal Investigator: Benoit BRUNSCHWEILER, MD
    • Sub-Investigator: Cédric JOSEPH, MD
  • Besançon, France, 25030
    • Not yet recruiting
    • CHU de Besancon
    • Contact: Pauline SERGENT
    • Principal Investigator: Pauline SERGENT, MD
    • Sub-Investigator: Kévin BOUILLER, MD
    • Sub-Investigator: Isabelle PLUVY, MD
  • Bordeaux, France, 33076
    • Recruiting
    • Chu Bordeaux
    • Principal Investigator: Frédéric-Antoine DAUCHY, MD
    • Contact: Frédéric-Antoine DAUCHY
    • Sub-Investigator: Thierry FABRE, MD
  • Boulogne Billancourt, France, 92104
    • Not yet recruiting
    • APHP
    • Contact: Thomas BAUER
    • Principal Investigator: Thomas BAUER, MD
    • Sub-Investigator: Aurélien DINH, MD
  • Brest, France, 29200
    • Recruiting
    • CHU Brest
    • Contact: Thomas WILLIAMS
    • Principal Investigator: Thomas WILLIAMS, MD
    • Sub-Investigator: Séverine ANSART, MD
  • Caen, France, 14033
    • Recruiting
    • CHU de Caen
    • Contact: Goulven ROCHCONGAR
    • Principal Investigator: Goulven ROCHCONGAR, MD
    • Sub-Investigator: Jocelyn MICHON, MD
  • Lille, France, 59037
    • Not yet recruiting
    • CHU de Lille
    • Contact: Eric SENNEVILLE
    • Principal Investigator: Eric SENNEVILLE, MD
    • Sub-Investigator: Henry MIGAUD, MD
    • Sub-Investigator: Louise PASQUESOONE, MD
  • Lyon, France, 69004
    • Recruiting
    • Hospices Civils de Lyon
    • Contact: Tristan FERRY
    • Principal Investigator: Tristan FERRY, MD
    • Sub-Investigator: cécile BATAILLER, MD
    • Sub-Investigator: Elliot SAPPEY-MARINIER, MD
    • Sub-Investigator: Sophie BROSSET, MD
    • Sub-Investigator: Mathilde LHERM, MD
  • Nancy, France, 54000
    • Not yet recruiting
    • CHRU Nancy
    • Contact: Didier MAINARD
    • Principal Investigator: Didier MAINARD, MD
    • Sub-Investigator: Sibylle BEVILACQUA, MD
  • Nantes, France, 44093
    • Recruiting
    • CHU de Nantes
    • Contact: Christophe Nich
    • Principal Investigator: Christophe Nich, MD
    • Sub-Investigator: David BOUTOILLE, MD
  • Nîmes, France, 30029
    • Not yet recruiting
    • CHU de Nimes
    • Contact: Nicolas CELLIER
    • Principal Investigator: Nicolas CELLIER, MD
    • Sub-Investigator: Paul LOUBET, MD
  • Pierre-Bénite, France, 69310
    • Not yet recruiting
    • Hospices Civils de Lyon
    • Contact: Michel-Henry FESSY
    • Principal Investigator: Michel-Henry FESSY, MD
    • Sub-Investigator: Claire TRIFFAULT-FILLIT, MD
    • Sub-Investigator: Nicolas SIGAUX, MD
    • Sub-Investigator: Antoine PIERREFEU, MD
  • Poitiers, France, 86021
    • Not yet recruiting
    • Chu de Poitiers
    • Contact: Pierre PRIES
    • Principal Investigator: Pierre PRIES, MD
    • Sub-Investigator: Gwenaël LE MOAL, MD
  • Toulouse, France, 31059
    • Recruiting
    • Chu de Toulouse
    • Contact: Pierre DELOBEL
    • Principal Investigator: Pierre DELOBEL, MD
    • Sub-Investigator: Nicolas REINA, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 78 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Patient with suspected chronic osteomyelitis (stage III of the Cierny-Mader classification) of a long bone of the tibia, femur, humerus or forearm, at the diaphysis, metaphysis or epiphysis, defined as follows:

  • Supposed inoculation > 3 months ;

  • At least one of the following clinical signs at the suspected infected site:

    • Spontaneous or supporting pain ;
    • Presence of fistula; or history of fistula discharge
    • Presence of serous or purulent flow;
    • Presence of bone exposure;
    • Local Inflammation;
    • Fever in the absence of any other explanation.

  • At least one of the following radiological signs at the suspected infected site:

    • Bone reshaping with osteolysis or periosteal apposition;
    • Presence of intramedullary abscess (if MRI performed);
    • Presence of a fistulous pathway to the intramedullary (if MRI performed);
    • Presence of bone sequestration visible on CT scan (if CT scan performed).
• Patient in whom conventional surgical treatment of chronic osteomyelitis is possible, with decortication and corticotomy with endomedullary curettage (to eradicate bone sequestrums, reduce the inoculum, and identify the bacterium(s) involved) and secondary intramedullary residual cavity;
• Patient in whom 3 months of systemic antibiotic therapy post-operatively are planned;
• If osteosynthetic material is present in the infection site, this material should be considered preoperatively as completely removable during chronic osteomyelitis surgery;
• Patient in whom a direct closure without tension is possible, or in whom a skin and soft-tissue/muscle flap can be performed within 15 days after the initial surgery;
• Male or female patient between 18 and 80 years of age;
• Patient who has given written informed consent to participate in the study;
• Geographically stable patient;
• Patient able to comply with follow-up visits, protocol schedule and therapeutic treatment, according to investigator's judgement;
• Affiliated patient or beneficiary of a social security system

Exclusion Criteria:

• Acute hematogenic osteomyelitis (Cierny-Mader stage I) ;
• Cortical osteitis (Cierny-Mader stage II);
• Septic pseudoarthrosis (Cierny-Mader stage IV);
• Patient requiring an estimated skin and soft-tissue/muscle flap that cannot be done within 15 days after surgery for the treatment of chronic osteomyelitis;
• Woman who is pregnant, nursing or who is considering becoming pregnant during the study period;
• Patient participating in another interventional study that could interfere with it;
• Patient known to have hypersensitivity to aminoglycosides (especially gentamicin), sulfites (including calcium sulfate) or calcium hydroxyapatite;
• Contraindication to the use of Cerament-G: severe myasthenia (class IV or higher according to the MGFA classification), , severe renal insufficiency (creatinine clearance <30 mL/min according to the Cockcroft-Gault formula, or GFR < 30 ml/min/1.73² according to the CKD-EPI or MDRDs equation or, dialysis patient), pre-existing disorders of calcium metabolism (total plasma calcium (or total corrected plasma calcium according to albuminemia) outside normal laboratory values);
• Patient with endocrine or metabolic disorders known to affect osteogenesis (e.g., Paget's disease, renal osteodystrophy, hyperthyroidism, parathyroid disorder, Ehler-Danlos syndrome, osteogenesis imperfecta);
• Patient with one or more untreated malignant cancers (including Marjolin's ulcer), or undergoing radiotherapy or chemotherapy;
• Adult patient protected by law, under guardianship or trusteeship.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Innovative strategy; usual medical and surgical care with corticotomy and use of a bone substitute (Cerament-G) delivering gentamicin locally (± skin and soft-tissue/muscle flap) and antibiotic therapy.	Procedure: Corticotomy and use of the bone substitute : Cerament-G device.; Corticotomy and Cerament-G device
Active Comparator: Reference strategy; Medico-surgical usual care with corticotomy (± skin and soft-tissue/muscle flap), and antibiotic therapy.	Procedure: Corticotomy; Corticotomy

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Incremental Cost-Utility Ratio (ICUR) between the two treatments strategies for chronic long bone osteomyelitis	At 24 months (M24)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrence of bone infection	Proportion of patients with at least one recurrence of infection on the studied bone and time to recurrence. The Event Validation Committee will confirm the recurrence of infection.	At 24 months (M24)
Intraoperative and Postoperative complications	Number and types of intraoperative and postoperative complications up to 24 months (including fracture) according to CTCAE and Clavien-Dindo classifications; and proportion of patients with at least one complication during follow-up	From inclusion to 24 months (M24)
Repeated surgeries for complication	Number of repeat surgeries for complication up to 24 months; and proportion of patients who had at least one repeat surgery for complication during follow-up	From first surgery to 24 months (M24)
Proportion of patients with amputations	Proportion of patients with amputation of the area containing the bone studied.	At 24 months (M24)
Bone healing and bone remodelling/consolidation	Proportion of patients with bone healing and proportion of patients with bone remodelling/consolidation, assessed from a standard radiograph (confirmed by the Event Validation Committee).	At 12 months (M12)
Serious Adverse Events (SAEs) attributable to systemic antibiotic therapy.	Number and types of serious adverse events (SAEs) attributable to systemic antibiotic therapy following the first intervention; and proportion of patients with at least one SAE attributable to this systemic antibiotic therapy; within 3 months of the first intervention.	Within 3 months of the first intervention (M3)
Acute renal failure	Proportion of patients with acute renal failure within 3 months of the first procedure	Within 3 months of the first procedure (M3)
Adverse Events related to the use of Cerament-G	Cost of both strategies estimated at 24 months	At 24 months (M24)
Real cost	Real cost associated of a corticotomy procedure using Cerament-G	24 months (M24)
Estimated utility	Estimated utility measured with the EQ-5D (EuroQol Group-5 dimensions) questionnaire.	At inclusion, at Week 4/Week 6, Month 3, Month 6, Month12, Month 18 and Month 24 (usual follow-up visits) as well as after each repeat surgery according to the same schedule
Estimated incremental cost-effectiveness ratio	Estimated incremental cost-effectiveness ratio with no recurrence of infection as efficacy endpoint	At 24 months (M24)
Budgetary impact analysis	Budgetary impact analysis carried out from the perspective of the French Health Insurance.	24 months (M24)

Collaborators and Investigators

• Sponsor: Hospices Civils de Lyon

Study record dates

Study Major Dates

• Study Start (Actual): October 14, 2021
• Primary Completion (Estimated): November 14, 2026
• Study Completion (Estimated): November 14, 2026

Study Registration Dates

• First Submitted: March 16, 2021
• First Submitted That Met QC Criteria: March 17, 2021
• First Posted (Actual): March 18, 2021

Study Record Updates

• Last Update Posted (Estimated): April 15, 2024
• Last Update Submitted That Met QC Criteria: April 12, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: bone substitute; Bone infection; chronic osteomyelitis
• Additional Relevant MeSH Terms: Infections; Musculoskeletal Diseases; Bone Diseases; Bone Diseases, Infectious; Osteomyelitis
• Other Study ID Numbers: 69HCL20_0065; 2020-A02299-30 (Other Identifier: ANSM)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No