Antibiotic Impregnated Cement Coated Intramedullary Nailing in the Management of Infected Fractures and Chronic Osteomyelitis of Long Bones (original) (raw)
Related papers
Innovative Publication, 2016
Background: In a era of high velocity injuries, compound fractures are very common in orthopaedic practice n despite of preventive measures taken pre operatively and post operatively, infected non unions still common and they pose real challenge to the treating surgeon and makes the patient debilitating. In infected non-union case, the preference has to be given to eradication of the infection before aiming to achieve fracture union. Many methods of treatment have been described in the past including ilizarov fixator and Antibiotic cement impregnated intramedullary nailing(ACIIMN). Sustained and gradual release of heat stable antibiotics which are mixed with the bone cement at a high concentration and coating it on Intramedullary nail(ACIIMN) has gained popularity among the techniques used to treat infected non unions. Our study is aimed at summarizing our experience with the use of antibiotic cement-impregnated intramedullary nail (ACIIMN) for control of infection in cases of infected non-union. This is a report of series of 27 infected non-union cases, both femur and tibia which were treated by Antibiotic cement impregnated intramedullary nailing(ACIIMN) in our institute. Aims and objectives: To evaluate the outcome of treatment of infected non-unions of long bones treated by Antibiotic cement impregnated intramedullary nailing(ACIIMN). Materials and Methods: Our's is prospective study involving 27 cases of infected non-unions of long bones treated by Antibiotic cement impregnated intramedullary nailing(ACIIMN) at our institute from 2012-2015. The outcome of procedure was evaluated with regards to infection control, deformity, bony union and limb length discrepancy etc. Results: Infection was eradicated in 23 cases with ACIIN and the fractures united. In 4 cases, though the infection was controlled with ACIIN, they required subsequent procedures like exchange nailing with bone grafting to achieve bony union. Conclusion: Antibiotic cement impregnated nailing is a very simple yet economical and very effective procedure than the other methods in treatment of infected non-unions of long bones.
IP Innovative Publication Pvt. Ltd., 2017
Introduction: Management of chronic osteomyelitis demands prolonged Antibiotic therapy. Antibiotics may be administered systemically or locally. Local antibiotic therapies have definite advantages. In this study we used Indigenous Antibiotic Impregnated malleable PMMA Cement Rod. Aim of this study is to evaluate the efficacy of Indigenous Antibiotic Impregnated Malleable PMMA Cement Rod in the treatment of chronic osteomyelitis of long bones. Methods: This study involved retrospective evaluation of 63 patients of chronic osteomyelitis of long bones treated at our institute between February 2011 to January 2016. All patients with chronic osteomyelitis of long bones with less than 2 cm of sequestrum formation were included in the study. Patients with infected non-union were treated with other modalities of treatment and were excluded from the study. Initially for first three years we treated 33 patients of chronic osteomyelitis of long bones with surgical removal of infected and dead bone and soft tissue followed by local Antibiotics Impregnated PMMA Beads. These patients were considered as Group A. Later since February 2014 we started treating patients with Indigenous Antibiotic Impregnated Malleable PMMA Cement Rod and these patients were considered as Group B. Results: There were 33 patients in group A. 26 patients cured with complete irradication of the infection. Cultures performed on tissue sample taken at the time of Beads removal were negative in these cases. In 9 patients removal of Beads was difficult. 7 patients had persistent pain, swelling and inflammation. On investigations they had raised CRP, Total count and Neutrophillia. They all underwent second surgical procedure-removal of Beads and further treatment with Masquelet technique. One of these 7 patients had pathological fracture which was stabilized with Antibiotic impregnated PMMA intramedullary nail. These 7 cases required 16 to 23 weeks for complete cure of infection. The average time required for complete recovery in Group A patients was 17 weeks. There were 30 patients in group B. All patients were completely cured in a mean time period of 8 weeks (range, 6–11 weeks). No patient required a second surgical procedure to achievecontrol of infection. Tissue samples obtained at the time of Rod removal showed no growth on culture in all these patients. Conclusion: Our study results demonstratesvery effective and complete cure of chronic osteomyelitis in less time period with the use of Indigenous Antibiotic Impregnated Cement Rod technique as against the use of Antibiotic Impregnated Cement Beads.
Management of infected non union of long bones by antibiotic cement impreganted nails and beads
Journal of Bone and Joint Surgery-british Volume, 2013
Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation.
Chirurgia Narządów Ruchu i Ortopedia Polska
Introduction. Inflammations of long bones are severe complications of fractures. The gradual development of industry and its automotive branch generates a higher number of injuries, including high-energy fractures, mostly open [1,2]. These injuries, which are primarily infected, despite the use of empirical antibiotic therapy, lead to osteomyelitis. Intramedullary nails coated with polymethyl methacrylate (PMMA) containing a targeted antibiotic help heal the inflammation and fixate bone fragments, providing biomechanical silence that facilitates bone union. Objective. The aim of this study was to achieve healing of inflammation in patients after an open long bone fracture by using a high concentration of antibiotic targeted at the site of infection after prior thorough sequestrectomy. Materials and methods. The study involved 10 patients with long bone osteomyelitis treated between 2016 and 2018 with intramedullary nails coated with antibiotic-loaded PMMA which were used after previous treatment failed. In all patients open fractures led to osteomyelitis. The infection was removed during surgery, a sequestrectomy and Judet procedure were performed, and then a nail with a targeted antibiotic was implanted. Results. Complete healing of inflammation was achieved in 8 patients (80%), recurrence of inflammation was observed in 1 patient (10%), bone union was achieved in 3 patients (33%). Conclusions. The effectiveness of long bone osteomyelitis treatment is contingent on prior elimination of inflammation focus, good condition of the skin and soft tissues, administration of local targeted antibiotic therapy and stabilization of bone fragments. The treatment involving intramedullary nails coated with antibiotic-loaded PMMA is the method of choice where other treatment modalities have failed.
Antibiotics
Antibiotic cement-coated intramedullary nails (ACCINs) are increasing in popularity as a viable solution for the treatment of fracture-related infections (FRIs), infected long bone nonunions, and arthrodeses without an external fixator. ACCINs effectively manage to fulfill three of the basic principles for eradicating osteomyelitis: dead space management, antibiotic delivery, and bone stability. We performed a retrospective review of 111 patients who were treated with ACCINs between January 2014 and December 2020. In our series, 87.4% (n = 97) of patients achieved healed and uninfected bone or stable arthrodesis at a mean follow-up of 29.2 months (range, 6–93 months). Additionally, 69.1% (n = 67) of healed patients were resolved after only one procedure, and the remainder (30.9%, n = 30) healed after one or more additional procedures. The mean number of additional procedures was 2.1 (range, 1–6 additional procedures). The overall limb salvage rate was 93.7% (n = 104). The majority o...
Journal of Bone and Joint Infection
Background: The study was done (1) to report on our recent experience with antibiotic-loaded calcium sulfate-coated interlocking intramedullary nails (CS-IMN) for infection prevention or infection eradication and (2) to compare the efficacy of CS-IMN versus antibiotic-loaded polymethylmethacrylate-coated IMN (PMMA-IMN) for infection eradication. Methods: We retrospectively reviewed the medical records of consecutive patients who underwent a limb salvage procedure for infection cure or infection prevention with PMMA-IMN or CS-IMN. We reviewed patient demographics, host-type, pre-operative infecting organisms, intraoperative cultures, as well as our main outcomes: infection control rate, achievement of union/fusion, and limb salvage. Results: 33 patients were treated with CS-IMN: 9 patients with goal of infection cure and 24 patients for infection prophylaxis. When used for infection prophylaxis, there was a 100 % (24/24 patients) prevention of infection rate, 95.5 % union rate (21/22 patients), and 100 % (24/24 patients) limb salvage rate. Nine patients were treated with CS-IMN to eradicate infection and were compared to a cohort of 28 patients who were treated with PMMA-IMN. The infection was eradicated in 7/9 patients (77.8 %) in the CS-IMN group versus 21/26 patients (80 %) in the PMMA-IMN group (p = 0.44). Bone union/fusion was achieved in 8/9 patients (88.9 %) in the CS-IMN group versus 21/24 patients (87.5 %) in the PMMA-IMN group (p = 0.11). The limb salvage rate in the CS-IMN group was 100 % (9/9 patients) versus 89 % (25/28 patients) in the PMMA-IMN group. Conclusions: CS-IMN are safe and easy to use, and we have therefore expended our indications for them. CS-IMN are very effective at infection prophylaxis in high-risk cases where infection is suspected. Early analysis suggests that CS-IMN are non-inferior to PMMA-IMN for infection eradication. This is our preliminary data that show this novel technique to be safe in a small cohort and may be as effective as the more established method. Future studies with larger cohorts of patients will be required to confirm these findings.
Chirurgia Narządów Ruchu i Ortopedia Polska
Introduction. Treatment of fractures or non-union of long bones with infection requires debridement of the medullary cavity, antibiotics in high concentrations in the bone and biofilm, elimination of dead space in the place of debridement and mechanical stability at the site of infection. External stabilization is inconvenient for the patient and makes skin plastics difficult. Material and methods. There were 13 patients (6 women and 7 men), aged 18-82 years, treated with debridement and stabilization with intramedullary nail covered with Antibiotic Loaded Acrylic Cement (ALAC). Indications for nail covered with ALAC (ACIIN): infected fractures or infected nonunion of the femur (6), tibia (6) and humerus (1) diaphysis. Follow-up: 1-13 years (average 6.5 years). Etiology of infection: S. aureus (11), Staph. Epidermidis (1), mixed infection: MRSA and Pseudomonas aeruginosa (1). Up to 40 g of ALAC with gentamycin in a dose below 1 g were added: 2 g vancomycin (11), 1 g vancomycin and 1 g meropenem (1-mixed infection), 1 g vancomycin and 1 g ceftriaxone (1-MSSA)-based on preoperative culture. In the absence of a conclusive antibiogram, vancomycin was a pre-emptive therapy, focused on the most common pathogen. Nail locking applied: static (5), dynamic (2); without locking (6). Results. Healing of the infection was achieved in 11, bone union in 9 of 13 patients. Non-union in 4 cases: large segmental defects of the femoral shaft (2); tibial nonunion (2). Conclusions. ACIIN nails with the addition of 5% targeted antibiotic can be an effective treatment for infected fractures or infected nonunions of the femoral, tibial and humeral diaphysis. They offer comfortable bone stabilization and local treatment of infection.
Injury, 2017
Background: Infected non-union is complex and debilitating disorder affecting orthopaedic surgeon and patient in terms of cost and time. Many methods are described in the literature for treatment of infected non-union. Local high concentration of antibiotic and mechanical stability of antibiotic cement impregnated intramedullary nail (ACIIN) proves cost and time effective. Recently it was suggested that ACIIN can achieve both union and infection control in infected non-unions with bone gap less than 4 cm. The aim of our study was to investigate this hypothesis and study the outcome of antibiotic cement impregnated intramedullary nail in term of both infection control and osseous union. Materials and methods: We retrospectively studied 21 patients with infected diaphyseal femoral non-union. Inclusion criteria were bone gap less than 4 cm after debridement and more than 1 year follow-up of the case. ACIIN prepared using K nail was used as primary procedure after adequate debridement. Infection control and osseous union was judged on the basis of clinical, radiological and haematological parameters. All patients were followed up with an average follow-up of 20.23±3.65 months (range 14-28 months). Results: Infection control was achieved in all 21 patients at end of 12 months follow-up, out of which 16 patients had osseous union and infection control without any secondary procedure. Of the remaining 5 patients: two patients had good infection control but had broken ACCIN due to non-compliance to weight bearing protocol. One patient underwent exchange nailing and plate augmentation whilst the other underwent simple exchange nailing, One more patient who had infection control but had persistent non-union had to undergo exchange nailing and augmented plating to achieve union. One other patient required debridement and implant removal and attained union and fifth patient required two additional debridements to control infection after which the fracture united. Apart from above 5 cases there were two further complications of knee stiffness. Conclusion: In infected non-union with bone gap less than 4 cm, ACIIN can achieve both infection control and osseous union in significant number of cases. All such cases should be primarily operated with aim to achieve this outcome and use of thicker nail and ensuring proper compliance from patients regarding weight bearing will improve the outcomes.
Acta orthopaedica Belgica, 2017
The infected non union of the long bones in the presence of the intramedullary nail is a dreaded complication of fracture management. Around 7% patients may develop an infected non union of the long bones in intramedullary nailing. Amongst the various grades of infection, grade three infection is the most difficult to cure and manage as it involves an osteomyelitic bone. Amongst an array of therapeutic modalities, the two stage methods are commonly used with the first stage aimed at controlling the infection and the second stage at inducing union. This increases the number of surgical procedures. We used an Ilizarov threaded rod coated with antibiotic impregnated cement to replace the intramedullary nail with the idea of delivering higher concentration of antibiotic locally as well as provide stability. We achieved a union rate of 91% in a relatively small number of patients with this single procedure. The antibiotic impregnated cement coated Ilizarov rod that we used in our study a...