Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis (original) (raw)
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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.
BMC Musculoskeletal Disorders
Background Chronic osteomyelitis is a challenge for orthopedic surgeons. Most patients with osteomyelitis receive two-stage management according to Cierny-Mader. The first stage includes radical debridement and insertion of an antibiotic-impregnated cement spacer (ACS) (beads, rods, nails, or blocks) into the bone defect. The second stage is performed 6–8 weeks later, when the spacer is removed and a cancellous autograft is placed within the bone defect. The possibility of ACS as definitive management for osteomyelitis, avoiding the second stage, is presented. Methods Sixteen patients with osteomyelitis received radical debridement and insertion of an ACS in all forms into the bone defect as a definitive management. In 8 patients, the tibia was infected, 4 had femur infection, 2 humerus, 1 fibula, and 1 ankle. The mean age at the time of the first stage of reconstruction was 49 years (range, 13–71 years). According to the Cierny-Mader classification, 1 patient was C-M IA, another wa...
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.
Journal of Medical Research and Surgery, 2024
Background: In the era of modern transportation there is an increased incidence of compound fractures especially of long bones. As the skin barrier is broken, the bacteria from dirt, other contaminants can colonize at the wound site and thus can cause infection. Healing at the fracture site and that of soft tissues can be severely compromised by infection. So, treating the infection first followed by definitive fixation of fracture will nearly take 4-6 weeks. The antibiotic nailing technique can thus achieve both the targets in a short time. Local delivery of drug controls the infection and the fixation achieves stability. This even reduces the side effects due to over use of systemic and oral antibiotics. Osteomyelitis is also very common which can be hematogenous or post traumatic. This can weaken the bone and can cause fractures with trivial trauma. Discharging sinuses may also be accompanying. So even in this scenario long term use of antibiotics systemically may be required causing side effects. Antibiotic nailing can be very useful in this scenario. Methods: This is a prospective observational study. 20 patients above age of 20 years who were admitted or on follow up during the period of 2 years were considered for study. The patients with infected fractures with or without implant in situ and patients with chronic osteomyelitis with discharging sinuses were included. ASAMI criteria: The final outcome is graded based on ASAMI criteria proposed by Paley et al. This was usually developed for determining the outcome after treatment of nonunion with Ilizarov ring fixator. It was applied in our study with some modification. Results: The average duration for achieving bony union was around 5 months (20 weeks). Minimum duration for bony union was around 4 months (16 weeks). Maximum duration for bony union was around 7 months (28 weeks) Average duration for control of infection in case of chronic osteomyelitis was around 4 months. Minimum duration for control of symptoms was 5 months. Maximum duration for control of symptoms was 7 months. Conclusion: Antibiotic impregnated cement coated intramedullary nailing is a very good and effective treatment for infected nonunion and chronic osteomyelitis long bones with bone defect less than 2 cm. In case of infected nonunion, as the bone ends will be sclerosed, freshening of ends and bone grafting is needed.
Local Antibiotic Therapy in Osteomyelitis
Seminars in Plastic Surgery, 2009
The local delivery of antibiotics in the treatment of osteomyelitis has been used safely and effectively for decades. Multiple methods of drug delivery have been developed for the purposes of both infection treatment and prophylaxis. The mainstay of treatment in this application over the past 20 years has been non-biodegradable polymethylmethacrylate, which has the advantages of excellent elution characteristics and structural support properties. Biodegradable materials such as calcium sulfate and bone graft substitutes have been used more recently for this purpose. Other biodegradable implants, including synthetic polymers, are not yet approved for use but have demonstrated potential in laboratory investigations. Antibiotic-impregnated metal, a recent development, holds great promise in the treatment and prophylaxis of osteomyelitis in the years to come.
Journal of Evidence Based Medicine and Healthcare
BACKGROUND The classical method of treatment of chronic osteomyelitis with sequestrum needs saucerization and sequestrectomy which become quite difficult when small sequesrtrae are spread over a long span in medullary canal. To saucerize such a long segment is not only difficult, it may be dangerous because of excessive blood loss and mechanically the bone become weak. A pathological fracture or iatrogenic fracture is definite possibility. Intramedullary reaming has its selected indication in osteomyelitis of long bones when remnants of dead infected bone are intramedullary embedded in an endosteal new bone formation. Previously intramedullary reaming with irrigation and suction was devised for treatment of this type of chronic osteomyelitis of long bones. This needed complex and costly instrumentation which cannot be afforded by all the orthopaedic surgeons. So, a new technique was developed without any extra instrumentation and expenditure ensuring complete removal of sequestrum.
Annals of Clinical Microbiology and Antimicrobials
Background: Osteomyelitis is an acute or chronic inflammatory process of the bone following infection with pyogenic organisms like Staphylococcus aureus. Tobramycin (TOB) is a promising aminoglycoside antibiotic used to treat various bacterial infections, including S. aureus. The aim of this study was to investigate the efficacy of tobramycinloaded calcium phosphate beads (CPB) in a rabbit osteomyelitis model. Methods: Tobramycin (30 mg/mL) was incorporated into CPB by dipping method and the efficacy of TOB-loaded CPB was studied in a rabbit osteomyelitis model. For juxtaposition, CPB with and without TOB were prepared. Twentyfive New Zealand white rabbits were grouped (n = 5) as sham (group 1), TOB-loaded CPB without S. aureus (group 2), S. aureus only (group 3), S. aureus + CPB (group 4), and S. aureus + TOB-loaded CPB (group 5). Groups infected with S. aureus followed by CPB implantation were immediately subjected to surgery at the mid-shaft of the tibia. After 28 days post-surgery, all rabbits were euthanized and the presence or absence of chronic osteomyelitis and the extent of architectural destruction of the bone were assessed by radiology, bacteriology and histological studies. Results: Tobramycin-loaded CPB group potentially inhibited the growth of S. aureus causing 3.2 to 3.4 log 10 reductions in CFU/g of bone tissue compared to the controls. Untreated groups infected with S. aureus showed signs of chronic osteomyelitis with abundant bacterial growth and alterations in bone architecture. The sham group and TOBloaded CPB group showed no evidence of bacterial growth. Conclusions: TOB-incorporated into CPB for local bone administration was proven to be more successful in increasing the efficacy of TOB in this rabbit osteomyelitis model and hence could represent a good alternative to other formulations used in the treatment of osteomyelitis.
The Thai Journal of Veterinary Medicine, 2013
Three types of gentamicin beads were compared in a rat osteomyelitis model. The gentamicin beads were prepared in cylinder shape (diameter 2 mm x height 4 mm). Gentamicin impregnated polymethylmethacrylate (GI-PMMA) beads were fabricated according to manufacturer's instructions. Gentamicin coated native calcium sulfate (G-NCS) bead and gentamicin coated high porous calcium sulfate (G-HPCS) bead were prepared in laboratory. Osteomyelitis was induced in the rat's tibias by using methicillin resistance Staphylococcus aureus (MRSA). After 3 weeks of infection, the infected tibias were implanted with GI-PMMA bead, G-NCS bead, G-HPCS bead or sham treatment (control). Radiographic change, white blood cell count and infection signs were weekly monitored for 6 weeks. At the end of the experiment, all tibias were collected for histopathologic examination and bone culture. Although white blood cell count and infection signs were not significantly different among different group of rats, the radiolucent area reduced significantly in GI-PMMA, G-NCS and G-HPCS compared to the control group. There was no significant difference in bacterial count among the groups, however, the histopathologic results revealed new bone development in G-NCS and G-HPCS groups, and a large bone defect in GI-PMMA group resulting from bead removal. This study suggests that the G-HPCS can be used as a local antibiotic carrier for management of osteomyelitis instead of calcium sulfate and polymethylmethacrylate beads.
The Bone & Joint Journal, 2014
Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer-Irrigator-Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny-Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients. Cite this article: Bone Joint J 2014; 96-B:783-8.