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Rupp M, Walter N, Bärtl S, Heyd R, Hitzenbichler F, Alt V. Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:17-24. [PMID: 37970721 PMCID: PMC10916768 DOI: 10.3238/arztebl.m2023.0233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) is a challenge to physicians and other workers in health care. In 2018, there were 7253 listed cases of FRI in Germany, corresponding to an incidence of 10.7 cases per 100 000 persons per year. METHODS This review is based on pertinent publications retrieved from a search in PubMed with the search terms "fracture," "infection," "guideline," and "consensus." Aside from the primary literature, international guidelines and consensus recommendations were evaluated as well. RESULTS FRI arise mainly from bacterial contamination of the fracture site. Staphylococcus aureus is the most commonly detected pathogen. The treatment is based on surgery and antibiotics and should be agreed upon by an interdisciplinary team; it is often difficult because of biofilm formation. Treatment options include implant-preserving procedures and single-stage, two-stage, or multi-stage implant replacement. Treatment failure occurs in 10.3% to 21.4% of cases. The available evidence on the efficacy of various treatment approaches is derived mainly from retrospective cohort studies (level III evidence). Therefore, periprosthetic joint infections and FRI are often discussed together. CONCLUSION FRI presents an increasing challenge. Preventive measures should be optimized, and the treatment should always be decided upon by an interdisciplinary team. Only low-level evidence is available to date to guide diagnostic and treatment decisions. High-quality studies are therefore needed to help us meet this challenge more effectively.
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Affiliation(s)
- Markus Rupp
- These authors share first authorship
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Nike Walter
- These authors share first authorship
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Susanne Bärtl
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Robert Heyd
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
| | - Florian Hitzenbichler
- Department for Hospital hygiene and Infectiology, University Hospital Regensburg, Germany
| | - Volker Alt
- Department for Trauma surgery, University Hospital Regensburg, Germany
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Vargas-Hernández JS, Sánchez CA, Renza S, Leal JA. Effectiveness of antibiotic-coated intramedullary nails for open tibia fracture infection prevention. A systematic review and meta-analysis. Injury 2023; 54 Suppl 6:110857. [PMID: 38143139 DOI: 10.1016/j.injury.2023.110857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Open Tibia fractures are associated with high rates of Fracture Related Infection (FRI). Given the negative outcomes and increased costs related to the latter, several prophylactic local antibiotic delivery methods have been proposed, aiming to decrease the FRI rate. Our objective with this study was to determine the effectiveness of antibiotic-coated intramedullary nails for open tibia FRI prevention. PATIENTS AND METHODS We conducted a PRISMA compliant systematic review and meta-analysis. Queries were performed on Embase, PubMed, Lilacs and Cochrane data libraries. Seventeen studies were included for qualitative analysis and 2 studies were amenable for meta-analysis. RESULTS Global infection, deep infection and non-union rates were 8.4%, 5.4% and 3.7% in the antibiotic-coated nail group and 22%, 14% and 14% in the non-antibiotic-coated nail group respectively. The meta-analysis showed a protective trend that favored the antibiotic-coated nail group although it didn't achieve statistical significance: deep infection Relative Risk (RR) (RR = 0.17 CI95% [0.02 - 1.31]); global infection RR = 0.36 CI95% [0.10 - 1.35]) and non-union (RR = 0.14 CI95% [0.02 - 1.22]), CONCLUSIONS: Our findings suggest a favorable trend towards antibiotic-coated nail, with decreased risk of global infection, deep infection and non-union as compared to non-antibiotic-coated nail in patients with open tibia fractures. Nonetheless, higher level evidence studies are required to confirm our findings.
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Affiliation(s)
| | - Carlos A Sánchez
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - Stephanie Renza
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - Jaime Andrés Leal
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
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Zamorano ÁI, Albarrán CF, Vaccia MA, Parra RI, Turner T, Rivera IA, Garrido OA, Suárez PF, Zecchetto P, Bahamonde LA. Gentamicincoated tibial nail is an effective prevention method for fracture-related infections in open tibial fractures. Injury 2023; 54 Suppl 6:110836. [PMID: 38143136 DOI: 10.1016/j.injury.2023.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 12/26/2023]
Abstract
Fracture-related infection (FRI) is a common complication following open tibia fracture (OTF), especially in patients with high-energy trauma or comorbidities. The use of gentamicin-coated nail (GCN) has been proposed as a local adjuvant to prevent FRI in high-risk patients. HYPOTHESIS The incidence of FRI is expected to be lower in OTF treated with a GCN, alongside with no detrimental effects on fracture healing time. OBJECTIVES This study aimed to evaluate the effectiveness of GCNs as a definitive fixation method and prophylaxis for FRI in OTFs. Secondary outcomes included non-union rates and time to healing. METHODS The study design was a mixed cohort, including a prospective group of patients treated with GCN (Expert Tibial Nail PROtect™, Depuy Synthes, Johnson&Johnson Company Inc, New Jersey, USA) and a retrospectively evaluated group treated with non-gentamicin-coated nail (NGCN). Patients with at least 12 months of follow-up were included. The treatment protocol consisted of timely administration of antibiotics, surgical debridement, and early soft-tissue coverage. Exclusion criteria included protocol infringement, traumatic amputation, and loss of follow-up. Statistical analysis was performed using Stata v14.0, with a significance level of p < 0.05. RESULTS The study included 243 patients, 104 in GCN group and 139 NGCN group. External Fixator use was higher in the NGCN group, but this did not significantly affect the FRI rate. GCN use was associated with a significantly lower incidence of FRI (2.88% GCN group vs. 15.83% NGCN group, OR 0.16, p < 0.01). Furthermore, GCN use was found to be a protective factor against tibial non-union (OR 0.41, p = 0.03). There were no adverse effects attributed to locally administered gentamycin. The NGCN cohort had a higher incidence of polytrauma, although the difference was not statistically significant. A longer time to heal as well as more FRI and Non-union according to the progression in Gustilo-Anderson classification was observed in the GCN group. CONCLUSION Our findings suggest that GCN is an effective prophylactic method to reduce the risk of FRI in open tibial fractures at 12-month follow-up, as well as, probably derived from this protective effect, leading to lower fracture consolidation times when compared with cases treated without GCN.
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Affiliation(s)
- Álvaro I Zamorano
- Head of Lower Extremities Trauma Unit, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile; University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile.
| | - Carlos F Albarrán
- Orthopaedic and Traumatology Resident, Medical School, University of Chile, Postgraduate School. Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
| | - Matías A Vaccia
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile; Lower Extremities Trauma Unit Staff, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Rodrigo I Parra
- Lower Extremities Trauma Unit Intern, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Tomás Turner
- Lower Extremities Trauma Unit Intern, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Ignacio A Rivera
- Emergency Department Mutual de Seguridad Clinical Hospital, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Osvaldo A Garrido
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
| | - Pablo F Suárez
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
| | - Pierluca Zecchetto
- University of Chile Clinical Hospital, Orthopaedic Surgery Service Attending, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile; Lower Extremities Trauma Unit Staff, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile
| | - Luis A Bahamonde
- Lower Extremities Trauma Unit Staff, Orthopaedic and Traumatology Service, Hospital Clínico Mutual de Seguridad, Avenida Libertador Bernardo O´Higgins 4848, Santiago, 9190015, Chile; Chairman, Orthopaedic and Traumatology Service, University of Chile Clinical Hospital, Avenida Dr. Carlos Lorca Tobar 999, Santiago, 8380456, Chile
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Antibiotic-Loaded Coatings to Reduce Fracture-Related Infections: Retrospective Case Series of Patients with Increased Infectious Risk. Antibiotics (Basel) 2023; 12:antibiotics12020287. [PMID: 36830197 PMCID: PMC9952500 DOI: 10.3390/antibiotics12020287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Local antibiotic delivery strategies have been increasingly employed for the prevention of fracture-related infections (FRIs). The aim of this study is to evaluate the efficacy and safety of antibiotic-coated implants in the prevention of FRIs after surgical treatment in patients with increased infectious risk. A retrospective observational study has been conducted on patients with upper and lower limb fractures treated with internal fixation or prosthetic replacements, using a gentamicin coated nail (CN) and/or antibiotic-loaded hydrogel applied to the implant of choice (ALH). The study included 37 patients (20 M, 17 F), with a mean age of 63 years. The mean estimated preoperative infectious risk score was 6.4%. ALH was used in 27 cases, tibial CNs were implanted in 4 cases, and both were employed in 6 cases. The antibiotics used locally were gentamicin in 72.97% of cases (27 patients) and a combination of gentamicin + vancomycin in 27.03% of cases (10 patients). Mean follow-up was 32 months. Only one case (2.94%) showed onset of FRI at 5 months after surgery. Local antibiotic prophylaxis by coating resulted in a reduction in the incidence FRI, as compared to the estimated preoperative risk. The use of ALH allows for the choice of antibiotic; however, the application of antibiotics seems more nonuniform when applied to a nail.
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Bottagisio M, Palombella S, Lopa S, Sangalli F, Savadori P, Biagiotti M, Sideratou Z, Tsiourvas D, Lovati AB. Vancomycin-nanofunctionalized peptide-enriched silk fibroin to prevent methicillin-resistant Staphylococcus epidermidis-induced femoral nonunions in rats. Front Cell Infect Microbiol 2023; 12:1056912. [PMID: 36683682 PMCID: PMC9851397 DOI: 10.3389/fcimb.2022.1056912] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Implant-related infections and infected fractures are significant burdens in orthopedics. Staphylococcus epidermidis is one of the main causes of bone infections related to biofilm formation upon implants. Current antibiotic prophylaxis/therapy is often inadequate to prevent biofilm formation and results in antibiotic resistance. The development of bioactive materials combining antimicrobial and osteoconductive properties offers great potential for the eradication of microorganisms and for the enhancement of bone deposition in the presence of infections. The purpose of this study is to prevent the development of methicillin-resistant S. epidermidis (MRSE)-infected nonunion in a rat model. Methods To this end, a recently developed in our laboratories bioactive material consisting of antibiotic-loaded nanoparticles based on carboxylic acid functionalized hyperbranched aliphatic polyester (CHAP) that are integrated into peptide-enriched silk fibroin sponges with osteoconductive properties (AFN-PSF) was employed, whose biocompatibility and microbiological tests provided proof of its potential for the treatment of both orthopedic and dental infections. In particular, non-critical femoral fractures fixed with plates and screws were performed in Wistar rats, which were then randomly divided into three groups: 1) the sham control (no infection, no treatment); 2) the control group, infected with MRSE and treated with peptide-enriched silk fibroin sponges incorporating non-drug-loaded functionalized nanoparticles (PSF); 3) the treated group, infected with MRSE and treated with peptide-enriched silk fibroin sponges incorporating vancomycin-loaded functionalized nanoparticles (AFN-PSF). After 8 weeks, bone healing and osteomyelitis were clinically assessed and evaluated by micro-CT, microbiological and histological analyses. Results The sham group showed no signs of infection and complete bone healing. The PSF group failed to repair the infected fracture, displaying 75% of altered bone healing and severe signs of osteomyelitis. The AFN-PSF treated group reached 70% of fracture healing in the absence of signs of osteomyelitis, such as abscesses in the cortical and intraosseous compartments and bone necrosis with sequestra. Discussion AFN-PSF sponges have proven effective in preventing the development of infected nonunion in vivo. The proposed nanotechnology for local administration of antibiotics can have a significant impact on patient health in the case of orthopedic infections.
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Affiliation(s)
- Marta Bottagisio
- IRCCS Istituto Ortopedico Galeazzi, Laboratory of Clinical Chemistry and Microbiology, Milan, Italy
| | - Silvia Palombella
- IRCCS Istituto Ortopedico Galeazzi, Cell and Tissue Engineering Laboratory, Milan, Italy
| | - Silvia Lopa
- IRCCS Istituto Ortopedico Galeazzi, Cell and Tissue Engineering Laboratory, Milan, Italy
| | - Fabio Sangalli
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Renal Biophysics, Department of Biomedical Engineering, Bergamo, Italy
| | - Paolo Savadori
- IRCCS Istituto Ortopedico Galeazzi, Department of Endodontics, Milan, Italy
| | | | - Zili Sideratou
- National Centre for Scientific Research "Demokritos", Institute of Nanoscience and Nanotechnology, Aghia Paraskevi, Greece
| | - Dimitris Tsiourvas
- National Centre for Scientific Research "Demokritos", Institute of Nanoscience and Nanotechnology, Aghia Paraskevi, Greece
| | - Arianna B Lovati
- IRCCS Istituto Ortopedico Galeazzi, Cell and Tissue Engineering Laboratory, Milan, Italy
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Kalbas Y, Klingebiel F, Pape HC. Antibiotic coated nails: Rationale, development, indications and outcomes. J Orthop Surg (Hong Kong) 2022; 30:10225536221118521. [PMID: 36545939 DOI: 10.1177/10225536221118521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The concept of antibiotic-coated implants, mainly coated intramedullary nails, has become increasingly used for the treatment of fracture related infections. After a long period of hand-made implants, commercially fabricated implants combine several benefits. Antibiotic-coated nails constitute a solid treatment option for unstable diaphyseal infections with fractures or non-unions. They release high concentrations of antibiotics locally, while retaining reduction and providing axial stability. This review aims to provide an overview about the background, the development, the indications, the treatment strategies and the outcomes of antibiotic-coated intramedullary nails.
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Affiliation(s)
- Yannik Kalbas
- Department of Trauma Surgery and Harald-Tscherne Laboratory, 27243University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Felix Klingebiel
- Department of Trauma Surgery and Harald-Tscherne Laboratory, 27243University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery and Harald-Tscherne Laboratory, 27243University of Zurich, University Hospital Zurich, Zurich, Switzerland
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Healthcare resource use and costs related to surgical infections of tibial fractures in a Spanish cohort. PLoS One 2022; 17:e0277482. [DOI: 10.1371/journal.pone.0277482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Surgical site infection constitutes a serious complication in the healing process of bone fractures and has been associated with increases in medical resource use and healthcare costs. This study evaluates the economic impact of surgical site infection in tibial fractures in a Spanish cohort. It is a retrospective, single-centre, comparative cohort study of patients with tibial fractures with longitudinal follow-up for up to 18 months post-surgery. Included patients (n = 325) were adults, with tibial fracture, either isolated or polyfracture, or polytrauma with an Injury Severity Score >15. Patients had been surgically treated within 30 days of the tibial fracture by external or internal fixation, or external followed by internal fixation. Most patients (84.9%) had an American Society of Anaesthesiology score of 1–2. 20% of the patients had one open tibial fracture, 12.3% had polytrauma, and 20% had multiple fractures. Most patients were treated with a nail (41.8%) or a plate (33.8%). 56 patients (17.2%) developed surgical site infection. Patients with infection had significantly higher hospital length of stay (34.9 vs 12.0 days; p<0.001; +191%), readmissions (1.21 vs 0.25; p<0.001; +380%) and mean operating theatre time (499 vs 219 min; p<0.001; +128%) than patients without infection. Mean length of stay in intensive care did not significantly increase with infection (2.8 vs 1.7 days; p = 0.25). Total in-hospital costs for patients with infection increased from €7,607 to €17,538 (p<0.001; +131%). Overall, infections were associated with significantly increased healthcare resource use and costs. Preventive strategies to avoid infections could lead to substantial cost savings.
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Malhotra A, Krishna A, Garg SK, Gupta S, Jindal R, Jain G. Short term results with the use of PLA antibiotic coated nail in open tibia fractures: A prospective study. J Orthop 2022; 34:183-188. [PMID: 36090781 PMCID: PMC9459675 DOI: 10.1016/j.jor.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/14/2022] [Accepted: 08/23/2022] [Indexed: 10/31/2022] Open
Abstract
Background Antibiotic impregnated cement coated nails have been described in literature with promising success rates. However, they need removal at a later stage. This study focuses on use of a PLA-precoated antibiotic nail that stops eluting antibiotic after a while and can be retained later as it behaves as a standard interlocking nail in the long run. Purpose To study if PLA (polylactic acid) -antibiotic coated nails reduces infection and non-union rates and improve the functional outcome in open tibial shaft fracture cases. Materials and methods In this prospective cohort study, we included 54 patients with open tibia shaft fractures treated with wound debridement and internal fixation using a reamed PLA (polylactic acid)-antibiotic coated nail (CE-certified, OSSIPRO, MatrixTM). Results Forty patients with a Grade 2 and ten with grade 3A open tibial fracture, according to the Gustilo-Anderson classification, completed a minimum of six months of follow-up and were included in the analysis. At the final follow-up, four patients (all with grade 3A fracture) had an active infection, 10 (four of grade 2 and six of grade 3A) had non-union, the mean physical component score (SF-36 score) was 55.2 ± 20.10 (grade 2; 58.95 ± 9.99, grade 3A; 40.19 ± 16.37, P value 0.002), and the mean mental component score (SF-36 score) was 54.96 ± 23.5 (grade 2; 57.96 ± 16.63, grade 3A; 42.94 ± 23.75, P value 0.04). Furthermore, Multivariate analysis showed age and grade of fracture to be independently related to the development of infection and non-union. Conclusion Although the use PLA-antibiotic coated nail looks promising, short-term results have revealed no additional benefit in terms of reduced infection rates, improved union rates or functional outcomes. Large multicentric randomized controlled trials and a long term follow up are advised to further explore the role of PLA coated antibiotic nails in open tibial fractures.
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Affiliation(s)
- Anubhav Malhotra
- Trauma & Orthopaedics, Wirral University Teaching Hospitals NHS Trust, UK
| | - Anant Krishna
- Department of Orthopaedics, SGT Medical College Hospital, Gurugram, India
| | - Sudhir Kumar Garg
- Department of Orthopaedics, Government Medical College & Hospital, Chandigarh, India
| | | | - Rohit Jindal
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Gunjar Jain
- Department of Orthopaedics. AIIMS, Bhubneswar, India
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Walter N, Rupp M, Krückel J, Alt V. Individual and commercially available antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions - a systematic review. Injury 2022; 53 Suppl 3:S74-S80. [PMID: 35613970 DOI: 10.1016/j.injury.2022.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
The treatment of infected non-unions of the femur and the tibia remains difficult and requires control of the infection and successful bone healing. Antimicrobial coating of intramedullary nails promises both infection control and stabilization for subsequent bone healing. Both results for custom-made and commercially available antimicrobial coating for intramedullary nails have been published in the past mainly consisting of retrospective case series. The purpose of this work is to review the published literature on techniques and clinical outcome of antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions. A systematic literature research in Medline, PubMed, Embase and Cochrane Library was performed in accordance to the PRISMA guidelines. Articles reporting on antimicrobial-coated intramedullary nails for the treatment of infected long bone non-unions were eligible for inclusion. In total, 22 publications were found reporting on 506 infected non-unions of the tibia and femur treated with an antimicrobial-coated nail. Most of them consisted of retrospective case series (72.7%). 469 and 37 patients were treated with an individual antibiotic-loaded PMMA-coating and commercially available gentamicin-coating for intramedullary nails, respectively. The overall infection eradication rate was 90.0% (range 68.7-100%) and the bone consolidation rate was 85.5% (range 57.9-100%). Coating specific side effects were not reported. In conclusion, the treatment of infected long bone non-unions with antimicrobial-coated nails is associated with a high infection control and bone consolidation rate and seems to be a reasonable treatment options with minimal side effects. However, scientific quality of the publications is low and randomized controlled trials are needed.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany
| | - Jonas Krückel
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany.
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Buckman SA, Forrester JD, Bessoff KE, Parli SE, Evans HL, Huston JM. Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surg Infect (Larchmt) 2022; 23:817-828. [DOI: 10.1089/sur.2022.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara A. Buckman
- Division of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Kovi E. Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Sara E. Parli
- Department of Pharmacy Services, University of Kentucky, Lexington, Kentucky, USA
| | - Heather L. Evans
- Division of General and Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jared M. Huston
- Departments of Surgery and Science Education, Zucker School of Medicine, Northwell Health, Manhasset, New York, USA
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Rohilla R, Arora S, Kundu A, Singh R, Govil V, Khokhar A. Functional and radiological outcomes of primary ring fixator versus antibiotic nail in open tibial diaphyseal fractures: A prospective study. Injury 2022; 53:3464-3470. [PMID: 36008173 DOI: 10.1016/j.injury.2022.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/25/2022] [Accepted: 08/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Management of open fractures of tibia is still a matter of debate due to high incidence of infections. Traditionally external fixators have been advocated in managing open tibial fractures. Due to limited efficacy of systemic antibiotics, recently antibiotic coated intramedullary interlocking nails have been developed for the management of open tibia fractures. Therefore, we conducted this prospective randomized study to compare the functional and radiological outcomes of primary ring fixator versus antibiotic coated nail in open diaphyseal tibial fractures. METHODS The study included 32 patients with Gustilo-Anderson type II and type IIIA fractures of tibial diaphysis. Out of them 16 patients were managed with Ring External Fixator (Group I) and 16 were managed with OssiproÒ gentamicin intramedullary interlocking tibial nail (Group II). The radiological and functional outcomes were assessed at final follow-up according to and SMFA criteria. Statistical analysis of the data was performed using IBM SPSS statistics 2.0 software. Chi square test and independent student t-test were used and a P value <0.05 was considered statistically significant RESULTS: Union was achieved in 15 patients (93.8%) in group I and 13 patients (81.2%) in group II. Pin tract infection was seen in 6 patients (37.5%) in group I, whereas infection was present in 2 patients (12.5%) in group II. Bone results were excellent in 13 patients (81.3%), good in 2 patients (12.5%), poor in one patient (6.3%). In group II, bone results were excellent in 12 patients (75%), good in one patient (6.2%), poor in 3 patients (18.8%). At 1 year of final follow up, mean SMFA score was 24.41±5.87 in group I, whereas mean SMFA score was 23.703±8.02 in group II. CONCLUSION Ring fixator as well as antibiotic coated tibial interlocking nail achieved comparable rates of union in the present study. Complication rates were similar in both the groups and the functional and radiological outcomes were comparable in both groups. Results of this study indicate that although ring fixation is an established option for management of open tibial fractures, antibiotic-coated intramedullary nail is also a reliable option in open Grade II and grade IIIA injuries. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Rajesh Rohilla
- Department of Sports Medicine, Pt. BD Sharma PGIMS, Rohtak, India
| | - Sahil Arora
- Department of Orthopedics, Pt. BD Sharma PGIMS, Rohtak, India.
| | - Ankush Kundu
- Department of Orthopedics, Pt. BD Sharma PGIMS, Rohtak, India
| | - Roop Singh
- Department of Orthopedics, Pt. BD Sharma PGIMS, Rohtak, India
| | - Vasudha Govil
- Department of Anaesthesia, Pt. BD Sharma PGIMS, Rohtak, India
| | - Arya Khokhar
- Homestead High School, Cupertino, CA 95014, United States
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Steflik MJ, Griswold BG, Patel DV, Blair JA, Davis JM. Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAⅢ open tibia fractures. Injury 2022; 53:3471-3474. [PMID: 35948512 DOI: 10.1016/j.injury.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures. METHODS A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT). RESULTS Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714). CONCLUSION This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.
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Affiliation(s)
- Michael J Steflik
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States.
| | - B Gage Griswold
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
| | - Dhara V Patel
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
| | - James A Blair
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
| | - Jana M Davis
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, United States
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13
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Miwa S, Yamamoto N, Hayashi K, Takeuchi A, Igarashi K, Tsuchiya H. Surgical Site Infection after Bone Tumor Surgery: Risk Factors and New Preventive Techniques. Cancers (Basel) 2022; 14:cancers14184527. [PMID: 36139686 PMCID: PMC9497226 DOI: 10.3390/cancers14184527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
The management of malignant bone tumors requires multidisciplinary interventions including chemotherapy, radiation therapy, and surgical tumor resection and reconstruction. Surgical site infection (SSI) is a serious complication in the treatment of malignant bone tumors. Compared to other orthopedic surgeries, the surgical treatment of malignant bone tumors is associated with higher rates of SSIs. In patients with SSIs, additional surgeries, long-term administrations of antibiotics, extended hospital stays, and the postponement of scheduled adjuvant treatments are required. Therefore, SSI may adversely affect functional and oncological outcomes. To improve surgical outcomes in patients with malignant bone tumors, preoperative risk assessments for SSIs, new preventive techniques against SSIs, and the optimal use of prophylactic antibiotics are often required. Previous reports have demonstrated that age, tumor site (pelvis and tibia), extended operative time, implant use, body mass index, leukocytopenia, and reconstruction procedures are associated with an increased risk for SSIs. Furthermore, prophylactic techniques, such as silver and iodine coatings on implants, have been developed and proven to be efficacious and safe in clinical studies. In this review, predictive factors of SSIs and new prophylactic techniques are discussed.
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14
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Patel KH, Galanis A, Balasubramanian P, Iliadis AD, Heidari N, Vris A. A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03338-4. [PMID: 35943591 DOI: 10.1007/s00590-022-03338-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. METHODS Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. RESULTS One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. CONCLUSION Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.
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Affiliation(s)
- Kavi H Patel
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK.
| | | | - Prabu Balasubramanian
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Alexios D Iliadis
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Nima Heidari
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - Alex Vris
- Limb Reconstruction and Bone Infection Service, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
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15
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3D-Printed Gentamicin-Releasing Poly-ε-Caprolactone Composite Prevents Fracture-Related Staphylococcus aureus Infection in Mice. Pharmaceutics 2022; 14:pharmaceutics14071363. [PMID: 35890261 PMCID: PMC9320525 DOI: 10.3390/pharmaceutics14071363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 12/07/2022] Open
Abstract
Bacterial infections are a serious healthcare complication in orthopedic and trauma surgery worldwide. Compared to systemic, local antibiotic prophylaxis has been shown to provide a higher antibiotic dose and bioavailability at the bone site with minimum toxic effects. However, there are still not enough biomaterial and antibiotic combinations available for personalized implant sizes for patients. The aim of this study was to develop a bone fixation plate coating made of a composite of poly-ε-caprolactone, hydroxyapatite and halloysite nanotubes loaded with gentamicin sulphate and fabricated via fused filament fabrication 3D printing technology. The mechanical and thermal properties of the biomaterial were analyzed. The in vitro release kinetics of gentamicin sulphate were evaluated for 14 days showing a burst release during the first two days that was followed by a sustained release of bactericidal concentrations. The composite loaded with 2 and 5% gentamicin sulphate exhibited complete antimicrobial killing of Staphylococcus aureus in an ex vivo mouse femur fixation plate infection model. Moreover, a fixation plate of the composite loaded with 5% of gentamicin sulphate was able to prevent S. aureus infection in the bone and surrounding tissue in an in vivo mouse bone fixation plate infection model 3 days post-surgery. In conclusion, the newly developed composite material successfully prevented infection in vivo. Additionally, the ability to use fused filament fabrication 3D printing to produce patient-specific implants may provide a wider range of personalized solutions for patients.
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16
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Cao H, Qiao S, Qin H, Jandt KD. Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges. J Funct Biomater 2022; 13:jfb13030086. [PMID: 35893454 PMCID: PMC9326756 DOI: 10.3390/jfb13030086] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/12/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022] Open
Abstract
The uses of implantable medical devices are safer and more common since sterilization methods and techniques were established a century ago; however, device-associated infections (DAIs) are still frequent and becoming a leading complication as the number of medical device implantations keeps increasing. This urges the world to develop instructive prevention and treatment strategies for DAIs, boosting the studies on the design of antibacterial surfaces. Every year, studies associated with DAIs yield thousands of publications, which here are categorized into four groups, i.e., antibacterial surfaces with long-term efficacy, cell-selective capability, tailored responsiveness, and immune-instructive actions. These innovations are promising in advancing the solution to DAIs; whereas most of these are normally quite preliminary “proof of concept” studies lacking exact clinical scopes. To help identify the flaws of our current antibacterial designs, clinical features of DAIs are highlighted. These include unpredictable onset, site-specific incidence, and possibly involving multiple and resistant pathogenic strains. The key point we delivered is antibacterial designs should meet the specific requirements of the primary functions defined by the “intended use” of an implantable medical device. This review intends to help comprehend the complex relationship between the device, pathogens, and the host, and figure out future directions for improving the quality of antibacterial designs and promoting clinical translations.
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Affiliation(s)
- Huiliang Cao
- Interfacial Electrochemistry and Biomaterials, School of Materials Science and Engineering, East China University of Science and Technology, Shanghai 200237, China
- Lab of Low-Dimensional Materials Chemistry, Key Laboratory for Ultrafine Materials of Ministry of Education, East China University of Science & Technology, Shanghai 200237, China
- Chair of Materials Science, Otto Schott Institute of Materials Research (OSIM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| | - Shichong Qiao
- Department of Implant Dentistry, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- National Clinical Research Center for Oral Diseases, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai 200011, China
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| | - Hui Qin
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People’s Hospital, Shanghai 200233, China
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| | - Klaus D. Jandt
- Chair of Materials Science, Otto Schott Institute of Materials Research (OSIM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Jena Center for Soft Matter (JCSM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Jena School for Microbial Communication (JSMC), Neugasse 23, 07743 Jena, Germany
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
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17
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Simplified Antibiotic-Coated Plating for Infected Nonunion, Fracture-Related Infection, and Single-Stage Prophylactic Fixation. J Orthop Trauma 2022; 36:e255-e259. [PMID: 35703848 DOI: 10.1097/bot.0000000000002270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 02/02/2023]
Abstract
Antibiotic-coated implants are increasing in prevalence in the treatment of fracture-related infections. Coated plates may be desirable in certain anatomic locations or to augment nail fixation. We describe a simple, reproducible technique for the fabrication of antibiotic-coated plates and our initial results of a small case series.
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18
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Development of Silver-Containing Hydroxyapatite-Coated Antimicrobial Implants for Orthopaedic and Spinal Surgery. Medicina (B Aires) 2022; 58:medicina58040519. [PMID: 35454358 PMCID: PMC9029955 DOI: 10.3390/medicina58040519] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022] Open
Abstract
The prevention of surgical site infections is directly related to the minimization of surgical invasiveness, and is in line with the concept of minimally invasive spine therapy (MIST). In recent years, the incidence of postoperative infections has been increasing due to the increased use of spinal implant surgery in patients at high risk of infection, including the elderly and easily infected hosts, the limitations of poor bone marrow transfer of antibiotics, and the potential for contamination of surgical gloves and instruments. Thus, the development of antimicrobial implants in orthopedic and spinal surgery is becoming more and more popular, and implants with proven antimicrobial, safety, and osteoconductive properties (i.e., silver, iodine, antibiotics) in vitro, in vivo, and in clinical trials have become available for clinical use. We have developed silver-containing hydroxyapatite (Ag-HA)-coated implants to prevent post-operative infection, and increase bone fusion capacity, and have successfully commercialized antibacterial implants for hip prostheses and spinal interbody cages. This narrative review overviews the present status of available surface coating technologies and materials; describes how the antimicrobial, safety, and biocompatibility (osteoconductivity) of Ag-HA-coated implants have been demonstrated for commercialization; and reviews the clinical use of antimicrobial implants in orthopedic and spinal surgery, including Ag-HA-coated implants that we have developed.
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Janko M, Dust F, Wagner PV, Gurke R, Frank J, Henrich D, Marzi I, Verboket RD. Local Fixation of Colistin With Fibrin Spray: An in vivo Animal Study for the Therapy of Skin and Soft Tissue Infections. Front Surg 2022; 9:749600. [PMID: 35372468 PMCID: PMC8968937 DOI: 10.3389/fsurg.2022.749600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Skin and soft tissue infections (SSTI) are a commonly known entity of diseases associated with difficult treatment procedures. The current gold standard when there is a rapidly progressing infection of soft tissues with a risk of sepsis is radical surgical debridement accompanied by systemic antibiotic therapy. In clinical settings, local antibiotics alone or formulated within carrier material are commonly used alongside this therapy regimen. One possibility of local antibiotic application is the fixation of colistin with fibrin glue spray. It is not yet sufficiently researched how the local antibiotic concentrations remain as high as possible over time. Methods We conducted an animal study including 29 male Wistar rats inducing sterile back sores reaching the muscle fascia. We sprayed only colistin, simultaneously or consecutively, with fibrin glue in different groups in order to measure the tissue concentration of the antibiotic applied locally. Results After liquid chromatography and quadrupole mass spectrometry analysis, it could be demonstrated that in comparison to the colistin group, tissue concentrations of colistin stayed significantly higher in the wound tissue when it was fixed with fibrin glue. This was observed in both groups, the simultaneous as well as in the consecutively fibrin glue sprayed groups after colistin application. Conclusion The fixation of colistin with the fibrin-glue-spray technique as a carrier for local antibiotic therapy is an easy and inexpensive method and shows promising potential for the treatment of SSTI.
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Affiliation(s)
- Maren Janko
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
- *Correspondence: Maren Janko
| | - Fabian Dust
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - Pia Viktoria Wagner
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt, Germany
| | - Robert Gurke
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt, Germany
- Pharmazentrumfrankfurt/ZAFES, Department of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Johannes Frank
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - Dirk Henrich
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - René Danilo Verboket
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
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20
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Lopas LA, Albertson S, Solomon E, Watson DT, Shah AR, Maxson BJ, Infante AF, Donohue D, Downes KL, Sanders RW, Mir HR. Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion. J Orthop Trauma 2022; 36:44-50. [PMID: 34554718 DOI: 10.1097/bot.0000000000002215] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion. DESIGN Retrospective chart review. SETTING Level 1 trauma center. PARTICIPANTS Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant. INTERVENTION Surgical debridement and placement of a type of antibiotic-coated intramedullary implant. MAIN OUTCOME MEASUREMENTS Union and need for reoperation. RESULTS At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods. CONCLUSIONS Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Perisano C, Greco T, Polichetti C, Inverso M, Maccauro G. Antibiotic-Coated Nail in Open Tibial Fracture: A Retrospective Case Series. J Funct Morphol Kinesiol 2021; 6:97. [PMID: 34940506 PMCID: PMC8704641 DOI: 10.3390/jfmk6040097] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 12/26/2022] Open
Abstract
Implant-associated infections still represent one of the main problems in treatment of open fracture. The role of systemic antibiotic prophylaxis is now agreed and accepted; however, recent literature seems to underline the importance of local antibiotic therapy at the fracture site, and antibiotic nails have been shown to play a role in the treatment of open fractures in terms of fracture healing and lower risk of infection. We retrospectively analyzed our results, from January 2016 to March 2020, with the use of coated nails in the treatment of open tibial fractures, evaluating the rates of infection and fracture healing as primary outcomes and the rate of reoperations, time from trauma to nailing and hospital stay as secondary outcomes. Thirty-eight patients treated with coated nail (ETN ProtectTM, Synthes) were included in the study. Minimum follow-up was of 18 months. Thirty-four of 38 patients achieved bone union and 2 patients underwent septic non-union. In our series, no systemic toxicity or local hypersensitivity to antibiotics were recorded. From this study, use of antibiotic-coated nails appears to be a valid and safe option for treatment of open tibial fractures and prevention of implant-related infections, particularly in tibial fractures with severe soft tissue exposure and impairment.
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Affiliation(s)
- Carlo Perisano
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.P.); (C.P.); (M.I.); (G.M.)
| | - Tommaso Greco
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.P.); (C.P.); (M.I.); (G.M.)
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Chiara Polichetti
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.P.); (C.P.); (M.I.); (G.M.)
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michele Inverso
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.P.); (C.P.); (M.I.); (G.M.)
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulio Maccauro
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (C.P.); (C.P.); (M.I.); (G.M.)
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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22
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Greco T, Cianni L, Polichetti C, Inverso M, Maccauro G, Perisano C. Uncoated vs. Antibiotic-Coated Tibia Nail in Open Diaphyseal Tibial Fracture (42 according to AO Classification): A Single Center Experience. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7421582. [PMID: 34692841 PMCID: PMC8531764 DOI: 10.1155/2021/7421582] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022]
Abstract
Implant-associated infections remain one of the main problems in the treatment of open tibia fractures. The role of systemic antibiotic prophylaxis is now agreed and accepted; nevertheless, recent literature also seems to emphasize the importance of local antibiotic therapy at the fracture site. Several therapeutic strategies have been proposed to overcome this new need. Antibiotic-coated nails play crucial role in this, allowing both infection prevention and favoring the fracture stabilization. We describe the outcome of patients with open diaphyseal tibia fracture treated either with a standard uncoated nail or a gentamicin-coated nail from January 2016 to December 2018 at our second level emergency-urgency department. Primary outcomes were infection rate and bone union rate. Other outcomes reported are reoperation rate, time between injury and nailing, and safety of antibiotic nail. Numerical variables were tabulated using mean, standard deviation, minimum, maximum, and number of observations. Categorical variables were tabulated using number of observations. 23 patients treated with uncoated nail and 23 patients treated with antibiotic-coated tibia nail were included in the study and were evaluated for a minimum follow-up of 18 months. Among the 46 patients, 9 were Gustilo-Anderson type I, 21 type II, and 16 type III open fracture. Regarding the bone healing rate at 12 months, 16 fractures in the first group and 18 in the second were completely healed. 4 infections were found in the first group (3 superficial surgical site infection and 1 osteomyelitis) and 3 superficial infections in the second one. No adverse events have been recorded with antibiotic-coated nails. In this unicentric retrospective study observed no deep wound infections and good fracture healing in the use of antibiotic-coated nails. Antibiotic nails have been shown to play a role in the treatment of fractures in critically ill patients with severe soft tissue damage.
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Affiliation(s)
- Tommaso Greco
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Luigi Cianni
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Chiara Polichetti
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Michele Inverso
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Giulio Maccauro
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
- Orthopedics and Traumatology, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Carlo Perisano
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome 00168, Italy
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De Meo D, Ceccarelli G, Iaiani G, Lo Torto F, Ribuffo D, Persiani P, Villani C. Clinical Application of Antibacterial Hydrogel and Coating in Orthopaedic and Traumatology Surgery. Gels 2021; 7:gels7030126. [PMID: 34462412 PMCID: PMC8406094 DOI: 10.3390/gels7030126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023] Open
Abstract
Implant related infection is one of the most frequent complications in orthopaedic and trauma surgery. Local antibiotic treatment strategies are becoming part of the prevention and treatment methodology for this fearful complication. To date, there are two coatings available on the market, both with a polylactic acid base. Current evidence supports the use of these types of coatings in the prophylaxis of periprosthetic infections and fracture-related infections. However, their therapeutic use has been less investigated. The purpose of this article is to summarise recent evidence relating to the clinical application of antibacterial hydrogels and coatings in orthopaedic and traumatology surgery and indicating which future applications may benefit from it.
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Affiliation(s)
- Daniele De Meo
- Orthopaedic and Traumatology Unit, Department of General Surgery, Plastic Surgery, Orthopedics, Policlinico Umberto I Hospital—Sapienza, University of Rome, Piazzale A. Moro 3, 00185 Rome, Italy; (P.P.); (C.V.)
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161 Rome, Italy; (G.C.); (G.I.); (F.L.T.); (D.R.)
- Correspondence: ; Tel.: +39-33-3874-5373
| | - Giancarlo Ceccarelli
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161 Rome, Italy; (G.C.); (G.I.); (F.L.T.); (D.R.)
- Department of Public Health and Infectious Diseases—Sapienza, University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy
| | - Giancarlo Iaiani
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161 Rome, Italy; (G.C.); (G.I.); (F.L.T.); (D.R.)
- Department of Public Health and Infectious Diseases—Sapienza, University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy
| | - Federico Lo Torto
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161 Rome, Italy; (G.C.); (G.I.); (F.L.T.); (D.R.)
- Plastic Surgery Unit, Department of General Surgery, Plastic Surgery, Orthopedics, Policlinico Umberto I Hospital—Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Diego Ribuffo
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161 Rome, Italy; (G.C.); (G.I.); (F.L.T.); (D.R.)
- Plastic Surgery Unit, Department of General Surgery, Plastic Surgery, Orthopedics, Policlinico Umberto I Hospital—Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Pietro Persiani
- Orthopaedic and Traumatology Unit, Department of General Surgery, Plastic Surgery, Orthopedics, Policlinico Umberto I Hospital—Sapienza, University of Rome, Piazzale A. Moro 3, 00185 Rome, Italy; (P.P.); (C.V.)
| | - Ciro Villani
- Orthopaedic and Traumatology Unit, Department of General Surgery, Plastic Surgery, Orthopedics, Policlinico Umberto I Hospital—Sapienza, University of Rome, Piazzale A. Moro 3, 00185 Rome, Italy; (P.P.); (C.V.)
- M.I.T.O. (Infections in Traumatology and Orthopedics Surgery) Study Group, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161 Rome, Italy; (G.C.); (G.I.); (F.L.T.); (D.R.)
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Review on Surface Treatment for Implant Infection via Gentamicin and Antibiotic Releasing Coatings. COATINGS 2021. [DOI: 10.3390/coatings11081006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Surface treatment of metallic implants plays a crucial role in orthopedics and orthodontics. Metallic implants produce side-effects such as physical, chemical/electro-chemical irritations, oligodynamic/catalytic and carcinogenic effects. These effects cause bacterial infections and account for huge medical expenses. Treatment for these infections comprises repeated radical debridement, replacement of the implant device and intravenous or oral injection antibiotics. Infection is due to the presence of bacteria in the patient or the surrounding environment. The antibiotic-based medication prevents prophylaxis against bacterial colonization, which is an emphatic method that may otherwise be catastrophic to a patient. Therefore, preventive measures are essential. A coating process was developed with its drug infusion and effect opposing biofilms. Modification in the medical implant surface reduces the adhesion of bacterial and biofilms, the reason behind bacterial attachment. Other polymer-based and nanoparticle-based carriers are used to resolve implant infections. Therefore, using an implant coating is a better approach to prevent infection due to biofilm.
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Goh GS, Tornetta P, Parvizi J. Facilitating the Approval Process of Anti-Infective Technologies and Advancing Them to the Market: Insights from an FDA Workshop on Orthopaedic Device-Related Infections. J Bone Joint Surg Am 2021; 103:e57. [PMID: 34357892 DOI: 10.2106/jbjs.21.00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Orthopaedic device-related infection is one of the most devastating complications in orthopaedic and trauma surgery. With increasing life expectancies as well as the lifelong risk of bacterial seeding on an implant, the prevention and treatment of device-related infection remains an important area for research and development. To facilitate information exchange and enhance collaboration among various stakeholders in the orthopaedic community, the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) organized an inaugural workshop on orthopaedic device-related infections, exploring the regulatory challenges that are faced when proceeding from the bench level to marketing and clinical implementation of new infection-control devices and products. This article summarizes the perspectives of scientists, clinicians, and industry partners on the current regulatory approval process for orthopaedic anti-infective technologies as well as the proposed strategies to overcome these regulatory challenges.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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26
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Wong Wei Kang N, Tan WPJ, Phua YMC, Min ATG, Naidu K, Umapathysivam K, Smitham PJ. Intramedullary nail: the past, present and the future - a review exploring where the future may lead us. Orthop Rev (Pavia) 2021; 13:25546. [PMID: 34745479 PMCID: PMC8567815 DOI: 10.52965/001c.25546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/02/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intramedullary nails (IMNs) are the current gold standard treatment for long bone diaphyseal and selected metaphyseal fractures. The design of IMNs has undergone many revisions since its invention in the 16th century, with a dramatic increase in novel designs in recent years aiming to further improve intramedullary fixation techniques. AIMS To map the evolution of IMNs in orthopedic surgery, discuss the limitations and complications of current IMNs and identify novel IMNs that may influence future design innovations. METHODS We undertook a scoping review on the status of orthopedic IMNs by reviewing Google Scholar with the following keywords. Publications and patents selected for retrieval were initially assessed on the title and abstract by five independent reviewers. 52 papers were retrieved for complete text examination, and secondary references were checked from these papers. The results were discussed within the research group and consensus was obtained describing novel IMNs. RESULTS Novel IMN designs include growth factor and/or antimicrobial coatings targeting fracture healing and perioperative infection risk, respectively; minimally invasive expandable IMNs to avoid the need for interlocking screws; and novel materials such as carbon fiber for their theoretically superior biomechanical properties and avoidance of artifact on CT and MRI imaging. CONCLUSION The novel IMNs proposed in recent years collectively aim to improve intramedullary fixation techniques by reducing operative time and radiation exposure, improving fracture healing or monitoring bone cancer progression. However, more research and development are necessary to solve these complex problems.
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Affiliation(s)
| | | | | | | | | | | | - Peter Jonathan Smitham
- Adelaide Medical School; Department of Orthopedics and Trauma, Royal Adelaide Hospital & Discipline of Orthopedics & Trauma, The University of Adelaide
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Franz D, Raschke M, Giannoudis PV, Leliveld M, Metsemakers WJ, Verhofstad MHJ, Craig JA, Shore J, Smith A, Muehlendyck C, Kerstan M, Fuchs T. Use of antibiotic coated intramedullary nails in open tibia fractures: A European medical resource use and cost-effectiveness analysis. Injury 2021; 52:1951-1958. [PMID: 34001375 DOI: 10.1016/j.injury.2021.04.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/01/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE In patients with open tibial fractures, bone and wound infections are associated with an increased hospital length of stay and higher costs. The infection risk increases with the use of implants. Innovations to reduce this risk include antibiotic-coated implants. This study models whether the use of a gentamicin-coated intramedullary tibial nail is cost-effective for trauma centers managing patients with a high risk of infection. EFFICACY Absolute infection risk and relative risk reduction, by fracture grade, for antibiotic-coated nails compared to standard nails for patients with open tibial fractures were estimated based on the results of a meta-analysis, which assessed the additional benefit of locally-administered prophylactic antibiotics in open tibia fractures treated with implants. The observed efficacy of antibiotic-coated nails in reducing infections was applied in an economic model. METHODS The model compared infection rates, inpatient days, theatre usage and costs in high risk patients, with a Gustilo-Anderson (GA) grade III open fracture, for two patient cohorts from a trauma center perspective, with a 1-year time horizon. In one cohort all GAIII patients received a gentamicin-coated nail whilst GAI and GAII patients received a standard nail. All patients in the comparator cohort received a standard nail. Four European trauma centers provided patient-level data (n=193) on inpatient days, procedures and related costs for patients with and without infections. RESULTS Using the gentamicin-coated nail in patients at high risk of infection (GAIII) was associated with 75% lower rate of infection and cost savings (€477 - €3.263) for all included centers; the higher cost of the implant was offset by savings from fewer infections, inpatient days (-26%) and re-operations (-10%). This result was confirmed by extensive sensitivity analyses. CONCLUSIONS Analyses demonstrated that infection rates and total costs for in-hospital treatment could be potentially reduced by 75% and up to 15% respectively, by using a gentamicin-coated nail in patients at high risk of infection. Fewer infections, reduced inpatient days and re-operations may be potentially associated with use of antibiotic-coated implants. Results are sensitive to the underlying infection risk, with greatest efficacy and cost-savings when the coated implant is used in high risk patients.
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Affiliation(s)
- D Franz
- Franz und Wenke, Beratung im Gesundheitswesen GbR, Technologiehof Mendelstraße 11, 48149 Münster, Germany.
| | - M Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Germany.
| | - P V Giannoudis
- Department of Trauma and Orthopaedic Surgery, University Hospital of Leeds, England.
| | - M Leliveld
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - J A Craig
- York Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - J Shore
- York Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - A Smith
- Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - C Muehlendyck
- J&J, Hummelsbutteler Steindamm 71, 22851 Norderstedt, Germany.
| | - M Kerstan
- J&J, Synthes GmbH, Luzernstrasse 21, 4528 Zuchwil, Switzerland.
| | - T Fuchs
- Vivantes Klinikum im Friedrichshain, Zentrum für Muskuloskelettale Medizin, Klinik für Orthopädie, Unfall-, Hand- und Wiederherstellungschirurgie Standort Landsberger Allee 49, 10249 Berlin, Germany.
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28
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Treatment of severely open tibial fractures, non-unions, and fracture-related infections with a gentamicin-coated tibial nail-clinical outcomes including quality of life analysis and psychological ICD-10-based symptom rating. J Orthop Surg Res 2021; 16:270. [PMID: 33865407 PMCID: PMC8052745 DOI: 10.1186/s13018-021-02411-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Implant-associated infections depict a major challenge in orthopedics and trauma surgery putting a high burden on the patients and health care systems, strongly requiring improvement of infection prevention and of clinical outcomes. One strategy includes the usage of antimicrobial-coated implants. We evaluated outcomes after surgical treatment using a gentamicin-coated nail on (i) treatment success in terms of bone consolidation, (ii) absence of infection, and (iii) patient-reported quality of life in a patient cohort with high risk of infection/reinfection and treatment failure. METHODS Thirteen patients with open tibia fractures (n = 4), non-unions (n = 2), and fracture-related infection (n = 7) treated with a gentamicin-coated intramedullary nail (ETN ProtectTM) were retrospectively reviewed. Quality of life was evaluated with the EQ-5D, SF-36, and with an ICD-10-based symptom rating (ISR). RESULTS At a mean follow-up of 2.8 years, 11 of the 13 patients (84.6%) achieved bone consolidation without any additional surgical intervention, whereas two patients required a revision surgery due to infection and removal of the implant. No specific implant-related side effects were noted. Quality of life scores were significantly lower compared to a German age-matched reference population. The mean ISR scores revealed mild psychological symptom burden on the scale depression. CONCLUSION The use of a gentamicin-coated intramedullary nail seems to be reasonable in open fractures and revision surgery for aseptic non-union or established fracture-related infection to avoid infection complications and to achieve bony union. Despite successful treatment of challenging cases with the gentamicin-treated implant, significantly reduced quality of life after treatment underlines the need of further efforts to improve surgical treatment strategies and psychological support.
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Nichol T, Callaghan J, Townsend R, Stockley I, Hatton PV, Le Maitre C, Smith TJ, Akid R. The antimicrobial activity and biocompatibility of a controlled gentamicin-releasing single-layer sol-gel coating on hydroxyapatite-coated titanium. Bone Joint J 2021; 103-B:522-529. [PMID: 33641411 PMCID: PMC7954144 DOI: 10.1302/0301-620x.103b3.bjj-2020-0347.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Aims The aim of this study was to develop a single-layer hybrid organic-inorganic sol-gel coating that is capable of a controlled antibiotic release for cementless hydroxyapatite (HA)-coated titanium orthopaedic prostheses. Methods Coatings containing gentamicin at a concentration of 1.25% weight/volume (wt/vol), similar to that found in commercially available antibiotic-loaded bone cement, were prepared and tested in the laboratory for: kinetics of antibiotic release; activity against planktonic and biofilm bacterial cultures; biocompatibility with cultured mammalian cells; and physical bonding to the material (n = 3 in all tests). The sol-gel coatings and controls were then tested in vivo in a small animal healing model (four materials tested; n = 6 per material), and applied to the surface of commercially pure HA-coated titanium rods. Results The coating released gentamicin at > 10 × minimum inhibitory concentration (MIC) for sensitive staphylococcal strains within one hour thereby potentially giving effective prophylaxis for arthroplasty surgery, and showed > 99% elution of the antibiotic within the coating after 48 hours. There was total eradication of both planktonic bacteria and established bacterial biofilms of a panel of clinically relevant staphylococci. Mesenchymal stem cells adhered to the coated surfaces and differentiated towards osteoblasts, depositing calcium and expressing the bone marker protein, osteopontin. In the in vivo small animal bone healing model, the antibiotic sol-gel coated titanium (Ti)/HA rod led to osseointegration equivalent to that of the conventional HA-coated surface. Conclusion In this study we report a new sol-gel technology that can release gentamicin from a bioceramic-coated cementless arthroplasty material. In vitro, local gentamicin levels are in excess of what can be achieved by antibiotic-loaded bone cement. In vivo, bone healing in an animal model is not impaired. This, thus, represents a biomaterial modification that may have the potential to protect at-risk patients from implant-related deep infection. Cite this article: Bone Joint J 2021;103-B(3):522–529.
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Affiliation(s)
- Tim Nichol
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Jill Callaghan
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Robert Townsend
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Ian Stockley
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Paul V Hatton
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Christine Le Maitre
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Thomas John Smith
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Robert Akid
- Department of Materials, University of Manchester, Manchester, UK
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Schwarz EM, McLaren AC, Sculco TP, Brause B, Bostrom M, Kates SL, Parvizi J, Alt V, Arnold WV, Carli A, Chen AF, Choe H, Coraça‐Huber DC, Cross M, Ghert M, Hickok N, Jennings JA, Joshi M, Metsemakers W, Ninomiya M, Nishitani K, Oh I, Padgett D, Ricciardi B, Saeed K, Sendi P, Springer B, Stoodley P, Wenke JC. Adjuvant antibiotic-loaded bone cement: Concerns with current use and research to make it work. J Orthop Res 2021; 39:227-239. [PMID: 31997412 PMCID: PMC7390691 DOI: 10.1002/jor.24616] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 02/04/2023]
Abstract
Antibiotic-loaded bone cement (ALBC) is broadly used to treat orthopaedic infections based on the rationale that high-dose local delivery is essential to eradicate biofilm-associated bacteria. However, ALBC formulations are empirically based on drug susceptibility from routine laboratory testing, which is known to have limited clinical relevance for biofilms. There are also dosing concerns with nonstandardized, surgeon-directed, hand-mixed formulations, which have unknown release kinetics. On the basis of our knowledge of in vivo biofilms, pathogen virulence, safety issues with nonstandardized ALBC formulations, and questions about the cost-effectiveness of ALBC, there is a need to evaluate the evidence for this clinical practice. To this end, thought leaders in the field of musculoskeletal infection (MSKI) met on 1 August 2019 to review and debate published and anecdotal information, which highlighted four major concerns about current ALBC use: (a) substantial lack of level 1 evidence to demonstrate efficacy; (b) ALBC formulations become subtherapeutic following early release, which risks induction of antibiotic resistance, and exacerbated infection from microbial colonization of the carrier; (c) the absence of standardized formulation protocols, and Food and Drug Administration-approved high-dose ALBC products to use following resection in MSKI treatment; and (d) absence of a validated assay to determine the minimum biofilm eradication concentration to predict ALBC efficacy against patient specific micro-organisms. Here, we describe these concerns in detail, and propose areas in need of research.
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Affiliation(s)
- Edward M. Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Alex C. McLaren
- Department of Orthopaedic Surgery, College of Medicine‐Phoenix University of Arizona Phoenix Arizona
| | - Thomas P. Sculco
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Barry Brause
- Department of Infectious Diseases, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Mathias Bostrom
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Stephen L. Kates
- Department of Orthopaedic Surgery Virginia Commonwealth University Richmond Virginia
| | - Javad Parvizi
- Department of Orthopaedics Rothman Institute at Thomas Jefferson University Hospital Philadelphia Pennsylvania
| | - Volker Alt
- Department of Trauma Surgery University Medical Centre Regensburg Regensburg Germany
| | - William V. Arnold
- Department of Orthopaedics Rothman Institute at Thomas Jefferson University Hospital Philadelphia Pennsylvania
| | - Alberto Carli
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Antonia F. Chen
- Department of Orthopaedics, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
| | - Hyonmin Choe
- Department of Orthopaedic Yokohama City University Yokohama Japan
| | - Débora C. Coraça‐Huber
- Department of Orthopaedic Surgery, Experimental Orthopedics, Research Laboratory for Biofilms and Implant Associated Infections Medical University of Innsbruck Innsbruck Austria
| | - Michael Cross
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery McMaster University Hamilton Ontario Canada
| | - Noreen Hickok
- Department of Orthopaedic Surgery, Department of Biochemistry & Molecular Biology Thomas Jefferson University Philadelphia Pennsylvania
| | | | - Manjari Joshi
- Division of Infectious Diseases, R Adams Cowley Shock Trauma Center University of Maryland Baltimore Maryland
| | | | - Mark Ninomiya
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Kohei Nishitani
- Department of Orthopaedic Surgery Graduate School of Medicine, Kyoto University Sakyo Kyoto Japan
| | - Irvin Oh
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Douglas Padgett
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Benjamin Ricciardi
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Kordo Saeed
- Southampton University Hospitals NHS Foundation Trust, Department of Microbiology, Microbiology and Innovation Research Unit (MIRU) and University of Southampton, School of Medicine Southampton UK
| | - Parham Sendi
- Institute for Infectious Diseases University of Bern, Bern and Department of Infectious Diseases, Hospital Epidemiology and Department of Orthopaedics and Traumatology, University of Basel Basel Switzerland
- Department of Orthopaedics and Traumatology University Hospital Basel Basel Switzerland
| | - Bryan Springer
- Department of Orthopaedic Surgery, OrthoCarolina Hip and Knee Center Atrium Musculoskeletal Institute Charlotte North Carolina
| | - Paul Stoodley
- Department of Microbial Infection and Immunity and Orthopaedics The Ohio State University Columbus Ohio
| | - Joseph C. Wenke
- Orthopaedic Trauma Department U.S. Army Institute of Surgical Research Fort Sam Houston Texas
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De Meo D, Cannari FM, Petriello L, Persiani P, Villani C. Gentamicin-Coated Tibia Nail in Fractures and Nonunion to Reduce Fracture-Related Infections: A Systematic Review. Molecules 2020; 25:E5471. [PMID: 33238408 PMCID: PMC7700538 DOI: 10.3390/molecules25225471] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/19/2020] [Accepted: 11/17/2020] [Indexed: 12/24/2022] Open
Abstract
The incidence of a fracture-related infection (FRI) can reach 30% of open tibia fractures (OTF). The use of antibiotic-coated implants is one of the newest strategies to reduce the risk of infection in orthopedic surgery. The aim of this study was to investigate the efficacy and safety of a gentamicin-coated tibia nail in primary fracture fixation (FF) and revision surgery (RS) of nonunion cases in terms of FRI incidence. We conducted a systematic review according to the PRISMA checklist on Pub-Med, Cochrane, and EMBASE. Of the 32 studies, 8 were included, for a total of 203 patients treated: 114 were FF cases (63% open fractures) and 89 were RS cases, of which 43% were infected nonunion. In the FF group, four FRI were found (3.8%): three OTF (Gustilo-Anderson III) and one closed fracture; bone healing was achieved in 94% of these cases. There were four relapses of infection and one new onset in the RS group; bone healing occurred in 88% of these cases. No side effects were found. There were no significant differences in terms of FRI, nonunion, and healing between the two groups. Gentamicin-coated tibia nail is an effective therapeutic option in the prophylaxis of high-risk fracture infections and in complex nonunion cases.
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Affiliation(s)
- Daniele De Meo
- Orthopaedic and Traumatology Department, Policlinico Umberto I Hospital-Sapienza, University of Rome, Piazzale A. Moro, 3, 00185 Rome, Italy; (L.P.); (P.P.); (C.V.)
- M.I.T.O. Group (Infectious Diseases in Traumatology and Orthopedics Surgery), Policlinico Umberto I Hospital, Viale del Policlinico, 155,00161 Rome, Italy
| | - Federico M. Cannari
- Orthopaedic and Traumatology Department, Tor Vergata University, Via Cracovia, 50,00133 Rome, Italy;
| | - Luisa Petriello
- Orthopaedic and Traumatology Department, Policlinico Umberto I Hospital-Sapienza, University of Rome, Piazzale A. Moro, 3, 00185 Rome, Italy; (L.P.); (P.P.); (C.V.)
| | - Pietro Persiani
- Orthopaedic and Traumatology Department, Policlinico Umberto I Hospital-Sapienza, University of Rome, Piazzale A. Moro, 3, 00185 Rome, Italy; (L.P.); (P.P.); (C.V.)
| | - Ciro Villani
- Orthopaedic and Traumatology Department, Policlinico Umberto I Hospital-Sapienza, University of Rome, Piazzale A. Moro, 3, 00185 Rome, Italy; (L.P.); (P.P.); (C.V.)
- M.I.T.O. Group (Infectious Diseases in Traumatology and Orthopedics Surgery), Policlinico Umberto I Hospital, Viale del Policlinico, 155,00161 Rome, Italy
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Mills RJ, Boyling A, Cheng TL, Peacock L, Savage PB, Tägil M, Little DG, Schindeler A. CSA-90 reduces periprosthetic joint infection in a novel rat model challenged with local and systemic Staphylococcus aureus. J Orthop Res 2020; 38:2065-2073. [PMID: 32009241 DOI: 10.1002/jor.24618] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 01/03/2020] [Indexed: 02/04/2023]
Abstract
Infection of orthopedic implants is a growing clinical challenge to manage due to the proliferation of drug-resistant bacterial strains. In this study, we aimed to investigate whether the treatment of implants with ceragenin-90 (CSA-90), a synthetic compound based on endogenous antibacterial peptides, could prevent infection in a novel rat model of periprosthetic joint infection (PJI) challenged with either local or systemic Staphylococcus aureus. A novel preclinical model of PJI was created using press-fit porous titanium implants in the distal femur of male Wistar rats. Sterile implants were pre-treated with 500 μg CSA-90 in saline. S. aureus was applied either directly at the time of surgery or administered via tail vein injection immediately afterward. Animals were monitored daily for clinical and radiographic evidence of infection for a total of 6 weeks. Post-study microbiological, radiographic, and histological analysis were performed to determine the incidence of PJI and assess osseointegration. CSA-90 treated groups demonstrated a reduced rate of PJI as confirmed by deep tissue swab culture at the time of cull compared with untreated groups with both local (33% vs 100%; P = .009) and systemic (10% vs 90%; P < .0001) S. aureus inoculation. Median survival time also increased from 8 to 17 days and from 8 to 42 days, respectively. In conclusion, this study describes a novel preclinical model of local and hematogenous PJI using a porous metal implant. CSA-90 reduced the incidence of PJI in this model supporting its further development as an antimicrobial coating for orthopedic implants.
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Affiliation(s)
- Rebecca J Mills
- Department of Orthopaedic Research and Biotechnology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Division of Medical Sciences, University of Oxford, Oxford, UK
| | - Alexandra Boyling
- Department of Orthopaedic Research and Biotechnology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tegan L Cheng
- Department of Orthopaedic Research and Biotechnology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lauren Peacock
- Department of Orthopaedic Research and Biotechnology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Paul B Savage
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, Utah
| | - Magnus Tägil
- Department of of Orthopaedics, Lund University Hospital, Lund, Sweden
| | - David G Little
- Department of Orthopaedic Research and Biotechnology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Aaron Schindeler
- Department of Orthopaedic Research and Biotechnology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
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Galvain T, Chitnis A, Paparouni K, Tong C, Holy CE, Giannoudis PV. The economic burden of infections following intramedullary nailing for a tibial shaft fracture in England. BMJ Open 2020; 10:e035404. [PMID: 32847903 PMCID: PMC7451536 DOI: 10.1136/bmjopen-2019-035404] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Determine the impact of infections on direct costs and healthcare resource use in England for patients undergoing intramedullary nailing (IMN) for tibial shaft fractures. DESIGN Non-concurrent cohort based on retrospectively collected data with 2-year follow-up. SETTING England. PARTICIPANTS The study population included adult patients (≥18 years) in England with a diagnosis of tibial shaft fracture (International Classification of Diseases-10, S822) in the inpatient setting between May 2003 and June 2017 followed by a procedure for IMN for tibial shaft fracture within 30 days. Patient data were derived from the Clinical Practice Research Datalink linked to National Health Service Hospital Episode Statistics datasets. PRIMARY INDEPENDENT VARIABLE Infection. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was total inpatient costs from index stay admission through 1 year of follow-up. Secondary outcome included cumulative total healthcare costs, and resource utilisation at 30 days, 90 days, 1 year and 2 years. RESULTS Overall, 805 patients met the inclusion criteria. At index inpatient stay, 3.7% had a post-IMN infection, rising to 11.7% at 1 year. One-year inpatient costs were 80% higher for patients with infection (p<0.001). Total costs were estimated to be £14 756 (95% CI £13 123 to £16 593) for patients with infection versus £8279 (95% CI £7946 to £8626). Length of stay (LOS), readmission and reoperation were the key drivers of healthcare costs (all p<0.001). After adjustment, LOS was higher by 109% (95% CI 62% to 169%), from 10.5 days to 21.9 days, for patients with infection. The odds of being readmitted or requiring reoperation were higher by 5.18 times (95% CI 3.01 to 9.13) and 2.47 times (95% CI 1.48 to 4.09), respectively, for patients with infection versus those without infection. CONCLUSIONS Post-IMN infection significantly increases inpatient costs, LOS, readmissions and reoperations associated with tibial fracture fixation. Healthcare burden could be reduced through novel surgical site infection prevention strategies.
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Affiliation(s)
- Thibaut Galvain
- Department of Health Economics and Market Access, Johnson and Johnson Medical Devices, Issy-les-Moulineaux, France
| | - Abhishek Chitnis
- Department of Real World Analytics and Research, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Konstantina Paparouni
- Department of Health Economics and Market Access, DePuy Synthes, Zuchwil, Switzerland
| | - Cindy Tong
- Department of Health Economics and Market Access, Johnson and Johnson Medical Devices, Somerville, New Jersey, USA
| | - Chantal E Holy
- Department of Real World Analytics and Research, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK
- School of Medicine, University of Leeds, Leeds, West Yorkshire, UK
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Tsikopoulos K, Sidiropoulos K, Kitridis D, Hassan A, Drago L, Mavrogenis A, McBride D. Is coating of titanium implants effective at preventing Staphylococcus aureus infections? A meta-analysis of animal model studies. INTERNATIONAL ORTHOPAEDICS 2020; 45:821-835. [PMID: 32761434 DOI: 10.1007/s00264-020-04660-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 06/11/2020] [Indexed: 12/25/2022]
Abstract
AIM OF THE STUDY To assess the effects of the available coating methods against methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) biofilm development on titanium implants. METHODS We searched the MEDLINE, Embase, and CENTRAL databases until May 18, 2019, for studies that used animal models of infections to evaluate various titanium implant coating methods to prevent S. aureus infection. Twenty-seven studies were eligible for inclusion in qualitative synthesis. Of those, twenty-three were considered in pair-wise meta-analysis. In addition, subgroup analysis of implant protection strategies relative to uncoated controls was performed, and any adverse events stemming from the coating applications were reported. Quality assessment was performed using SYRCLE's risk of bias tool for animal studies. RESULTS Meta-analysis showed that active coating with antibiotics was favoured over uncoated controls (standardised mean differences [SMD] for MRSA and MSSA were - 2.71 [95% CI, - 4.24 to - 1.18], p = 0.0005, and - 2.5 [- 3.79 to - 1.22], p = 0.0001, respectively). Likewise, large effect sizes were demonstrated when a combination of active and conventional non-degradable passive coatings was compared with controls (SMDs for MRSA and MSSA were - 0.62 [95% CI, - 1.15 to - 0.08], p = 0.02, and - 1.93 [95% CI, - 2.87 to - 0.98], p < 0.001, respectively). DISCUSSION/CONCLUSION As a standalone prevention method, active titanium coating with antibiotics yielded promising results against both MSSA and MRSA. Combinations between active and non-degradable passive coatings, potentially allowing for sustained antimicrobial substance release, provided consistent hardware infection protection. Thus, we recommend that future research efforts focus on combined coating modalities against S. aureus biofilm infections in the presence of titanium implants. SYSTEMATIC REVIEW REGISTRATION CRD42019123462.
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Affiliation(s)
| | | | - Dimitrios Kitridis
- 1st Orthopaedic Department of Aristotle University, G. Papanikolaou General Hospital, Exohi, Thessaloniki, Greece
| | - Anas Hassan
- Orthopaedic Department, Lister Hospital, Stevenage, East and North Hertfordshire, UK
| | - Lorenzo Drago
- Laboratory of Clinical Microbiology, Department of Biochemical Sciences for Health, University of Milan, Milan, Italy
| | - Andreas Mavrogenis
- Orthopaedic Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Donald McBride
- Orthopaedic Department, University Hospitals of North Midlands, Stoke-on-Trent, UK
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Vicenti G, Bizzoca D, Cotugno D, Carrozzo M, Riefoli F, Rifino F, Belviso V, Elia R, Solarino G, Moretti B. The use of a gentamicin-coated titanium nail, combined with RIA system, in the management of non-unions of open tibial fractures: A single centre prospective study. Injury 2020; 51 Suppl 3:S86-S91. [PMID: 31591005 DOI: 10.1016/j.injury.2019.09.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Nonunion is a quite common complication of open tibial shaft fractures. This prospective case series investigates the use of the gentamicin-coated titanium intramedullary tibial nail, in association with the RIA system, in patients with tibial exposed nonunions. METHODS Between January 2015 and January 2018, patients meeting the inclusion and exclusion criteria were recruited. INCLUSION CRITERIA patients aged 18 or more; non-union after an open tibial shaft fracture; previous treatment with a circular external fixator. EXCLUSION CRITERIA a known allergy to aminoglycosides; pin tract infections; persistent soft-tissues damage; patients pregnant, breastfeeding or planning to become pregnant during the study; history of malignant disease; a life expectancy of fewer than three months; medical illness or cognitive disorders precluding participation in the follow-up examination. All the patients underwent a clinical and radiological follow-up at one-, three-, six- and twelve-months post-operatively. Clinical evaluation was performed using the following validated scores: Euro-Quality 5 D (EQ-5D); American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and the Visual Analogue Scale (VAS) for pain. RESULTS Seventeen patients met the inclusion and exclusion criteria (male: 11; female: 6; mean age: 41.12 ± 11.4). Fracture healing was observed in all the patients; the mean time needed to obtain the fracture healing was 7.18 months. A significant improvement of the quality of life, evaluated with the EQ-5D, and of the mean VAS for pain was observed from the three-months follow-up. The mean AOFAS score showed a significant increase at six-months follow-up. CONCLUSIONS The use of gentamicin-coated nails in association with the RIA system demonstrated a safe and effective treatment of tibial non-unions.
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Affiliation(s)
- Giovanni Vicenti
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Davide Bizzoca
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Domenico Cotugno
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Massimiliano Carrozzo
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy.
| | - Flavia Riefoli
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Francesco Rifino
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Vito Belviso
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Rossella Elia
- Division of Plastic and Reconstructive Surgery, University of Bari, Italy
| | - Giuseppe Solarino
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Biagio Moretti
- Orthopedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari "Aldo Moro" - AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100 Bari, Italy
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Vallet-Regí M, Lozano D, González B, Izquierdo-Barba I. Biomaterials against Bone Infection. Adv Healthc Mater 2020; 9:e2000310. [PMID: 32449317 PMCID: PMC7116285 DOI: 10.1002/adhm.202000310] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/17/2020] [Indexed: 12/12/2022]
Abstract
Chronic bone infection is considered as one of the most problematic biofilm-related infections. Its recurrent and resistant nature, high morbidity, prolonged hospitalization, and costly medical care expenses have driven the efforts of the scientific community to develop new therapies to improve the standards used today. There is great debate on the management of this kind of infection in order to establish consistent and agreed guidelines in national health systems. The scientific research is oriented toward the design of anti-infective biomaterials both for prevention and cure. The properties of these materials must be adapted to achieve better anti-infective performance and good compatibility, which allow a good integration of the implant with the surrounding tissue. The objective of this review is to study in-depth the antibacterial biomaterials and the strategies underlying them. In this sense, this manuscript focuses on antimicrobial coatings, including the new technological advances on surface modification; scaffolding design including multifunctional scaffolds with both antimicrobial and bone regeneration properties; and nanocarriers based on mesoporous silica nanoparticles with advanced properties (targeting and stimuli-response capabilities).
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Affiliation(s)
- María Vallet-Regí
- Departamento de Química en Ciencias Farmacéuticas Facultad de Farmacia Universidad Complutense de Madrid Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12 Plaza Ramón y Cajal s/n, Madrid 28040, Spain; CIBER de Bioingeniería Biomateriales y Nanomedicina CIBER-BBN C/Monforte de Lemos, 3–5 Madrid 28029, Spain
| | - Daniel Lozano
- Departamento de Química en Ciencias Farmacéuticas Facultad de Farmacia Universidad Complutense de Madrid Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12 Plaza Ramón y Cajal s/n, Madrid 28040, Spain; CIBER de Bioingeniería Biomateriales y Nanomedicina CIBER-BBN C/Monforte de Lemos, 3–5 Madrid 28029, Spain
| | - Blanca González
- Departamento de Química en Ciencias Farmacéuticas Facultad de Farmacia Universidad Complutense de Madrid Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12 Plaza Ramón y Cajal s/n, Madrid 28040, Spain; CIBER de Bioingeniería Biomateriales y Nanomedicina CIBER-BBN C/Monforte de Lemos, 3–5 Madrid 28029, Spain
| | - Isabel Izquierdo-Barba
- Departamento de Química en Ciencias Farmacéuticas Facultad de Farmacia Universidad Complutense de Madrid Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12 Plaza Ramón y Cajal s/n, Madrid 28040, Spain; CIBER de Bioingeniería Biomateriales y Nanomedicina CIBER-BBN C/Monforte de Lemos, 3–5 Madrid 28029, Spain
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Savvidou OD, Kaspiris A, Trikoupis I, Kakouratos G, Goumenos S, Melissaridou D, Papagelopoulos PJ. Efficacy of antimicrobial coated orthopaedic implants on the prevention of periprosthetic infections: a systematic review and meta-analysis. J Bone Jt Infect 2020; 5:212-222. [PMID: 32670776 PMCID: PMC7358967 DOI: 10.7150/jbji.44839] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction: Implant-associated infections are a major problem in orthopaedic surgery. Local delivery systems of antimicrobial agents on the implant surface have attracted great interest recently. The purpose of this study was to identify antimicrobial coatings currently used in clinical practice, examining their safety and effectiveness in reducing post-operative infection rates. Materials and Methods: A systematic review was conducted in four databases (Medline, Embase, Cochrane, Cinahl) according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines up to December 2019, using the key words “orthopaedic implant coated”, “coated implant infection”, “silver coating ” and “antibiotic coating”. Results: Seven articles involving 1307 patients (561 with coated implants and 746 controls who were not) comparing the incidence of periprosthetic infections after the application of internal fracture fixation, total arthroplasties and endoprostheses were evaluated. Three different coating technologies were identified: gentamicin coating for tibia nail and total arthroplasties; silver technology and povidone-iodine coating for tumour endoprostheses and titanium implants. Meta-analysis demonstrated that patients who were treated with antimicrobial coated implants presented lower infection rates compared to controls over the seven studies (Q = 6.1232, I2 = 0.00, 95% CI: 1.717 to 4.986, OR: 2.926, Z= 3.949, p<0.001). Subgroup statistical analysis revealed that each coating technique was effective in the prevention of periprosthetic infections (Q = 9.2606, I2 = 78.40%, 95% CI: 1.401 to 4.070, OR: 2.388, Z= 3.200, p<0.001). Conclusion: All technologies were reported to have good biocompatibility and were effective in the reduction of post-operative peri-prosthetic infection rates.
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Affiliation(s)
- Olga D Savvidou
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology/Division for Orthopaedic Research, School of Health Sciences, University of Patras, Patras 26504, Greece
| | - Ioannis Trikoupis
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - George Kakouratos
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Stavros Goumenos
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Dimitra Melissaridou
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Panayiotis J Papagelopoulos
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
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Makhdom AM, Buksbaum J, Rozbruch SR, Da Cunha R, Fragomen AT. Antibiotic Cement-Coated interlocking Intramedullary Nails in the Treatment of Septic Complex Lower Extremity Reconstruction; A Retrospective Analysis with Two year Minimum Follow up. J Bone Jt Infect 2020; 5:176-183. [PMID: 32670771 PMCID: PMC7358971 DOI: 10.7150/jbji.46570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/09/2020] [Indexed: 01/22/2023] Open
Abstract
Background: To report on our experience with antibiotic cement coated interlocking intramedullary nails (ACC-IMNs) for limb salvage in septic complex lower extremity reconstruction with a minimum of 2-year follow up. Methods: We retrospectively reviewed the records of all consecutive patients who underwent a limb salvage procedure with ACC-IMNs. We reviewed patients' demographics, the preoperative infecting organism, and host type, time to bone union, complications, limb salvage rates, and infection control rates. Results: There were 28 patients with a mean age of 62 years (range 22-88). The mean follow up period was 40 months (range 28-84). The ACC-IMNs were used in 14 patients (50 %) to achieve knee fusion after failed revisions of infected total knee arthroplasty, in 8 patients (28%) for septic tibial nonunion, and in 6 patients (21%) with ankle fusion nonunions. Bony union/fusion was achieved in 87 % (21/24) of patients. The infection was controlled in 80% (21/26) of patients. Four out the five patients who had recurrent infection were type B hosts (p=0.63). The limb salvage rate was 89% (25/28). The overall complication rate was 32%. Conclusions: The use of ACC-IMNs was an effective treatment strategy and associated with high limb salvage and bone union rates. Furthermore, the infection recurrence rate was low. Knee fusion patients after failed TKA should be counseled preoperatively for a potential high complication rate.
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Affiliation(s)
- Asim M Makhdom
- Foothills Medical Group, Upper Alleghany Health System, Olean, NY and Bradford, PA, USA
| | - Joshua Buksbaum
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA.,SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, NY, USA
| | - S Robert Rozbruch
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Rachael Da Cunha
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Austin T Fragomen
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
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Rupp M, Popp D, Alt V. Prevention of infection in open fractures: Where are the pendulums now? Injury 2020; 51 Suppl 2:S57-S63. [PMID: 31679836 DOI: 10.1016/j.injury.2019.10.074] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/07/2019] [Accepted: 10/22/2019] [Indexed: 02/02/2023]
Abstract
Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Daniel Popp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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40
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Compression of Nonunions With the PRECICE Magnetic Intramedullary Compression Nail. Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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41
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Arens D, Zeiter S, Nehrbass D, Ranjan N, Paulin T, Alt V. Antimicrobial silver-coating for locking plates shows uneventful osteotomy healing and good biocompatibility results of an experimental study in rabbits. Injury 2020; 51:830-839. [PMID: 32164954 DOI: 10.1016/j.injury.2020.02.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
Infections after internal fixation of fractures remain a challenge. Silver is known for its antimicrobial activity, including activity against multi-resistant strains. The aim of the current study was to analyze the biocompatibility and potential influence on the osteotomy healing process of a silver-coating technology for locking plates compared to silver-free locking plates in an established rabbit model. The implants used in this study were 7-hole titanium locking plates, and plasma electrolytic oxidation (PEO) silver-coated equivalents. A total of 24 rabbits were used in this study (12 coated, 12 non-coated). An osteotomy of the midshaft of the humerus was created and the humerus stabilized with the 7-hole locking plates with a total of 6 screws. Radiographs were taken on day 0, week 2, 4, 6, 8, and 10 for continuous radiographical evaluation. All animals were euthanized after 10 weeks and further assessment was performed using X-rays, micro-CT, non-destructive four-point bending biomechanical testing and semi-quantitative histopathological evaluation. Furthermore, silver concentration was measured in the blood, kidney, liver, spleen, brain, feces and soft tissue around the plate. Radiographs showed normal undisturbed and completed healing of the osteotomy in all animals without any differences between the two groups over the entire observation period. Micro-CT analysis revealed overall tissue volume as well as tissue density to be comparable between the two groups. Mechanical testing showed comparable stiffness with an average stiffness relative to contralateral bones of 75.7 ± 16.1% in the silver-free control group compared to 69.7 ± 18.5% (p-value: 0.46). Semi-quantitative histopathological evaluation showed no remarkable difference in the analysis of the osteotomy gap healing or in the surrounding soft tissue area. There were detectable silver concentrations in the soft tissue around the plate after 10 weeks. Silver in the blood was only found in 3 animals within the first two weeks and all animals were free of silver afterwards. There were no detectable silver concentrations in the brain, liver, spleen, axillary lymph nodes and kidney. This study shows undisturbed osteotomy healing of the presented antimicrobial silver surface coating and a good biocompatibility in this rabbit model.
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Affiliation(s)
- Daniel Arens
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | - Dirk Nehrbass
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | | | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany.
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Schmal H, Brix M, Bue M, Ekman A, Ferreira N, Gottlieb H, Kold S, Taylor A, Toft Tengberg P, Ban I. Nonunion - consensus from the 4th annual meeting of the Danish Orthopaedic Trauma Society. EFORT Open Rev 2020; 5:46-57. [PMID: 32071773 PMCID: PMC7017598 DOI: 10.1302/2058-5241.5.190037] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention. Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology. The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability. The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray. Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli. The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.
Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037
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Affiliation(s)
- Hagen Schmal
- Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Orthopaedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
| | - Michael Brix
- Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark
| | - Mats Bue
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Anna Ekman
- Orthopaedic Department, Södersjukhuset, Stockholm, Sweden
| | - Nando Ferreira
- Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Hans Gottlieb
- Department of Orthopaedic Surgery, Herlev Hospital, Herlev, Denmark
| | - Søren Kold
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Andrew Taylor
- Department of Orthopaedic Surgery, Nottingham University Hospitals, UK
| | - Peter Toft Tengberg
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Ilija Ban
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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Abstract
Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Pinto D, Manjunatha K, Savur AD, Ahmed NR, Mallya S, Ramya V. Comparative study of the efficacy of gentamicin-coated intramedullary interlocking nail versus regular intramedullary interlocking nail in Gustilo type I and II open tibia fractures. Chin J Traumatol 2019; 22:270-273. [PMID: 31443939 PMCID: PMC6823723 DOI: 10.1016/j.cjtee.2019.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/05/2019] [Accepted: 03/28/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Open tibia fracture is prone to infection, consequently causing significant morbidity and increasing the hospital stay, occupational loss and onset of chronic osteomyelitis. Intramedullary nailing is one choice for treating tibia shaft fractures. To improve the delivery of antibiotics at the tissue-implant interface, many methods have been proposed as a part of prophylaxis against infection. This study was conducted to study the role of gentamicin-impregnated intramedullary interlocking (IMIL) nail in the prevention of infection in Gustilo type I and II open tibia fractures and to compare the results with regular intramedullary nail. METHODS The study included 28 patients with open tibia fractures (Gustilo type 1 or type 2); of them 14 underwent regular IMIL nailing and the other 14 were treated with gentamicin-coated nailing. Randomization was done by alternate allocation of the patients. Follow-up was done postoperatively (day 1), 1 week, 6 weeks, and 6 months for bone union, erythrocyte sedimentation rate (ESR), hemoglobin and C-reactive protein (CRP). Statistical significance was tested using unpaired t-test. A p value less than 0.05 was considered significant. RESULTS There were 4 cases of infection in controls (regular IMIL nail) and no infection among patients treated with gentamicin-coated nail during the follow up (X2 = 4.66, p = 0.031). At 6 months postoperatively, CRP (p = 0.031), ESR (p = 0.046) and hemoglobin level (p = 0.016) showed significant difference between two groups. The bone healing rate was better with gentamicin-coated nail in comparison to regular IMIL nail at 6 months follow-up (p = 0.016). CONCLUSION Gentamicin-coated IMIL nail has a positive role in preventing infection in Gustilo type I and II open tibia fractures.
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Affiliation(s)
- Deepak Pinto
- Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, India
| | - K. Manjunatha
- Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, India
| | - Amarnath D. Savur
- Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, India
| | - Naufal Rizwan Ahmed
- Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, India
| | - Sharan Mallya
- Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, India,Corresponding author.
| | - V. Ramya
- Department of Community Medicine, Basaveshwara Medical College, Chitradurga, India
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46
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Abstract
INTRODUCTION Non-union of a long bone fracture remains a challenge in orthopaedic and trauma surgery. In the current study, we sought to determine the clinical effectiveness of tibial non-union treatment utilizing an antibiotic-coated intramedullary nail (Expert Tibia Nail (ETN) PROtect®) regarding prevention and treatment of infection and the clinical outcome. PATIENTS AND METHODS 36 patients suffering from tibial non-unions that were treated with the ETN PROtect® in the course of non-union treatment between February 2010 and March 2015 were included in this clinical observational study. Clinical and radiological examinations were performed preoperatively as well as 4, 6 and 12 weeks and 6 and 12 months postoperatively as part of a standardized follow-up program. Data regarding perioperative complications, weight-bearing capacity, radiological signs of consolidation and subjective health status were assessed at each time point. Laboratory parameters such as C-reactive protein (CRP) and leukocyte count were collected preoperatively in order to assess the patients' risk profile for infection. RESULTS Patients had an average of 6.2 previous surgeries and 22 patients (61.1%) had a positive bacterial culture from intraoperatively removed tissue during the first operative treatment. 29 patients (80.6%) achieved full weight-bearing after an average of 7.7 months, furthermore 80.6% of patients achieved osseous consolidation. 3 deep infections occurred, including one amputation. Subjective health status increase based on the SF-12 questionnaire during our follow-up program. CONCLUSION The results from the current study indicate that the use of the ETN PROtect® in the applied non-union therapy has a high clinical effectiveness regarding osseous consolidation and time to weight bearing. In addition, the use of gentamicin-coated nails in the treatment of tibial non-unions might contribute to both successful treatment of the underlying infection and prevention of perioperative infection. The gentamicin-coated nail may serve as a beneficial adjunct treatment in the applied non-union therapy in addition to all established techniques in the treatment of infected non-unions.
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Abstract
Implants and their technological advances have been a critical component of musculoskeletal care for almost a century. Modern implants are designed to enhance bone ingrowth, promote soft-tissue healing, and prevent infection. Porous metals and short-stem fixation devices have rendered previously unreconstructable bony deficits reconstructable. Stem cells, growth factors, and novel biocompatible compounds have been designed to promote and enhance soft tissue attachment to implants. Antimicrobial modifications have been engineered onto implants to deter bacterial attachment, and innovative surface modifications and eluting technologies may be in our near future. Yet, given the enormous economic pressures in orthopaedics, marketing claims of innovation often exceed scientific accomplishment. Vigilance is thus required in distinguishing transformational discovery from unsubstantiated claims.
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Jorge-Mora A, Amhaz-Escanlar S, Fernandez-Pose S, García-Iglesias A, Mandia-Mancebo F, Franco-Trepat E, Guillán-Fresco M, Pino-Minguez J. Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases. J Bone Jt Infect 2019; 4:155-162. [PMID: 31555500 PMCID: PMC6757014 DOI: 10.7150/jbji.34072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/21/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives. Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives. Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually. Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.
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Affiliation(s)
- Alberto Jorge-Mora
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain.,Musculoskeletal Pathology Group, Laboratory 18, Institute IDIS, Servicio Galego de Saúde, Santiago de Compostela, Spain
| | - Samer Amhaz-Escanlar
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain
| | - Sabela Fernandez-Pose
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Adrián García-Iglesias
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | - Fermín Mandia-Mancebo
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain
| | - Eloi Franco-Trepat
- Musculoskeletal Pathology Group, Laboratory 18, Institute IDIS, Servicio Galego de Saúde, Santiago de Compostela, Spain
| | - María Guillán-Fresco
- Musculoskeletal Pathology Group, Laboratory 18, Institute IDIS, Servicio Galego de Saúde, Santiago de Compostela, Spain
| | - Jesús Pino-Minguez
- Division of Traumatology, Santiago University Clinical Hospital, Santiago de Compostela, Spain.,Faculty of Medicine, University of Santiago de Compostela, Spain
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Gieling F, Peters S, Erichsen C, Richards RG, Zeiter S, Moriarty TF. Bacterial osteomyelitis in veterinary orthopaedics: Pathophysiology, clinical presentation and advances in treatment across multiple species. Vet J 2019; 250:44-54. [PMID: 31383419 DOI: 10.1016/j.tvjl.2019.06.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 06/23/2019] [Accepted: 06/23/2019] [Indexed: 11/16/2022]
Abstract
Bacterial osteomyelitis in veterinary patients can be challenging to diagnose and treat, given limited therapeutic options and reported success rates. Osteomyelitis is frequently associated with surgical implant devices, including those required to optimise stability and healing of fractures. However, management of osteomyelitis sometimes necessitates the removal of these surgical implant devices in order to eradicate infection or limit implant-related osteolysis. The goal of this article is to provide a general and species-specific review of bacterial osteomyelitis in a selection of domestic veterinary species, including cats, dogs, horses, cattle and camelids, with a focus on classification, clinical presentation, aetiologic agents, and common therapeutic interventions reported in the literature. New treatment options emerging from research and human medicine will be also discussed, as they also apply to current or future care of veterinary patients with osteomyelitis.
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Affiliation(s)
- Fabian Gieling
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Sarah Peters
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Christoph Erichsen
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - R Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Stephan Zeiter
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland.
| | - T Fintan Moriarty
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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Abstract
Implant-related infection is one of the leading reasons for failure in orthopaedics and trauma, and results in high social and economic costs. Various antibacterial coating technologies have proven to be safe and effective both in preclinical and clinical studies, with post-surgical implant-related infections reduced by 90% in some cases, depending on the type of coating and experimental setup used. Economic assessment may enable the cost-to-benefit profile of any given antibacterial coating to be defined, based on the expected infection rate with and without the coating, the cost of the infection management, and the cost of the coating. After reviewing the latest evidence on the available antibacterial coatings, we quantified the impact caused by delaying their large-scale application. Considering only joint arthroplasties, our calculations indicated that for an antibacterial coating, with a final user's cost price of €600 and able to reduce post-surgical infection by 80%, each year of delay to its large-scale application would cause an estimated 35 200 new cases of post-surgical infection in Europe, equating to additional hospital costs of approximately €440 million per year. An adequate reimbursement policy for antibacterial coatings may benefit patients, healthcare systems, and related research, as could faster and more affordable regulatory pathways for the technologies still in the pipeline. This could significantly reduce the social and economic burden of implant-related infections in orthopaedics and trauma. Cite this article: C. L. Romanò, H. Tsuchiya, I. Morelli, A. G. Battaglia, L. Drago. Antibacterial coating of implants: are we missing something? Bone Joint Res 2019;8:199-206. DOI: 10.1302/2046-3758.85.BJR-2018-0316.
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Affiliation(s)
- C. L. Romanò
- Studio Medico Associato Cecca-Romanò, Milan, Italy
| | - H. Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - I. Morelli
- Specialty School of Orthopaedics, University of Milan, Milan, Italy
| | - A. G. Battaglia
- Specialty School of Orthopaedics, University of Milan, Milan, Italy
| | - L. Drago
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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