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Garabano G, Pereira S, Alamino LP, Munera MA, Ernst G, Bidolegui F, Pesciallo CA. Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails. Injury 2023; 54 Suppl 6:110650. [PMID: 36858895 DOI: 10.1016/j.injury.2023.02.033] [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: 11/21/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. METHODS We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. RESULTS We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). CONCLUSION Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. LEVEL OF EVIDENCE III comparative, observational, non-randomized.
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Affiliation(s)
- Germán Garabano
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina.
| | - Sebastian Pereira
- Orthopaedic and Trauma Surgery Department, Sirio - Libanes Hospital, Campana 4658, C1419, Buenos Aires, Argentina
| | - Leonel Perez Alamino
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
| | - Mateo Alzate Munera
- Orthopaedic and Trauma Surgery Department, Sirio - Libanes Hospital, Campana 4658, C1419, Buenos Aires, Argentina
| | - Glenda Ernst
- Scientific Advisory Committee, British Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Bidolegui
- Orthopaedic and Trauma Surgery Department, Sirio - Libanes Hospital, Campana 4658, C1419, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Orthopaedic and Trauma Surgery Department, British Hospital of Buenos Aires, Perdriel 74, C1280 AEB, Buenos Aires, Argentina
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Zhang Y, Tian S, Liu M, Zhai W, Zhou Y, Peng A. Comparison of antibiotic-impregnated bone cement coverage versus vacuum sealing drainage in semi-open bone grafting using for tibial fracture with infected bone and soft tissue defect: a retrospective analysis. BMC Musculoskelet Disord 2023; 24:401. [PMID: 37208629 DOI: 10.1186/s12891-023-06475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 04/28/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To compare antibiotic-impregnated bone cement coverage (bone cement surface technique; BCS-T) versus vacuum sealing drainage (VSD) for tibial fracture with infected bone and soft tissue defect. METHOD This retrospective analysis compared the clinical outcomes in patients undergoing BCS-T (n = 16) versus VSD (n = 15) for tibial fracture with infected bone and soft tissue defect at the Third Hospital of Hebei Medical University from March 2014 to August 2019. For BCS-T group, osseous cavity was filled with autograft bone graft after debridement, and then the wound was covered with a 3-mm layer of bone cement impregnated with vancomycin and gentamycin. The dressing was changed every day in the first week, and every 2 ~ 3 days in the second week. For VSD group, a negative pressure of -150 ~ -350 mmHg was maintained, and the dressing was changed every 5-7 days. All patients received antibiotics treatment based on bacterial culture results for 2 weeks. RESULTS The 2 groups did not differ in age, sex and key baseline characteristics, including type of Gustilo-Anderson classification, size of the bone and soft tissue defect, the percentage of primary debridement, bone transport, and the time from injury to bone grafting. The median follow-up was 18.9 months (range:12-40). The time to complete coverage of bone graft by granulation tissue was 21.2 (15.0-44.0) and 20.3 (15.0-24.0) days in the BCS-T and VSD groups, respectively (p = 0.412). The 2 groups also did not differ in wound healing time (3.3 (1.5-5.5) versus 3.2(1.5-6.5) months; p = 0.229) and bone defect healing time (5.4(3.0-9.6) versus 5.9(3.2-11.5) months; p = 0.402). However, the cost of covering material was significantly reduced in the BCS-T group (2071 ± 134 versus 5542 ± 905 yuan; p = 0.026). Paley functional classification at 12 months did not differ between the 2 groups (excellent in 87.5% versus 93.3% in the 2 groups; p = 0.306). CONCLUSION BCS-T could achieve clinical outcomes similar to VSD in patients receiving bone graft for tibial fracture with infected bone and soft tissue defect, but material cost was significantly reduced. Randomized controlled trials are needed to verify our finding.
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Affiliation(s)
- Yanlong Zhang
- Trauma Center, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, Hebei, China
| | - Shuwei Tian
- Hebei Provincial General Hospital, Shijiazhuang, 050057, Hebei, China
| | - Meiyu Liu
- The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Wenfang Zhai
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Yujie Zhou
- Trauma Center, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, Hebei, China
| | - Aqin Peng
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
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Garabano G, Del Sel H, Rodriguez JA, Perez Alamino L, Pesciallo CA. The effectiveness of antibiotic cement-coated nails in post-traumatic femoral and tibial osteomyelitis - comparative analysis of custom-made versus commercially available nails. J Bone Jt Infect 2022; 6:457-466. [PMID: 35024298 PMCID: PMC8738920 DOI: 10.5194/jbji-6-457-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/10/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The first objective of this
retrospective study was to assess infection control rates in patients with
chronic post-traumatic osteomyelitis (CPTO) of the femur or tibia treated
with antibiotic cement-coated nails. The second objective was to compare the
efficacy of custom-made nails versus commercially available
antibiotic-coated nails in terms of infection control and need for
reoperation. Methods: We reviewed a consecutive series of CPTO
patients treated with antibiotic-coated nails who had a minimum follow-up of
24 months. We recorded the characteristics of the initial injury, the type
of nail used, cement–nail debonding, infecting microorganisms, operating
time, infection control, need for reoperation, and failure rate. We
performed a comparative analysis between nails manufactured in the operating
room (i.e., custom-made) and those commercially available. Results:
Thirty patients were included. The affected bones were the femur
(n=15) and the tibia (n=15). Twenty-one of the 30 initial
injuries were open fractures. Staphylococcus aureus was the most frequently
isolated microorganism (50 %). Sixteen patients were treated with
custom-made nails and 14 with commercially available antibiotic-coated
nails. At the time of extraction, four out of five custom-made antibiotic-coated
nails experienced cement–bone debonding. Commercial nails were associated
with shorter operating times (p<0.0001). The overall infection
control rate was 96.66 %. Eight (26.66 %) patients needed reoperation.
There was one failure (3.33 %) in the group treated with custom-made
antibiotic-coated nails. We did not find significant differences between
nail types in terms of reoperation, infection control, and failure rate.
Conclusions: The use of antibiotic cement-coated nails proved
useful in CPTO treatment. Commercially available nails had significantly
shorter operating times and did not present cement–bone debonding during
removal. Our results seem to indicate that both nail types are similar in
terms of infection control and reoperation rates.
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Affiliation(s)
- Germán Garabano
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Perdriel 74 (C1280 AEB), Buenos Aires, Argentina
| | - Hernán Del Sel
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Perdriel 74 (C1280 AEB), Buenos Aires, Argentina
| | - Joaquin Anibal Rodriguez
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Perdriel 74 (C1280 AEB), Buenos Aires, Argentina
| | - Leonel Perez Alamino
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Perdriel 74 (C1280 AEB), Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Department of Orthopaedic and Traumatology, British Hospital of Buenos Aires, Perdriel 74 (C1280 AEB), Buenos Aires, Argentina
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Ismat A, Walter N, Baertl S, Mika J, Lang S, Kerschbaum M, Alt V, Rupp M. Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques. J Orthop Traumatol 2021; 22:56. [PMID: 34940945 PMCID: PMC8702599 DOI: 10.1186/s10195-021-00614-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 11/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use. Methods A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible. Results A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant. Conclusion Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted. Level of evidence III.
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Affiliation(s)
- Abdullah Ismat
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Susanne Baertl
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Joerg Mika
- Experimental Rheumatology Unit, Department of Orthopedics, Jena University Hospital, Waldkliniken Eisenberg GmbH, Klosterlausnitzer Strasse 81, 07607, Eisenberg, Germany
| | - Siegmund Lang
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Kulkarni GS, Kulkarni S, Babhulkar S. Cement beads and cement spacers: indications, techniques, and clinical results. OTA Int 2021; 4:e118(1-6). [PMID: 37609476 PMCID: PMC10441671 DOI: 10.1097/oi9.0000000000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/22/2020] [Indexed: 08/24/2023]
Abstract
Objectives To report our experience on the use of antibiotic coated nails (ACN) and cement beads for the management of bone infections. Materials and methods Infected nonunion (INU) cases were classified as: Type I (mild infection with no gap), Type II (moderate with good alignment, severe infection, gap <3 cm, no deformity), Type III (severe infection with gap ≥3 cm, deformity and limb shortening). Treatment involved either the insertion of ACN and cast (Type I), insertion of ACN, beads and external fixator (Type II), or Ilizarov methodology (Type III). A subset of 28 open fractures were admitted with severe contamination or delayed presentation with established infection and treated with debridement, ACN insertion, and antibiotic beads placed in soft tissue dead space areas. Results Results of 133 cases were classified excellent, good, and poor. Type I INU reported 40 excellent and 22 good results. Type II INU reported 28 (39%) excellent, 30 (43%) good, and 13 (18%) poor results. Poor results were due to uncontrolled infection and knee stiffness. Three patients required knee fusion and 1 required amputation. Fracture union was reported in 68 cases. Four of the 28 Gustilo grade III open fractures treated with ACN developed infected nonunion and had poor function caused by stiff knees. Conclusions An antibiotic impregnated cement nail (ACN) fills the dead space and elutes high concentrations of antibiotics providing some mechanical stability. We recommend the adjunct use of an ACN for the management of INU cases and for use in select cases of Gustilo grade III open fractures.
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Affiliation(s)
| | - Sunil Kulkarni
- GSKs Fracture and Orthopedic Hospital, PG Institute of Swasthiyog Pratishthan, Miraj
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Liu JZ, Crist BD. Coated nails: is their use supported by the literature? OTA Int 2021; 4:e110(1-4). [PMID: 37609482 PMCID: PMC10441681 DOI: 10.1097/oi9.0000000000000110] [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: 10/13/2020] [Revised: 11/05/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
Antibiotic-coated intramedullary nails have been popularized in recent decades for treating long-bone infections. They are especially useful in treating diaphyseal infections requiring stability, such as those involving fractures and nonunions. The nails are made by injecting antibiotic-impregnated polymethylmethacrylate or "cement" around a metal core using a silicone tube as a mold. There are a variety of techniques that can be used to customize the nail to the affected site. Antibiotic cement has long been demonstrated as an effective local antibiotic delivery system. It is able to elute high concentrations of antibiotics while having little systemic toxicity. Several case series have reported good outcomes using this technique, defined by bone union and infection control. Further research is needed to determine the amount of weight that can safely be transferred through the nail and to optimize antibiotic elution.
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Affiliation(s)
- Jane Z Liu
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
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Custom-Made Antibiotic Cement-Coated Nail for the Treatment of Infected Bone Defect. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6693906. [PMID: 33748280 PMCID: PMC7954627 DOI: 10.1155/2021/6693906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
Background Longbone infected bone defect remains a great challenge due to multiple surgeries, long-term treatment duration, and uncertain prognosis. Treatment principles include eradication/debridement, stabilization, and antibiotic administration. An antibiotic cement-coated nail has shown great prospects due to both local antibiotic elution and stabilization of bone defects. However, the current fabrication technique remains to be improved. Methods For the first time, we described a new method for custom-made cement-coated nail fabrication based on a 3D printing technique. A retrospective study of 19 consecutive patients with long bone infected bone defects from one medical center was conducted who met the inclusion and exclusion criteria from November 2016 to May 2020. The treatment involved thorough debridement, custom-made antibiotic cement-coated nail filling, and culture-specific systemic antibiotic treatment guided by a multidisciplinary team. Clinical and radiographic examinations (X-ray and CT scans) were used to evaluate bony union. Clinical and laboratory examinations were used to evaluate the infection control. The SF-36 score was used to evaluate patients' quality of life pre- and postoperatively. Results The mean follow-up was 98.8 weeks (ranging from 40 to 192). All cases achieved infection control, 3 cases achieved bone healing after one-stage operation, and 12 cases achieved bone healing after a two-stage bone graft procedure. At the last follow-up, none of the 19 patients had infection recurrence or 1 case had failure of the protective plate. The pre- and postoperative SF-36 score showed that there were statistical differences in all the 9 aspects. Conclusions The precise custom-made antibiotic cement-coated intramedullary nail through the 3D printing technique used in this study is an effective strategy for the treatment of infected bone defects of long bone. This technique may help to increase the infection control rate and promote bone healing.
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Mitchell B, Girard PJ, Kent WT. Antibiotic-Impregnated Intramedullary Cement Nail-Induced Acute Generalized Exanthematous Pustulosis and Septic Shock: A Case Report. JBJS Case Connect 2020; 10:e0441. [PMID: 32649114 DOI: 10.2106/jbjs.cc.19.00441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 28-year-old woman with an infected proximal femur nonunion was treated with an antibiotic-coated intramedullary nail. Shortly after discharge, the patient presented to the emergency department and was readmitted with a morbilliform rash sparing the left lower extremity. She became hemodynamically unstable, despite cessation of intravenous antibiotics, requiring transfer to the intensive care unit and urgent removal of her antibiotic nail. She improved after surgery, and biopsy results from the rash confirmed acute generalized examthematous pustulosis. CONCLUSION Acute generalized exanthematous pustulosis is a rare, dermatologic crisis that can be precipitated by antibiotics, even in the form of antibiotic cement.
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Affiliation(s)
- Brendon Mitchell
- 1Department of Orthopedic Surgery, University of California-San Diego, San Diego, California
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Foster AL, Moriarty TF, Trampuz A, Jaiprakash A, Burch MA, Crawford R, Paterson DL, Metsemakers WJ, Schuetz M, Richards RG. Fracture-related infection: current methods for prevention and treatment. Expert Rev Anti Infect Ther 2020; 18:307-321. [DOI: 10.1080/14787210.2020.1729740] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Andrew L Foster
- AO Research Institute Davos, Davos, Switzerland
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women’s Hospital, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Queensland, Australia
| | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Septic Unit Charité-Universitätsmedizin, Berlin, Germany
| | - Anjali Jaiprakash
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
| | | | - Ross Crawford
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
| | - David L Paterson
- University of Queensland Centre of Clinical Research (UQCCR), Brisbane, Australia
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Belgium
| | - Michael Schuetz
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Australia
- Department of Orthopaedic Surgery, Royal Brisbane and Women’s Hospital, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Queensland, Australia
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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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Finelli CA, Dos Reis FB, Fernandes HA, Dell'Aquila A, Carvalho R, Miki N, Franciozi C, Abdalla R, Salles MJC. Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients. Patient Saf Surg 2019; 13:39. [PMID: 31827616 PMCID: PMC6889343 DOI: 10.1186/s13037-019-0215-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN). Methods A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up. Results After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection. Conclusion This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur. Trial registration ISRCTN82233198. Retroactively registered on July 29, 2019.
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Affiliation(s)
- Carlos Augusto Finelli
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Fernando Baldy Dos Reis
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Helio Alvachian Fernandes
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Adriana Dell'Aquila
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Rogério Carvalho
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Natalia Miki
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Carlos Franciozi
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Rene Abdalla
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Mauro José Costa Salles
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil.,2Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP Brazil
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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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13
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Metsemakers WJ, Kuehl R, Moriarty TF, Richards RG, Verhofstad MHJ, Borens O, Kates S, Morgenstern M. Infection after fracture fixation: Current surgical and microbiological concepts. Injury 2018; 49:511-522. [PMID: 27639601 DOI: 10.1016/j.injury.2016.09.019] [Citation(s) in RCA: 287] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/08/2016] [Indexed: 02/02/2023]
Abstract
One of the most challenging complications in trauma surgery is infection after fracture fixation (IAFF). IAFF may result in permanent functional loss or even amputation of the affected limb in patients who may otherwise be expected to achieve complete, uneventful healing. Over the past decades, the problem of implant related bone infections has garnered increasing attention both in the clinical as well as preclinical arenas; however this has primarily been focused upon prosthetic joint infection (PJI), rather than on IAFF. Although IAFF shares many similarities with PJI, there are numerous critical differences in many facets including prevention, diagnosis and treatment. Admittedly, extrapolating data from PJI research to IAFF has been of value to the trauma surgeon, but we should also be aware of the unique challenges posed by IAFF that may not be accounted for in the PJI literature. This review summarizes the clinical approaches towards the diagnosis and treatment of IAFF with an emphasis on the unique aspects of fracture care that distinguish IAFF from PJI. Finally, recent developments in anti-infective technologies that may be particularly suitable or applicable for trauma patients in the future will be briefly discussed.
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Affiliation(s)
- W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - R Kuehl
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland
| | | | | | - M H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands, The Netherlands
| | - O Borens
- Orthopedic Septic Surgical Unit, Department of the Locomotor Apparatus and Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - S Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, USA
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital of Basel, Switzerland
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14
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Koury KL, Hwang JS, Sirkin M. The Antibiotic Nail in the Treatment of Long Bone Infection: Technique and Results. Orthop Clin North Am 2017; 48:155-165. [PMID: 28336039 DOI: 10.1016/j.ocl.2016.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Antibiotic cement nails provide a useful and relatively simple technique to treat intramedullary osteomyelitis of the long bones. These devices provide stability as well as local, targeted antibiotics, which are both critical aspects of osteomyelitis management. Additionally, the use of a threaded core is a critical component of successful cement nail assembly. With adherence to the simple principles outlined in this review, surgeons can expect reliably good results using these drug-delivery implants.
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Affiliation(s)
- Kenneth L Koury
- Department of Orthopaedics, Complex Fractures, Nonunions and Osteomyelitis, University Physician Associates, North Jersey Orthopaedic Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, 140 Bergen Street, Suite D1610, Newark, NJ 07103, USA
| | - John S Hwang
- Department of Orthopaedics, Complex Fractures, Nonunions and Osteomyelitis, University Physician Associates, North Jersey Orthopaedic Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, 140 Bergen Street, Suite D1610, Newark, NJ 07103, USA
| | - Michael Sirkin
- Department of Orthopaedics, Complex Fractures, Nonunions and Osteomyelitis, University Physician Associates, North Jersey Orthopaedic Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, 140 Bergen Street, Suite D1610, Newark, NJ 07103, USA.
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15
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Tosounidis TH, Calori GM, Giannoudis PV. The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update. Eur J Trauma Emerg Surg 2016; 42:417-423. [PMID: 27402484 PMCID: PMC4969338 DOI: 10.1007/s00068-016-0700-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/17/2016] [Indexed: 12/22/2022]
Abstract
Purpose Reamer–irrigator–aspirator (RIA) is an innovative device that its indications have recently been expanded to the management of long bone infections. Methods In this narrative review, we summarise the most important studies in the field and we present the current open questions pertaining to the use of RIA in the management of osteomyelitis of long bones. Results The relevant literature is sparse and low quality. Nevertheless, the use of RIA for infected cases has yielded promising outcomes in specialised centres. Technical aspects that merit special attention in osteomyelitis of long bones are its inapplicability in small diameter long bones, the inadequate debridement of wide metaphyseal areas and the potential bleeding sequelae. The use of RIA in open fracture management to reduce infection risk has not gained acceptance. The antibiotic impregnated nails and rods constitute a complimentary strategy for the management of infections. Conclusions The use of RIA for the management of long bone infections is an innovative and promising strategy. High quality studies are needed to shed light in its efficacy compared to conventional methods of management of osteomyelitis of long bones.
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Affiliation(s)
- T H Tosounidis
- Academic Department of Trauma and Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, LS7 4SA, UK
| | - G M Calori
- G. Pini Institute, University of Milan, Piazza Cardinal Ferrari 1, Milan, Italy
| | - P V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK.
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, LS7 4SA, UK.
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