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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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Pujol O, Vicente M, Castellanos S, Joshi-Jubert N, Corona P. Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport. Strategies Trauma Limb Reconstr 2023; 18:155-162. [PMID: 38404568 PMCID: PMC10891350 DOI: 10.5005/jp-journals-10080-1595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/04/2023] [Indexed: 02/27/2024] Open
Abstract
Aim Distal tibial injuries combining bone loss, articular destruction and infection can be treated through distraction osteogenesis combined with ankle fusion. Bone transport is not without complications. This study investigates our preliminary results using a retrograde prefabricated gentamicin-coated nail (ETN PROtect®) to treat complications after infected bone defects of the distal tibial were managed by ankle arthrodesis and distraction osteogenesis. Materials and methods This is a retrospective case series study. All consecutive patients with bone transport complications after ankle arthrodesis and distraction osteogenesis who were subsequently operated on using a retrograde ETN PROtect® nail were analysed. The cases occurred between 2017 and 2020. The primary objective was to report on the resolution of the clinical problem and the risk of deep infection after nail implantation. Results Five patients have included: two docking site non-unions, two regenerated bone fractures and one hypotrophic regenerated bone. These complications were resolved in all patients (5/5, 100%). A painless, stable and plantigrade ankle arthrodesis was achieved in all cases. No patient developed a local infection or required nail removal (mean follow-up: 35.2 months). The mean LEFS score was 46.8 ± 13.8 and the mean knee ROM was 112 ± 12.7°. All patients tolerated full weight-bearing. All patients were very satisfied with the procedure (mean SAPS score was 93.8 points). Conclusion The staged retrograde nailing technique using the ETN PROtect® nail may represent an effective and safe treatment for bone transport complications in high-infection-risk patients. Furthermore, the technique allows simultaneous achievement of ankle arthrodesis. The patients had good functional outcomes and were satisfied with the procedure. Clinical significance This strategy of using retrograde gentamicin-coated tibial nails offers a solution to resolve bone transport complications while simultaneously achieving functional ankle arthrodesis. How to cite this article Pujol O, Vicente M, Castellanos S, et al. Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport. Strategies Trauma Limb Reconstr 2023;18(3):155-162.
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Affiliation(s)
- Oriol Pujol
- Department of Orthopaedic Surgery, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Ciències Morfològiques), Barcelona, Spain
| | - Matías Vicente
- Department of Orthopaedic Surgery, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Ciències Morfològiques); Department of Orthopaedic Surgery, Septic and Reconstructive Surgery Unit, Vall d'Hebron University Hospital; Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Sara Castellanos
- Department of Orthopaedic Surgery, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Ciències Morfològiques), Barcelona, Spain
| | - Nayana Joshi-Jubert
- Department of Orthopaedic Surgery, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Ciències Morfològiques); Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Pablo Corona
- Department of Orthopaedic Surgery, Vall d'Hebron University Hospital; Universitat Autònoma de Barcelona (Departament de Cirurgia i Ciències Morfològiques); Department of Orthopaedic Surgery, Septic and Reconstructive Surgery Unit, Vall d'Hebron University Hospital; Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Barcelona, Spain
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Li H, Wang D, Zhang W, Xu G, Xu C, Liu W, Li J. Potential side effects of antibacterial coatings in orthopaedic implants: A systematic review of clinical studies. Front Bioeng Biotechnol 2023; 11:1111386. [PMID: 36845182 PMCID: PMC9947536 DOI: 10.3389/fbioe.2023.1111386] [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: 11/29/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
Objective: The systematic review aimed to determine the potential side effects of antibacterial coatings in orthopaedic implants. Methods: Publications were searched in the databases of Embase, PubMed, Web of Science and Cochrane Library using predetermined keywords up to 31 October 2022. Clinical studies reporting side effects of the surface or coating materials were included. Results: A total of 23 studies (20 cohort studies and three case reports) reporting the concerns about the side effects of antibacterial coatings were identified. Three types of coating materials, silver, iodine and gentamicin were included. All of studies raised the concerns regarding safety of antibacterial coatings, and the occurrence of adverse events was observed in seven studies. The main side effect of silver coatings was the development of argyria. For iodine coatings, only one anaphylactic case was reported as an adverse event. No systemic or other general side effects were reported for gentamicin. Conclusion: Clinical studies on the side effects of antibacterial coatings were limited. Based on the available outcomes, the most reported side effects of antibacterial coatings in clinical use were argyria with silver coatings. However, researchers should always pay attention to the potential side effects of antibacterial materials, such as systematic or local toxicity and allergy.
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Affiliation(s)
- Hua Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Daofeng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Wupeng Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,School of Medicine, Nankai University, Tianjin, China
| | - Gaoxiang Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Cheng Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,*Correspondence: Cheng Xu, ; Wanheng Liu, ; Jiantao Li,
| | - Wanheng Liu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,*Correspondence: Cheng Xu, ; Wanheng Liu, ; Jiantao Li,
| | - Jiantao Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,*Correspondence: Cheng Xu, ; Wanheng Liu, ; Jiantao Li,
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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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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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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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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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11
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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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12
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Mosselhy DA, Assad M, Sironen T, Elbahri M. Nanotheranostics: A Possible Solution for Drug-Resistant Staphylococcus aureus and their Biofilms? NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:E82. [PMID: 33401760 PMCID: PMC7824312 DOI: 10.3390/nano11010082] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 12/14/2022]
Abstract
Staphylococcus aureus is a notorious pathogen that colonizes implants (orthopedic and breast implants) and wounds with a vicious resistance to antibiotic therapy. Methicillin-resistant S. aureus (MRSA) is a catastrophe mainly restricted to hospitals and emerged to community reservoirs, acquiring resistance and forming biofilms. Treating biofilms is problematic except via implant removal or wound debridement. Nanoparticles (NPs) and nanofibers could combat superbugs and biofilms and rapidly diagnose MRSA. Nanotheranostics combine diagnostics and therapeutics into a single agent. This comprehensive review is interpretative, utilizing mainly recent literature (since 2016) besides the older remarkable studies sourced via Google Scholar and PubMed. We unravel the molecular S. aureus resistance and complex biofilm. The diagnostic properties and detailed antibacterial and antibiofilm NP mechanisms are elucidated in exciting stories. We highlight the challenges of bacterial infections nanotheranostics. Finally, we discuss the literature and provide "three action appraisals". (i) The first appraisal consists of preventive actions (two wings), avoiding unnecessary hospital visits, hand hygiene, and legislations against over-the-counter antibiotics as the general preventive wing. Our second recommended preventive wing includes preventing the adverse side effects of the NPs from resistance and toxicity by establishing standard testing procedures. These standard procedures should provide breakpoints of bacteria's susceptibility to NPs and a thorough toxicological examination of every single batch of synthesized NPs. (ii) The second appraisal includes theranostic actions, using nanotheranostics to diagnose and treat MRSA, such as what we call "multifunctional theranostic nanofibers. (iii) The third action appraisal consists of collaborative actions.
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Affiliation(s)
- Dina A. Mosselhy
- Nanochemistry and Nanoengineering, Department of Chemistry and Materials Science, School of Chemical Engineering, Aalto University, 02150 Espoo, Finland;
- Microbiological Unit, Fish Diseases Department, Animal Health Research Institute, Dokki, Giza 12618, Egypt
- Department of Virology, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland;
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 66, 00014 Helsinki, Finland
| | - Mhd Assad
- Nanochemistry and Nanoengineering, Department of Chemistry and Materials Science, School of Chemical Engineering, Aalto University, 02150 Espoo, Finland;
| | - Tarja Sironen
- Department of Virology, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland;
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 66, 00014 Helsinki, Finland
| | - Mady Elbahri
- Nanochemistry and Nanoengineering, Department of Chemistry and Materials Science, School of Chemical Engineering, Aalto University, 02150 Espoo, Finland;
- Nanochemistry and Nanoengineering, Institute for Materials Science, Faculty of Engineering, Kiel University, 24143 Kiel, Germany
- Center for Nanotechnology, Zewail City of Science and Technology, Sheikh Zayed District, Giza 12588, Egypt
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13
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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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Mallon Z, Provus J, Lee G. Removing a Retained Antibiotic Cement Nail from a Tibia: A Case Report. JBJS Case Connect 2020; 10:e2000106. [PMID: 33021518 DOI: 10.2106/jbjs.cc.20.00106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE We present a case of osteomyelitis after a grade 3A open tibial shaft fracture complicated by incomplete removal of an antibiotic intramedullary rod. The authors are unaware of any reports with this specific complication and provide a novel technique for cement mantle removal involving a distal tibial corticotomy and antegrade cement impaction. CONCLUSION Antibiotic nails can successfully treat intramedullary osteomyelitis, but surgeons may encounter unexpected issues due to custom, intraoperative fabrication. This case describes one example of how to solve the intraoperative problem of a retained cement mantle during antibiotic rod extraction.
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Affiliation(s)
- Zachary Mallon
- The Permanente Medical Group, Department of Orthopaedic Surgery, Vacaville, California
| | - Jason Provus
- The Permanente Medical Group, Department of Orthopaedic Surgery, Vacaville, California
| | - Gavin Lee
- The Permanente Medical Group, Department of Orthopaedic Surgery, Vacaville, California
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15
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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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Stoian AB, Demetrescu I, Ionita D. Nanotubes and nano pores with chitosan construct on TiZr serving as drug reservoir. Colloids Surf B Biointerfaces 2020; 185:110535. [DOI: 10.1016/j.colsurfb.2019.110535] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 01/12/2023]
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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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Pawar V, Bulbake U, Khan W, Srivastava R. Chitosan sponges as a sustained release carrier system for the prophylaxis of orthopedic implant-associated infections. Int J Biol Macromol 2019; 134:100-112. [DOI: 10.1016/j.ijbiomac.2019.04.190] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/13/2019] [Accepted: 04/29/2019] [Indexed: 12/31/2022]
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19
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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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Pan C, Zhou Z, Yu X. Coatings as the useful drug delivery system for the prevention of implant-related infections. J Orthop Surg Res 2018; 13:220. [PMID: 30176886 PMCID: PMC6122451 DOI: 10.1186/s13018-018-0930-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 08/22/2018] [Indexed: 12/13/2022] Open
Abstract
Implant-related infections (IRIs) which led to a large amount of medical expenditure were caused by bacteria and fungi that involve the implants in the operation or in ward. Traditional treatments of IRIs were comprised of repeated radical debridement, replacement of internal fixators, and intravenous antibiotics. It needed a long time and numbers of surgeries to cure, which meant a catastrophe to patients. So how to prevent it was more important than to cure it. As an excellent local release system, coating is a good idea by its local drug infusion and barrier effect on resisting biofilms which were the main cause of IRIs. So in this review, materials used for coatings and evidences of prevention were elaborated.
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Affiliation(s)
- Chenhao Pan
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Zubin Zhou
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
| | - Xiaowei Yu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, 200233 China
- Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital East Campus, Shanghai University of Medicine and Health Sciences, Shanghai, 201306 China
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Helbig L, Bechberger M, Aldeeri R, Ivanova A, Haubruck P, Miska M, Schmidmaier G, Omlor GW. Initial peri- and postoperative antibiotic treatment of infected nonunions: results from 212 consecutive patients after mean follow-up of 34 months. Ther Clin Risk Manag 2018; 14:59-67. [PMID: 29379296 PMCID: PMC5757496 DOI: 10.2147/tcrm.s152008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Infected nonunions of the long bones belong to the most feared complications in the field of orthopedic and trauma surgery. Optimal antibiotic therapy should start early with the first revision surgery. Therefore, the aim of this study was to evaluate our peri- and postoperative antibiotic regime in context with the microbial spectrum and antibiotic resistances of patients with infected nonunions and to assess the possible impact on healing rates. METHODS We included all patients with first revision surgery during 2010-2015 due to nonunion of long bones with a clinical history of infection treated with radical debridement, local application of a gentamicin-impregnated bone cement, and systemic cefuroxime. Mean follow-up was 34.2 months. Data collection was performed retrospectively using a computerized databank with information about microbial species from intraoperatively acquired tissue samples and respective antibiograms. Bone fusion rates were evaluated based on findings of the latest X-rays and computed tomography scans. RESULTS Two hundred and twelve patients with nonunion and history of infection were selected; 171 patients had positive intraoperative microbial evidence of infection. Bacterial testing was mostly positive in fractures of the tibia (47.4%) and the femur (27.5%). Coagulase-negative Staphylococcus spp. were the most frequently detected (44.4%) followed by mixed infections (18.7%) and Staphylococcus aureus (10.5%). Antibiograms revealed that 62.6% of our cases were cefuroxime sensitive; 87.7% were gentamicin sensitive. Only 10.5% showed resistance to both cefuroxime and gentamicin. There was no statistically significant difference of fusion rates between patients with different microbial species or different antibiograms. CONCLUSION Our data suggest that besides the high variety of different detected species, initial antibiotic treatment with a combination of systemic cefuroxime and local gentamicin-loaded bone cement is effective and in almost 90% the later determined microbial infection was sensitive to this treatment. Therefore, we recommend initial treatment according to this algorithm until specific antibiograms are available from intraoperatively acquired tissue samples.
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Affiliation(s)
- Lars Helbig
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | - Maren Bechberger
- Pharmacy Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Riyadh Aldeeri
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | - Adriana Ivanova
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | | | - Matthias Miska
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | | | - Georg W Omlor
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
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Schmidmaier G, Kerstan M, Schwabe P, Südkamp N, Raschke M. Clinical experiences in the use of a gentamicin-coated titanium nail in tibia fractures. Injury 2017; 48:2235-2241. [PMID: 28734495 DOI: 10.1016/j.injury.2017.07.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 07/03/2017] [Accepted: 07/09/2017] [Indexed: 02/02/2023]
Abstract
Despite the improvement of surgical techniques surgical site infections (SSIs) still remain clinically challenging in high risk patients undergoing osteosynthesis for tibia fractures. The use of an antibiotic coated implant might reduce the adhesion of bacteria on the implant surface and could therefore reduce the rate of implant-related infection or osteomyelitis. A gentamicin-coated tibia nail was evaluated in a prospective study. Four centers enrolled 100 patients (99 treated) with fresh open or closed tibia fractures, or for non-union revision surgery and followed them for 18 months. Data collected included infection events, radiographs, SF-12, EQ-5D, Iowa Ankle score, and the WOMAC questionnaire. Sixty-eight of the 99 treated patients suffered from a fresh fracture, while in 31 patients, the intramedullary nail was implanted for revision purposes, including non-unions due to infection. Fifteen (22%) of the fresh fractures were GA Type III. The follow-up rate was 87% and 82% at 12 months and 18 months, respectively. Deep surgical site infections occurred in 3 fresh fractures and two in revision surgeries. We did not observe any local or systemic toxic effects related to gentamicin during this study. The use of the antibiotic coated nail is an option in patients with a high infection risk, like open factures or infected non unions, in the prevention of the onset of an implant-related infection or osteomyelitis.
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Affiliation(s)
- G Schmidmaier
- Trauma and Reconstructive Surgery HTRG, Center of Orthopaedics, Traumatology and Spinal Cord Injury - University Clinic of Heidelberg, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany.
| | - M Kerstan
- Clinical Research, DePuy Synthes, Zuchwil, Switzerland
| | - P Schwabe
- Trauma- and Reconstructive Surgery, CMSC, Charité University Medicine, Germany
| | - N Südkamp
- Clinic for Orthopaedics and Trauma Surgery, Department of Surgery, University Clinic of Freiburg, Germany
| | - M Raschke
- Clinic for Trauma-, Hand-, and Reconstructive Surgery, University Clinic Münster, Germany
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CORR Insights ®: Phosphatidylcholine Coatings Deliver Local Antimicrobials and Reduce Infection in a Murine Model: A Preliminary Study. Clin Orthop Relat Res 2017; 475:1854-1856. [PMID: 28083754 PMCID: PMC5449326 DOI: 10.1007/s11999-017-5237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/06/2017] [Indexed: 01/31/2023]
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Haubruck P, Schmidmaier G. [Susceptibility to infections and behavior of stainless steel : Comparison with titanium implants in traumatology]. Unfallchirurg 2017; 120:110-115. [PMID: 28070629 DOI: 10.1007/s00113-016-0300-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite modern treatment options, implant-associated infections (IAI) remain a severe and challenging complication in the treatment of trauma patients. Almost 30 years after the introduction of implants made of titanium alloy into the treatment of trauma patients, there is still no uniform consensus regarding the clinical benefit of titanium alloy in the context of patients with IAI. OBJECTIVE We sought to determine if implants made of titanium alloy have been proven to be less susceptible regarding IAI in contrast to implants made of stainless steel. MATERIAL AND METHODS A review of the current literature on IAI in association with the utilized implant material was conducted. Relevant articles from the years 1995 to 2016 were searched in the PubMed database. A total of 183 articles were identified and all abstracts were reviewed for relevance. A total of 14 articles met the inclusion criteria and were stratified according to the level of evidence and furthermore evaluated regarding the influence of the implant material on IAI. RESULTS AND DISCUSSION Considerable debate remains concerning the influence of the implant material on the susceptibility to IAI; however, the available literature shows that despite slight tendencies, there is no proof of titanium alloy being favorable in the susceptibility to IAI. Furthermore, the literature shows that the design of plates for osteosynthesis might influence IAI. In particular, plates that cause less soft tissue damage and preserve perfusion of the periosteum proved to be beneficial regarding IAI.
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Affiliation(s)
- Patrick Haubruck
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - Gerhard Schmidmaier
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland.
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