Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes

Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections

SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.

Antibiotic cement nails manufactured with threaded rods or cannulated intramedullary nails are better than those made with guidewires and do not debond

Purpose

The purpose of this study was to comparatively evaluate cement debonding at the time of removal of antibiotic cemented coated nails (ABNs) with cores made with a guidewire ($120), a regular intramedullary nail ($1100) or a threaded rod from a circular frame external fixator set ($60).

Methods

A retrospective study was performed on 32 ABNs that had been implanted for long bone infections after intramedullary nailing. All ABNs were manufactured intraoperatively by the treating surgeon using 2 grams of vancomycin and single package of Tobramycin Simplex Cement (Stryker, Kalamazoo, MI). The powder, antibiotics, and polymer were mixed and then injected into an ABN cement mold (Bonesetter Holdings USA). Debonding was assessed at time of removal by the operating surgeon. Rates of cement debonding between the 3 groups were statistically compared.

Results

Debonding occurred in 0/12 of the cement nails manufactured with an intramedullary nail, 0/7 threaded rod ABNs, and 6/13 guidewire ABNs. There was a significant difference in the rate of debonding between the 3 groups (P < 0.01). Removal of the remnant cement was accomplished with thin osteotomes, long pituitary rongeurs, or reamers. The canal was visualized using an arthroscope to ensure complete removal of the cement.

Conclusion

ABNs fabricated with standard intramedullary nails or threaded rods did not lead to any debonding. Debonding of the cement from the inner core of an antibiotic nail often requires significant effort to remove the remnant cement. Given that threaded rods are often cheaper than guidewires, we recommend that ABNs be fabricated with either threaded rods or interlocking nails, but not guidewires, depending on the level of stability required.

Antibiotic-Coated Intramedullary Nailing Managing Long Bone Infected Non-Unions: A Meta-Analysis of Comparative Studies

Long bone infected non-unions are such an orthopedic challenge that antibiotic-coated intramedullary nailing (ACIN) has become a viable therapeutic option for their management. This study aims to provide a comprehensive assessment of the available data about the use of antibiotic-coated nailing in the treatment of long bone infected non-unions. Following the PRISMA guideline in this meta-analysis, a systematic literature search was conducted across major databases for studies evaluating ACIN in long bone infected non-unions. The primary outcome measures included union rates, infection control, complications and functional status. Five eligible studies encompassing 183 patients in total met the inclusion criteria. The meta-analysis revealed no difference in the union rate in the antibiotic-coated intramedullary nailing group compared to that of the control group (OR = 1.73 [0.75-4.02]). Antibiotic-coated intramedullary nailing demonstrated no association with higher infection eradication (OR = 2.10 [0.97-4.54]). Also, functional outcome measure was mostly not significantly different between ACIN and control interventions. According to this meta-analysis, compared to the management of controls, ACIN is neither linked to increased union rates nor decreased infection rates. The paucity of research on this topic emphasizes the continuous need for additional well-designed randomized controlled trials for the application of antibiotics-coated intramedullary nailing in long bone non-unions.

Infection after intramedullary nailing of femoral and tibial diaphyseal fractures

PURPOSE

Management of fracture-related infection (FRI) after intramedullary fixation (IF) is a challenge. The aim of the present study is to describe a series of 26 patients with FRI after IF and to evaluate factors possibly related to the outcome.

METHODS

Baseline variables were obtained at the time of IF: age, sex, body mass index, affected bone, open fracture, substance abuse, use of an external fixator, type of nail, reaming, soft-tissue reconstruction and surveillance culture result. After diagnosis of the infection, information was obtained about the time interval between IF and diagnosis and classification according to both the Willeneger and Roth and Makridis systems. Treatment modalities were grouped and analysed according to: use of antimicrobials, surgical debridement, nail removal or retention and spacer use. Cultures of bone or deep soft tissues were performed. Patients were followed up for 12 months, and outcomes (remission, relapse, death and loss of follow-up) were evaluated, as well as fracture consolidation.

RESULTS

Remission was observed in 42.3% of patients. There was no significant association between any baseline variable and outcome. There was a significant association between Makridis stage 2 classification and recurrence or death. Treatment strategy was not significantly associated with outcome, and 65.4% of cases had positive culture results, with Enterobacter cloacae as the predominant agent. Consolidation was observed in 81.8% of patients and was not significantly related to the outcome.

CONCLUSION

There was a significant association between Makridis classification and the outcome. Consolidation rate was not associated with the outcome regarding the treatment of the infection.

Analysis of risk factors for serous exudation of biodegradable material calcium sulfate in the treatment of fracture-related infections

Objective: To explore the related risk factors of serous exudation after antibiotic-loaded calcium sulfate treatment of fracture-related infections and to provide a theoretical basis for clinical treatment and prevention of serous exudation complications. Methods: The clinical data of 145 patients with limb fracture-related infection treated with antibiotic-loaded calcium sulfate in Xi'an Honghui Hospital from January 2019 to December 2022 were retrospectively analyzed. All patients were diagnosed with fracture-related infection by preoperative magnetic resonance examination, bacterial culture and gene detection and received antibiotic-loaded calcium sulfate implantation. The postoperative serous exudation was recorded through hospitalization observation, outpatient review or follow-up. The collected clinical data were sorted out, and the patient data were divided into serous exudation groups and non-exudation groups. Firstly, the clinical data of the two groups were compared by single-factor analysis to screen out the risk factors. Then multivariate binary Logistic regression analysis determined the independent risk factors and protective factors. Results: 1) According to the inclusion and exclusion criteria, there were 145 cases with complete clinical data, including 27 cases in the non-infectious exudation group and 118 cases in the non-exudative group; 2) Univariate analysis showed that the history of diabetes, smoking history, calcium sulfate implantation, drainage time, combined flap surgery, geometric shape of implanted calcium sulfate, and thickness of soft tissue covered by the surgical area were all associated with the occurrence of non-infectious exudation after antibiotic-loaded calcium sulfate implantation (p < 0.05); 3) The amount of implanted calcium sulfate was more [OR = 5.310, (1.302-21.657), p = 0.020], combined with flap surgery [OR = 3.565, (1.195-10.641), p = 0.023], and the thickness of soft tissue coverage in the operation area was thinner [OR = 5.305, (1.336-21.057), p = 0.018]. Longer drainage time [OR = 0.210, (0.045-0.967), p = 0.045] was a protective factor for non-infectious exudation after antibiotic-loaded calcium sulfate implantation. Conclusion: 1) The probability of serous exudation in patients with fracture-associated infection after antibiotic-loaded calcium sulfate surgery was 18.62%. This complication may cause a heavier economic and psychological burden on patients; 2) With the increase of bone infection area and the application of more calcium sulfate, the incidence of serous exudation after antibiotic-loaded calcium sulfate surgery in patients with the fracture-related infection will increase, so we should use the amount of calcium sulfate reasonably on the premise of sufficient control of infection in clinical work, and the incidence of serous exudation will also increase due to the recent skin flap surgery and the thinner soft tissue coverage of calcium sulfate implantation area; 3) Under the premise of being able to drain the drainage from the surgical area, the longer drainage time of the drainage tube has a positive effect on preventing the occurrence of serous exudation.

Infection after surgical implant generation network (SIGN) nailing in treatment of long bone shaft fractures in Ethiopia: analysis of a 4-year results

BACKGROUND

One of the challenge to manage long bone fracture is the risk of infection. Intramedullary nailing is the standard treatment of long bone shaft fractures. Infection from the surgical site during orthopedic management is posing postoperative burdens in different perspectives like patient perspectives and healthcare facilities. However, there is limited information on the magnitude of infection in Ethiopia after surgical implant generation network (SIGN) nailing in the treatment of long bone shaft fractures. Therefore, the current study aimed to assess the prevalence of infection in patients with long bone shaft fractures treated with surgical implant generation network (SIGN) nailing.

OBJECTIVE

To assess prevalence of infection in patients with long bone shaft fractures treated with SIGN nailing at Felege Hiwot Referral Hospital from January 1, 2015, to December 31, 2018, Bahir Dar, Northwest, Ethiopia.

METHODS

This was a retrospective study over a period of 4 years. SIGN surgical-related data, presence or absence of infection from the documented information were collected from the chart/the source. The types of infection were also collected with the standard classification as superficial, deep and deep with osteomyelitis. Age, sex, fracture pattern, nature of fracture, mechanism of injury, prophylaxis antibiotics, nail type, follow-up in weeks and other factors were also extracted from the patients' charts with structured checklist. Data were analyzed with statistical package for social sciences (SPSS) version 23. The analyzed data were presented with texts, tables and a graph.

RESULTS

Three hundred and eighty-two long bone fractures were treated by locked SIGN intramedullary nailing during the study period. After screening the inclusion criteria, a total of 311 cases were included in this study. A total of 13 (4.2%) patients who treated with SIGN intramedullary nailing developed infection.

CONCLUSIONS

We conclude that the overall prevalence of infection with SIGN intramedullary nailing is almost similar with the surgeries done in the developed countries.

Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting

Introduction: Infection is the chief complication that makes open fractures difficult to treat. Most low- and middle-income countries (LMICs) are missing out on modern management techniques developed to achieve better outcomes in high-income countries (HICs). One of these is the use of locked intramedullary (IM) nails. This study aimed to determine the factors associated with infection of open fractures treated with the surgical implant generation network (SIGN) nail at a Nigerian tertiary hospital. Methods: Data were collected prospectively on 101 open fractures of the femur and tibia over an 8-year period. Active surveillance for infection was done on each patient. Infection was diagnosed as the presence of wound breakdown or purulent discharge from (or near) the wound or surgical incision. Potential risk factors were tested for association with infection. Results: There were 101 fractures in 94 patients with a mean age of 37.76 years. The following treatment-related factors demonstrated significant associations with infection - timings of antibiotic administration (p < 0.001 ) and definitive fracture fixation (p = 0.002 ); definitive wound closure (p < 0.001 ), fracture-reduction methods (p = 0.005 ), and surgery duration (p = 0.007 ). Conclusions: Although this study has limitations precluding the drawing up of final conclusions, the findings suggest that the risk factors for infection of nailed open fractures in LMICs are similar to those in HICs. Consequently, outcomes can potentially improve if LMICs adopt the management principles used in HICs in scientifically sound ways that are affordable and socially acceptable to their people. Further studies are suggested to establish our findings.

Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection

PURPOSE

The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England).

METHODS

A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required.

RESULTS

All 13 patients achieved infection remission rate with an average follow-up of 19.7 months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8 months (range 4-12) from debridement. No patients developed aseptic wound leak.

CONCLUSIONS

Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.

Antibiotic Cement-Coated Interlocked Intramedullary Nails for the Treatment of Infected Nonunion After Intramedullary Nailing

OBJECTIVE

To evaluate outcomes using an interlocking antibiotic cement-coated nail and culture-specific systematic antibiotics in the treatment of infected nonunion after intramedullary nailing.

DESIGN

Retrospective observational cohort study.

SETTING

Urban level I trauma center.

PATIENTS/PARTICIPANTS

Forty-one nonconsecutive patients who presented to a level I trauma center who underwent interlocked antibiotic nailing for treatment of infected nonunion status after primary intramedullary nailing.

OUTCOMES

Eradication of infection, radiographic union by 2-year follow-up.

RESULTS

Antibiotic nailing successfully eradicated infection and led to fracture healing in 35 patients (85.4%), while 6 patients (14.6%) had persistent infection and required further surgical treatment. Of the 6 patients who required further treatment, 5 eventually went on to heal with fracture union and eradication of their infection, while 1 required a salvage procedure. Of the 5 patients who eventually went on to heal, 4 of them healed with repeat antibiotic or intramedullary nails, while 1 required segmental resection and bone grafting before healing.

CONCLUSIONS

This study suggests that the proposed interlocked antibiotic nailing technique is a viable therapeutic option to eradicate infected nonunion and support fracture healing.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bone Transport Treatment of Osteomyelitis Due to Thermal Osteonecrosis After IM Nailing of Tibial Stress Fracture Nonunion: A Case Report

CASE

We present a case of a female athlete who sustained a nonunion of a tibial stress fracture and was treated with intramedullary nailing (IMN). The patient developed osteomyelitis likely secondary to a thermal osteonecrosis during the index procedure and required resection of the necrotic tibia and bone transport using the Ilizarov technique.

CONCLUSIONS

The authors believe that all actions should be taken to avoid thermal osteonecrosis during reaming for tibial IMN, especially in patients with a small medullary canal. We believe that bone transport with the Ilizarov technique is an effective treatment method for patients who develop tibial osteomyelitis after treatment of tibial shaft fractures.

Innovations in orthopaedic trauma: Top advancements of the past two decades and predictions for the next two

The first Trauma and Orthopaedic unit dates back to 1780, originally dedicated to the treatment of children's deformities. The specialty has subsequently become multifaceted, with a plethora of subspecialty areas of which orthopaedic trauma is the most commonly practiced. Recently there has been a significant demand for an evidence base with more than 130,000 of the 162,000 publications in the last century occurring within the past 20 years. This narrative review will summarise some of the more landmark changes within orthopaedic trauma that have been made within the past 20 years, whilst also attempting to predict where the specialty will continue to develop as we move forward.

[Infected nonunion: diagnostic and therapeutic work-up]

BACKGROUND

Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone.

OBJECTIVE

Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated.

MATERIAL AND METHODS

In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48‑h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth.

RESULTS

In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis.

CONCLUSION

If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.

Outcome of monolateral rail fixator in infected nonunion of femur diaphysis developing after intramedullary fixation

INTRODUCTION

Consensus is lacking regarding management of posttraumatic infected diaphyseal nonunions of femur following intramedullary nailing. Present study reports outcomes of single stage standardised treatment protocol using monolateral rail external fixator/limb reconstruction system in this type of infected diaphyseal femoral nonunions.

METHODS

This retrospective study included 26 patients with mean age of 31.7 years having posttraumatic infected diaphyseal femoral nonunions following intramedullary nailing and managed with radical debridement and monolateral rail fixator. The results were assessed by Association for the Study and Application of the Method of Ilizarov criteria.

RESULTS

Mean intraoperative bone gap was 4.34 (range, 2-7) cm. Mean gain in bone length was 4.04 (range, 0-7) cm. Fracture united primarily in 22 cases and after freshening of edges, fixator adjustment and fibular grafting in three more patients. Infection persisted in one patient. Most common complications were superficial pin tract infection (15 patients) and loss of more than 30° knee flexion (13 patients). The bone results were excellent, good, and poor in 15, 9, and 2 patients, respectively. The functional results were excellent, good, fair, and poor in 11,13,1 and 1 patient, respectively.

CONCLUSION

Single stage procedure including radical debridement, acute docking, distraction osteogenesis at corticotomy site and stabilization with monolateral rail fixator reliably achieves good to excellent bone and functional results, union and eradication of infection in majority of infected nonunions of femoral diaphysis developing after intramedullary fixation. We recommend acute docking in bone gap ≤ 5 cm.

Uncoated vs. Antibiotic-Coated Tibia Nail in Open Diaphyseal Tibial Fracture (42 according to AO Classification): A Single Center Experience

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.

Biofilm and its implications postfracture fixation: All I need to know

Biofilm represents an organized multicellular community of bacteria having a complex 3D structure, formed by bacterial cells and their self-produced extracellular matrix. It usually attaches to any foreign body or fixation implant. It acts as a physical protective barrier of the bacteria from the penetration of antibodies, bacteriophages, granulocytes and biocides, antiseptics, and antibiotics. Biofilm-related infections will increase in the near future. This group of surgical site infections is the most difficult to diagnose, to suppress, to eradicate, and in general to manage. Multispecialty teams involved in all stages of care are an effective way to improve results and save resources and time for the benefit of patients and the health system. Significant steps have occurred recently in the prevention and development of clever tools that we can employ in this everlasting fight with the bacteria. Herein, we attempt to describe the nature and role of the "biofilm" to the specific clinical setting of surgical site infections in the field of orthopaedic trauma surgery.

Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis

PURPOSE

This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018.

METHODS

A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period.

RESULTS

Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6-80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1-624) and mean follow-up 51 months (range 6-126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79-87) of all cases, increasing to 94% (95% CI 92-96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6-11) and amputation in 3% (95% CI 2-3). Final outcomes overlapped across treatment strategies.

CONCLUSION

Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.

Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: a retrospective study of 19 cases

Background

The incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis.

Methods

We retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed.

Results

A total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55 months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively.

Conclusion

Intramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.

Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients

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.

Evaluation of the clinical use of the ETN PROtect® in non-union therapy

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.

Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review

Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.

Non-union: Indications for external fixation

External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.

Treatment of infection following intramedullary nailing of tibial shaft fractures-results of the ORS/ISFR expert group survey

OBJECTIVE

The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally.

MATERIALS AND METHODS

A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1-4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts' personal scores and between experts' scores was performed. An agreement mean and correlation degree between experts' scores was calculated. Finally, a success rate report between groups was performed.

RESULTS

Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts' scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections.

CONCLUSIONS

Experts' and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies.

EVIDENCE

Clinical Question.

Clinical experiences in the use of a gentamicin-coated titanium nail in tibia fractures

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.

Closed Tibial shaft fractures treated with the Ilizarov method: A ten year case series

OBJECTIVES

To review the outcomes of patients treated with the Ilizarov method for an isolated, closed, simple diaphyseal, Tibial fracture at our institution over the last decade.

METHODS

The Ilizarov frame database was used to identify 76 skeletally mature patients who sustained an isolated, closed, extra-articular, simple, diaphyseal Tibial fracture; the injury also known as a "nail-able Tibial fracture."

RESULTS

The average age of the patient was 38 (17-70). All 76 patients progressed to union. The average time until union was 148 (55-398) days. The coronal and sagittal alignment was 3° (0-17°) and 4° (0-14°) respectively. No patient suffered from compartment syndrome. No patient developed septic arthritis. No patient had documented anterior knee pain or secondary knee specialist input post frame removal. On average, there were 9(4-29) follow up appointments and 10(5-26) radiographs post frame application. There is a 59% chance of a patient having a difficulty post frame application. The malunion rate was 5%. Persisting pinsite infection post frame removal occurred in 5 patients (6.5%). Drilling of the pinsite sequestrum resolved the infection in four of these patients, giving a deep infection rate of 1.3%.

CONCLUSIONS

The Ilizarov method has a role to play in the treatment of simple closed Tibial shaft fractures in patients who need to kneel. Patient education is a priority however; the patient must be made aware of the difficulty rate associated with the Ilizarov method when compared to the complication profile of alternative treatments.

The Antibiotic Nail in the Treatment of Long Bone Infection: Technique and Results

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.

Effect of a standardized treatment regime for infection after osteosynthesis

Background

Infection after osteosynthesis is an important complication with significant morbidity and even mortality. These infections are often caused by biofilm-producing bacteria. Treatment algorithms dictate an aggressive approach with surgical debridement and antibiotic treatment. The aim of this study is to analyze the effect of such an aggressive standardized treatment regime with implant retention for acute, existing <3 weeks, infection after osteosynthesis.

Methods

We conducted a retrospective 2-year cohort in a single, level 1 trauma center on infection occurring within 12 months following any osteosynthesis surgery. The standardized treatment regime consisted of implant retention, thorough surgical debridement, and immediate antibiotic combination therapy with rifampicin. The primary outcome was success. Success was defined as consolidation of the fracture and resolved symptoms of infection. Culture and susceptibility testing were performed to identify bacteria and resistance patterns. Univariate analysis was conducted on patient-related factors in association with primary success and antibiotic resistance.

Results

Forty-nine patients were included for analysis. The primary success rate was 63% and overall success rate 88%. Factors negatively associated with primary success were the following: Gustilo classification (P = 0.023), higher number of debridements needed (P = 0.015), inability of primary closure (P = 0.017), and subsequent application of vacuum therapy (P = 0.030). Adherence to the treatment regime was positively related to primary success (P = 0.034).

Conclusions

The described treatment protocol results in high success rates, comparable with success rates achieved in staged exchange in prosthetic joint infection treatment.

Infection after fracture osteosynthesis - Part II

In the first part of this article, we have discussed the pathogenesis, clinical presentation, diagnosis and classification of infection after fracture osteosynthesis with implants, termed here as osteosynthesis-associated infection (OAI). Prolonged antibiotic treatment is usually necessary. Implant retention and maintenance of fracture stability to allow for fracture healing in spite of infection are allowed for OAI. Depending on the severity of infection, status of fracture healing and host status, the treatment follows five common pathways. These are non-operative treatment, debridement with implant retention, conversion of fixation, implant removal and suppression therapy. The decision-making process leading to each treatment pathway and challenging scenarios is discussed in detail.

Patients' safety: is there a systemic release of gentamicin by gentamicin-coated tibia nails in clinical use?

INTRODUCTION

Osteitis is one of the most serious complications in orthopedic surgery. Expert Tibia Nail (ETN) PROtect™ coated with a biodegradable layer of gentamicin-laden polymer was developed for prophylaxis of osteomyelitis. In systemic administration, gentamicin has only a small therapeutic index and serious side effects; it is potentially nephrotoxic as well as ototoxic. It is not yet known if relevant gentamicin concentrations are released into the systemic circulation after implantation of gentamicin-coated nails. In order to evaluate the patients' risks profiles and increase patient safety, we measured gentamicin levels in pre- and postoperative serum samples of patients undergoing implantation of ETN PROtect.

METHODS

Twenty-five patients who received ETN PROtect between March 2012 and August 2014 were included in this study. Collection of blood samples occurred before the operation, at weeks 1-4, 3 and 6 months, and up to 1 year after the implantation. Measurement of gentamicin levels in serum samples was performed at the central laboratory of Heidelberg University Hospital. Additionally, laboratory parameters, C-reactive protein, leukocyte number, urea and creatinine concentrations were analyzed in routine controls before and after operating and assessed for systemic side effects.

RESULTS

Over the course of this prospective observational study, we were able to determine that gentamicin-coated nails do not release gentamicin into the systemic circulation above the lowest detectable level of 0.2 mg/dL. There were slight increases in the mean inflammation and renal retention markers, but no gentamicin-associated side effects could be linked to implantation. Furthermore, no allergic reactions could be detected during our study.

CONCLUSION

Our findings suggest that there is no relevant release of gentamicin into the systemic circulation causing a systemic effect, and serious side effects due to gentamicin-coated tibia nails should not be feared. Postoperative monitoring of renal function does not seem necessary because of the implantation of ETN PROtect.

Minimally Invasive Surgery for Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail: Preliminary Results of an Innovative Modified Technique

The aim of the present longitudinal prospective study was to evaluate the clinical, functional, and radiologic outcomes and patient satisfaction of those who had undergone minimally invasive surgery (MIS) for tibiotalocalcaneal arthrodesis with an intramedullary nail. The 28 patients, who had consecutively undergone surgery with the MIS technique, were evaluated clinically and radiographically at 1, 2, 3, and 6 months after surgery and at last follow-up examination. For the clinical evaluation, the American Orthopaedic Foot and Ankle Society scale and visual analog scale for the foot and ankle were used in the preoperative and final follow-up examinations. The patients rated their satisfaction on a scale from 0 to 10. The mean score obtained with the American Orthopaedic Foot and Ankle Society scale was 68.28 ± 5.02 (range 58 to 74) points and with the visual analog scale for the foot and ankle was 70.76 ± 7.72 (range 58 to 82) points, with a mean follow-up of 25.07 ± 6.32 (range 6 to 40) months. The clinical improvement was statistically significant with both types of evaluation (p ≤ .05), comparing the preoperative and follow-up periods. Fusion was achieved in all patients, with a mean fusion time of 14.85 ± 4.12 (range 8 to 56) weeks. The alignment of the ankle and foot was optimal in 27 of 28 patients (96.42%), and patient satisfaction was rated as 6.71 ± 1.37 (range 5 to 10) points. Finally, the use of MIS for tibiotalocalcaneal arthrodesis with intramedullary nail results in fusion of the articulation with a low complication rate.

The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update

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.

Increased risk of adverse events in management of femur and tibial shaft fractures with plating: An analysis of NSQIP data

BACKGROUND

The management of femoral and tibial shaft fractures has long been among the simplest in orthopaedic trauma. Little data exist on the predictors of complications associated with these fractures. The evolving healthcare system is creating a focus on quality metrics and changing payment models. It is critical that traumatologists develop a better understanding of complication rates associated with these injuries so that they may continue to improve patient care while also reducing overall medical costs.

METHODS

Using the ACS-NSQIP database, we evaluated patient demographics, comorbidities and 30-day complications of femoral and tibial fractures. A bivariate analysis was then used to compare rates of minor and major post-operative complications within 30 days. A multivariate logistic regression was performed, assessing the odds of developing a minor and/or major complication up to 30 days post-surgery.

RESULTS

2891 patients were identified. For femoral fractures, intramedullary nailing (IMN) demonstrated an overall complication rate of 14.9% (n = 151) whereas open reduction and internal fixation (ORIF) with plating showed an overall complication rate of 15.6% (n = 70). Patients undergoing plating of the femur or tibia were 2 times more likely than the IMN patients to demonstrate postoperative complications.

CONCLUSION

Our study is the first to demonstrate that plating of femoral and tibial fractures doubles the odds of developing a complication. As our healthcare system shifts to bundled payment plans, it is impertinent for the orthopaedic surgeon to understand the risk factors associated with fracture treatments in order to assess the best treatment plan.

Custom-Made Antibiotic Cement Nails in Orthopaedic Trauma: Review of Outcomes, New Approaches, and Perspectives

Since the first description in 2002 by Paley and Herzenberg, antibiotic bone cement nails (ACNs) have become an effective tool in the orthopaedic trauma surgeons' hands. They simultaneously elute high amounts of antibiotics into medullary canal dead space and provide limited stability to the debrided long bone. In this paper, we perform a systematic review of current evidence on ACNs in orthopaedic trauma and provide an up-to-date review of the indications, operative technique, failure mechanisms, complications, outcomes, and outlooks for the ACNs use in long bone infection.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model

BACKGROUND

Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained.

QUESTIONS/PURPOSES

In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus?

METHODS

An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection.

RESULTS

Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9).

CONCLUSIONS

Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result.

CLINICAL RELEVANCE

This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.