Role of Antibiotic Cement Coated Nailing in Infected Nonunion of Tibia

Fracture related infection in open tibial fractures

Open tibia fractures frequently occur following high-energy trauma. Contamination of the fracture site combined with limited soft tissue coverage and blood supply means that these open fractures are associated with a high rate of complications, including fracture related infection (FRI). FRI is associated with lowered patient outcomes and requires early recognition and appropriate surgical and medical management. The current evidence on FRI after open tibial fractures largely is limited to case series, small retrospective cohort studies and expert opinion. Recent expert consensus has produced guidelines with the aim of standardising care for these patients. This review summarises the current management strategies employed in treating FRI following open tibial fractures and where possible the evidence behind them.

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.

Antibiotic impregnated cement coated intramedullary nail (ACCIN) using bronchoscopy tubing: technical tips, case series and a review of the literature

Antibiotic impregnated cement coated intramedullary nails (ACCINs) have been used in clinical practice for many years and have been shown to help eradicate infection in tibial osteomyelitis while providing stability. We present a novel technique for preparation using bronchoscopy tubing, as well as technical tips and a review of the literature, for ease of preparation and potential subsequent retrieval.

Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones

Background Fractures of long bones can sometimes lead to complications such as infection or nonunion, resulting in significant patient morbidity. Surgical intervention and antibiotics are often necessary to treat these complications. Antibiotic-impregnated cement/polymer-coated intramedullary nails have emerged as an effective surgical treatment for infected nonunion and open fractures. These implants elude high concentrations of antibiotics at the infection site while stabilizing the fracture. Extensive research has shown promising results, with success rates ranging from 60% to 100%. Benefits of these implants include stable fracture fixation, early weight-bearing, and reduced need for prolonged antibiotic therapy. However, concerns remain regarding antibiotic resistance and potential toxicity. This study aims to evaluate the efficacy and safety of these implants in managing infected nonunion and open fractures of the femur and tibia. Methods This prospective hospital-based study aimed to assess the efficacy and safety of antibiotic-impregnated cement/polymer-coated intramedullary nails for managing infected nonunion and open fractures of the femur and tibia. The study included patients aged 18 or older who received treatment with these implants between January 1, 2021 and December 31, 2022. Patients allergic to vancomycin or teicoplanin, with gap nonunion >2 cm, or lost to follow-up were excluded. Data on demographics, fracture details, previous treatment, surgery, antibiotics, and outcomes were collected using a structured proforma. Surgeries involved implant removal, debridement, culture testing, reaming, fracture reduction, and stabilization with an antibiotic-impregnated cement/polymer-coated intramedullary nail. Postoperatively, patients received antibiotics, had wound inspections, and were gradually allowed weight-bearing. Follow-up appointments and radiographic/laboratory assessments were conducted at regular intervals. The primary outcome was successful bone union, and secondary outcomes included time to union, infection rate, nonunion rate, and revision surgery. Results The majority of participants were male, with a mean age of 39.76 years. Most fractures were Gustilo-Anderson grade 3 (46.7%) and involved the tibia (73.3%). The mean bone gap after debridement was 1.3 cm. The median follow-up period was 8.21 months. Infection was controlled in 93.3% of patients, with the tibia being the most common site (70.0%). Successful bone union was achieved in 90.0% of patients, with a mean union rate of 22.13 weeks for tibial fractures and 17.21 weeks for femoral fractures. Among patients with bone union, 60.0% did not require additional procedures. Most patients had excellent bony (76.7%) and functional (70.0%) outcomes. The most common complications were the persistence of bone nonunion, impingement of proximal nail, and debonding of nail cement, each occurring in 10.0% of patients. Conclusion The study concluded that antibiotic-impregnated cement/polymer-coated intramedullary nails are effective in managing infected nonunion and open fractures of the femur and tibia. The procedure demonstrated a high success rate in controlling infections (93.3%) and achieving bone union (90.0%). Paley's criteria showed excellent bony and functional outcomes in the majority of patients. These findings support the use of this treatment option for such fractures.

Individual and commercially available antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions - a systematic review

The treatment of infected non-unions of the femur and the tibia remains difficult and requires control of the infection and successful bone healing. Antimicrobial coating of intramedullary nails promises both infection control and stabilization for subsequent bone healing. Both results for custom-made and commercially available antimicrobial coating for intramedullary nails have been published in the past mainly consisting of retrospective case series. The purpose of this work is to review the published literature on techniques and clinical outcome of antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions. A systematic literature research in Medline, PubMed, Embase and Cochrane Library was performed in accordance to the PRISMA guidelines. Articles reporting on antimicrobial-coated intramedullary nails for the treatment of infected long bone non-unions were eligible for inclusion. In total, 22 publications were found reporting on 506 infected non-unions of the tibia and femur treated with an antimicrobial-coated nail. Most of them consisted of retrospective case series (72.7%). 469 and 37 patients were treated with an individual antibiotic-loaded PMMA-coating and commercially available gentamicin-coating for intramedullary nails, respectively. The overall infection eradication rate was 90.0% (range 68.7-100%) and the bone consolidation rate was 85.5% (range 57.9-100%). Coating specific side effects were not reported. In conclusion, the treatment of infected long bone non-unions with antimicrobial-coated nails is associated with a high infection control and bone consolidation rate and seems to be a reasonable treatment options with minimal side effects. However, scientific quality of the publications is low and randomized controlled trials are needed.

A Comparative Study of Treatment With External Fixator Versus Antibiotic Coated Intramedullary Nail in Infected Non-union Long Bones

Introduction: Infected non-union of bones shows problems in providing stability and controlling the infection. The treatment comprises debridement with or without the use of antibiotic cement and achieving stability by either external or internal fixation with or without bone grafting. The use of antibiotic-impregnated cement-coated intramedullary nailing gives stability and treats the infection, thereby permitting early mobilization. External fixation is a definitive mode of fracture stabilization indicated in cases of infected non-unions of the humerus, tibia, and juxta-articular bone. The present study was conducted to compare the results of management of infected non-union long bones treated with an external fixator (Ilizarov and Limb Reconstruction System (LRS)) and vancomycin-coated intramedullary nail.

Materials and method: The present prospective study was conducted on 40 study subjects aged >18 years, and were randomly divided using the alternative method into two groups. Group A: 20 Patients were treated with antibiotic-coated intramedullary interlocking nail (ACIIN). Group B: 20 patients were treated with the external fixator (LRS/Ilizarov). All patients were then evaluated post-operatively using laboratory investigations, and for any sign of inflammation or infection. Results were evaluated using association for the study and application of methods of Ilizarov (ASAMI) scoring system. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA).

Results: It was observed that 80.0% of patients in Group A, and 70% of subjects in Group B showed bony union, revealing a statistically significant (p-value<0.05) difference. Infection control, limb length discrepancy, and deformity were also assessed in both groups. Bone and functional outcomes were assessed using the ASAMI score in both groups. In LRS/Ilizarov, it was observed that 55% of subjects had no infection, 15% showed loosening, and 30% had an infection.

Conclusion: The ACIIN should not be used for bone defects more than 4 cm as it does not achieve stability and for these cases, procedures like external fixators (Ilizarov and LRS) should be used. Antibiotic-coated nail eliminated the complications of the external fixators like pin loosening, and pin infections and was technically less demanding. In our study, stiffness of adjacent joints was more in external fixators (LRS/Ilizarov) than ACIIN.

Treatment of Periprosthetic Joint Infection and Fracture-Related Infection With a Temporary Arthrodesis Made by PMMA-Coated Intramedullary Nails – Evaluation of Technique and Quality of Life in Implant-Free Interval

Background

Antimicrobial coating of intramedullary nails with polymethyl methacrylate (PMMA) bone cement promises infection control and stabilization for subsequent bone healing. However, when removing the implant, bone cement can debond and remain in the medullary cavity of the long bones, representing a nidus for reinfection. This work presents a technique comprising reinforcement of PMMA-coated intramedullary nails with cerclage wire to prevent such problems in patients treated for fracture-related infection (FRI) or knee periprosthetic joint infection (PJI) with a static spacer as temporary arthrodesis allowing weight-bearing in the implant-free interval. Outcomes of this surgical treatment were evaluated in terms of (i) associated complications and (ii) patient-reported quality of life.

Methods

In this retrospective case series, 20 patients with PJI (n = 14, 70%) and FRI (n = 6, 30%) treated with PMMA-coated intramedullary nails reinforced with cerclage wire between January 2021 and July 2021 were included. Quality of life during the implant-free interval was evaluated with the EQ-5D, SF-36, and an ICD-10 based psychological symptom rating and compared with previously analyzed cohorts of successfully treated PJI and FRI patients in whom eradication of infection and stable bone consolidation was achieved.

Results

Complications during the implant-free interval comprised a broken nail in one case (5.0%) and a reinfection in one case (5.0%). Coating-specific side effects and cement debonding during removal did not occur. The mean physical health component score of SF-36 was 26.1 ± 7.6, and the mean mental health component score reached a value of 47.1 ± 18.6. The mean EQ-5D index value was 0.36 ± 0.32 and the mean EQ-5D visual analogue scale rating was 47.4 ± 19.4. The scores were significantly lower than those in the successfully treated FRI cohort but not in the PJI cohort. The mean ICD-10-based symptom rating scores revealed psychological symptom burden on the depression scale and enhanced levels of anxiety in comparison with healed FRI and PJI patients.

Conclusion

Reinforcement of PMMA bone cement-coated implants seems to be a reasonable treatment option to create a temporary arthrodesis, preventing detachment of the bone cement when the implant was removed.

Level of Evidence: IV.

Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion

OBJECTIVE

To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion.

DESIGN

Retrospective chart review.

SETTING

Level 1 trauma center.

PARTICIPANTS

Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant.

INTERVENTION

Surgical debridement and placement of a type of antibiotic-coated intramedullary implant.

MAIN OUTCOME MEASUREMENTS

Union and need for reoperation.

RESULTS

At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods.

CONCLUSIONS

Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings.

LEVEL OF EVIDENCE

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

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques

Background

Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use.

Methods

A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible.

Results

A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant.

Conclusion

Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted.

Level of evidence

III.

Review on Surface Treatment for Implant Infection via Gentamicin and Antibiotic Releasing Coatings

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.

Custom-Made Antibiotic Cement-Coated Nail for the Treatment of Infected Bone Defect

Background

Longbone infected bone defect remains a great challenge due to multiple surgeries, long-term treatment duration, and uncertain prognosis. Treatment principles include eradication/debridement, stabilization, and antibiotic administration. An antibiotic cement-coated nail has shown great prospects due to both local antibiotic elution and stabilization of bone defects. However, the current fabrication technique remains to be improved.

Methods

For the first time, we described a new method for custom-made cement-coated nail fabrication based on a 3D printing technique. A retrospective study of 19 consecutive patients with long bone infected bone defects from one medical center was conducted who met the inclusion and exclusion criteria from November 2016 to May 2020. The treatment involved thorough debridement, custom-made antibiotic cement-coated nail filling, and culture-specific systemic antibiotic treatment guided by a multidisciplinary team. Clinical and radiographic examinations (X-ray and CT scans) were used to evaluate bony union. Clinical and laboratory examinations were used to evaluate the infection control. The SF-36 score was used to evaluate patients' quality of life pre- and postoperatively.

Results

The mean follow-up was 98.8 weeks (ranging from 40 to 192). All cases achieved infection control, 3 cases achieved bone healing after one-stage operation, and 12 cases achieved bone healing after a two-stage bone graft procedure. At the last follow-up, none of the 19 patients had infection recurrence or 1 case had failure of the protective plate. The pre- and postoperative SF-36 score showed that there were statistical differences in all the 9 aspects.

Conclusions

The precise custom-made antibiotic cement-coated intramedullary nail through the 3D printing technique used in this study is an effective strategy for the treatment of infected bone defects of long bone. This technique may help to increase the infection control rate and promote bone healing.

Salvaging Chronic Nonunion of Femoral Neck and Infected Nonunion of Ipsilateral Femoral Shaft Fracture Using Intramedullary Antibiotic Cement Spacer and External Fixator Alone

Concomitant ipsilateral fractures of femoral neck and shaft are rare injuries and pose challenging management. Infected non-unions of such fractures can further complicate the management options and have not been discussed in the literature. We present a case of an eight-month-old atrophic non-union of ipsilateral femoral shaft and femoral neck with evidence of intramedullary infection that was managed using a cost-effective, low strain rail fixator assembly and an intramedullary antibiotic cement spacer. Both fracture non-unions were salvaged without the need for any additional procedure. The patient returned to his regular activities within a year follow-up period. There was no clinical evidence of infection during the last follow-up at 16 months, and inflammatory markers were within normal limits. The current case study suggests that while aggressive debridement and intramedullary antibiotic cement spacer can control the intramedullary infection, and simultaneous union of even atrophic nonunion of femoral shaft and femoral neck, both, can be obtained using a tensioned Schanz pin-based external fixator without the need for any secondary procedure. Such a fixator and cement spacer assembly can thus address the dual purpose of fracture stabilization during infection control as well as the union of the non-union sites.

Does the induced membrane have antibacterial properties? An experimental rat model of a chronic infected nonunion

INTRODUCTION

The Masquelet procedure proved its efficiency in treating infected nonunion filling bony gaps up to 25 cm. Yet the use of local antibiotics is still questionable in the daily practice with lack of evidence regarding its usefulness in controlling infection. An experimental rat model is put in place to study the antibacterial properties of the induced membrane produced during the first stage of Masquelet.

METHOD

Twenty-three-month-old wistar male rats are inoculated with a 0.5 mL solution of 10^8 CFU/mL MRSA over a critical fracture done on the right femur. Six weeks later, remaining 11 rats exhibiting signs of a chronic infection with a sinus tract and oozing pus along with radiological nonunion are used for a first stage Masquelet procedure. They are randomly divided into two groups with six rats having no local antibiotic in the cement mixture and five rats having 3 g of vancomycin mixed with gentamycin loaded cement. Six weeks later (twelve weeks from baseline), all eleven rats are euthanized and blood samples for C-reactive protein are withdrawn. The induced membrane is identified and resected along with bone fragments and sent for cultures and pathology.

RESULTS

MRSA is isolated in the cultures of all six rats in the first group where no local antibiotic was added. Altered polymorphonuclears with abscess and pus are noted on four of six pathology samples. However in the second group where local antibiotics were added, three out of five rats exhibited eradication of MRSA (p = 0.034) and all samples did not exhibit clear infection signs on pathology. A pyo-epithelioid over a foreign body reaction is seen predominantly in this group demonstrating a regenerative process.

DISCUSSION

The induced membrane does not have antimicrobial properties capable of overcoming an infected nonunion on its own. When local antibiotics were added during the first stage of the Masquelet procedure, new bone formation occurred indicating the need to control an infection in order for bone union to occur.

CONCLUSION

Local antibiotics use in adjunction to extensive debridement is advisable during the first stage of a Masquelet procedure for an infected nonunion.

Single-Stage Tibiotalocalcaneal Arthrodesis With Use of an Antibiotic-Coated Intramedullary Nail for Limb Salvage Following an Open Pilon Fracture Complicated by Osteomyelitis: A Case Report

Severe limb deformity can create a major disability, which can ultimately lead to a nonambulatory lifestyle. Limb deformities created by open fractures not only put a patient at risk for a nonfunctional lifestyle but also may lead to gross contamination and osteomyelitis of the osseous structures. At times, these deformities require amputation for better functionality. It is our belief, however, that an attempt at limb salvage should always be considered. When encountering limb deformities with osteomyelitis, most literature refers to a staged technique in which 2 procedures need to be performed: this includes external fixation and/or a temporary antibiotic spacer followed by a permanent intramedullary nail after complete resolution of the infection. Staged procedures prolong the non-weightbearing status of the patient, often decreasing quality of life. The use of a single-stage antibiotic-coated nail has rarely been discussed in the literature. Here we discuss a single-stage technique that may be an option for major deformity limb salvage in the setting of chronic osteomyelitis. This is a case report presenting a 60-year-old female who suffered an open pilon fracture resulting in osteomyelitis and was successfully treated with use of an antibiotic-coated intramedullary nail in a single stage.

Preliminary outcomes of proximal femur megaspacers

There are very few therapeutic alternatives for patients with proximal femoral epiphyseal bone deficit combined with a fracture at another level and signs of infection. This combination can be successfully managed with a proximal femur megaspacer. This article is intended to review our variation of this technique and to show the initial results obtained from 11 cases. Of these 11 cases, there were 6 women and 5 men. The mean age was 66 years. The average number of previous surgeries was 3. Definitive prosthetic reconstructive treatment was achieved in 7 of these 11 subjects. The average time to reimplantation was 11.7 months. Fractures or nonunion healed uneventfully. Bone union and infection control were achieved in 10 of the 11 patients.