• Users Online: 122
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 9-12

Role of antibiotic-impregnated bone cement rod in control of bone infection and assessing its role in union in cases of infective nonunion of long bones


Department of Orthopaedics, Dr.D.Y. Patil Medical College, Pune, Maharashtra, India

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Yuvraj Singh Hira
Department of Orthopaedics, Dr. D.Y. Patil Medical College, Pune-411 018, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joas.joas_52_17

Rights and Permissions
  Abstract 


INTRODUCTION: Managing and treating infected nonunion is one of the most challenging clinical scenarios despite numerous advances in the fixation methods, soft-tissue management, and antibiotic therapy. The infection of the fracture site causes internal fixation to become unstable and it slows down fracture healing.
AIMS AND OBJECTIVES: To assess role of antibiotic-impregnated bone cement rod in control of bone infection and assessing its role in union in cases of infective nonunion of long bones.
MATERIALS AND METHODS: This was a prospective study comprising of 30cases of established infected nonunion of long bones carried out in a tertiary care center in Western Maharashtra. Patients of nonunion of long bone diaphysis with established clinical and laboratory evidence of infection were included in the study.
RESULTS: Twenty-one cases showed complete union at 6months or earlier. Two more cases showed significant callus formation. In three cases, there was no callus formation at fracture site till 6months.
DISCUSSION: Various authors in their studies confirmed that gentamicin and vancomycin are antibiotics which maintain activity even after being exposed to the high temperatures resulting from poly(methyl methacrylate) hardening.
CONCLUSION: From our study, we confirm that the use of antibiotic-impregnated bone cement rod has a significant role in control of bone infection and also assists in union in cases of infective nonunion of long bones.

Keywords: Antibiotics, bone rod, cement, infection, long bones, nonunion


How to cite this article:
Pisal T, Hira YS, Solunke SS, Basvaraj Sangam SP, Patil AC, Gupta S. Role of antibiotic-impregnated bone cement rod in control of bone infection and assessing its role in union in cases of infective nonunion of long bones. J Orthop Allied Sci 2018;6:9-12

How to cite this URL:
Pisal T, Hira YS, Solunke SS, Basvaraj Sangam SP, Patil AC, Gupta S. Role of antibiotic-impregnated bone cement rod in control of bone infection and assessing its role in union in cases of infective nonunion of long bones. J Orthop Allied Sci [serial online] 2018 [cited 2018 Nov 19];6:9-12. Available from: http://www.joas.in/text.asp?2018/6/1/9/234474




  Introduction Top


Infected nonunion of long bones is chronic, tedious, and huge challenge that presents a huge problem to the surgeon today in terms of cost of treatment and time elapsed during the treatment.[1] Some of the factors that lead to infected nonunion are open fracture, loss of soft-tissue or bone infection after internal fixation, chronic osteomyelitis, pathological fracture, and surgical debridement of infected bone.[2] Almost all of the infections that are encountered in orthopedic trauma are caused by biofilm-forming bacteria.[3] Biofilm consists of hydrated matrix of polysaccharide and protein. Once a biofilm is formed, it protects the microorganism from antimicrobial, opsonization, and phagocytosis, and thus, it contributes to re-occurrence of infections.[4] To manage and treat biofilm-related infection, the four principles laid down by Cierny and Mader must be observed and followed: (1) complete surgical debridement with dead space management,(2) fracture/nonunion stabilization,(3) soft-tissue coverage, and (4) adequate antibiotic level.[5] The treatment of nonunion follows a two-stage procedure. Stage 1 is of debridement with or without antibiotic cement bead insertion along with systemic antibiotic therapy to change an infected nonunion to aseptic nonunion. Stage 2 is carried out to achieve stability which can be achieved either by external fixation or by internal fixation with or without bone grafting.[2],[6],[7],[8],[9],[10] The use of antibiotic-impregnated cement-coated intramedullary(IM) nailing for infected nonunion of tibia and femur fractures has been well documented.[11],[12],[13],[14],[15],[16],[17],[18] The cement nail which is inserted helps in providing stability across the fracture site which is essential in the management of infected nonunion and which cannot be achieved by cement beads.[17],[18] Antibiotic cement release antibiotic at local site up to 36weeks and it helps in providing a therapeutic effect on refractory infection and has few side effects.[16],[17] Gentamicin has been most frequently used agent which is followed by vancomycin as they have broad spectrum of activity, heat stability, and low allergenicity.[19],[20]

Based on the above studies, we were encouraged to carry out a study assessing the role of antibiotic-coated cement rod in control of infection and also analyze its role in union infected nonunion of long bones.

Aims and objectives

To assess the role of antibiotic-impregnated bone cement rod in control of bone infection and assess its role in union in cases of infective nonunion of long bones.


  Materials and Methods Top


  • This was a prospective study comprising of 30cases of established infected nonunion of long bones carried out in a tertiary care center in Western Maharashtra for 2years from June 2014 to July 2016
  • Inclusion criteria: Patients of nonunion of long bones diaphysis with established clinical and laboratory evidence of infection were included in the study
  • Exclusion criteria: Patient with immature bony skeleton, bone gaps, or infection involving the joint were excluded from this study
  • Wound and sinus swabs were sent for gram stain and culture sensitivity
  • Antibiotics used in cement were vancomycin and gentamicin due to their heat-stable properties.



  Results Top


In our study, we included 30patients in total of infective nonunion of long bones. Out of 30patients, male patients were 22 and we had 8female patients in our study. Out of 30patients [Figure 1], 21patients were of femur nonunion and 9 were of tibia nonunion. The age range of the patients was 18–45years with a mean age of 34.5years. Twenty patients had a culture of Staphylococcusaureus from a preoperative or an intraoperative specimen. Six patients had a culture that was positive for Enterobacter. Rest of the patient had a sterile culture despite obvious signs of infection. All the patients were treated with the same regimen. First, all the wounds and sinus were properly cleaned and culture swabs were taken and sent for evaluation, and later on, patients were treated with open reduction and internal fixation with antibiotic-coated cement rod. Sterile dressing was done on day 2, day 5, and day 8, and sutures were removed on day 14. Twenty-six cases showed complete union at 6months or earlier. Two more cases showed significant callus formation. In two cases, there was no callus formation at fracture site till 6months. Fracture union occurred at 6months or earlier in eight cases. Four cases showed solid bony union at 8months. No refractures occurred in these cases. In one case where infection healed but nonunion persisted, she was given an external fixator. Later, the patient obtained a satisfactory union. However, two patients continued to have an infected nonunion. In both of these cases, the Rod with anti-biotic cement was removed and patients given external fixator. Twenty-three patients experienced no recurrence of infection. Four patients continued to have draining wounds, but the discharge was significantly reduced. In two cases, it was a thin watery fluid, and in two other cases, the discharge persisted as a purulent discharge, which was greatly reduced in volume. Patients were discharged after suture removal and were followed up in outpatient department at regular intervals of 2weeks each to assess the progress.
Figure 1: Treatment pictures of femur

Click here to view



  Discussion Top


IM infection is a well-recognized complication of IM nailing for trauma. Infected nonunions of long bones are particularly very difficult to treat. The combination of mechanical instability and infection of the fractured bone provides an unfavorable condition for fracture healing. Thirty patients who had an infected nonunion of the long bone were treated using antibiotic bone cement rod. Twenty-one femurs and 9 tibias were treated. The age range of the patients was 18–45years with a mean age of 34.5years. In our study, we had used 40g of plain cement mixed with 1g of injection vancomycin powder or 40g of gentamicin bone cement alone or in combination with 1g of injection vancomycin powder. Sterling et al.[21] confirmed that gentamicin and vancomycin are antibiotics which maintain activity even after being exposed to the high temperatures resulting from poly(methyl methacrylate) hardening. Klekamp et al.[22] recommended combining vancomycin and an aminoglycoside in bone cement for their potential synergistic effect in the treatment of severe infections caused by resistant S.aureus. This was confirmed by studies of González Della Valle et al.[23] Miller et al.[24] confirmed that when infection is associated with fractures, stability is important in the treatment of infection. The antibiotic-impregnated cement rod fills dead space while locally eluting high concentrations of antibiotics. It simultaneously provides mechanical support for the bone.

In our study, we found that twenty-three patients experienced no recurrence of infection. Four patients continued to have draining wounds, but the discharge was significantly reduced. In two cases, it was a thin watery fluid, and in two other cases, the discharge persisted as a purulent discharge, which was greatly reduced in volume. Schlatterer and Anders(2005)[25] in their study encountered one case that required re-debridement and exchange antibiotic re-rodding after 6weeks. This patient went on to full recovery and one case had persisting discharging sinus. In the study done by Paley and Herzenberg [11] to treat IM infections with antibiotic cement rods, they noted no recurrence of infection in any of the nine cases studied by them. Emami et al.[26] treated 37cases of infected tibia nonunion. Twenty-one patients required repeat debridement. No recurrence of infection was noted in any cases for 2years of follow-up.

We found that in our study, we had achieved 26cases of complete union at 6months or earlier. Two more cases showed significant callus formation. In two cases, there was no callus formation at fracture site till 6months. In the study done by Paley and Herzenberg [11] to treat IM infected nonunions in three cases with antibiotic cement rods, they achieved fracture healing after re-nailing or plating once infection healed. Ueng et al.[27] obtained bony union in diaphyseal infected nonunions in 15patients with antibiotic beads, external skeletal fixation, and staged bone grafting. Fifteen cases were considered and all united. External fixator was removed at 7–15months(average 9months).


  Conclusion Top


On the basis of our study conducted, we recommend the use of antibiotic-impregnated bone cement rod in control of bone infection and that it significantly helps in union of infective nonunion of long bones.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
TohCL, JupiterJB. The infected nonunion of the tibia. Clin Orthop Relat Res 1995;(315):176-91.  Back to cited text no. 1
    
2.
PatzakisMJ, ZalavrasCG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. JAm Acad Orthop Surg 2005;13:417-27.  Back to cited text no. 2
[PUBMED]    
3.
StoodleyP, EhrlichGD, SedghizadehPP, StoodleyLH, BaratzME, AltmanDT, etal. Orthopaedic biofilm infections. Curr Orthop Pract 2011;22:558-63.  Back to cited text no. 3
    
4.
NelsonCL. The current status of material used for depot delivery of drugs. Clin Orthop Relat Res 2004;(427):72-8.  Back to cited text no. 4
    
5.
CiernyG, MaderJ. The surgical treatment of adult osteomyelitis. In: EvartsCM, editor. Surgery of Musculoskeletal System. NewYork, USA: Churchill Livingstone; 1983. p.4814-34.  Back to cited text no. 5
    
6.
Court-BrownCM. Fracture of tibia and fibula. In: BulholzRW, HeckmanJD, Court-BrownCM, editors. Rockwood and Greens Fracture in Adults. 6thed. Lippincot Willianms and Wilkins; 2006. p.2080-146.  Back to cited text no. 6
    
7.
BealsRK, BryantRE. The treatment of chronic open osteomyelitis of the tibia in adults. Clin Orthop Relat Res 2005;(433):212-7.  Back to cited text no. 7
    
8.
UengSW, ChuangDC, ChengSL, ShihCH. Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer. JTrauma 1996;40:345-50.  Back to cited text no. 8
[PUBMED]    
9.
ChenCE, KoJY, WangJW, WangCJ. Infection after intramedullary nailing of the femur. JTrauma 2003;55:338-44.  Back to cited text no. 9
[PUBMED]    
10.
WuCC, ShihCH. Distal tibial non-union treated by intramedullary reaming with external immobilisation. JTrauma 2002;433:212-7.  Back to cited text no. 10
    
11.
PaleyD, HerzenbergJE. Intramedullary infections treated with antibiotic cement rods: Preliminary results in nine cases. JOrthop Trauma 2002;16:723-9.  Back to cited text no. 11
[PUBMED]    
12.
QiangZ, JunPZ, JieXJ, HangL, BingLJ, CaiLF, etal. Use of antibiotic cement rod to treat intramedullary infection after nailing: Preliminary study in 19patients. Arch Orthop Trauma Surg 2007;127:945-51.  Back to cited text no. 12
    
13.
MadanagopalSG, SeligsonD, RobertsCS. The antibiotic cement nail for infection after tibial nailing. Orthopedics 2004;27:709-12.  Back to cited text no. 13
[PUBMED]    
14.
ThonseR, ConwayJ. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. JOrthop Trauma 2007;21:258-68.  Back to cited text no. 14
[PUBMED]    
15.
SancinetoCF, BarlaJD. Treatment of long bone osteomyelitis with a mechanically stable intramedullar antibiotic dispenser: Nineteen consecutive cases with a minimum of 12months follow-up. JTrauma 2008;65:1416-20.  Back to cited text no. 15
[PUBMED]    
16.
NelsonCL, HickmonSG, HarrisonBH. Elution characteristics of gentamicin-PMMA beads after implantation in humans. Orthopedics 1994;17:415-6.  Back to cited text no. 16
[PUBMED]    
17.
NizegorodcewT, PalmieriG, MarzettiE. Antibiotic-coated nails in orthopedic and trauma surgery: State of the art. Int J Immunopathol Pharmacol 2011;24:125-8.  Back to cited text no. 17
[PUBMED]    
18.
RielRU, GladdenPB. Asimple method for fashioning an antibiotic cement-coated interlocking intramedullary nail. Am J Orthop(Belle Mead NJ) 2010;39:18-21.  Back to cited text no. 18
[PUBMED]    
19.
DhanasekharR, JacobP, FrancisJ. Antibiotic cement impregnated nailing in the management of infected nonunion of femur and tibia. Kerala J Orthop 2013;26:93-7.  Back to cited text no. 19
    
20.
KimJW, CuellarDO, HaoJ, SeligsonD, MauffreyC. Custom-made antibiotic cement nails: Acomparative study of different fabrication techniques. Injury 2014;45:1179-84.  Back to cited text no. 20
[PUBMED]    
21.
SterlingGJ, CrawfordS, PotterJH, KoerbinG, CrawfordR. The pharmacokinetics of simplex-tobramycin bone cement. JBone Joint Surg Br 2003;85:646-9.  Back to cited text no. 21
[PUBMED]    
22.
KlekampJ, DawsonJM, HaasDW, DeBoerD, ChristieM. The use of vancomycin and tobramycin in acrylic bone cement: Biomechanical effects and elution kinetics for use in joint arthroplasty. JArthroplasty 1999;14:339-46.  Back to cited text no. 22
[PUBMED]    
23.
González Della ValleA, BostromM, BrauseB, HarneyC, SalvatiEA. Effective bactericidal activity of tobramycin and vancomycin eluted from acrylic bone cement. Acta Orthop Scand 2001;72:237-40.  Back to cited text no. 23
    
24.
MillerME, AdaJR, Webb LX. Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails. Clin Orthop Relat Res 1989;(245): 233-8.  Back to cited text no. 24
    
25.
SchlattererDR, AndersM. Antibiotic Impregnated Cement Rods in the Treatment of Long Bone Infections. Available from: http://www.hwbf.org/ota/am/ota03/otapo/OTP03051.htm.[Last accessed on 2005Sep15].  Back to cited text no. 25
    
26.
EmamiA, Mjöberg B, LarssonS. Infected tibial nonunion. Good results after open cancellous bone grafting in 37cases. Acta Orthop Scand 1995;66:447-51.  Back to cited text no. 26
    
27.
UengWN, WeiFC, ShihCH. Management of femoral diaphyseal infected non union with antibiotic beads local therapy, external skeletal fixation, and staged bone grafting. Clin Orthop 1999;46:97-103.  Back to cited text no. 27
    


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed403    
    Printed7    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]