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BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2020

01-12-2020 | Wound Debridement | Research article

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

Authors: Hong-An Zhang, Chun-Hao Zhou, Xiang-Qing Meng, Jia Fang, Cheng-He Qin

Published in: BMC Musculoskeletal Disorders | Issue 1/2020

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Abstract

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.
Literature
1.
Court-Brown CM, Keating JF, McQueen MM. Infection after intramedullary nailing of the tibia. Incidence and protocol for management. J Bone Joint Surg Br. 1992;74(5):770–4.
2.
Tsang ST, Mills LA, Frantzias J, Baren JP, Keating JF, Simpson AH. Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and  an analysis of the risk factors for failure. Bone Joint J. 2016;98-B(4):534–41.
3.
Court-Brown CM. Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Orthop Trauma. 2004;18(2):96–101.
4.
Young S, Lie SA, Hallan G, Zirkle LG, Engesaeter LB, Havelin LI. Risk factors for infection after 46,113 intramedullary nail operations in low- and middle-income countries. World J Surg. 2013;37(2):349–55.
5.
Mauffrey C, Hak DJ, Giannoudis P, Alt V, Nau C, Marzi I, Augat P, Oh JK, Frank J, Mavrogenis A, et al. Treatment of infection following intramedullary nailing of tibial shaft fractures—results of the ORS/ISFR expert group survey. Int Orthop. 2019;43(2):417–23.CrossRefPubMed
6.
Simpson AH, Tsang JST. Current treatment of infected non-union after intramedullary nailing. INJURY. 2017;48:S82–90.CrossRefPubMed
7.
Makridis KG, Tosounidis T, Giannoudis PV. Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes. Open Orthop J. 2013;7:219–26.
8.
Simpson AH, Tsang JST. Current treatment of infected non-union after intramedullary nailing. Injury. 2017;48:S82–90.
9.
Mioc M, Prejbeanu R, Deleanu B, Anglitoiu B, Haragus H, Niculescu M. Extra-articular distal tibia fractures—controversies regarding treatment options. A single-centre prospective comparative study. Int Orthop. 2018;42(4):915–19.
10.
Barger J, Fragomen AT, Rozbruch SR. Antibiotic-coated interlocking intramedullary nail for the treatment of long-bone osteomyelitis. JBJS Rev. 2017;5(7):e5.CrossRefPubMed
11.
G D: Reaming of the medullary cavity and its effect on diaphyseal bone. A fluorochromic, microangiographic and histologic study on the rabbit tibia and dog femur. Acta orthopaedica Scandinavica. Supplementum 1969, 128:1–153.
12.
Kobbe P, Tarkin IS, Pape HC. Use of the ‘reamer irrigator aspirator’ system for non-infected tibial non-union after failed iliac crest grafting. INJURY. 2008;39(7):796–800.CrossRefPubMed
13.
Zalavras CG, Singh A, Patzakis MJ. Novel technique for medullary canal débridement in tibia and femur osteomyelitis. Clin Orthop Relat Res. 2007;461:31–34.
14.
Dawson J, Kiner D, Gardner WN, Swafford R, Nowotarski PJ. The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma. 2014;28(10):584–90.
15.
Wolcott RD, Rumbaugh KP, James G, Schultz G, Phillips P, Yang Q, Watters C, Stewart PS, Dowd SE. Biofilm maturity studies indicate sharp debridement opens a time- dependent therapeutic window. J Wound Care. 2010;19(8):320–8.CrossRefPubMed
16.
El-Husseiny M, Patel S, MacFarlane RJ, Haddad FS. Biodegradable antibiotic delivery systems. J Bone Joint Surg Br. 2011;93(2):151–7.CrossRefPubMed
17.
Beuerlein MJ, McKee MD. Calcium sulfates: what is the evidence? J Orthop Trauma. 2010;24(Suppl 1):S46–51.CrossRefPubMed
18.
Ferguson JY, Dudareva M, Riley ND, Stubbs D, Atkins BL, McNally MA. The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases. Bone Joint J. 2014;96-B(6):829–36.CrossRefPubMed
19.
Papagelopoulos PJ, Mavrogenis AF, Tsiodras S, Vlastou C, Giamarellou H, Soucacos PN. Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis. J Int Med Res. 2006;34(6):704–12.CrossRefPubMed
20.
Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, Athanasou NA, Ochsner PE, Kuehl R, Raschke M, et al. Fracture-related infection: a consensus on definition from an international expert group. Injury. 2018;49(3):505–10.CrossRefPubMed
21.
Cierny GR, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin OrthopRelat Res. 2003;414:7–24.CrossRef
22.
Simpson AH, Deakin M, Latham JM. Chronic osteomyelitis. The effect of the extent of surgical resection on infection-free survival. J Bone Joint Surg Br. 2001;83(3):403–7.
23.
Kanakaris N, Gudipati S, Tosounidis T, Harwood P, Britten S, Giannoudis PV. The treatment of intramedullary osteomyelitis of the femur and tibia using the reamer-irrigator-aspirator system and antibiotic cement rods. Bone Joint J. 2014;96-B(6):783–8.CrossRefPubMed
24.
Giannoudis PV, Pape HC, Cohen AP, Krettek C, Smith RM. Review: systemic effects of femoral nailing: from Kuntscher to the immune reactivity era. Clin Orthop Relat Res. 2002;(404):378–86.
25.
Pape HC, Zelle BA, Hildebrand F, Giannoudis PV, Krettek C, van Griensven M. Reamed femoral nailing in sheep: does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am. 2005;87(11):2515–22.
26.
Masquelet AC, Benko PE, Mathevon H, Hannouche D, Obert L. Harvest of cortico-cancellous intramedullary femoral bone graft using the Reamer-Irrigator-Aspirator (RIA). Orthop Traumatol Surg Res. 2012;98(2):227–32.
27.
Greco T, Vitiello R, Cazzato G, Cianni L, Malerba G, Maccauro G, Perisano C. Intramedullary antibiotic coated nail in tibial fracture: a systematic review. J Biol Regul Homeost Agents. 2020;34(3 Suppl. 2):63–9.PubMed
28.
Qiang Z, Jun PZ, Jie XJ, Hang L, Bing LJ, Cai LF. Use of antibiotic cement rod to treat intramedullary infection after nailing: preliminary study in 19 patients. Arch Orthop Trauma Surg. 2007;127(10):945–51.CrossRefPubMed
29.
Megas P, Saridis A, Kouzelis A, Kallivokas A, Mylonas S, Tyllianakis M. The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method. INJURY. 2010;41(3):294–9.CrossRefPubMed
30.
Ayouba G, Lemonne F, Kombate NK, Bakriga B, Yaovi EJ, André-Pierre MU. Interest of nailing associated with the Masquelet technique in reconstruction of bone defect. J Orthop. 2020;20:228–31.CrossRefPubMed
31.
Careri S, Vitiello R, Oliva MS, Ziranu A, Maccauro G, Perisano C. Masquelet technique and osteomyelitis: innovations and literature review. Eur Rev Med Pharmacol Sci. 2019;23(2 Suppl):210–6.PubMed
32.
Granchi D, Verri E, Ciapetti G, Stea S, Savarino L, Sudanese A, Mieti M, Rotini R, Dallari D, Zinghi G, et al. Bone-resorbing cytokines in serum of patients with aseptic loosening of hip prostheses. J Bone Joint Surg Br. 1998;80(5):912–7.CrossRefPubMed
33.
Buchholz HW, Engelbrecht H. Depot effects of various antibiotics mixed with Palacos resins. Chirurg. 1970;41(11):511–5.
34.
Klemm K. Gentamicin-PMMA-beads in treating bone and soft tissue infections (author's  transl). Zentralbl Chir. 1979;104(14):934–42.
35.
Wahl P, Guidi M, Benninger E, Ronn K, Gautier E, Buclin T, Magnin JL, Livio F. The levels of vancomycin in the blood and the wound after the local treatment of bone and soft-tissue infection with antibiotic-loaded calcium sulphate as carrier material. Bone Joint J. 2017;99-B(11):1537–44.CrossRefPubMed
36.
Gu Z, Wang S, Weng W, Chen X, Cao L, Wei J, Shin JW, Su J. Influences of doping mesoporous magnesium silicate on water absorption, drug release, degradability, apatite-mineralization and primary cells responses to calcium sulfate based bone cements. Mater Sci Eng C Mater Biol Appl. 2017;75:620–8.
37.
Luo S, Jiang T, Yang Y, Yang X, Zhao J. Combination therapy with vancomycin-loaded calcium sulfate and vancomycin-loaded  PMMA in the treatment of chronic osteomyelitis. BMC Musculoskelet Disord. 2016;17(1):502.
38.
Ferguson JY, Dudareva M, Riley ND, Stubbs D, Atkins BL, McNally MA. The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases. Bone Joint J. 2014;96-B(6):829–36.
39.
Badie AA, Arafa MS. One-stage surgery for adult chronic osteomyelitis: concomitant use of  antibiotic-loaded calcium sulphate and bone marrow aspirate. Int Orthop. 2019;43(5):1061–70.
40.
Romanò CL, Logoluso N, Meani E, Romanò D, De Vecchi E, Vassena C, Drago L. A comparative study of the use of bioactive glass S53P4 and antibiotic-loaded  calcium-based bone substitutes in the treatment of chronic osteomyelitis: a retrospective comparative study. Bone Joint J. 2014;96-B(6):845–50.
Metadata
Title
Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: a retrospective study of 19 cases
Authors
Hong-An Zhang
Chun-Hao Zhou
Xiang-Qing Meng
Jia Fang
Cheng-He Qin
Publication date
01-12-2020
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2020
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/s12891-020-03734-z

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