Stabilisation of infected peri-articular nonunions with an antibiotic impregnated cement coated locking plate: Technique and indications

Abstract

Management of fracture nonunion in the setting of subacute or chronic bacterial infection is a clinical challenge. Treatment must concurrently manage fracture instability and bacterial contamination. When acute infection occurs following fracture fixation, surgical debridement, antibiotic suppression and retention of stable fracture fixation hardware have been shown to be successful [1]. When fracture healing has not occurred alongside deep infection, alternative tactics must be explored. A general approach involves implant removal, thorough excisional debridement and irrigation, fracture stabilisation and focused systemic antibiotic therapy with or without additional local antibiosis. The use of antibiotic impregnated poly-methylmethacrylate (PMMA) as a nonbiodegradable drug delivery vehicle is well described in the orthopaedic literature [2,3]. Antibiotic impregnated PMMA can be placed in open fractures, areas of bone loss, soft tissue wounds, as well as in the setting of acute and chronic orthopaedic infections. Multiple authors have also reported the success of antibiotic impregnated PMMA intramedullary (IM) implants to stabilise and treat infected long bone nonunions [4–6]. The stabilisation and management of infected peri-articular nonunions remains a clinical challenge. In some clinical scenarios, limb stability is best achieved with a plate and screw device. We describe the creation and use of an antibiotic impregnated PMMA cement covered periarticular plate for this problem. This approach is highly effective in the provisional or definitive treatment of infected periarticular nonunions. It provides local delivery of antibiotics, immediate osseous stability, complete soft tissue closure and early range of motion.