Successful management of intramedullary nail associated infection with reaming and antibiotic cement beads/rod

Abstract

Objective To assess the efficacy of using reaming and antibiotic cement beads/rod for intramedullary nail as-sociated infection. Methods Data of 12 patients with intramedullary infection of tibia or femur following intramedullary nailing from October 2014 to April 2016 were retrospectively analyzed. There were 10 men and 2 women aged from 19 to 63 years old with an average age of 39.2 years. In 5 cases the disease was localized in the femur with one case of nonunion, and in other 7 cases the disease was localizedin the tibia with two cases of nonunion. The initial injury included closed fracture in 8 patients and open fracture in 4 patients which were all Gustilo-AndersonⅡ. According to the Cierny-Mader classification of adult osteomyelitis, 6 cases were typeⅠ (medullary osteomyelitis), 4 cases were type Ⅰcombined with type Ⅲ (medullary and localized osteomyelitis), and 2 cases were typeⅠ combined with type Ⅳ (medullary and diffuse osteomyelitis). Surgical technique included removal of the intramedullary nailand reaming and irrigation of the medullary canal to remove intramedullary debris. The drainage sinus and soft tissues abscess were excised if existed. An local or enbloc resection for the infected or necrotic bone was performed if there was lo-cal or diffuse infection in the fracture sites. Ilizarov technique was performed for segment bone defect. The bone union was ob-served in nine patients and stable nonunion in one. Antibiotic PMMA beads were inserted into intramedullary canal for these ten cases after debridement, and the antibiotic beads were removed approximately 12-14 days after implantation. The antibiotic ce-ment rod was inserted into the medullary canal to provide stabilization in the other 2 cases. All the patients received intravenous antibiotics systemically for three weeks, and followed by three weeks of oral antibiotics. Results At a mean follow-up period of 23.5 months (range, 15-33 months), no recurrence of infection was observed. There were 3 cases of nonunions. One case of tibial nonunion had been achieved union 10 months after insertion of an antibiotic cement rod. One with stable nonunion of tibia was treated with antibiotic PMMA beads, and enbloc resection for the infected bone was performed after the extension of infection had been narrowed at the nonunion. 6 cm of bone defect was treated with bone transport and then union was obtained 16 months after operation. The third case was infected nonunion in the femur with 4 cm bone defect after debridement. The femur was shortened and temporarily stabilized with the intramedullary antibiotic cement rod. The rod was removed three months after the operation, and then the femur was lengthened. The docking site and the regeneration area were healed 12 months after the lengthening opera-tion. Conclusion The clinical results shows that reaming and antibiotic cement beads/rod appears an effective and safe alterna-tive for management of intramedullary nail associated infection of the tibia and femur. Key words: Femur; Tibia; Infection; Fracture fixation, intramedullary