Antibiotic-impregnated Cement Beads Research Articles

Two-Stage Reimplantation in Infected Total Knee Arthroplasty.

Two-stage reimplantation is considered the gold standard for the management of periprosthetic joint infection. The first stage involves the removal of the prosthesis, followed by extensive debridement of all nonviable tissues, synovectomy, irrigation, and reaming of the medullary canals. Once the joint has been prepared, antibiotic-impregnated cement beads and/or spacer are inserted. Antibiotic-impregnated spacers are now more commonly used, and an increasing number of orthopaedic surgeons are using articulating spacers if indicated. Antibiotics are then prescribed to the patient based on the sensitivities of the infecting organism. The duration of systemic antibiotic use is decreasing, and short courses of antibiotic therapy have been shown to be as efficacious as prolonged therapy between the first and second stages. The second stage of the procedure involves removal of the antibiotic-impregnated cement beads and/or spacer, repeat irrigation and debridement, and final reconstruction with revision components. While two-stage reimplantation was considered the gold standard in many parts of the world, recent studies have demonstrated that it is associated with a considerable failure rate. This may be due to the lack of accurate diagnostic tools for infection eradication, and future investigation of risk factors for failure of the two-stage reimplantation should be conducted.

Outcomes of cement beads and cement spacers in the treatment of bone defects associated with post-traumatic osteomyelitis

BackgroundCement spacers (Masquelet technique) have traditionally been used for the treatment of segmental bone defects. However, no reports have used cement spacers for the treatment of small/partial segmental bone defects associated with osteomyelitis and compared the outcomes with cement beads.MethodsWe retrospectively analysed 40 patients with post-traumatic osteomyelitis of the tibia who underwent treatment, which was performed in two stages. In the first stage, thorough debridement was performed, and bone defects were filled with either antibiotic-impregnated cement beads (bead group, 18 patients) or spacers (spacer group, 22 patients). In the second stage, the cement beads or spacers were removed (for the spacer group, the induced membrane formed by the spacer was preserved) and the bone defects were filled with cancellous autografts.ResultsAll patients in the bead group had small/partial segmental bone defects after debridement, while 3 patients in the spacer group had large/segmental bone defects.The mean volume of bone defects of the spacer group (40.4 cm3) was significantly larger than that of the bead group (32.4 cm3). The infection control rate (88.9%,16/18 vs 90.9%, 20/22), bone healing time (8.5 months vs 7.5 months) and complication rates (22.2%, 4/18 vs 27.2%, 6/22) were comparable between bead group and spacer group.ConclusionThe results of this study suggest that cement spacers may have an infection control rate comparable to cement beads in the treatment of bone defects associated with post-traumatic osteomyelitis. Furthermore, cement spacers could be used for the reconstruction of small/partial segmental bone defects as well as for large/segmental bone defects, whereas cement beads were not suitable for the reconstruction of large/segmental bone defects.

English

OBJECTIVE: In developing country the incidence of chronic pyogenic infection of long bone is high among children and adults. This entity is difficult to be managed by conventional systemic antibiotics alone. Many treatment methods for long bone osteomyelitis were attempted but unfortunately the eradication of chronic osteomyelitis remains a problem. Local antibiotic therapy has been introduced by arthroplasty surgeons and subsequently this method has been tried for treating chronic osteomyelitis. Treatment of chronic osteomyelitis using antibiotic-impregnated bone cement beads or nail after thorough debridement has become a good option of treatment. Therefore this prospective study has been designed to evaluate the effect of local antibiotic therapy in the form of bone cement beads or nail for eradication of chronic pyogenic long bone osteomyelitis. METHODS: Thirty patients with chronic osteomyelitis of metaphyseal and diaphyseal area of long bones were studied prospectively about outcome of treatment. The diagnosis of chronic osteomyelitis was made on the basis of clinical and radiological features and confirmed by deep aspiration, staining and culture sensitivity of the aspirate. Patients suffering from fungal or tubercular osteomyelitis were excluded. Also the patients with small bones osteomyelitis or open injury more than Gustilo type 2 were excluded. Antibiotic impregnated polymethylmethacrylate beads or nails were implanted after thorough debridement and wound closed primarily. Two dose of intervenous antibiotic were used, one before and another after operation. Beads or nails were removed at the end of six weeks. Patients were followed up for an average period of two years. RESULT: Out of thirty patients in this study, twenty eight patients were cured completely and two patients had persistent discharge till the last follow up visit. No organism found in six cases. No systemic adverse reactions were seen. CONCLUSION: The present study observes that approximately 93% patients were completely free from recurrence in two year follow-up. However, two patients with metaphyseal osteomylitis had persistence discharge probably due to inadequate removal of glycocalyx in the metaphyseal region where the bone tissue is spongy in nature.

An Improved Technique for Removing Intramedullary Antibiotic Beads in Osteomyelitis of the Tibial Shaft

The intramedullary insertion of antibiotic-impregnated cement beads is used widely for the treatment of intramedullary infection. This report describes an improved technique for removing chains of antibiotic beads inserted into the intramedullary cavity. We examined four cases in three patients of the intramedullary insertion of chains of antibiotic-impregnated cement beads for the treatment of osteomyelitis of the diaphysis of the tibia after the fixation of fractures with interlocking nails. During bead removal, the tip of an intramedullary guidewire was bent into a hook shape and was then engaged with the chain of impacted beads. The guidewire was removed from the intramedullary cavity, permitting the extraction of any beads adhering to the wire. As beads came into contact with the tip of the intramedullary guidewire, they could be extracted easily. No additional incision or bone fenestration was required. The use of a hook-shaped intramedullary guidewire simplifies the removal of chains of antibiotic-impregnated cement beads without the need for an invasive procedure. This technique makes the use of chains of cement beads a favorable choice for treating intramedullary infection.

Two-stage revision for the treatment of the infected total elbow arthroplasty

We report our experience of staged revision surgery for the treatment of infected total elbow arthroplasty (TEA). Between 1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent a first-stage procedure with the intention to proceed to second-stage procedure when the infection had been controlled. A single first-stage procedure with removal of the components and cement was undertaken for 29 TEAs (85%), followed by the insertion of antibiotic-impregnated cement beads, and five (15%) required two or more first-stage procedures. The most common organism isolated was coagulase-negative Staphylococcus in 21 TEAs (62%). A second-stage procedure was performed for 26 TEAs (76%); seven patients (seven TEAs, 21%) had a functional resection arthroplasty with antibiotic beads in situ and had no further surgery, one had a persistent discharge preventing further surgery. There were three recurrent infections (11.5%) in those patients who underwent a second-stage procedure. The infection presented at a mean of eight months (5 to 10) post-operatively. The mean Mayo Elbow Performance Score (MEPS) in those who underwent a second stage revision without recurrent infection was 81.1 (65 to 95). Staged revision surgery is successful in the treatment of patients with an infected TEA and is associated with a low rate of recurrent infection. However, when infection does occur, this study would suggest that it becomes apparent within ten months of the second stage procedure.

Efficacy of Antibiotic-Impregnated Bone Cement Beads Against Organisms Found in Abdominal Vascular Graft Infections

Graft infection often involves several different organisms. Antibiotic-impregnated polymethylmethacrylate (PMMA) beads may be effective in controlling reinfection after infected graft replacement. We sought to determine an effective antibiotic combination in PMMA beads for use in vascular graft infection. PMMA beads were impregnated with different combinations of antibiotics including daptomycin (DA), tobramycin (TO), and meropenim (ME). Beads were plated into separate 0.8% Mueller-Hinton agar plates with vancomycin-resistent enterococcus (VRE), Klebsiella, S. epidermidis, and methicillin-resistent Staphylococcus aureus (MRSA). Antibiotic inhibition was recorded in millimeters using the disc agar-diffusion method and averaged from three separate platings. DA alone was not active against Klebsiella (average = 0 mm). TO alone was not active against VRE, Klebsiella, or MRSA. ME showed broad-spectrum activity against all organisms with >15 mm inhibition halo. The efficacy of ME was decreased by TO but not DA. Adding DA and TO to ME did not improve efficacy. Meropenem in PMMA beads shows activity against difficult pathogens encountered in vascular graft infections. Daptomycin can be added for double-coverage against multi-drug resistant gram-positive pathogens such as VRE and MRSA. Tobramycin appears to reduce the efficacy of meropenem when used in combination.TableAverage inhibition halo in millimetersVREKlebsiellaS. epidermidisMRSADA9.8010.29.6TO2.010.714.04.7DA + TO8.010.814.39.9ME17.015.321.017.3ME + DA17.21621.717.7ME + TO13.813.516.713.4ME + DA + TO16.915.021.017.0Control3.26.98.74.2 Open table in a new tab

Osteogenic and chondrogenic potential of biomembrane cells from the PMMA‐segmental defect rat model

A layer of cells (the "biomembrane") has been identified in large segmental defects between bone and surgically placed methacrylate spacers or antibiotic-impregnated cement beads. We hypothesize that this contains a pluripotent stem cell population with potential valuable applications in orthopedic tissue engineering. Objectives using biomembranes harvested from rat segmental defects were to: (1) Culture biomembrane cells in specialized media to direct progenitor cells along bone or cartilage cell differentiation lineages; (2) evaluate harvested biomembranes for mesenchymal stem cell markers, and (3) define relevant gene expression patterns in harvested biomembranes using microarray analysis. Culture in osteogenic media produced mineralized nodules; culture in chondrogenic media produced masses containing chondroitin sulfate/sulfated proteoglycans. Molecular analysis of biomembrane cells versus control periosteum showed significant upregulation of key genes functioning in mesenchymal stem cell differentiation, development, maintenance, and proliferation. Results identified significant upregulation of WNT receptor signaling pathway genes and significant upregulation of BMP signaling pathway genes. Findings confirm that the biomembrane has a pluripotent stem cell population. The ability to heal large bone defects is clinically challenging, and novel tissue engineering uses of the biomembrane hold great promise in treating non-unions, open fractures with large bone loss and/or infections, and defects associated with tumor resection.

A Prospective, Randomized Clinical Trial Comparing an Antibiotic-Impregnated Bioabsorbable Bone Substitute With Standard Antibiotic-Impregnated Cement Beads in the Treatment of Chronic Osteomyelitis and Infected Nonunion

A Prospective, Randomized Clinical Trial Comparing an Antibiotic-Impregnated Bioabsorbable Bone Substitute With Standard Antibiotic-Impregnated Cement Beads in the Treatment of Chronic Osteomyelitis and Infected Nonunion

Salvage of Charcot foot neuropathy superimposed with osteomyelitis: a case report

The risk of amputation is dramatically increased in diabetic patients with osteomyelitis of the foot complicated by Charcot neuroarthropathy. Antibiotic-impregnated cement beads have been widely reported in the treatment of deep soft tissue and bone infections. This case report demonstrates that this approach can also aid the management of infected, unstable diabetic Charcot foot.

A Prospective, Randomized Clinical Trial Comparing an Antibiotic-Impregnated Bioabsorbable Bone Substitute With Standard Antibiotic-Impregnated Cement Beads in the Treatment of Chronic Osteomyelitis and Infected Nonunion

We sought to compare the effectiveness of an antibiotic-impregnated bioabsorbable bone substitute (BBS, tobramycin-impregnated medical-grade calcium sulfate) with antibiotic-impregnated polymethylmethacrylate (PMMA) cement beads after surgical débridement in patients with chronic nonhematogenous osteomyelitis and/or infected nonunion. A prospective, randomized clinical trial. A university-affiliated teaching hospital. Thirty patients requiring surgical treatment for chronic long bone infection or infected nonunion were included: BBS (15 patients, mean age 44.1 years) PMMA (15 patients, mean age 45.6 years). Patients were randomized to receive either BBS or PMMA to the bone void created by surgical débridement. Eradication of infection, new bone growth, rate of union, repeat operative procedures complications. Patients were followed for a mean 38 months (range, 24-60 months). One patient was lost to follow-up in each group. In the BBS group, infection was eradicated in 86% (12 of 14) of patients. Seven of eight patients achieved union of their nonunion, and five patients underwent seven further surgical procedures. In the PMMA group, infection was eradicated in 86% (12 of 14) of patients. Six of eight patients achieved union of their nonunion, and nine patients required 15 further surgical procedures. There were more reoperations in the PMMA group (15 versus seven, P = 0.04), and these procedures tended to be of greater magnitude. The results of this preliminary study suggest that, in the treatment of chronic osteomyelitis and infected nonunion, the use of an antibiotic-impregnated BBS is equivalent to standard surgical therapy in eradicating infection and that it may reduce the number of subsequent surgical procedures. A larger, definitive study on this topic is required.

A two-stage retention débridement protocol for acute periprosthetic joint infections.

Due to the historically poor infection control rates with débridement and component retention for acute periprosthetic infections we developed a new approach for treating acute periprosthetic total joint infections: initial débridement with prosthesis retention and placement of antibiotic-impregnated cement beads followed by a second débridement within 7 days, at which time the beads are removed and new modular parts inserted. Intravenous antibiotics were used for 6 weeks followed by oral antibiotics. Depending on the clinical situation, antibiotics are discontinued or in selected patients continued indefinitely. We determined the ability of this two-stage débridement to control infection. We retrospectively reviewed the charts of 20 patients who underwent this technique; 2 had postoperative and 18 had hematogenous infections. The primary outcome measure was the infection control. The minimum followup was 1 year (mean, 3.5 years; range, 1.2-7.5 years). Two of the 20 patients had persistent infection. There were no failures in the acute postoperative group (0 of 2) and two of 18 in the acute hematogenous group. Of the 18 patients without evidence of persistent infection, 10 were no longer on antibiotics at the most recent followup and eight were treated with long-term antibiotics due to compromised host status. The control of infection in 18 of 20 patients using this technique compares favorably with historical success rates, which range from 24% to 100%. Further research is required to analyze the individual contribution of débridement technique, the use of serial débridements, local depot antibiotics, and combination antibiotic therapy on short-term infection control rates and the long-term persistent control of periprosthetic infection. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.

Use of antibiotic cement rod to treat intramedullary infection after nailing: preliminary study in 19 patients

The treatment of intramedullary infections after nailing usually includes removal of the nail, debridement, and, in some cases, insertion of antibiotic-impregnated cement beads. We use this self-made antibiotic cement rod to treat intramedullary infections. Compared with the beads, it provides some limited mechanical support and can be preserved in the canal for a long time. We reviewed 19 infected patients who underwent removal of the nails, excision of sinus tracks, debridement of the canal and insertion of the rods. No recurrent infection occurred in 18 cases and 11 cases achieved bone healing, 6 cases achieved partial union. One patient had nonunion and one patient underwent amputation because of severe primary trauma and long-term infection. The rod was removed between 35 and 123 days after implantation. We conclude that the antibiotic cement rods could be a relatively effective, simple and inexpensive method of treating intramedullary infections after nailing.

Staged arthroplasty as salvage procedure for deep hip infection following intertrochanteric fracture

Deep hip infection is a rare complication of intertrochanteric fractures and an optimal treatment has not yet been reported. Twenty-seven patients who contracted deep hip sepsis following the failed primary treatment of an intertrochanteric fracture were treated with two-stage hip arthroplasty. Antibiotic-impregnated cement beads were implanted following resection arthroplasty in the first 15 patients, and a temporary cement spacer prosthesis was used in the other 12 hips. There was only one recurrence of infection at an average follow-up of 4.8 years. Complications included non-union of the greater trochanter in four patients, intraoperative femoral fracture in two and fracture of the cement prosthesis in one. The use of an interim spacer was associated with better hip function in the interim period; a decreased operative time and less blood loss at the time of arthroplasty; and a higher hip score at final follow-up. Staged arthroplasty is an effective salvage procedure for deep hip infection after the failed treatment of an intertrochanteric fracture. The use of a temporary spacer maintains hip function between stages, makes arthroplasty less complicated, and improves the clinical outcome.

In Vitro Elution of Vancomycin from Calcium Phosphate Cement

Antibiotic-impregnated bone cement beads have become popular for the treatment of osteomyelitis and/or prosthesis infection. However, bone cement has the disadvantage of heating up during polymerization of cement. Recently, calcium phosphate cement (CPC) has been used as a bone replacement and augmentation, and it does not heat up during polymerization. First, we measured the release rate of vancomycin (VCM) from bone cement and CPC impregnated with VCM for 2 weeks in vitro. The mean concentration of VCM for CPC was 62.6 times at 7 days (258 ± 29 vs 4.12 ± 1.0) and 6.7 times at 13 days (15.5 ± 5.5 vs 2.3 ± 0.7). Second, we were successful in treating 2 cases of osteomyelitis and prosthesis infection with VCM-impregnated CPC. From this study, we concluded that VCM-impregnated CPC might be an effective material for the treatment of osteomyelitis and/or prosthesis infection.

Efficacy of Vancomycin-Impregnated Cement Beads for the Treatment of MRSA Infection of Failed Graft Tissue at the Mandible

The oral and nasal cavities are regions likely to harbor methicillin-resistant Staphylococcus aureus (MRSA). Therefore, when performing a surgical procedure in these areas, standard precautions are observed and the use of third-generation cephalosporins is restricted to prevent the onset of MRSA infection. However, after extensive surgery such as mandibular resection and reconstruction, MRSA infection is likely to occur as a result of reduced host immunity and impaired tissue healing because of preoperative chemoradiotherapy. Antibiotic-impregnated cement beads gradually release the antibiotic to maintain regional concentrations above the minimum inhibitory concentration (MIC), to continuously suppress bacterial growth. In the field of orthopedics, cement beads impregnated with antibiotics have been effectively used to treat bone and joint infections. 1 In particular, cement beads impregnated with gentamicin were used successfully in 77% of cases in which infection developed following hip joint surgery. 1 Moreover, several studies have reported the usefulness of cement beads impregnated with gentamicin or tobramycin for the treatment of osteomyelitis of the jaw. 2-4 Many reports have documented the effectiveness of bone cement impregnated with vancomycin hydrochloride (VCM) in the treatment of MRSA infection of the hip joint or

Antibiotic-Impregnated Cement Beads for Chronic Osteomyelitis

Antibiotic-Impregnated Cement Beads for Chronic Osteomyelitis

Two-stage reimplantation without cement spacer for septic total knee replacement.

The management of an infected total knee implant is a major challenge to the orthopedic surgeon. We report the outcome using two-stage reimplantation without cement spacers between stages. Seven infected total knee replacements (TKR) were treated with the two-stage reimplantation technique from September 1994 through January 2001. Treatment of these patients consisted of thorough debridement and removal of the implants. No antibiotic-impregnated cement blocks or beads were inserted and only a long leg cylinder cast was applied for immobilization between stages. Intravenous antibiotics were used and C-reactive protein (CRP) values were monitored. All of the patients were free of infection and revision TKR was performed without using antibiotic-impregnated cement for fixation at an average interval of 6.3 weeks (range 6-10 weeks). The average length of follow-up was 3.5 years (range 1-7 years) and the average HSS (Hospital for Special Surgery) knee score was 86 points (range 78-94). A good result was obtained in one patient and excellent results in six patients. Average range of motion was 91 degrees (range 80 degrees -100 degrees ). No recurrence of infection was noted. Two-stage reimplantation without using a cement spacer between stages for septic total knee replacement is tolerable for patients, simpler for surgeons and can achieve good results without recurrence of infection.

Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases.

The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than 1 year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.

Calcific Myonecrosis of the Leg

Calcific myonecrosis is a rare complication of the leg after trauma. It usually develops as a late sequelae of compartment syndrome. Only approximately 21 cases have been reported in the English literature. The reported cases mostly have involved the anterior compartment of the leg. The current authors report the case of a 49-year-old man with a huge mass that involved the anterior and posterior compartments of the leg 30 years after initial trauma. Soft tissue sarcoma was suspected initially. A secondary infection developed after open incisional biopsy. After extensive debridement and closure of the wound over antibiotic-impregnated cement beads and a suction drain followed by compressive dressings, there has been no recurrence of the lesion or infection.

化膿性膝関節炎後の高度膝変形に対する治療経験

We experienced two cases of severe deformity after septic arthritis of the knee. Case 1 was a 52-year-old man diagnosed with septic arthritis of the knee in June, 1998. MSSA was cultured from knee fluid, and drainage and antibiotics therapy were performed nonetheless, six months later varus deformity progressed gradually, and bone defects of the femoral condyle and medial lesion of the tibia were found on radiograph and MRI. Knee arthrodesis was performed in June 1999. 16 months after operation, pain in the knee joint disappeared.Case 2 was a 58-year-old woman who developed coagraze negative staphylococcus infection of the right knee. Arthroscopic and antibiotic therapy were performed, but the right knee joint deteriorated gradually.. We performed TKA treatment using antibiotic-impregnated cement beads in April 2000. Seven months after operation, the range of motion of the right knee was 90 degrees.TKA performance should be evaluated based on laboratory date, and the results of histopathological examination and knee aspiration culture.