Treatment Of Infected Nonunion Research Articles

Use of antibiotic-cement coated plate in the treatment of Gustilo-Anderson type III long bone fractures in low- and middle-income countries vs external fixation: A multicentre randomized control trial study protocol

BackgroundOne of the great challenges in the management of open fractures is postoperative infection with a higher incidence in Gustilo-Anderson type III fractures. Definitive management of such fractures in developing countries is usually with external fixators with its attendant complications such as deep fracture-related infection, non-union, and consequent increased re-operation rates. Recently, there has been a novel method of using antibiotic-cement coated implants such as intramedullary nails and locking plates in the treatment of infected non-unions with reported excellent outcomes. This protocol aims to describe the hypothesis, objectives, design and statistical analysis of a randomized control trial that compares the infection rate between the use of antibiotics-cement coated plate and external fixation in the management of Gustilo-Anderson type III long bone fractures. MethodsThis is a multicentre, open-label, parallel group, superiority, randomized, control trial. All patients with type III long bone fractures who present at the emergency department will be screened for enrolment and only those patients that meet the inclusion criteria will be registered for the study. Patients will be randomized using a centralized 24-hr computerized randomization system into two groups: antibiotic-cement coated plate group and the external fixation group. The primary outcome will be occurrence of infection at any time during the course of one year follow-up which will be counted once for each of the patients. The secondary outcomes are union rate, re-operation rate and change in Health Related Quality of Life (HRQoL) from baseline to end of follow-up. Analysis will be done using R (R Core Team, 2023) and Rstudio (Rstudio Team, 2023). DiscussionLiterature has shown that use of antibiotic-coated plate in the management of severe open long bone fractures is effective in reducing infection rate. A significant difference in infection rate with use of antibiotic-cement coated plate compared to use of external fixator for open fractures will be a welcome intervention in developing countries. Trial registrationThe study protocol is registered with ClinicalTrials,gov (NCT06193330)

Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions

Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions

Treatment of Infected Nonunions With Bone Defects Using Autologous Bone Graft and Absorbable Antibiotic-Loaded Calcium Sulfate-Hydroxyapatite Paste.

Revision surgery in the presence of infection carries high risks. We describe our results using a new technique to treat these challenging problems. We treated infected nonunions with cavitary voids with adjuvant antibiotic loaded calcium sulfate-hydroxyapatite paste composite and autologous bone graft (ABG) layer technique coupled with stable fixation. Thirty consecutive patients who underwent revision foot and ankle surgery for an infected nonunion were prospectively studied. Following multidisciplinary team workup, surgical debridement and biopsies were undertaken. Bone voids were measured and classified according to containment and size. ABG was mixed and layered with an adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste followed by surgical reconstruction including arthrodesis and fixation. Empirical and pathogen-specific antibiotics were instituted until intraoperative sample-specific antibiotics were identified and used. Patients were prospectively followed up for a minimum of 1 year. The male-female ratio was 16:14, mean age was 51.3 years, and 23.3% smoked at definitive surgery. Void volume was <1 cm3 (n=9), 1-2 cm3 (n = 13), and >2 cm3 (n=8). No patients either were lost to follow-up or had a further infective episode at a mean of 38.3 months; 86.7% united with fusion on imaging. Four patients had radiographic evidence of nonunion; 3 were asymptomatic and 1 required revision surgery (void >2 cm3). Independent ambulation was achieved at an average of 12 weeks, at 1 year mean American Orthopaedic Foot & Ankle Society score was 77.7 (SD 9.59), and the Manchester-Oxford Foot Questionnaire reached an effect size >0.5 in all domains at 1 year following surgery. The union rate was independent of smoking status and vitamin D deficiency (P = .94). Layered autologous bone grafting with adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste has been shown to be effective and safe in revision arthrodesis, with low comorbidities in void gaps without infection recurrence.

The Antibiotic Cement Coated Nail and Masquelet Technique for the Treatment of Infected Nonunion of Tibia with Bone Defect and Varus Deformity: A Case Report

The Antibiotic Cement Coated Nail and Masquelet Technique for the Treatment of Infected Nonunion of Tibia with Bone Defect and Varus Deformity: A Case Report

Impact of High-Dose Anti-Infective Agents on the Osteogenic Response of Mesenchymal Stem Cells.

Treatment of infected nonunions and severe bone infections is a huge challenge in modern orthopedics. Their treatment routinely includes the use of anti-infective agents. Although frequently used, little is known about their impact on the osteogenesis of mesenchymal stem cells. In a high- and low-dose set-up, this study evaluates the effects of the antibiotics Gentamicin and Vancomycin as well as the antifungal agent Voriconazole on the ability of mesenchymal stem cells to differentiate into osteoblast-like cells and synthesize hydroxyapatite in a monolayer cell culture. The osteogenic activity was assessed by measuring calcium and phosphate concentrations as well as alkaline phosphatase activity and osteocalcin concentration in the cell culture medium supernatant. The amount of hydroxyapatite was measured directly by radioactive 99mTechnetium-HDP labeling. Regarding the osteogenic markers, it could be concluded that the osteogenesis was successful within the groups treated with osteogenic cell culture media. The results revealed that all anti-infective agents have a cytotoxic effect on mesenchymal stem cells, especially in higher concentrations, whereas the measured absolute amount of hydroxyapatite was independent of the anti-infective agent used. Normed to the number of cells it can therefore be concluded that the above-mentioned anti-infective agents actually have a positive effect on osteogenesis while high-dose Gentamycin, in particular, is apparently capable of boosting the deposition of minerals.

English

BACKGROUND Infected non-union is a complex, debilitating and challenging disorder affecting orthopaedic surgeon and patient in terms of cost and time.1 Antibiotic impregnated nail has been a cheap and effective method used for treatment of infected nonunion. Factors that may lead to infected non-union are many.2,3 High local concentrations of antibiotics with minimal systemic levels and without systemic side effects make local antibiotic therapy a very useful technique in treating infected non-union. 4 Buchholz and Engelbrecht were the first to use antibiotic impregnated cement.5 Major advantage of using antibiotic impregnated cement is, it provides high concentration of antibiotics locally with less systemic side effects.6 The purpose of this study was to determine the functional outcome of antibiotic impregnated nail in treatment of infected non-union of femur and tibia. Antibiotic cement impregnated intra-medullary nail can provide stability, help in control of infection,7 is easy to remove, and also provides all the advantages of the cement beads.8,9 METHODS This prospective study was done on 25 cases at Government Medical College Thrissur from 01 September 2016 to 01 April 2018. Functional results were evaluated with regard to control of infection, bony union, deformity, limb leg discrepancy and complications (both intra and post-operative complications). RESULTS Most of the cases had type 2 open injury initially, accounting for 49 %. Staphylococcus aureus was reported in 56 % of cases. Infection control was achieved in 23 cases. Bony union was visualised in 18 cases, remaining 5 cases united following bone grafting. In 2 cases there was no control of infection and no bony union was achieved, later antibiotic nail removal and Ilizarov fixation was planned. Bone grafting was done in 10 cases. CONCLUSIONS Antibiotic impregnated cement nailing is a simple, economical and very effective procedure with less complication and shorter duration of treatment when compared with other conventional procedures. KEYWORDS Infected Non-Union, Long Bones, Antibiotic Impregnated Cement Nail

Surgical treatment outcome after serial debridement of infected nonunion\u2014A retrospective cohort study

PurposeReported outcome after multiple staged surgical treatment of infected nonunion is scarce. We, therefore, asked: (1) What is the clinical outcome in infected nonunion patients after multiple staged revision surgery? (2) Are different pathogens evidenced after surgical treatment in patients who have undergone more or less surgeries?MethodsAll enrolled patients were surgically treated for long bone-infected nonunion between January 2010 and March 2018. Besides patients´ demographics outcome in terms of bony consolidation and major complications defined as death during inward treatment, amputation and recurrence of infection during follow-up of at least 12 months were assessed. Microbiological findings were assessed and compared between two groups with less than five versus five or more surgical revisions.ResultsBone consolidation was achieved in 86% of the patients while complications such as femoral or transtibial amputation, recurrence of infection or even death during inpatient treatment could be evidenced in six patients (14%). In patients who underwent multiple-stage surgery for five or more times, germ changes and repeated germ detection was more common than in patients with less surgeries.ConclusionsSurgical treatment of infected nonunions poses a high burden on the patients with major complications occurring in about 14% of the patients using a multiple staged treatment concept. Future prospective studies comparing outcomes after limited with multiple staged revision surgeries are necessary.

Infected Non Union of Tibia Managed by Limb Reconstruction System- A Prospective Cohort Study

Introduction: Infected non union of Tibia is one of the most commonly faced problem in both compound as well as closed fractures of Tibia, treated surgically. Few patients also present with gap at the fracture site which may be either due to bone loss during trauma or due to debridement of dead bone during previous surgeries. Treatment of infected non union is always challenging with unpredictable outcomes. Limb Reconstruction System (LRS) is one of the systems available to treat this complex situation. Aim: To evaluate the role of LRS in treatment of infected non union of Tibia in terms of union time, total duration of fixator applied and Visual Analouge Score (VAS). Materials and Methods: Twenty one patients of infected gap, non union of tibia were included in the study and were treated with debridement, resection of dead bone and application of LRS and segment transport. The results were evaluated in terms of union time, total duration of fixator applied and VAS. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. SPSS statistics 24.0 was used for analysis. Mean, median and mode were used to describe continuous variable. Results: Out of 21 patients, 19 were males and two were females. The mean age of patients was 29.43±14.07 years. The mean limb length discrepancy was 23.3 mm (range, 15-40 mm). The mean duration from injury to LRS application was 7.9 months (range, 6-12 months). Mean duration of follow-up was 29.5 months (range, 16-50 months). Average union time was 44 weeks and average fixator time was 11.2 months. Bony and function results were good and excellent in 90% cases. Conclusion: The use of monolateral rail external fixator LRS is an effective method for the treatment of infected non union of tibia augmented with a fibular strut graft. This provides good results in terms of bony union, subsidence of infection and functional results.

Descriptive study of outcome of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of weight bearing long bones

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Infected non-union of tibia and femur is a debilitating disorder for patient as well as challenging task for treating surgeon. Conventionally treatment of infected non-union is a two staged procedure. But antibiotic cement-impregnated intramedullary nailing (ACIINs) is a single staged and cost-effective procedure. Hence we intended to study the outcome of ACIIN use in infected non-union of tibia and femur.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a hospital based prospective case series type of descriptive study conducted in Department of Orthopedics, SMS Medical College and Hospital, Jaipur. We studied 35 cases of infected non-union of femur and tibia fracture with interlock nail in situ. All patients were treated with interlock nail removal, debridement and freshening of sclerosed bony ends and fixation with ACIIN. All were followed for at least 6 months for infection control and bony union and final results were evaluated by Paley’s bony criteria and functional criteria.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Infection was controlled in 94.28% cases. Bony union was achieved in 88.57% cases (19 femur and 12 tibia). Average duration for bony union was 7.3 months for femur and 8 months for tibia. According to Paley’s criteria for bony outcome and functional outcome 65.71% and 51.43% had shown excellent outcome respectively.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; ACIIN is a good modality for treatment of infected non union of tibia and femur in terms of infection control and bony union and has a good functional outcome when bone gap is less.&lt;/p&gt;

Evaluation of the clinical use of the ETN PROtect® in non-union therapy

IntroductionNon-union of a long bone fracture remains a challenge in orthopaedic and trauma surgery. In the current study, we sought to determine the clinical effectiveness of tibial non-union treatment utilizing an antibiotic-coated intramedullary nail (Expert Tibia Nail (ETN) PROtect®) regarding prevention and treatment of infection and the clinical outcome. Patients and methods36 patients suffering from tibial non-unions that were treated with the ETN PROtect® in the course of non-union treatment between February 2010 and March 2015 were included in this clinical observational study. Clinical and radiological examinations were performed preoperatively as well as 4, 6 and 12 weeks and 6 and 12 months postoperatively as part of a standardized follow-up program. Data regarding perioperative complications, weight-bearing capacity, radiological signs of consolidation and subjective health status were assessed at each time point. Laboratory parameters such as C-reactive protein (CRP) and leukocyte count were collected preoperatively in order to assess the patients’ risk profile for infection. ResultsPatients had an average of 6.2 previous surgeries and 22 patients (61.1%) had a positive bacterial culture from intraoperatively removed tissue during the first operative treatment. 29 patients (80.6%) achieved full weight-bearing after an average of 7.7 months, furthermore 80.6% of patients achieved osseous consolidation. 3 deep infections occurred, including one amputation. Subjective health status increase based on the SF-12 questionnaire during our follow-up program. ConclusionThe results from the current study indicate that the use of the ETN PROtect® in the applied non-union therapy has a high clinical effectiveness regarding osseous consolidation and time to weight bearing. In addition, the use of gentamicin-coated nails in the treatment of tibial non-unions might contribute to both successful treatment of the underlying infection and prevention of perioperative infection. The gentamicin-coated nail may serve as a beneficial adjunct treatment in the applied non-union therapy in addition to all established techniques in the treatment of infected non-unions.

Status quo and difficulties in standardized treatment of infected nonunion of tibia

In recent years, infection and infected nonunion after surgical treatment of tibial fracture have gradually increased, which has brought tremendous psychological and economic burdens to patients. At present, awareness and attention in the field of traumatic bone infections is insufficient, and many experienced orthopedic surgeons lack the basic knowledge and formal training on management of traumatic bone infections. Tibial intramedullary nail infection and infectious bone defect nonunion are difficult to treat and have a high recurrence rate. This article reviews the special principles of bacterial biofilm formation, surface competition, Klemm three factors and bone infection typing in the treatment of bone infection, the reamed debridement of tibial intramedullary nail fixation infection, the application of local antibiotics and the comparison between bone transport and inducing membrane techniques in the treatment of infectious nonunion. This article aims to provide some help for orthopedic surgeons in the systematic treatment of tibial infection. Key words: Osteomyelitis; Tibial fractures; Fracture fixation, intramedullary; Infected nonunion

Early outcome of interlocking intramedullary nailing of infected tibia fracture nonunions: A report of 2 cases

Background: Eradication of infection and fracture union are the two major objectives of treatment of infected non unions. Recent studies indicate that locked intramedullary nailing of tibia fracture non unions provide a mechanical environment which enhances fracture healing even in the presence of infection. It also allows early weight-bearing without the burden of an external frame making it more acceptable to patients than external fixators.The Cases: The authors present 2 cases of infected tibia non unions. The first case had segmental fibulectomy, fracture debridement, deep tissue sampling, locked intramedullary nailing, cancellous bone grafting and antibiotic therapy. The second case had segmental fibulectomy, wound and fracture debridement, deep tissue sampling, locked intramedullary nailing, cancellous bone grafting, fasciocutaneous flap wound cover and antibiotic therapy.Results: The first case had a satisfactory (early) outcome having achieved full weight bearing at 12 weeks with no clinical evidence of infection. Similarly, the second case had a good outcome having achieved full weight bearing without clinical signs of infection at 12 weeks (although immediate post-op period was complicated by surgical site infection which was effectively managed). Based on these two cases, the importantguiding principles were identified and discussed.Conclusion: With appropriate surgical technique and strict adherence to surgical principles, the outcome of interlocking intramedullary nailing for infected tibia non unions are satisfactory.Keywords: Early Outcome, Intramedullary Nailing, Tibia, Fracture Non unions

Treatment of infected nonunion by external fixation

Objective To explore the curative effects of external fixation in the treatment of infected nonunion. Methods From June 2009 to December 2016, 45 patients with infected nonunion were treated by external fixation at Department of Orthopaedics, West China Hospital. They were 36 males and 9 females with an average age of 45.3 years (range, from 14 to 65 years). The sites of fracture included tibia in 31 patients, femur in 12, humerus in one, and ulna-radius in one. The median time from injury to application of external fixation was 16.8 months and the average number of previous operations was 2.3 times. After debridement, 24 cases had a bone defect of 6.0 cm in length on average (range, from 3.5 to 10.4 cm). After discharge, the patients were regularly followed up at the outpatient department and any of their complications was recorded in detail. At the final follow-ups, the protocol of ASAMI (Association for the Study and Application of the Method of Ilizarov) was used to evaluate their bone and functional results. Results All the 45 patients were followed up for 16 to 106 months (average, 43.9 months). One patient had to receive amputation because of uncontrollable infection and all the other 44 cases achieved bony union. The bone defects were successfully reconstructed by external bone transport in 24 patients. The time for external fixation averaged 20.5 months. According to the evaluation by ASAMI at the final follow-ups, the bone was rated as excellent in 28 patients, as good in 12, as fair in one and as poor in 3, giving an excellent to good rate of 90.9%; the function was rated as excellent in 11 patients, as good in 21, as fair in 8 and as poor in 4, giving an excellent to good rate of 72.7%. Conclusion In eradication of infection and treatment of fracture nonunion, external fixation can be used not only to avoid the infection risk due to internal fixation but also to correct a complex deformity and repair a large bone defect, allowing early weight-bearing for the patients. Key words: Fractures, ununited; Infection; External fixation; Bone transport

Antibiotic coated hinged threaded rods in the treatment of infected nonunions and intramedullary long bone infections

IntroductionLocal delivery of high dose antibiotics in the form of antibiotic impregnated polymethyl methacrylate (PMMA) cement beads or coated rods is commonly used in the management of long bone infections. The downsides of antibiotic cement beads for intramedullary long bone infections are associated with difficulty in removal from the medullary canal, bead breakage, and lack of stability. Antibiotic cement-coated smooth flexible guide wires, rods and nails can have complications such as delamination or debonding of the cement. In addition, the current techniques for cement rod insertion have a risk of iatrogenic joint contamination.To improve upon this technique and decrease potential complications, we propose the use of an antibiotic cement-coated hinged threaded rod as a temporary intramedullary spacer. This technique utilizes both an antegrade and retrograde insertion of the threaded rod into the medullary canal through the bony defect site with connection at the hinge to treat intramedullary long bone infections and infected nonunions. Material and MethodsA total of 40 patients were included in the study. The details in making the cement rod were well documented. The shape of cement rod and the integrity of the cement at the time of rod insertion and rod removal were compared to identify any cement debonding or delamination. Potential postoperative complications including iatrogenic joint infection, displacement or breakage of the threaded cement rods, and fracture displacement were all carefully documented. The preliminary biological effect of the initial debridement and antibiotic cement rod placement was determined using the negative conversion rate of intraoperative cultures. ResultsA single antibiotic coated threaded rod was inserted in 18 cases. Two separate antibiotic coated threaded rods were inserted and connected via hinge in 22 cases. There were zero cases of rod breakage and no secondary loss of reduction from antibiotic rod placement to the definitive staged operation. There were zero iatrogenic joint infections. There were zero cases of cement debonding or delamination from the rod. The conversion rate to a negative culture after initial debridement and antibiotic rod placement was 85% (34/40 cases). ConclusionsThe use of an antibiotic coated cement threaded rod with a hinge as an intramedullary spacer provides the benefits of local antibiotic delivery, offers improved construct stability, makes implant removal easier without delamination of the cement mantle, and utilizes the versatility of a hinge to prevent violation of native joints when treating infected nonunions and intramedullary long bone infections.

Treatment of infected non-unions with segmental defects with a rail fixation system

We conducted this study to evaluate the use of rail fixation system in infected gap non-union of femur and tibia as an alternative to the established Ilizarov circular fixator technique. Prospective study. The study was done in the Department of Orthopaedic surgery in a medical school and level I trauma center to which the authors are/were affiliated. Between June 2010 and June 2015, 40 patients with infected gap non-union of femur and tibia were treated with the rail fixation system. Patients who were willing to undergo surgery and participate in the post-operative rehabilitation were included in the study. After radical debridement, the system was applied and corticotomy done. For closure of bone gap, acute docking and distraction was done in 18 cases and segmental bone transport in 22 cases. Early mobilization of patient was done along with aggressive physiotherapy. Bone and functional results were calculated according to ASAMI scoring system, and complications were classified according to Paley classification. The mean follow-up period was 22.56 months (range 8–44). Bone union with eradication of infection was achieved in all but 1 case (97.5%). Bone results were excellent in 57.5%, good 40%, fair 0% and poor in 2.5% cases, while functional result was excellent in 32.5%, good 65%, fair 0% and poor in 2.5% cases. The rail fixation system is an excellent alternative method to treat infected gap non-union of femur and tibia. It is simple, easy to use and patient-friendly.

Evaluation of single stage protocol using Locked plate as primary fixation in treatment of infected non-union of long bones

Background: Infected non-union of long bones is one of the most challenging problems in clinical practice. In the treatment of infected non-union it is often difficult to achieve union and eradication of infection. The treatment strategy of infected non-union generally involves two stages: control of infection by local radical debridement of dead tissue and external fixator application followed by definitive treatment of bone stabilization and bone-grafting. Treatment with different methods of external fixators like Ilizarov, Orthofix had been gold standard in the past decade. However due to complications like prolonged fixation time, poor patient compliance, pin loosening and refracture after removal, there is need for alternative method of primary bone stabilization in infected non-union of long bones. The present study evaluates the results of single stage protocol of aggressive local radical debridement and internal fixation with locking compression plate as a primary means of stabilization in the treatment of infected non-union. Materials and Methods: Twenty one cases of infected non-union (5 femurs, 15 humerus, 1 tibia) were included in present study. The procedure included single stage protocol of exploration of the nonunion with aggressive local debridement, implant removal and reaming of intramedullary canal, antibiotic spacers and beads and Locking compression plate (LCP) as primary means of stabilization. Based on requirement and judgment by treating surgeon, revision debridement and removal of antibiotic bead with bone grafting was done as planned procedure. The evaluation of results included the union of the bone (both clinically and radiological), eradication of infection, complication rate, number of reintervention surgery. Result: The mean follow-up was 14 months (range 6 months to 5 years). We had achieved infection free union in 19 cases out of total 21cases. In 1 patient with previous infection had recurrence for which revision surgery with implant removal and refixation with L.C.P and bone grafting done? In another patient additional L.C.P plate with bone graft is applied. Infection free union is achieved in both cases. The functional outcome was satisfactory in most cases. The time to bone healing averaged 4.2 months (range 3 to 7 months) Conclusion: The proposed technique is effective in treating infected nonunion with resolution of infection and bone union. The inclusion of locking compression plate as internal splint improves stability of fixation, and along with proper and adequate local radical debridement, can be used as alternative method of fixation for obtaining fracture union with a good functional result.

A study on functional outcome of ilizarov fixation in the management of infected non-union of long bones

Introduction: Nonunion of long bones especially tibia when associated with infection has always been a challenge to orthopaedic surgeons. This study is conducted to report the results of the use of this technique for treatment of infected nonunion of long bones and the study of complications encountered during treatment. Material & Methods: An observational study was done on case records of 20 patients admitted and treated in Katuri Medical College with Ilizarov fixator for infected nonunion of long bones between August 2012 to September 2014 were taken for demographic information, details of treatment, radiological features and number of complications. Results: The mean age of the patients was 39.3 years with majority (65%) in the age group of 30-50 years. Out of the 20 patients, 17 were males and 3 were females. Out of the 20 cases treated with the Ilizarov fixator 19 cases sound union occurred without the need for any other intervention and complete resolution of infection was seen. Five patients had a limb length discrepancy of more than 2.5 cm. 70% had excellent bony results and 50% had excellent functional results. Keywords: Infected non-union, Ilizarov fixation, Functional outcome

Prospective study of infected non-union of long bones treated by Antibiotic impregnated intramedullary nailing

Background: In a era of high velocity injuries, compound fractures are very common in orthopaedic practice n despite of preventive measures taken pre operatively and post operatively, infected non unions still common and they pose real challenge to the treating surgeon and makes the patient debilitating. In infected non-union case, the preference has to be given to eradication of the infection before aiming to achieve fracture union. Many methods of treatment have been described in the past including ilizarov fixator and Antibiotic cement impregnated intramedullary nailing(ACIIMN). Sustained and gradual release of heat stable antibiotics which are mixed with the bone cement at a high concentration and coating it on Intramedullary nail(ACIIMN) has gained popularity among the techniques used to treat infected non unions. Our study is aimed at summarizing our experience with the use of antibiotic cement-impregnated intramedullary nail (ACIIMN) for control of infection in cases of infected non-union. This is a report of series of 27 infected non union cases, both femur and tibia which were treated by Antibiotic cement impregnated intramedullary nailing(ACIIMN) in our institute. Aims and objectives: To evaluate the outcome of treatment of infected nonunions of long bones treated by Antibiotic cement impregnated intramedullary nailing(ACIIMN). Materials and Methods: Our’s is prospective study involving 27 cases of infected nonunions of long bones treated by Antibiotic cement impregnated intramedullary nailing(ACIIMN) at our institute from 2012- 2015. The outcome of procedure was evaluated with regards to infection control, deformity, bony union and limb length discrepancy etc. Results: Infection was eradicated in 23 cases with ACIIN and the fractures united. In 4 cases, though the infection was controlled with ACIIN, they required subsequent procedures like exchange nailing with bone grafting to achieve bony union. Conclusion: Antibiotic cement impregnated nailing is a very simple yet economical and very effective procedure than the other methods in treatment of infected non-unions of long bones. Keywords: long bones, Infected non-union, antibiotic cement impregnated intramedullary nail

Ilizarov ring fixator in treatment of infected nonunion of tibia

Infective nonunion of a long bone is very notorious to be treated and prone to limb shortening when treated by conventional methods. In this case report, we treated a patient having infected nonunion of tibia initially by complete excision of all devitalized tissue from site of nonunion causing bone gap of 7 cm, followed by application of Ilizarov ring fixator using bifocal osteosynthesis by single upper tibial osteotomy. Bone transportation done at a rate of 1 mm/day followed by compression-distraction at the nonunion site following accordion maneuver. Results showed satisfactory bony union by bifocal osteosynthesis with single osteotomy.

Bone Grafting: Sourcing, Timing, Strategies, and Alternatives.

Acute fractures, nonunions, and nonunions with bone defects or osteomyelitis often need bone graft to facilitate union. There are several factors to consider when it is determined that a bone graft is needed. These factors include the source of the bone graft (autograft vs. allograft), proper timing for placement of the bone graft, strategies to avoid further complications (particularly in the setting of osteomyelitis), and with the development of a variety of bone graft substitutes, whether alternatives to autograft are available and appropriate for the task at hand. Autograft bone has commonly been referred to as the "gold standard" of bone grafts, against which the efficacy of other grafts has been measured. The best timing for when to place a bone graft or substitute is also somewhat controversial, particularly after an open fracture or a potentially contaminated bed. The treatment of infected nonunions, particularly those that require a graft to facilitate healing, can be quite challenging. Typically, the infection is completely eradicated before placement of a bone graft, but achieving a sterile bed and the timing of a bone graft require strategic thinking and planning. This review outlines the benefits of autografts, the most suitable sites for harvesting bone grafts, the timing of bone graft procedures, the potential risks and benefits of grafting in the face of infection, and the currently available bone graft extenders.