Use Of Antibiotic Cement Research Articles

A Comparative Study of Treatment With External Fixator Versus Antibiotic Coated Intramedullary Nail in Infected Non-union Long Bones.

Infected non-union of bones shows problems in providing stability and controlling the infection. The treatment comprises debridement with or without the use of antibiotic cement and achieving stability by either external or internal fixation with or without bone grafting. The use of antibiotic-impregnated cement-coated intramedullary nailing gives stability and treats the infection, thereby permitting early mobilization. External fixation is a definitive mode of fracture stabilization indicated in cases of infected non-unions of the humerus, tibia, and juxta-articular bone. The present study was conducted to compare the results of management of infected non-union long bones treated with an external fixator (Ilizarov and Limb Reconstruction System (LRS)) and vancomycin-coated intramedullary nail. The presentprospective study was conducted on 40 study subjects aged >18 years, and were randomly divided using the alternative method into two groups. Group A: 20 Patients were treated with antibiotic-coated intramedullary interlocking nail (ACIIN). Group B: 20 patients were treated with the external fixator (LRS/Ilizarov). All patients were then evaluated post-operatively using laboratory investigations, and for any sign of inflammation or infection. Results were evaluated usingassociation for the study and application of methods of Ilizarov (ASAMI) scoring system. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA). It was observed that 80.0% of patients in Group A, and 70% of subjects in Group Bshowed bony union, revealing a statistically significant (p-value<0.05) difference. Infection control, limb length discrepancy, and deformity were also assessed in both groups. Bone and functional outcomes were assessed using the ASAMI score in both groups. In LRS/Ilizarov, it was observed that 55% of subjects had no infection, 15% showed loosening, and 30% had an infection. The ACIIN should not be used for bone defects more than 4 cm as it does not achieve stability and for these cases, procedures like external fixators (Ilizarov and LRS) should be used. Antibiotic-coated nail eliminated the complications of the external fixators like pin loosening, and pin infections and was technically less demanding. In our study, stiffness of adjacent joints was more in external fixators (LRS/Ilizarov) than ACIIN.

3-D Generated Anatomic Custom Talar Cement Spacers: A Technical Tip and Literature Review

Category:Basic Sciences/Biologics; Hindfoot; TraumaIntroduction/Purpose:Three dimensional printing is an actively emerging field within the realm of medical devices. This technology expands therapeutic options and customization of implants to individual patients. The ability to create products that replicate normal bony anatomy has been a significant advancement in the setting of difficult clinical scenarios. 3-D generated, custom implants increase the potential for joint and limb salvage with the goal of improving functional outcomes. We present a technical tip for utilizing 3-D printing technology to create custom, anatomically-matched antibiotic cement spacers for limb- salvage applications. We present two illustrative cases and share our experiences, lessons learned, and a succinct review of the pertinent literature merging 3-D printing and the use of antibiotic cement as temporary and permanent reconstructive solutions.Methods:While the majority of 3-D printing is done for the purpose of generating devices for implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. Two case illustrations demonstrate comorbid patients presenting with infected implants, osteomyelitis, bone loss, deformity and wound dehiscense. We describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus for the purpose of limb salvage.Results:Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which is joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution.Conclusion:Utilization of currently available 3-D printing technology as applied to production of anatomic cement spacers should be considered to enhance limb salvage. This innovative application of printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.

3-D generated anatomic custom talar cement spacers: case reports, technical tips and literature review

BackgroundWith today’s expanding use of total ankle arthroplasty, the ever-present trauma patient, and patients with uncontrolled comorbid conditions, surgeons face significant challenges for lower extremity reconstruction. These patients highlight some of those who may present with unique anatomy, bone loss, infection, and various other local and systemic factors that affect treatment options for successful outcomes. Three dimensional (3-D) printing for medical devices is allowing for new and customized ways to meet patient and surgeon goals of limb salvage and reconstruction.Case presentationsWhile the majority of 3-D printing is done for the purpose of implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. With two case illustrations including a talus fracture nonunion and infected subtalar arthrodesis nonunion, we describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus.DiscussionCase illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which are joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution.Innovative 3-D printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.

Antibiotic Cement in Arthroplasty: A Meta-analysis of Randomized Controlled Trials.

IntroductionPeriprosthetic joint infection (PJI) following arthroplasty surgery is a devastating complication. Antibiotic cement has been proposed as a way to reduce PJI rates. The aim of this systematic review and meta-analysis was to review all of the available randomized controlled trial (RCT) evidence on the use of antibiotic cement in arthroplasty.MethodsPubMed, MEDLINE, and Embase were searched. All records were screened in triplicate. Eligible RCTs were included. Data regarding study characteristics, patient demographics, and rates of superficial and deep infection were collected. The risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool 2.0.ResultsFive RCTs were included (n = 4,397). Four studies compared antibiotic cement to plain cement while one study compared high-dose dual-antibiotic (HDDA) cement to low-dose single-antibiotic (LDSA) cement. The mean age of included patients was 76.4 years (range: 68-83). There was no significant difference in superficial infection rates between antibiotic and plain cement (odds ratio (OR): 1.33, 95% Confidence Interval (CI): 0.77-2.30, p = 0.3). There was a large but non-significant reduction in deep infection rates for antibiotic cement (OR: 0.20, 95%CI: 0.03-1.32, p = 0.09). There was a significantly lower rate of infection with HDDA as compared to LDSA (OR: 0.31, 95% CI: 0.09-0.88, p = 0.041).ConclusionThe available evidence from RCTs reveals a potential benefit for antibiotic cement in arthroplasty surgery, though this difference is non-significant and highly imprecise. Furthermore, HDDA cement was significantly more effective than LDSA cement. There is a need for large, pragmatic trials on this topic.

Standardization of Acrylic Bone Cement Mixing Protocols for Total Knee Arthroplasty Results in Cost Savings.

Cost reduction is important in total joint replacement surgery. Bone cement is used to fixate implants in most knee replacement procedures. The authors instituted a 4-pronged approach to reduce the cost of cement. Their approach included reducing the cost of the cement powder, changing the type of mixing method, using less antibiotic cement, and decreasing the amount of cement required for smaller implants. The authors evaluated the implementation of this program and measured the overall costs of cementation during knee replacement. A retrospective review of total knee replacement cementation technique and cost was performed before and after the cost-reduction program was implemented. The type of cement and cement mixing equipment used, the amount of cement used, and the cost of cement and cement mixing equipment were examined. The authors also reported the short-term complication rate including 90-day readmission rate and 30-day revision rate. The program resulted in an overall decrease in cement-related costs from approximately $310 to $105 per case. Reductions in the amount of cement used and the use of antibiotic cement were shown. Among the 3 surgeons, adoption of the program varied. Bone cement is an expense of modern total knee replacement. Implementing a cost-reduction program can reduce cement costs without changing quality of cementation. [Orthopedics. 2018; 41(5):e671-e675.].

¿Es menor el riesgo de falla aséptica en reemplazos primarios de cadera cuando se utiliza cemento con antibiótico? Revisión sistemática de la bibliografía

BackgroundThe use of antibiotic cement has been shown to decrease the risk of periprosthetic hip infection. However, the long term effect of adding antibiotic to the bone cement continues being a controversial issue because of the possible change in its mechanical properties. The objective of this study is to identify the risk of long-term aseptic failure, with the use of antibiotic cement in primary hip arthroplasties. Materials and methodsA systematic literature search in Medline, Embase and Cochrane data was performed studies evaluating long-term (≥10 years) risk of aseptic failure total primary hip replacement cemented with or without antibiotic were included. The methodological study assessment was performed using the Newcastle-Ottawa scale and Jadad. Results5286 titles were identified. Four items were included in the analysis: 1 clinical trial of low quality and 3 prospective cohort of high quality. In the clinical trial, no differences in the risk of aseptical failure using antibiotic cement and regular cement (p=0.14) were found. Unlike, the three cohorts consistently demonstrated a statistically significant reduction (p<0.001) relative risk of aseptic failure at 10 years, with the use of antibiotic cement. DiscussionThe use of antibiotic cement for hip arthroplasties fixation exerts a protective effect and reduces the relative risk of long-term aseptic failure. Level of clinical evidenceII.

Management of infected nonunions by using antibiotic-impregnated bone cement

Background In patients with infected nonunion the primary goal is eradication of infection, before achieving union. Release of antibiotics from bone cement at a higher concentration prevents bacterial growth and formation of biofilm by bacteria. Penetration of antibiotics to the surrounding tissue, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. Patients and methods This was a prospective study of 12 patients with infected nonunions managed with antibiotic-impregnated bone cement who were followed up for an average period of 1.2 years, with encouraging results. The infected fracture site was exposed and thorough debridement done. The implant was replaced with vancomycin and clindamycin-impregnated cement following adequate debridement. Culture and sensitivity was done for the debrided tissues to identify the pathogen and sensitive antimicrobial agent. Follow-up was performed clinically, radiologically, and using laboratory investigations (by complete blood cell count, erythrocyte sedimentation rate, C-reactive protein). Results Infection was eradicated in all patients except one after an average period of 9 weeks (range: 6–14 weeks). Culture revealed no growth and discharge disappeared at the end of this period. Cement was removed after an interval of 6–12 weeks after control of infection and was replaced with definitive fixation with or without bone grafting. Conclusion Management of infected nonunions using antibiotic-impregnated cement is a simple and very effective method that allows infection control and promotes bone union. This simple procedure is encouraging, cost effective, and less cumbersome.

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part B: Management of Segmental Long Bone Defects. A Survey of Orthopaedic Trauma Association Members.

Treatment of segmental long bone defects is one of the areas of substantial controversy in current orthopaedic trauma. The main purpose of this survey was to determine current practice and practice variation within the Orthopaedic Trauma Association (OTA) membership on this topic. Survey. Web-based survey. Three hundred seventy-nine orthopaedic trauma surgeons. A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze various aspects of open fracture management, focusing on definitive treatment and materials used for grafting in "critical-sized" segmental bone defects. Between July and August 2012, a total of 379/1545 members responded for a 25% response rate. Overall, 89.5% (339/379) of respondents use some sort of antibiotic cement spacer before bone grafting. It was found that 92% of respondents preferred to use some type of autograft at time of definitive grafting of segmental defects. When using a grafting technique, 88% said they used some type of antibiotic cement. Within that context, 60.1% said graft placement should be done at 6 weeks. There continues to be substantial variation in the timing of bone graft placement after soft tissue healing and the source and form of graft used. The use of antibiotic cement is common in segmental defects that require delayed bone grafting. Obtaining base-line practice characteristics on controversial topics will help provide a foundation for assessing research needs and, therefore, goals. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Elevated Postoperative Blood Glucose and Preoperative Hemoglobin A1C Are Associated with Increased Wound Complications Following Total Joint Arthroplasty

Diabetes is an established risk factor for complications following total joint arthroplasty. However, the correlation between postoperative blood glucose and preoperative hemoglobin A1C levels with complications following total joint arthroplasty is not well described. All patients undergoing elective primary total joint arthroplasty at our institution from 2004 through 2011 with both postoperative blood glucose and preoperative hemoglobin A1C levels were identified in a retrospective review. From among 1702 patients, those with wound complications within thirty days after the index arthroplasty were identified. A control group matched for exact age, sex, procedure, tourniquet use, surgical approach, and use of antibiotic cement was also created. Thirty patients met the study group inclusion criteria. The mean patient age was seventy-two years (range, fifty-three to eighty-nine years); the majority (53%) of patients were female. The odds ratio for developing a wound complication was 3.75 (95% confidence interval, 1.25 to 11.22; p = 0.02) in patients with a mean postoperative glucose of >200 mg/dL, 3.0 (95% confidence interval, 0.97 to 9.30; p = 0.08) in patients with a maximum postoperative blood glucose of >260 mg/dL, and 9.0 (95% confidence interval, 1.14 to 71.20; p = 0.03) in patients with a preoperative hemoglobin A1C value of >6.7%. Patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty. These results show that poor preoperative and postoperative glucose control is independently associated with wound complications.

Sequestrectomy in Primary Osteomyelitis of the Humerus

Surgical treatment for primary osteomyelitis of the humerus is not well standardized; guidelines come from the scientific literature on osteomyelitis of the femur and tibia. Commonly deltopectoral approach is used for the proximal humerus and posterior approach for the distal humerus. Sequestrectomy alone or the use of antibiotic cement (bead pouch technique) is advised in case of chronic osteomyelitis. Berger and Buckwalter described a posterior approach to the proximal part of the humerus for an excisional biopsy of an osteoid-osteoma. We found that this approach is also useful for sequestrectomy in primary osteomyelitis of the humerus. We describe the technique and make a review of the literature.

An alternative management option for infected non-union of long bone fractures.

Management of infected non-union following fracture of a long bone is a challenge to the orthopaedic surgeon. Several methods of treating these cases have been described.(1-7) Although reports of single stage or multiple stage procedures exist in the literature, general consensus appears to favour a two-stage approach with initial debridement followed by the use of local antibiotic cement in the first stage.(2,5,8) This antibiotic-impregnated cement has been reported in previous papers as placed around an intramedullary nail or via antibiotic cement beads,(4-6,9) Cement beads offer no mechanical stability to the fracture site. Placing cement around an intramedullary device provides added concerns, such as cement nail debonding and the continued presence of metal, which could cause persistence of infection when in contact with endosteal sequestrate. We describe the use of an antibiotic cement nail fashioned by hand intra-operatively around a length of nylon tape. This eliminates the need for further metalwork during the infected stage, thereby reducing the chance of persistent non-union as well as providing some stability across the fracture site.

Reply to Letter to the Editor: Treatment of Early Postoperative Infections After THA: A Decision Analysis

We appreciate the opportunity to reply to the comments of Drs Wolf, Leithner, and Clar. Their comments regarding our study [1] are centered on the concept of applying risk stratification for patients being treated for an infected THA during the early postoperative period. They state that our study does not account for patient-related risk factors in its analysis and that we overlooked two studies [2, 3] that might have contributed insight into this element of the analysis. As is known, the success or failure of any medical intervention in general, and the treatment of periprosthetic joint infections in particular, are predicated on many factors. The concept of Bayes’ theorem and a priori risk are highlighted in this clinical scenario and are mentioned in our article. We believe strongly that risk stratification has an extremely important role in deciding a treatment regimen. What Wolf et al. fail to mention is that these are just concepts. Even for common orthopaedic procedures such as THA, the elements that lead to meaningful risk stratification are not fully understood or implemented, and moreover, in complex clinical scenarios such as with a periprosthetic joint infection, these elements and their application become even more challenging. The two studies referenced by Wolf et al. [2, 3] serve to highlight the lack of information on this concept in the literature. The study by McPherson et al. [3] reports on a staging system for patients with chronic infection who have had a resection arthroplasty as the first stage of a two-stage procedure. McPherson et al. report that the staging system they used correlated with the ultimate ability to successfully reimplant a prosthesis. Although this study provides insight into the specific clinical scenario of patients with a resection arthroplasty after a chronic infection awaiting a second-stage reimplantation, this does not in apply to the hypothetical clinical scenario of our patient 3 weeks after THA. In addition, although elements of this staging system might be useful for acute postoperative infections, the study by McPherson et al. [3] cannot be applied to fundamentally different clinical scenarios. In the study by DeMan et al. [2], no elements of risk stratification are provided, but rather this is a study reporting on the results of a specific algorithmic approach to infection. In addition and similar to the study by McPherson et al., DeMan et al. do not report on the outcomes of acute postoperative infection, but rather a combination of acute and chronic infections they treated. They also report the use of antibiotic cement for fixation of the femoral and acetabular components in approximately half of their cohort. The use of antibiotic cement for the single-stage approaches is mentioned specifically in our study with reported infection control rates. In addition, we discussed the concept of single- and two-stage exchanges being performed using cementless components. The study by De Man et al. does not apply to the clinical scenario presented by an acute postoperative infection. Although we fundamentally agree with Wolf et al. in their desire to use risk stratification in the analysis of different treatment algorithms, there are no published data that establish these parameters. We agree that prospective studies are warranted to better answer this question.

Infected Total Femoral Replacements: Evaluation of Limb Loss Risk Factors

A complication of total femoral replacement (TFR) is periprosthetic infection. Studies have shown that infected endoprostheses have a significant amputation rate, as high as 36.7%. This study examined possible risk factors that may attribute to unsalvageable TFRs following periprosthetic infections, including age, sex, primary vs secondary TFRs, number of irrigation and debridements, recent history of periprosthetic infection, early vs late infection, use of antibiotic cement, and the number of postoperative antibiotics. In a retrospective chart review, 10 patients who had periprosthetic infections of their TFRs were identified from our orthopedic surgical database between 2000 and 2010. Seven of 10 TFRs were unsalvageable due to infection. The 2 greatest risk factors that influenced unsalvageable TFR were age older than 50 years and recipients of secondary TFRs. All 6 patients older than 50 years had unsalvageable TFRs, whereas 1 of 4 patients younger than 50 years had an unsalvageable TFR (P<.05). Similarly, all 6 patients who received secondary TFRs had unsalvageable TFRs, whereas 1 of 4 patients who received a TFR as the primary method of treatment had an unsalvageable TFR (P<.05). No other risk factors showed statistical significance or could be identified as possible risk factors. Surgeons should educate patients who fall into high-risk categories about the benefits of early intervention, such as amputation, that could prevent additional surgeries and decrease the lengths of hospitalizations.

Minimizing Infection Risk: Fortune Favors the Prepared Mind

In the last century, an open fracture of the lower extremity would result in amputation and/or death until Joseph Lister described the antiseptic principle. The prepared mind must understand Lister to reduce infection. Lister described washing hands and reducing bacterial counts in the operating room (OR) through clean air techniques. Lister washed his hands, instruments, wounds, bandages, and sprayed carbolic acid to reduce bacteria. Evidence-based medicine supports simple measures, such as limiting OR traffic and personnel, wearing gowns and gloves, and carefully preparing the operative site. Charnley enforced the principles of Lister with laminar flow. OR efficiency and the use of antibiotic cement prevent infection. Data support preoperative antibiotics as the most important factor in reducing infection. Protocols for decolonization reduce infection. The prepared mind focuses on reducing the bacterial count in the OR and uses the host's ability to fight off infection.

Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones.

Background:In cases with infected non-union, the primary step is eradication of the infection before attempting to achieve union. Release of antibiotics from the bone cement at a high concentration and its penetration to the surrounding tissues, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. The aim of this study is to summarize our experience with the use of antibiotic cement-impregnated intramedullary nail (ACIIN) for control of infection in cases of infected non-union with bone defect.Materials and Methods:We prospectively studied 25 cases of infected non-union (23 femora and two tibiae). There were 24 males and one female, with the mean age being 33 years (range, 21–58 years). All patients had high-velocity road traffic accidents except one patient who had farmland injury. There were seven closed fractures, one grade I compound, two grade II compound fractures, five grade IIIA compound fractures, and 10 grade IIIB compound fractures. ACIIN was used in all cases after adequate debridement. Patients were classified according to the amount of bone defect present after debridement: group 1 with bone defect <4 cm (n=13), group 2 with bone defect ≥4–<6 cm (n=7), and group 3 with bone defect ≥6 cm (n=5). Infection control was judged on the basis of discharge through the wound and laboratory parameters. All patients were followed-up, with an average follow-up time of 29 months (range, 18–40 months). The mean duration of retention of the intramedullary rod was 8 weeks (range, 6–12 weeks).Results:In group 1, all cases achieved infection control, with three patients achieving bone union without any need of secondary procedure. In group 2, all cases achieved infection control but the time taken was significantly longer than for group 1 (P value 0.0002). All the cases required a secondary procedure in the form of either interlocking intramedullary nailing with iliac crest bone graft or Ilizarov ring fixator application to achieve union. None of the cases in group 3 achieved infection control.Conclusion:ACIINs are useful for infection control in cases of infected non-union with bone defect <6 cm. In cases with defect >6 cm, other alternatives should be used.

Efficacy of antibiotic‐impregnated cement in total hip replacement

Background and purpose Antibiotic‐impregnated cement is used as a spacer or during re‐implantation surgery for the treatment of infected total hip arthroplasties. The routine use of antibiotic‐impregnated cement during primary or uninfected revision total hip arthroplasty remains controversial. With this meta‐analysis of the published literature, we intended to assess efficacy and safety in the use of antibiotic‐impregnated cement for uninfected arthroplasty.Methods Following a detailed literature search, only studies reporting on the outcome of total hip replacement performed with antibiotic cement were included. Strict inclusion criteria were used and studies lacking sufficient sample size or critical data were excluded. 19 studies reporting on 36,033 hip replacements in 35,659 patients met the initial inclusion criteria. The main aim of the meta‐analysis was to determine the rate of deep infection with and without the use of antibiotic cement, and to assess the revision rate and the ultimate survivorship of arthroplasty using antibiotic cement.Results The rate of deep infection following primary total hip arthroplasty, at 1.2%, was significantly lower when antibiotic cement was used than when cement without antibiotics was used (2.3%). Similarly, the rate of deep infection following revision total hip arthroplasty when a standard combination of cement and antibiotic—or a custom‐made combination of cement and antibiotic, depending on the results of culture—was used, was almost half of the rate of deep infection when no antibiotics were present in the cement. Overall, the survivorship was 98% (101 failures in 5,178 hips) for primary arthroplasty and 88% (100 failures in 855 hips) for revision arthroplasty. There were no reported adverse events or complications associated with the use of antibiotic‐impregnated cement.Interpretation The use of antibiotic‐impregnated cement lowered the infection rate by approximately 50% in primary hip arthroplasty. For revisions of previously infected hips, combinations or culture‐dependent antibiotics lowered infection rates by approximately 40%.

Reducing the Risk of Deep Wound Infection in Primary Joint Arthroplasty With Antibiotic Bone Cement

Despite significant advances in intraoperative antimicrobial procedures, deep wound infection remains the most serious complication associated with primary, cemented total joint arthroplasty. A systematic review was conducted to evaluate studies of antibiotic bone cement prophylaxis for reducing the risk of deep wound infection. The literature included 22 articles providing estimates of the prophylactic effectiveness of antibiotic cement. In reducing deep wound infection, antibiotic cement was consistently superior to plain cement, similar to systematic antiobiotics, and independent and additive in effect when combined with other prophylactic measures. Randomized controlled trials in particular had important methodological limitations. However, the collective results nearly unanimously favored prophylactic use of antibiotic cement in primary arthoplasty procedures.