Intramedullary reaming and irrigation and antibiotic-loaded calcium sulfate implantation for the treatment of infection after intramedullary nailing: a retrospective study of 19 cases

Abstract

Background The incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis. Methods We retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed. Results A total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55 months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively. Conclusion Intramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.

Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma

“…Some scholars use antibiotic calcium sulfate-loaded bone transport to treat large bone defects and have achieved good results [ 15 , 16 ]. Calcium sulfate can replace PMMA as bone defect filling material, which can be degraded and absorbed by human body without secondary removal [ 9 ].…”

“…Our data showed that, compared with the TIBT group, the ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower overall complication incidence. Qin et al found that antibiotic-loaded calcium sulfate implantation for lower chronic limb osteomyelitis was a more successful method than wound irrigation–suction, and it greatly decreased infection recurrence and docking obstruction [ 15 , 16 ]. Our conclusions are consistent with this.…”

Antibiotic artificial bone implantation and external fixation for the treatment of infection after intramedullary nail fixation: a retrospective study of 33 cases

“…They believed that bone cement rods can integrate closely with the medullary cavity and eliminate dead spaces, which were beneficial to inflammation elimination and fracture healing [ 25 ]. However, antibiotic bone cement also has its own shortcomings, including: difficult placement in the medullary cavity, requirement for second operation to remove and unstable antibiotic release [ 3 ].…”

“…The standard for reaming is 1 ~ 2 mm larger than the original intramedullary diameter. when the fresh cancellous bone mud appeared in the groove of the soft drill bit, a long nozzle water gun was used to flush the medullary cavity along the opening of the intramedullary nail and the broken end of the fracture with no less than 6L of washing water [ 3 ]. After rinsed repeatedly with normal saline and hydrogen peroxide, infection area was soaked by iodophor solution for 10 mintues.…”

“…In view of the characteristics of intramedullary nail fixation, bacteria will spread to the entire medullary cavity along the intramedullary nail once infection occurs. It may develop into chronic osteomyelitis and affect fracture healing seriously, leading to dysfunction of the affected limb if not treated in time [ 3 ]. Infection after intramedullary nail fixation is one of the intractable problems in orthopedic clinics, and an unified standard treatment plan has not yet been formed.…”