Treatment of fracture-related infection of the lower extremity with antibiotic-eluting ceramic bone substitutes: case series of 35 patients and literature review

Abstract

Introduction The current treatment concepts of fracture-related infection (FRI) [Consensus Conference (Anti-Infection Task Force (AITF)) on the definition of acute or chronic osteomyelitis (cOM)] are associated with unsolved challenges and problems, underlining the need for ongoing medical research. Method Literature review of treatments for FRI and description of own cases. Results We could include eight papers with 394 patients reporting treatments and outcome in FRI. The infection was resolved in 92.9% (mean) of all treatments. The mean follow-up was 25 months with a persistent non-union in 7% of the patients. We diagnosed 35 (19f/16m; 56.4 ± 18.6 years) patients with bone infections anatomically allocated to the proximal and distal femur (12×), the pelvis (2×), distal tibia (3×), tibial diaphysis (11×), the ankle joint (4×) and calcaneus (3×). These 35 patients were treated (1) with surgical debridement; (2) with antibiotic-eluting ceramic bone substitutes; (3) bone stabilization (including nail fixation, arthrodesis nails, plates, or external ring fixation), (4) optionally negative pressure wound therapy (NPWT) and (5) optionally soft tissue closure with local or free flaps. The mean follow-up time was 14.9 ± 10.6 months (min/max: 2/40 month). The overall recurrence rate is low (8.5%, 3/35). Prolonged wound secretion was observed in six cases (17.1%, 6/35). The overall number of surgeries was a median of 2.5. Conclusion The results in the literature and in our case series are explicitly promising regarding the treatment of posttraumatic fracture-related infection.

In Vitro Evaluation of Gentamicin or Vancomycin Containing Bone Graft Substitute in the Prevention of Orthopedic Implant-Related Infections

“…One of the most feared complications in orthopedic surgery is the bacterial colonization of abiotic surfaces causing PJI and FRI, occurring in 1% to 2% of the patients receiving orthopedic implants [23]. Antibiotic-eluting BGS represent an attractive clinical option in the management of PJI and FRI. Gentamicin-loaded ceramic fillers have been extensively employed in clinics and their successful use reported in the literature [20][21][22][24][25][26][27][28]. The increasing emergence of aminoglycoside resistance has led to the development of a new BGS formulation enriched with vancomycin, an additional option alongside gentamicin in the orthopedic field [29].…”

“…To date, clinical outcomes of CG and CV have been published in PJI [22], FRI [25,27], chronic Osteomyelitis (cOM) [20,21], and Diabetic Foot Osteomyelitis (DFO) [26,28]. McNally and co-workers found a reduction of the recurrence rate of cOM of 4% in a one-stage procedure compared to common reports in the literature of about 10% [21].…”

“…Logoluso et al used a two-stage approach in the management of PJI, where CG was used in 13 patients and CV in 7 (only staphylococcal and enterococcal infections), finding only one recurrence of PJI in their series of 20 consecutive cases [22]. In FRI, the recurrence rate was reported in 7.7% [25] and 8.5% of cases [27], and in DFO in 10% [26].…”

Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection

“…Most importantly there were no late flap failures related to frame adjustments or bone transportation, demonstrating that carefully planned flaps with Ilizarov distraction is safe. Many centres prefer staged surgery for complex infections and often separate orthopaedic and plastic surgeries (Metsemakers et al, 2019;Lowenberg et al, 1996;Pesch et al, 2020). In some cases, it may be possible to treat the bone defect and soft tissue loss by acute shortening or angulation to allow wound closure (Rozbruch et al, 2006; Pierrie and Hsu, 2017), but this was not possible in these cases.…”

Reply to McNally's comment on “Bioactive glass S53P4 vs. autologous bone graft for filling defects in patients with chronic osteomyelitis and infected non-unions – a single center experience” by Steinhausen et al. (2021)

“…In addition, the definition of reinfection or persistence of infection used by other authors is less strict than ours. Other authors (Romano et al, 2014;Lindfors et al, 2017) define a "fair" outcome as a wound with prolonged drainage or serum leakage of up to 6 weeks. These findings would be interpreted as persistent infection/reinfection in our assessment.…”