Treatment of Proximal Femur Osteomyelitis Occurred after Proximal Femoral Nail Antirotation Fixation, with Antibiotic Cement-coated Tibia Intramedullary Nail: A Case Report

Abstract

Antibiotic cement-coated intramedullary nails maintain a locally high antibiotic concentration while contributing to bone stability. We present a case of femoral subtrochanteric fracture in a patient with an infected nonunion who was successfully treated for an infection and nonunion using an antibiotic cement-coated tibial intramedullary nail. A 79-year-old woman with a right femoral subtrochanteric fracture underwent internal fixation using proximal femoral nail antirotation (PFNA). She developed osteomyelitis with nonunion at the surgical site 10 months postoperatively. We decided to insert an antibiotic cement-coated tibial intramedullary nail. After coating the nail with bone cement mixed with antibiotics, bone fixation was achieved by inserting the nail at the site of the PFNA. The patient's symptoms improved, symptoms from the infection disappeared, and bone union was confirmed. Osteomyelitis occurred because of postoperative infection following a proximal femoral fracture. Antibiotic cement-coated tibial intramedullary nails are an effective option to treat patients with osteomyelitis of the femur and achieve bone union where nonunion persists with shallow a intramedullary femoral canal.

Cement-a-TAN Temporary Proximal Femoral Replacement for Staged Joint Replacement – A Case Report

“…Custom spacers can also be crafted from bone cement impregnated with antibiotics formed around a metal endoskeleton [ 5 , 6 , 8 ]. If bone loss is minimal, standard spacers and commercially available devices (such as PROSTALAC) may be sufficient but in cases of extensive proximal femur bone loss, options become limited [ 3 , 4 , 6 ].…”

“…The patient was non-weight-bearing for 6 weeks postoperatively, progressing to partial weight-bearing when union was observed at 4 months. The patient was reported as pain free and ambulant with a frame at 4 years follow-up [ 5 ]. In 2019, Mayes et al adapted this idea by securing a modular body onto the cephalic portion of a long IMN using antibiotic laden PMMA [ 6 ].…”

“…Infected non-union of proximal femoral fractures is difficult to treat: If debridement and revision fixation is unsuccessful then staged arthroplasty is indicated [ 1 , 2 , 3 , 4 , 5 ]. Stage one involves debridement of non-viable bone and soft tissue, multiple sampling for microbiology and insertion of an antibiotic-eluting temporary spacer [ 3 , 5 , 6 ].…”

“…Infected non-union of proximal femoral fractures is difficult to treat: If debridement and revision fixation is unsuccessful then staged arthroplasty is indicated [ 1 , 2 , 3 , 4 , 5 ]. Stage one involves debridement of non-viable bone and soft tissue, multiple sampling for microbiology and insertion of an antibiotic-eluting temporary spacer [ 3 , 5 , 6 ]. This ensures preservation and appropriate tensioning of the soft-tissue envelope, targeted delivery of a high concentration of antibiotics to the local area, systemic antibiotic therapy, reduces dead space, and allows weight-bearing which prevents the complications associated with immobility and potential prolonged bed rest [ 3 , 4 , 7 , 8 ].…”

Intramedullary nail: the past, present and the future – a review exploring where the future may lead us

“…39 However, limitations and challenges of this approach include: requiring an antibiotic that is heat resistant to the cementing process; arduous and long preparation time for the fabrication of the antibiotic cement nails 40 ; risk of adherence of cement to the plastic sleeve used to create the implant 40 ; and the increased diameter of the medullary canal required to accommodate the cement consequently requiring the need for additional reaming or the use of a thinner nail thereby compromising the strength of fixation. 41…”