Successful management of infected tibia IL nail by debridement, lavage, and antibiotic impregnated v-nail

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1 Interntionl Journl of Reserch in Orthopedics Gwli SR et l. Int J Res Orthop Sep;2(3): Reserch Article DOI: Successful mngement of infected tii IL nil y deridement, lvge, nd ntiiotic impregnted v-nil Stish R. Gwli 1 *, Vinod Brve 2, Shshiknt B. Kukle 3, Prmod V. Nirvne 4 1 Assistnt Professor, Deprtment of Orthopedics, Government Medicl College nd Hospitl, Ltur, Mhrshtr, Indi 2 Senior Resident, Deprtment of Orthopedics, Government Medicl College nd Hospitl, Ltur, Mhrshtr, Indi 3 Assistnt Professor, Deprtment of Orthopedics, Government Medicl College nd Hospitl, Ltur, Mhrshtr, Indi 4 Junior Resident III, Deprtment of Orthopedics, Government Medicl College nd Hospitl, Ltur, Mhrshtr, Indi Received: 25 June 2016 Accepted: 29 June 2016 *Correspondence: Dr. Stish. R. Gwli, E-mil: stishgwli61@gmil.com Copyright: the uthor(s), pulisher nd licensee Medip Acdemy. This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License, which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. ABSTRACT Bckground: Tii is most common sucutneous long one which is highly vulnerle for injury. Infected ILN tii nd non-union of tii is much common in clinicl prctice which clls for chllenging mngement protocols to control intrmedullry infection. Considerle judgment is required to tret n infection in frcture with implnt in situ. Mechnicl stility nd control of infections re two min fctors in mngement of infected tii with implnt in situ. To remove infected mteril nd io-film y seril reming of medullry cnl, thorough lvge nd locl deridement of infected frcture site nd sinuses is essentil nd must efore inserting ntiiotic impregnted nil. According to phrmcokinetic studies, ntiiotic delivery from ntiiotic impregnted one cement is 200 times higher concentrtion thn systemic dministrtion without ny systemic side effects. Locl high ntiiotic concentrtion not only prevents cteril growth ut lso prevents io-film formtion y cteri. The study ws conducted to evlute the efficcy of ntiiotic-impregnted PMMA cemented v-nils in mnging infected IL Niling tii without ny ony defects. Methods: They were 10 mles nd 02 femles, with men ge of 38.5 yers. Men follow-up ws of 24 months (rnge months). Men durtion for union ws ptients were followed up t 4, 8, 12 weeks nd 3, 6, 9 nd 12 months intervl. Functionl results were evluted with regrds to control of infection, ony union, deformity, lim length discrepncy nd complictions (intr nd post-opertive). Results: Rdiologicl nd functionl outcome ssessed ccording to complictions treted ccordingly. Conclusions: IL nil tii with infection cn e treted effectively if control of infection y deridement nd mechnicl stility (y v-nil), prevention of cteril growth y ntiiotic impregnted V-nil. Control of infection fter deridement is ddressed y ntiiotic impregnted v-nil is the min crux of tretment. After control of infection cemented V-nil is exchnged with stndrd IL-nil. Bone grfting is optionl, if fter exchnge niling there is no sign of union y 8 weeks. Insertion of ntiiotic impregnted cemented V-nils comined with dequte deridement; lvge nd systemic ntiiotic dministrtion significntly contriute to infection control fter intrmedullry niling. Keywords: Antiiotic cement impregnted intrmedullry nil, Infected tii ILN, Non-union tii, MRSA Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 120

2 INTRODUCTION Tii is most common sucutneous long one which is highly vulnerle for injury. 1 As ntero-medil surfce i.e. shin of tii is sucutneous, frctures re most of the times compound frctures. High velocity rod trffic ccident is ssocited with significnt contmintion in compound frctures. 2 So lso tii is commonest one which goes into nonunion. Due to these two resons, infected nonunion of tii is much common in clinicl prctice which clls for chllenging complex mngement protocols. Mechnicl stility is of primry importnce for control of infection. Infection will not e under control unless nd until mechnicl stility is given. Infected tii ILN is complex orthopedic prolem. Vrious tretment modlities re used to control infection nd give mechnicl stility till infection is erdicted. Lter on, definitive fixtion nd one grfting is stndrd protocol in most of the modlities. Mechnicl stility in presence of infection cn e given y conventionl externl fixtor OR ntiiotic impregnted v-nil OR Ilizrov externl fixtor. Conventionl externl fixtor hs very high percentge pin-trct infection nd pin loosening. Ilizrov technique is not widely prcticed routine orthopedic surgeons re not still expert in doing Ilizrov. Ilizrov fixtion gives very good results in infected gp non unions where long with ony union, one lengthening is desired. 3 Ilizrov clls for specil trining nd long lerning curve, so lso non-ffordility for implnts y poor ptients nd unvilility of instruments t ll set ups. Pin trct infection is more common with tensioned wires in ptients who do outdoor jos in rurl res. Ilizrov technique hs est literture record, ut not widely prcticed due to the resons mentioned ove in ll centres. Pley first introduced ntiiotic impregnted nil with stisfctory results. Phrmco-kinetic study shows, Antiiotic impregnted cement nil gives 200 times more locl ntiiotic concentrtion without ny systemic side effects, gives mechnicl stility, nd fills ded spcewhich prevents growth of cteri nd io-film formtion fter rdicl deridement. In the study ntiiotic impregnted cemented V nil for temporry fixtion fter rdicl deridement nd reming ws preferred. After 2-3 months when there is no infection, fixtion shifted over to finl modlity of fixtion of interlock niling. After 6-8 weeks of interlock niling, if necessry, the utogenous cncellous one grfting ws done if there re no signs of rdiologicl union. Antiiotic impregnted cement eds t wound site fter deridement ws useful to prevent locl cteril growth. METHODS 12 consecutive ptients with intrmedullry infections of the tiil shft were studied. They were 10 mles nd 02 femles, with men ge of 38.5 yers. Inclusion criteri All ptients with intrmedullry infection of tii frcture treted with IL nil nd one loss of less thn 1.0cm t frcture site with no union were included. 05 ptients hd closed frctures initilly nd 07 ptients hd n open frcture. Exclusion criteri Ptients with more thn 1.0 cm one loss were excluded from the study. Functionl results were evluted with regrds to control of infection, ony union, deformity, lim length discrepncy nd complictions (intr nd post-opertive). Mngement is sed upon, Rdicl thorough deridement loclly t frcture site nd thorough reming nd lvge of medullry cnl. Mechnicl stility y Intr-medullry nil/v-nil. Antiiotic impregnted cement coting over nil or cement eds t wound site. Rdicl thorough deridement Removl of sequestrum, infected grnultion tissue, infected nil removl nd reming of medullry cnl to remove infection from endosteum with seril reming. Mechnicl stility y intrmedullry nil All the 12 ptients hd IM nil in-situ. 10 ptients hd dischrging sinus t the time of presenttion, which verged 7.1 months, with rnge from 3 to 12 months. Out of 08 ptients with IM nil in-situ t presenttion, 02 ptients hd pin nd inility to er weight, with X-ry evidence showing no consolidtion t frcture site (Figure 1, Figure 6). 04 hd rdiologicl evidence of osteolysis on X-rys round nil, locking olts nd periostem nd little/no evidence of union. Tretment consisted of the following steps Ptients underwent pre-opertive evlution which includes: Complete lood count, ESR, C-rective protein, Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 121

3 culture nd sensitivity. Stndrd rdiogrphs of the prt in two views were lso otined. Opertive technique The infected IM nil ws removed first. And thorough deridement of the frcture site ws done. Deridement nd over-reming of medullry cnl. Preprtion of ntiiotic impregnted indigenous cement nil. Insertion of cement impregnted V-nil. The cnl ws remed using seril non-flexile remers. Over-sized reming ws done to remove endostel infected mteril, micro-sequestrum nd grnultion tissue from cnl. The reming mteril nd grnultion tissue were sent for repet cultures to confirm cteri. Thorough lvge performed. It includes thorough wsh with H 2 O 2 nd povidone iodine twice nd norml sline irrigtion in the oth ends of frcture to wsh out necrotic tissue nd lood clots. Figure 1: Pre-opertive; ) AP view, ) lterl nil insitu. Figure 3: Follow up union t frcture site; ) AP view, ) lterl view. Preprtion of ntiiotic impregnted indigenous cement nil Teflon tue method-preferred Mnul Guze Method Teflon tue method Figure 2: Post-opertive; ) AP view, ) lterl v-nil in-situ. Deridement It consists of excision of sinus trcts, scrred nd infected soft tissue ws performed. This included removl of ny sequestrum. All the nonvile nd infected tissues, including the skin, soft tissue nd one re excised nd infected vsculr ony ends were resected, till there ws punctute leeding from one ends (pprik sign). Specimens of the one, soft tissues nd ny purulent mteril were sent for culture nd ntiiotic sensitivity. Preprtion of intrmedullry cnl is n importnt step. Adequte/oversized reming is done so s to ccommodte lrger dimeter nil which ensures more stility. Preferly we rem with 10 mm size remer (if fesile sometimes 11 mm.) The lim ws prepred nd re-drped gin efore ntiiotic cement impregnted nil is prepred. The surgicl tem chnged their gloves nd gowns to mintin sepsis efore prepring cemented nil. The nil is prepred on seprte sterile tle. Nil length is mesured with guide wire. Antiiotic Impregnted v nil ws prepred with 40 grms of PMMA cement. The ntiiotic used ws one to which the cultured orgnism ws sensitive to s well s eing het stle. Vncomycin 2 gm nd gentmycin 80 mg or cefuroxime 1.5 gm re het stle nd re the preferred ntiiotics. Mnul mixing of cement ws performed with ntiiotics. According to culture nd sensitivity report, Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 122

4 ny of 02 ntiiotics were chosen. When the cement is in dough stte, it ws injected into sterilized TEFLON tue of inner dimeter of 9 mm or 10 mm ccording to the lst remer pssed. V-nil commonly used size is 6-7 mm of pproprite length. The v-nil ws then inserted in the teflon tue filled with cement. Bone cement is llowed to set for 8-9 minutes. When the cement sets, i.e. it hrdens, the teflon tue ws cut longitudinlly with sclpel lde. The finished ntiiotic cement nil ws redy for use (Figure 2, 7). Figure 4: Operted with v-nil in-situ; ) AP view, ) lterl view. chieve smooth cover encircling the circumference of nil. The prepred cemented nil with cement still in doughy stte is pssed through guze meter to check outer dimeter. If dimeter is more thn desired (1 mm less thn the lst remer size i.e. generlly 9-10 mm) outer cement is removed mnully. All this hs to e completed in precise time i.e. 7-8 minutes y experienced surgeon ecuse, cement sets fter 8-9 minutes nd ecomes stony hrd. An Antiiotic impregnted cemented nil which will imprt stility to the one, s well s relese high locl concentrtion of ntiiotic into the surrounding tissue ws then inserted. 4 According to Nde s Principle, ntiiotic is effective when pus is drined nd infected grnultion tissue is removed. So lso, ntiiotics prevent further pus formtion s ntiiotic cement impregnted nil delivers higher concentrtion loclly without ny locl/systemic side effects. Phrmco-kinetic study shows cement impregnted nil or eds delivers 200 times more concentrtion loclly. 5 Wound is inspected t intervls of hour. A repet deridement ws done whenever required. Intrvenous rod spectrum ntiiotics re given sed on culture nd sensitivity reports for 2 weeks follower y orl ntiiotics for 4 weeks depending on the orgnism isolted in culture nd sensitivity of the spirted remed mteril. A complete lood count (CBC), erythrocyte sedimenttion rte (ESR) nd C-rective protein (CRP) levels were performed t intervl of 02 weeks, nd 6 weeks. Clinicl nd rdiologicl ssessment nd l studies were used to ssess the progress of control of infection. Evidence of infection control ws guged minly cliniclly nd rdiologiclly. Criteri used were Figure 5: Finl union t 14 months. Teflon tue gives smooth nd uniform nil coting of ntiiotic impregnted PMMA nd thus voids impction of nil in medullry cnl t the time of removl. Mnul guze method Another method of preprtion of cemented v-nil is mnul ppliction of cement over circumference of nil. Bone cement ws prepred nd when it ws in dough stte, pplied mnully over the whole surfce of v-nil, leving extrction slot free. Cement is rolled mnully to No dischrging sinus nd dry wound edges. Decresed locl pin. No wrmth nd tenderness. No rdiogrphic evidence of/presence of the osteolytic re. Definitive frcture fixtion After confirmtion of infection control y clinicordiologicl nd hemtologicl investigtion indicting infection CBC, ESR, CRP levels, the study proceed for definitive frcture stiliztion fter 8-10 weeks of primry cemented nil insertion. Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 123

5 The interlocking nil with oth sttic nd dynmic locking ws crried out s per need of frcture geometry (Figure 3). In 03 cses, fter 08 weeks due to poor heling of one nd gp t the frcture ends on rdiologicl ssessment dynmiztion of long one frgment ws done nd union chieved. Autogenous cncellous one grfting ws done in 05 cses to chieve union when there were no signs of frcture heling fter 6-8 weeks of definitive fixtion. Grdul or lter on full weight ering llowed which ws protected initilly y PTB Cst for 4-6 wks. Figure 8: IL nil with infection t 3 months postopertive. RESULTS Intrmedullry reming mteril sent for culture nd ntiiotics sensitivity showed tht, positive culture of ll 10 cses, 02 were culture negtive cses. Per-opertively 07 ptients were culture positive for methicillin-resistnt Stphylococcus ureus (MRSA) 02 smples were positive for Pseudomons eruginos nd 02 cses were positive for citrocter group of species nd 01 cse for E. coli. Figure 6: Operted with v-nil in-situ; ) AP view, ) lterl view. The men durtion of indigenous cement nil ws 8 week (6 to 10 weeks). All the ptients except one chieved infection control s indicted y lortory prmeters nd clinicl evlution. In ptients who hd no control of infection, the procedure ws repeted nd fter tht he ws treted with definitive fixtion. Intrmedullry cultures were otined on removl of V- nil nd definitive fixtion with interlock niling nd the results showed no cteril growth in ll ptients. All the ptients were followed up for the verge period of 24 months (rnge months). 01 ptient ws lost in follow up nd t the end of 15 months he presented with union with cemented v-nil in situ. The verge time for union ws 16 weeks (rnge, weeks). Figure 7: Finl union t 14 month. Moiliztion of the ptient s per tolernce with ctive physiotherpy for regining nkle nd knee moility ws dvised till the rnge of movement ws stisfctory. Complictions Impction of cement nil. Deonding of cement. Impction of cement nil At the time of nil removl, impction ws common compliction. Cemented nil ws difficult to remove fter 6-8 weeks s there is significnt firosis round cement. Other possile resons for impction re non-uniformity Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 124

6 of cement mntle. In this study ptient presented lte i.e. fter weeks of cemented nil, nil ws stucked nd impcted in proximl frgment. We used osteotome to deond the cement from nil nd removed cement mnully. Afterwrds nil removl ws esy s the stucked cement to the medullr y cnl surfce ws removed. Deonding of cement In one ptient there ws deonding of cement mntle in distl frgment. Nil removed, frcture site opened nd lim elevted t 90 hip flexion with knee full extension. Gentle thumping over heel ided the cement mntle to deliver t proximl end of distl frgment which ws removed mnully from frcture site. High locl concentrtion of ntiiotic, 200 times greter thn systemic drug dministrtion without ny systemic side effects. Antiiotics level ove the miniml inhiitory concentrtion of sensitive orgnisms. Also, we cn modify ntiiotic s per the culture nd sensitivity report. Antiiotic concentrtion t source of infection is not dependent on the phrmcokinetics of the ntiiotic. Systemic toxicity of ntiiotics is not oserved. Wider surfce re of elution llows for high ntiiotic concentrtion long entire length of the one. This is essentil s necrotic nd vsculr segments re permele to systemic pr-enterl ntiiotic therpy. DISCUSSION The literture out one infection nd osteomyelitis tretment emphsizes upon the importnce of extensive surgicl deridement in eliminting this infections.6,7 However, surgicl deridement nd systemic ntiiotic tretment without locl ntiiotic ugmenttion is ssocited with higher rte of recurrence nd susequent opertions.6 This study demonstrte tht using n ntiiotic coted cemented nil is simple, cost effective, controls intrmedullry infection nd promotes frcture union nd erly moiliztion of the ptient. In this series, the tretment ws monitored through rdiogrphs nd clinicl wound oservtions. All ptients hd complete wound heling. No rdiogrphic evidence/presence of the osteolysis re were noted. In present study, mximum of 08 to 10 weeks with ntiiotic impregnted v-nil in-situ for control of infection. If the infection ws not controlled fter 6 weeks the nil ws removed nd nother ntiiotic impregnted nil with chnged ntiiotics s per culture nd sensitivity inserted. The ntiiotic used ws one which ws oth het stle nd to which the orgnism ws sensitive. These included the cephlosporin, mino glycosides nd Vncomycin. Oservtion during the study The cemented nil, provides mechnicl stility nd in ddition provides high locl concentrtion of the ntiiotic nd thus controls one infection which is pre-requisite for ony union to chieve. Advntges of ntiiotic cement impregnted niling There is high locl concentrtion of ntiiotic even in the presence of extensive scrring nd compromised vsculrity. Does not require use of cumersome Conventionl Externl fixtor OR Ilizrov. Ptient complince is found good with this method s IN Ex fix with Ilizrov the pprtus is ulky nd prone for pin trct infection (PTI). For this regulr follow up is not s cumersome s for Ex fix. Post-opertive moridity is less due to erly pssive moiliztion of lim nd it essentilly helps in finl rehilittion. Long sty in hospitl is voided. Hence the chnces for hospitl cquired infections re low. Ptients with elevted renl prmeters cn e treted with effective concentrtion of ntiiotic without side effects. Overll ptient complince in our study ws good nd cceptnce ws etter when compred with complince to externl fixtors in literture. CONCLUSION IL nil tii with infection cn e treted effectively if control of infection y deridement nd mechnicl stility (y V nil), prevention of cteril growth y ntiiotic impregnted V nil. Control of infection fter deridement is ddressed y ntiiotic impregnted V nil is the min crux of tretment. After control of infection, cemented v- nil is exchnged with stndrd IL-Nil. Bone grfting is optionl, if fter exchnge niling there is no sign of union y 8 weeks. Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 125

7 Insertion of ntiiotic impregnted cemented v-nils comined with dequte deridement, lvge nd systemic ntiiotic dministrtion significntly contriute to infection control fter intrmedullry niling. Funding: No funding sources Conflict of interest: None declred Ethicl pprovl: Not required REFERENCES Advntges of conventionl indigenously prepred cement nil It is sfe, ptient friendly, verstile procedure tht cn e dpted esily. The method utilises existing esily ville instrumenttion nd mterils to mnge complex prolem in highly cost effective wy. Antiiotic cement impregnted niling provides effective infection control nd good stility to promote union nd hs good ptient complince. Thus, ntiiotic cement impregnted niling is simple, economicl nd very effective procedure when compred to the trditionl methods in mngement of infected IM Nils in frcture tii. ACKNOWLEDGEMENTS The uthors re very grteful to ll ptients who consented for this study without which the efforts for this study were futile. The study is sincere ttempt to tret the ptients with miniml invsive methodology nd desire to get excellent functionl outcome in tertiry cre hospitl, following strict orthopedic principles. The uthors lso cknowledge ll pr-clinicl stff, concerned humn efforts towrds ptient cre in this endevour. 1. Boulton C, Roert V, Toole O. Tii nd fiul shft frctures. In Rockwood nd Greens Frcture in dults. 8 th edition. Wolters Kluwer Helth; 2015: Brown CM, Mcirnie J. The epidemiology of tii frctures. J Bone Joint Surg Br. 1995;77(3): Gregory D. Osteomyelitis In; Terry SC, Jmes HB. Cmpell Opertive Orthopedics. 12 th edition. Interntionl edition. Elsevier;2012: Dror P, John EH. Intrmedullry infections treted with ntiiotic cement rods: preliminry results in nine cses. J Orthopedic Trum. 2002;16(10): Cnle ST, Bety JH. Cmpell Opertive Orthopedics. 12 th edition. Interntionl edition. Elseviers;2012: Simpson AH, Dekin M, Lthm JM. The effect of the extent of surgicl resection on infection-free survivl. J Bone Joint Surg Br. 2001;83: Eckrdt JJ, Wirgnowicz PZ, Mr T. An ggressive surgicl pproch to the mngement of chronic osteomyelitis. Clin Orthop. 1994;298: Cheng YF, Ming SH, Wei MC. Cheng FC. Successful mngement of infected intrmedullry niling with reming, lvge, nd insertion of ntiiotic-impregnted cement rods. J Exp Clin Med. 2011;3(3): Cite this rticle s: Gwli SR, Brve V, Kukle SB, Nirvne PV. Successful mngement of infected tii IL nil y deridement, lvge, nd ntiiotic impregnted v-nil. Int J Res Orthop 2016;2: Interntionl Journl of Reserch in Orthopedics July-Septemer 2016 Vol 2 Issue 3 Pge 126