Antibiotic Cement Impregnated Nailing in Management of Infected Non-union of Femur and Tibia

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1 Originl Article Print ISSN: Online ISSN: X DOI: /ijss/2017/362 Antiiotic Cement Impregnted Niling in Mngement of Infected Non-union of Femur nd Tii A Srvnn 1, R Rj Gnesh 1, N Deen Muhmmed Ismil 2, Heer Anndn 3 1 Senior Assistnt Professor, Deprtment of Orthopedics, Institute of Orthopedics nd Trumtology, Mdrs Medicl College, Chenni, Tmil Ndu, Indi, 2 Director nd Professor, Deprtment of Orthopedics, Institute of Orthopedics nd Trumtology, Mdrs Medicl College, Chenni, Tmil Ndu, Indi, 3 Senior Clinicl Scientist, Deprtment of Clinicl Reserch, Dr. Agrwl s Helthcre Limited, Tirunelveli, Tmil Ndu, Indi Astrct Introduction: Infected non-union of long ones presents complex prolem to the treting surgeon. The tretment of nonunion trditionlly followed two-stged procedure. Single-stge procedure such s deridement nd use of ntiiotic cement impregnted intrmedullry nils hs een descried in the literture currently. Aim: To evlute the clinicl outcome of compound frctures of femur nd tii mnged y ntiiotic cement impregnted Küntscher nil. Mterils nd Methods: This prospective study ws done on 25 cses of infected non-union of femur nd tii. Functionl results were evluted with regrd to control of infection, ony union, nd complictions. Results: After n verge follow-up of 8 months, infection ws controlled in 24 of 25 (96%) ptients; one union ws chieved in 23 of 25 ptients (92%), rte of ony union verge of 26 weeks for tii, nd 24 weeks for femur. Conclusion: Antiiotic cement impregnted niling is simple, economicl, nd very effective procedure thn trditionl methods in mngement of infected non-unions of long ones. Key words: Antiiotic cement impregnted nil, Infected non-union, Long ones INTRODUCTION Despite dvnces in ntiiotics nd opertive tretment, infected non-union remins difficult to tret, with considerle moridity, nd helth-cre costs. Infected non-union hs een defined s stte of filure of union for 6-8 months with persistent infection t the frcture site. The incidence seems to e incresing, especilly in view of incresing high-velocity trum, which is more frequently treted with internl fixtion. 1-3 The presence of poorly vsculrized tissues, dherence of cteri to one, nd implnts long with slow cteril repliction rte contriute to persisting infection. 4,5 Access this rticle online Month of Sumission : Month of Peer Review : Month of Acceptnce : Month of Pulishing : Infected non-union presents with dul prolems of controlling infection nd providing stility. We present our single-stge procedure of tretment, Kuntscher nil coted with ntiiotic cement, which comines locl ntiiotic delivery with good lignment nd intrmedullry fixtion. The use of n ntiiotic impregnted cement coted IM niling for infected nonunion of tii nd femur frctures hs een well-documented in the literture Antiiotic nil provides osseous stility which is importnt in the mngement of n infected nonunion. Second, ntiiotic cement llows higher concentrtion of ntiiotic t the locl site thn is chievle with systemic ntiiotics nd is ssocited with fewer side effects. Antiiotic cement hs een shown to elute ntiiotic t the locl sites for up to 36 weeks thus hving therpeutic effect on refrctory infection. Unlike trditionl methods of mngement of infected non-union ntiiotic cement-coted niling cts s single-stge procedure y providing stility nd treting infection t the sme time long with other dvntges such s erly moiliztion, voidnce of pin site infections, ese of performnce, nd eing cost-effective. Corresponding Author: R Rj Gnesh, Deprtment of Orthopedics, Institute of Orthopedics nd Trumtology, Mdrs Medicl College, Chenni, Tmil Ndu, Indi. Phone: E-mil: rjgn1234@yhoo.in 187 Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4

2 Aim The im of the study is to evlute the clinicl outcome of compound frctures of femur nd tii mnged y ntiiotic cement impregnted Küntscher nil. MATERIALS AND METHODS This is prospective study of 25 cses of infected nonunion. One femle nd 24 mle ptients (ge rnge, yers) were included in the study. 12 of the ptients were Gustillo s clssifiction Grde III B compound, two were Grde II Compound, two were Gr I compound nd nine were closed frctures t the time of injury. All 25 ptients hd infected non-union t presenttion, nd 14 ptients hd one defect rnging from 1 to 2.5 cms fter initil deridement. Averge follow-up ws 8 months (rnge, 8-36 months). All ptients were evluted pre-opertive with X-rys, hemogloin, totl count, differentil count, sedimenttion rte, C-rective protein, pus C/S, comorid medicl issues, nd llergy to vncomycin. Preliminry thorough wound deridement ws done. Vncomycin 4 g ws mixed with 40 g stndrd viscosity gentmycin one cement nd ws coted over Küntscher nil of pproprite length prepred. In cse of the tii, fter selecting the Küntscher nil of pproprite length the Herzog s end of 8ºis creted with ench-press 5 cm from the proximl end of Figure 1. Nil dimeter is determined y the per-opertive reming dimeter. The medullry cnl is remed up to the mximum dimeter possile. Küntscher nil of 8 mm or 9 mm dimeter is chosen nd cement coted up to 1 mm less thn dimeter of the lst remer. When the cement reches doughy consistency Küntscher nil is coted nd mnully rolled up to uniform dimeter. Proximl eye of nil left open while distl nil tip cement is molded to smooth ullet-nose shpe. Nil inspected for spotty coverge nd smoothened. The dimeter required is checked with Küntscher dimeter mesuring guge nd excess cement is shved off nd nil rerolled efore the cement sets nd dimeter is rechecked. Bone cement is llowed to set for 15 min efore insertion for the monomer to evporte nd to prevent cement nil deonding. After setting of cement, nil plced intrmedullry. Primry wound closure is ttempted lterntively stged plstic surgery procedures plnned. RESULTS After n verge follow-up of 8 months, infection ws controlled in 24 of 25 (96%) ptients (Tle 1). Bone union ws chieved in 23 of 25 ptients (92%) (Tle 2). Rte of ony union verge of 26 weeks for Figure 2-4 nd 24 weeks for Figure 5-7 (Tle 3). Complictions encountered were non-union persisting in 2 cses, roken nd ending nil in 2 cses, nd nil cement deonding in 2 cses. Recurrence of infection ws oserved in 1 ptient (Tle 4). According to Pley s ony criteri, there were 20 excellent results, 2 good results, 1 fir, nd 2 poor result, respectively. According to Pley s functionl criteri 18 excellent results, 5 good results nd 2 poor results were recorded (Grphs 1 nd 2). DISCUSSION The tretment of infected nonunion requires procedures to control the infection nd to provide stility to chieve union. 9 There is no single universlly ccepted modlity of tretment presently ville for the mngement of infected nonunion. Conventionlly, infected non-union hs een mnged using two-step procedure to control the infection first nd susequently to tret the nonunion. Delivery of ntiiotics to the infection site systemiclly or loclly is essentil to control infection. Long-term Tle 1: Control of infection Bone treted Numer of cses Infection controlled Percentge Tii Femur Tle 2: Bony union Bone treted Numer of cses Union Percentge Tii Femur Tle 3: Rte of union Bone treted Minimum durtion (weeks) Mximum durtion (weeks) Men (weeks) Tii Femur Tle 4: Complictions Complictions Numer of cses Non union persisting 2 Infection not controlled 1 Nil ending 1 Nil rekge 1 Proximl nil impingement 2 Distl nil migrtion 1 Nil cement deonding 2 Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4 188

3 Grph 1: Pley s ony criteri Figure 1: Antiiotic Implnt Grph 2: Pley s functionl criteri infection nd repeted deridement crete excessive firosis round the non-union site nd hinder ntiiotic permeility. 14 Hence, delivery of ntiiotics to the locl site is fr more eneficil thn systemic dministrtion of ntiiotics. The use of ntiiotic-impregnted poly methyl methcrylte cement eds for locl delivery of ntiiotics without ny systemic toxicity hs een well documented for the mngement of osteomyelitis nd open frctures. 15,16 However, these ntiiotic cement eds do not provide ny stility cross frcture site nd cnnot e plced in the intrmedullry cnl s it entils difficult removl due to firous ingrowths. Gentmycin nd vncomycin re common choices for locl delivery of ntiiotics ecuse of their rod spectrum of ctivity, het stility, nd low llergenicity. Vncomycin up to 4 g nd gentmycin up to 2% per 40 g do not lter the mechnicl property of one cement. Elution of ntiiotics follows iphsic pttern, with n initil rpid phse nd secondry slow phse. 9,17 Elution is t its mximum during the 1 st dy, gretly declines on the 2 nd dy, nd then, grdully decreses over time nd Figure 2: ( nd ) Tii pre-opertive X-ry, compound Grde III B with flp cover stilize etween dys 5 nd 10. Animl nd clinicl studies consistently hve shown high locl concentrtions nd undetectle or very low serum levels of the loclly delivered ntiiotics with no systemic toxicity. The systemic sorption of the loclly delivered ntimicroil gent is limited nd results in extremely low serum levels, which hve rnged from 0.3 to 0.5 µg/ml in the cse of gentmycin. Clinicl nd experimentl studies show them to hve good elution properties from one cement, nd no deleterious effects on one heling. The process of surfce dhesion nd iofilm development is survivl 189 Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4

4 Figure 3: 24 weeks post-opertive X-ry tii Figure 6: Per-opertive picture of enlrged screw holes in femorl cortex Figure 4: (-d) Rnge of movement in 2 yers follow-up with ntiiotic nil in tii c d Figure 7: At 2 yers follow-up with good frcture union nd ptient ws le to weight er nd wlk with elow knee stump prosthesis All cses were further mnged with exchnge niling y Shym et l. 18, ut exchnge niling ws done for only 3 cses in our study to chieve ony union in 23 out 25 cses in our study. Qing et l. hve shown ony union in only 11 out of 19 cses. 7 Thonse et l. hve shown ony union in 17 out of 20 cses. 9 Rte of ony union verge of 26 weeks for tii nd 24 weeks for femur is comprle with results shown y Hn et l. of 26.4 weeks for tii nd 31.5 weeks for femur. 19 Figure 5: (-c) Pre-opertively elow knee mputee right lower lim with infected non-union shft of femur with implnt filure strtegy employed y cteri. This process is designed to nchor microorgnisms in nutritionlly dvntgeous environment with dhesion to implnt surfce voided in this technique. 11 Control of infection in 24 out of 25 cses in our study is comprle to results of infection control in ll cses y Ashok et l. Indin journl of orthopedics c CONCLUSION Antiiotic cement impregnted niling provides effective infection control nd good stility to promote union. It is dvntgeous over externl fixtors 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 non-unions of long ones. Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4 190

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