Vous êtes sur la page 1sur 5

The Journal of TRAUMA Injury, Infection, and Critical Care

Treatment of Long Bone Osteomyelitis With a Mechanically Stable Intramedullar Antibiotic Dispenser: Nineteen Consecutive Cases With a Minimum of 12 Months Follow-Up
Carlos Federico Sancineto, MD, and Jorge Daniel Barla, MD
Background: Antibiotic cement beads are the most common system of local antibiotic delivery. Unfortunately, bead strings do not give mechanical support to the fracture site, stability being fundamental in osteomyelitis treatment. Local treatment associated with bone stability should improve the results in posttraumatic osteomyelitis. The objective of this article is to present our experience in the treatment of long bone osteomyelitis using an intramedullary, mechanically stable antibiotic dispenser. Method: We present a retrospective review of a consecutive series of patients with a long bone osteomyelitis treated using an intramedullary, mechanically stable antibiotic dispenser. The dispenser used with a T-95 chest tube filled with poly(methyl methacrylate) antibiotic (vancomycin, gentamycin, or both, tobramycin or imipenem; depending on culture results) and with a metal center (Ender nail). Results: Fifteen patients were men and three were women, with an average age of 37 years (range, 18 52 years). In four cases, treatment involved the femur and in 15 the tibia. Positive cultures were obtained from each patient. Methicillinresistant Staphylococcus aureus was isolated in 17 cases. The intramedullary dispenser was removed between 6 and 76 weeks after surgery. Success was defined as negative cultures after dispenser removal. Follow-up period was between 10 and 54 months. Negative cultures were obtained from intramedullary reaming after dispenser removal in all but one patient who could not finish treatment because of local intolerance to antibiotic treatment. None of the 17 patients presented an infection recurrence. Conclusion: The combination of local antibiotic treatment with bone segment stability showed acceptable results in our short series of patients. Further investigation on locked intramedullary antibiotic dispensers providing improved stability will help us learn about this difficult clinical scenario. Key Words: Bone cement, Antibiotics.
J Trauma. 2008;65:1416 1420.

osttraumatic osteomyelitis is always a challenge for orthopedic surgeons. Complex cases usually require staged and repeated surgical procedures. Classic treatment includes aggressive tissue debridement, wound irrigation, and fracture stabilization associated with early soft tissue coverage.1 4 Once the bacteria causing infection are isolated, specific antibiotic therapy should be instituted. Adequate bone antibiotic concentration requires high doses for a prolonged period of time, increasing the possibility for toxicity and representing an important expense for treatment.5,6 Nevertheless, even after executing treatment protocol and achieving good results, posttraumatic osteomyelitis can reactivate. To improve the outcomes, local antibiotic therapy was introduced many years ago.7 Although systemic treatment cannot be avoided, the combination seems to be better than either of them alone.8 12 Antibiotic cement beads are probably the most common system of local antibiotic delivery. UnfortuSubmitted for publication June 1, 2006. Accepted for publication September 2, 2008. Copyright 2008 by Lippincott Williams & Wilkins From the Hospital Italiano de Buenos Aires, Argentia This study was presented during the Kuntscher Kreiss Meeting, August 4, 2003 and Orthopaedic Trauma Meeting, October, 2004. Address for reprints: Jorge Daniel Barla, MD, Potosi 4247 Buenos Aires, Argentina, ACK 1199; email: jorge.barla@hospitalitaliano.org.ar. DOI: 10.1097/TA.0b013e31818c6a09

nately, bead strings do not give mechanical support to the fracture site, and stability seems to be relevant in osteomyelitis treatment.1315 The objective of this article is to present a group of patients with long bone osteomyelitis treated with an intramedullary, mechanically stable antibiotic dispenser.

PATIENTS AND METHODS


We present a retrospective review of a consecutive series of patients with long bone osteomyelitis treated with an intramedullary mechanically stable antibiotic dispenser. The inclusion criteria consisted of lower limb shaft injuries suitable to be treated by an intramedullary nail where at least two locking screws could be set at each side of the fracture site. Three different groups of patients were treated. The first group (group A) consisted of patients with a nonunited and infected fracture. The segment was either not stabilized or fixed with an external fixator. The second group (group B) consisted of patients with acute or chronic infections initially treated by internal fixation. In the third group (group C), patients had healed fractures and presented with a reactivation of their chronic osteomyelitis. For patients in group A, an aggressive pin track and a wound debridement were performed. After this, they were temporally stabilized with an external fixator. The debridement procedures were repeated as many times as necessary until the bone was clean, when, with isolated bacteria and December 2008

1416

Treatment of Long Bone Osteomyelitis


complete soft tissue coverage, the temporal external fixator was removed and the pin tract debrided. The local dispense was then introduced. Patients in group B, after bacteriologic documentation of infection by bone biopsy, were treated by internal fixation removal, medullar debridement, and dispenser introduction. Patients in group C, with a positive deep bone biopsy and a healed fracture, were also treated with a local intramedullary antibiotic dispenser. To improve local stability, a kneeanklefoot cast was associated to the dispenser when the segment involved was the tibia. In femoral injuries, a custom brace including the pelvis and the affected lower limb or a two-pin external fixator was used. For the latter, one proximal and one distal screw were inserted to prevent femur rotation. Each patient underwent a minimum of 6-week specific intravenous antibiotic treatment. In acute osteomyelitis this was followed by another 6 weeks of oral antibiotics. In chronic cases, antibiotic treatment continued up to 6 months (Fig. 2). After hospital discharge, the patients were followed up at 1, 2, 4, and 6 weeks. During the follow-up period, a clinical and radiologic evaluation was performed searching for pain, swelling, wound drainage, etc. After 6 weeks, dispenser removal was planned. The timing for this procedure was decided depending on the limb reconstruction protocol. Success was defined as negative cultures from the reaming material after dispenser removal. Systemic antibiotic administration was stopped at least 3 days before this surgery to reduce the possibility of false-negative cultures. After nail removal, the follow-up protocol was repeated as above up to the 6 weeks period. Local evaluation was the parameter taken into account to decide on the following step. Wound healing and absence of local inflammation were the most important signs. C-reactive protein and sedimentation rates were used during follow-up as well, but abnormal results did not correlate in our series to osteomyelitis reactivation, relating visit frequency to limb reconstruction procedures. Those patients who did not need any further treatment were followed up monthly for the first 6 months, each 2 months for the following 6 months, and after that on an annual basis.

Preparation of Medullar Canal


The same technique was performed for all patients independent of their group. The bone segment was prepared following a traditional nailing technique. The canal was reamed both for debridement and enlargement for nail insertion. Cultures were obtained from the reaming material to double check the results obtained by biopsy. Irrigation was performed with 3 L of saline solution using a K10 plastic tube inserted in the canal. Finally, the dispenser was introduced.

Dispenser Construction Technique


The dispenser using a T-95 chest tube was cut to the length of the involved bone segment. Using a 60-mL syringe, the tube was filled with poly(methyl methacrylate) antibiotic (vancomycin 4 g/40 g of cement, gentamycin, or both, tobramycin or imipenem; depending on culture results). To keep as much cement as possible inside the tube, the opposite tube hole was occluded by an assistants thumb and the pressure was released to permit the cement to advance. After this, an Ender nail was introduced using the same thumb technique preventing all the cement to be extruded from the tube. The proximal aspect of the nail was left out to help in the manipulation of the dispenser both for introduction and removal. Once the cement polymerization takes place, the plastic tube was cut and removed (Fig. 1).

RESULTS
Antibiotic cement-coated dispensers were used in 19 cases (18 patients) of posttraumatic osteomyelitis. This in-

Fig. 1. (A) Ender nail and tube length selection. (B) Cement introduction using a 60-mL syringe. (C) Once the nail is inserted, the cement needs to get hard. (D) Intramedullary antibiotic dispenser.

Volume 65 Number 6

1417

The Journal of TRAUMA Injury, Infection, and Critical Care


cluded acute and chronic osteomyelitis secondary to the treatment of open fractures, complications after internal fixation of long bone injuries, or osteomyelitic reactivation of an already healed fracture. Fifteen patients were men and three were women with an average age of 37 years (range, 18 52 years) (Table 1). In four cases, treatment involved the femur and in 15 the tibia. Bactericidal antibiotic concentration is known to be present around antibiotic bone cement up to 6 weeks. Eleven patients (12 cases) were included in group A. Seven sustained an open fracture as the index injury. After the 6-week period, the next step for limb reconstruction was programmed. In nine cases, the dispenser was removed, a medullary reaming debridement performed, and the segment stabilized by an intramedullary nail. In two cases, a segmental bone defect was present. In one patient, bone transportation over the nail with an external fixator was performed (case 4). In the other patient, the defect was filled with cancellous bone graft mixed with vancomycin (case 7). One patient in this group was treated with a locked dispenser using a UTN (Synthes, Oberdorf, Switzerland) (case 5). Every patient achieved union. Following the protocol described, and because of healing signs at the fracture site after 6 weeks, the nails were left in place until bone union in two cases (cases 1 and 8). The nail was then removed on a delayed basis. One patient needed an early dispenser removal because of local antibiotic intolerance related to vancomycin hypersensitivity (case 3). He had the same intolerance during intravenous administration of this antibiotic. Five patients were included in group B. All had been initially treated by intramedullary nailing. An open fracture was the original injury in three patients and a close one in the other two. Four patients presented with an infected nonunion, and in two of them an active sinus track was detected. One patient presented with an acute infection after intramedullary nailing of a close tibial fracture (case 12). In every case, after bacteriologic documentation of infection, aggressive

Fig. 2. (A) Tibial infected nonunion. (B) Local intramedullary dispenser. (C) Six weeks after local and systemic antibiotic treatment a reamed intramedullary nailing was performed. (D) Union and nail removal.

Table 1 Patient Characteristics


Patient Age Segment Open Fracture Bacteria Local Antibiotic

Group A

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

34 20 26 44 36 52 45 29 18 42 41 20 34 50 33 41 38 65

Group B

Group C

Tibia Tibia Tibia Femur Tibia Tibia Tibia Tibia Femur Tibia Tibia Tibia Tibia Tibia Tibia Femur Femur Tibia TIBIA

GIIIB GIIIB GIIIB No GIIIB GIIIA GIII A GIIIB No No GIIIA GIIIB No GIIIA GII GIIIA No No No

MRSA/Enterobacter cloacae MRSA/Serratia spp MRSA MRSA MRSA MRSA MRSA MRSA MRSA MRSA MSSA*/pseudom Pseudomona/MRSA MSSA MRSA MRSA MRSA MRSA MRSA MRSA/Enterobacter cloacae

Vancomycin/gentamycin Vancomycin/tobramycin Vancomycin/gentamycin Vancomycin Vancomycin/tobramycin Vancomycin/gentamycin Vancomycin/gentamycin Vancomycin/gentamycin Vancomycin/gentamycin Vancomycin/gentamycin Vancomycin/gentamycin/imipenem Vancomycin/gentamycin/colis Vancomycin/gentamycin Vancomycin Vancomycin/gentamycin Vancomycin/gentamycin Vancomycin/tobramycin Vancomycin/gentamycin Vancomycin/gentamycin

* Staphylococcus sensitive to methicillin and Pseudomona aureoginosa. Staphylococcus resistent to methicillin.

1418

December 2008

Treatment of Long Bone Osteomyelitis


intramedullary debridement was performed and the dispenser introduced. In one patient (case 14), a locked dispenser with a cement-coated UTN was used. All but one patient underwent dispenser removal, medullary canal debridement by reaming, and renailing after 6 weeks. No signs of local infection were again present at the time of dispenser removal including complete healing of the sinus tracks. Three of the fractures healed uneventfully, and one patient needed a second exchange nailing to finally achieve union. The fracture treated with the UTN united without further procedures. One patient in this group (case 16) with an infected nonunion of the femur developed septic hip arthritis probably secondary to contamination at the insertion site. He was treated by an arthroscopic wash-out and antibiotic therapy. Although the patient clinically improved, he finally developed hip joint degeneration and ended with a total hip replacement. After this case, for femoral osteomyelitis, we use a trochanteric, extracapsular nail entrance point. In group C, two patients were included. Both presented with a reactivation of a chronic osteomyelitis. The protocol of intramedullary debridement once the bacteria were isolated was repeated. As fractures were already healed, and there was no programmed reconstruction procedure, the dispenser removal was performed as an elective case after the 6-week period. The agent most frequently isolated was a methicillinresistant Staphylococcus aureus in 17 cases. In 26% of the cases, there was an association of more than one bacteria. For the whole series, the intramedullary dispenser was removed between 6 and 76 weeks after surgery. Follow-up period after dispenser removal was between 12 and 54 months. Negative cultures were obtained after dispenser removal in all but one patient. This patient was described as part of group A (case 3). None of the other 17 patients developed an infection recurrence during the time of follow-up. In nonunited and infected fracture sites, the literature suggests that stability is extremely important to achieve good results.14,15,18 A cast alone is insufficient especially in the femur. On the other hand, wound evaluation and dressing exchange are more difficult. A cast always requires proximal and distal joint immobilization, increasing the risk for developing secondary joint stiffness.19 Intramedullary nailing represents the gold standard in the management of lower limb fresh or nonunited shaft fractures.20,21 In osteomyelitis, the traditional tool for bone stabilization is the external fixator.12 The most common complication associated to extended periods of treatment using this device is pin tract infections. If a delayed or nonunion situation develops, a nail will not be the best choice as it elevates the rate of deep infections.22,23 Using intramedullary nailing techniques from the beginning may have some benefits. First of all, it is well accepted that a good option for intramedullary osteomyelitis treatment consists of reaming the canal as an adjuvant therapy for bone debridement, and second, this prepares the segment for a locked nail if the fracture is still nonunited after the local antibiotic treatment.14,24 26 Research on intramedullary antibiotic delivery in animal models has been performed with encouraging results.27,28 Similar results were obtained by Tandon and Thomas18 after applying local antibiotic therapy plus intramedullary stability. They used a traditional hollow nail filled with gentamycin cement beads in the treatment of two cases of persistent intramedullary infections. Intramedullary cement rods have previously been described in the literature by Ohtsuda et al.29 and Madanagopal et al.30 They both showed success using an antibiotic cement nail in the treatment of a tibial infection after intramedullary nailing. Each group presented a single case with the latter author describing the surgical technique. Paley and Herzenberg26 showed their preliminary experience in the management of nine patients. All but one patient in their series had acute osteomyelitis related to limb lengthening with an external fixator over a nail. Recurrent infection was not seen during the time of follow-up. Recently, Thonse and Conway31 presented a clinical experience of cement-coated interlocking nails for the treatment of a population similar to ours. They conclude that local treatment added to intramedullar stability seems to be a good alternative in the treatment of infected long bones. Although our series includes acute cases, most of the patients treated had chronic osteomyelitis that represent a more complex scenario. Our intramedullary dispenser improves stability compared with cement beads. External fixator is used for a short period of time reducing the possibility of pin tract complications. Canal reaming helps intramedullary debridement and prepares the segment for a definitive intramedullary nailing if this is the chosen treatment. 1419

DISCUSSION
Local antibiotic treatment proved to be useful in the management of osteomyelitis.7,8,11 Some studies have shown that the combination of local antibiotic treatment with the traditional systemic one seems to improve the outcomes in terms of infection control.9,12 Different antibiotics have been tested in association with poly(methyl methacrylate). The ones used in this study are frequently found in the literature and effective local elution concentrations have been found up to 6 weeks after implantation.13,16,17 To prevent getting bacteriostatic rather than bactericidal antibiotic concentrations, our protocol included dispenser removal after this period. Two patients did remain with the intramedullary devise for a longer period of time. These two patients were treated with a locked dispenser with good tolerance, which was kept in place until cured. Removal was performed as an elective procedure. Volume 65 Number 6

The Journal of TRAUMA Injury, Infection, and Critical Care CONCLUSION


The combination of local antibiotic treatment with long bone segment stability showed acceptable results in our series of patients. None of the 17 patients who could complete our protocol treatment developed an infection recurrence during the time of follow-up.
Bertazzoni Minelli E, Benini A, Magnan B, Bartolozzi P. Release of gentamicin and vancomycin from temporary human hip spacers in two-stage revision of infected arthroplasty. J Antimicrob Chemother. 2004;53:329 334. 17. Cerretani D, Georgi G, Fornara P, et al. The in vitro elution characteristics of vancomycin combined with imipenem-cilostatin in acrylic bone-cements: a pharmacokinetic study. J Arthroplasty. 2002; 17:619 626. 18. Tandon SC, Thomas PB. Persistent osteomyelitis of the femur: two cases of exchange intramedullary nailing with gentamycin beads in the nail. Acta Orthop Scand. 1996;67:620 622. 19. Kardolani AH, Granted H, Edhage B, Jerre R, Styf J. Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand. 2000;71:160 167. 20. Canadian Orthopaedic Trauma Society. Non union following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial. J Bone Joint Surg Am. 2003;85:20932096. 21. Winquist RA, Hansen ST, Clawson DK. Closed intramedullary nailing of femoral fractures: a report of five hundred and twenty cases. J Bone Joint Surg Am. 1984;66:529 539. 22. Bernat M, Lecoq C, Lempidakis M, Martin G, Aswad R, Poitout DG. Secondary internal osteosynthesis after external fixation for recent or old open fractures of the lower limb. Rev Chir Orthop Reparatrice Appar Mot. 1996;82:137144. 23. Mahan J, Seligson D, Henry SL, Hynes P, Dobbins J. Factors in pin tract infections. Orthopaedics. 1991;14:305308. 24. Court-Brown C, Keating J, McQueen M. Infection after intramedullary nailing of the tibia. Incidence and protocol for management. J Bone and Joint Surg Br. 1992;74:770 775. 25. Klemm KW. Treatment of infected pseudoarthrosis of the femur and tibia with an interlocking nail. Clin Orthop Relat Res. 1989; (212):174 181. 26. Paley D, Herzenberg JE. Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases. J Orthop Trauma. 2002;16:723729. 27. Lucke M, Shmidmaier G, Sadoni S, et al. Gentamycin coating of metallic implants reduces implant-related osteomyelitis in rats. Bone 2003;32:521531. 28. Mader JT, Stevens CM, Stevens JH, Ruble R, Lathrop JT, Calhoun JH. Treatment of experimental osteomyelitis with a fibrin sealant antibiotic implant. Clin Orthop Relat Res. 2002;403:58 72. 29. Ohtsuda H, Yokoyama K, Higashi K, et al. Use of antibiotic impregnated bone cement nails to treat septic nonunion after open tibial fracture. J Trauma. 2002;52:364 366. 30. Madanagopal SG, Seligson D, Craig SR. The antibiotic cement nail for infection after tibial nailing. Orthopedics. 2004;27:709 712. 31. Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma. 2007;21:258 268. 16.

REFERENCES
1. 2. Mader JT, Cripps MW, Calhound JH. Adult posttraumatic osteomyelitis of the tibia. Clin Orthop Relat Res. 1999;360:14 21. Patzakis MJ, Zalavras ChG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg. 2005;13:417 427. Simpson W, Deakin M, Lataham JM. Chronic osteomyelitis. The effect of extent of surgical resection on infection-free-survival. J Bone Joint Surg Br. 2001;83:403 408. Testworth K, Cierny G III. Osteomyelitis debridement techniques. Clin Orthop Relat Res. 1999;360:8796. Cierny G III. Infected tibia nonunions (19811995). Clin Orthop Relat Res. 1999;360:97105. Mader JT, Shirtliff ME, Berquist SC, Calhoun J. Antimicrobial treatment of chronic osteomyelitis. Clin Orthop Relat Res. 1999; 360:47 65. Henry S, Ostermann P, Seligson D. The antibiotic bead pouch technique. The management of compound fractures. Clin Orthop Relat Res. 1993;295:54 62. Klemm KW. Antibiotic bead chains. Clin Orthop Relat Res. 1993; 295:6376. Osterman PA, Seligson D, Henry SL. Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases. J Bone Joint Surg Am. 1995;77:9397. Walenkamp GH, Kleijn LL, Leeuw M. Osteomyelitis treated with gentamycin-PMMA beads: 100 patients followed for 112 years. Acta Orthop Scand. 1998;69:518 522. Ueng S, Wei F, Shih C. Management of femoral diaphyseal infected nonunion with antibiotic beads local therapy, external skeletal fixation, and staged bone grafting. J Trauma. 1999;46:97103. Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res. 2004;427:89 93. Seligson D, Popham GJ, Voos K, Henry SL, Faghri M. Antibioticleaching from polymethyl methacrylate beads. J Bone Joint Surg Am. 2003;75:714 720. Miller ME, Ada JR, Webb LX. Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails. Clin Orthop Relat Res. 1989;(245):233238. Patzakis MJ, Wilkins J, Wiss DA. Infection following intramedullary nailing of long bones. Diagnosis and management. Clin Orthop Relat Res. 1986;212:182191.

3.

4. 5. 6.

7.

8. 9.

10.

11.

12.

13.

14.

15.

1420

December 2008

Vous aimerez peut-être aussi