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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.
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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.
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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.
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
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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
REFERENCES
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