A novel treatment approach to infected nonunion of long bones without systemic antibiotics

Strategies in Trauma and Limb Reconstruction, Jan 2018

Infected nonunion of long bones may require intravenous antibiotics over a lengthy period which may result in a high rate of complications. This study aims to assess the efficacy of local antibiotics used as a replacement to prolonged intravenous therapy. Thirteen patients with infected nonunion of long bones who failed at least one previous surgery were included. The infection was treated through extensive debridement, application of antibiotic-impregnated calcium sulphate pellets and the bone stabilized with external fixation. These patients were monitored for union and infection by clinical signs, laboratory values, and radiographs over a period of 24 months. The results support an eradication of infection and union in all patients with no antibiotic-associated complications. Local antibiotic delivery using calcium sulphate pellets provides an effective method for treatment of nonunion in long bones and is free of the complications from the intravenous route.

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A novel treatment approach to infected nonunion of long bones without systemic antibiotics

Strategies in Trauma and Limb Reconstruction A novel treatment approach to infected nonunion of long bones without systemic antibiotics Karim Z. Masrouha 0 Michael E. Raad 0 Said S. Saghieh 0 0 Department of Surgery, Orthopedics Division, American University of Beirut Medical Center , P. O. Box 11-0236, Riad El-Solh, Beirut 1107 2020 , Lebanon 1 Said S. Saghieh Infected nonunion of long bones may require intravenous antibiotics over a lengthy period which may result in a high rate of complications. This study aims to assess the efficacy of local antibiotics used as a replacement to prolonged intravenous therapy. Thirteen patients with infected nonunion of long bones who failed at least one previous surgery were included. The infection was treated through extensive debridement, application of antibiotic-impregnated calcium sulphate pellets and the bone stabilized with external fixation. These patients were monitored for union and infection by clinical signs, laboratory values, and radiographs over a period of 24 months. The results support an eradication of infection and union in all patients with no antibiotic-associated complications. Local antibiotic delivery using calcium sulphate pellets provides an effective method for treatment of nonunion in long bones and is free of the complications from the intravenous route. Infection; Nonunion; Local antibiotics; Calcium sulphate; Bone pellet; Long bones Introduction Infected nonunion is a dreaded complication of the long bone fractures because its management is challenging to both the patient and the orthopaedic surgeon [ 1 ]. Management involves surgical debridement, tissue reconstruction, a long-course of antibiotics and opioids. The complexity of care and its prolonged duration increases the cost of the treatment for the patient [ 2 ]. In addition, adverse sequelae may lead to bone loss, residual deformity, or even amputation [ 1 ]. Recent advances in surgical technique have tilted the balance towards limb salvage surgery [ 1 ]; however, only a few high-quality studies exist which describe the most beneficial and cost-effective post-operative antimicrobial treatment approach [ 3 ]. Currently, the most widely used approach is extensive surgical debridement followed by 6 weeks of highdose intravenous (IV) antibiotics [ 4 ]. The effective antibiotic penetration and eradication of infection requires 10–100 times the minimum inhibitory concentration (MIC). This high dose is required due to the bacterial biofilm formation and the local milieu at the infection site [ 5 ]. When systemic antibiotics are administered for a prolonged period, there is a significant risk of complications. The IV route requires frequent replacement because it is associated with IV-line thrombosis, infection, and stenosis [ 6 ]. Other complications include, but are not limited to, haematologic, renal, dermatologic, gastrointestinal, and other metabolic problems such as lactic acidosis [ 7 ]. Certain antibiotics used in the treatment of osteomyelitis are considered more toxic than others, particularly aminoglycosides and vancomycin. These two antibiotics require frequent measurement of trough and creatinine levels, further contributing to the burden of treatment [ 7 ]. The high frequency of Staphylococcus aureus infection and its high rates of methicillin resistance [ 8 ] dictate the use of vancomycin as a first-line treatment. Although effective, vancomycin is associated with nephrotoxicity in as many as 43% of patients in some studies [ 9 ]. The use of a local antibiotic delivery conduit was popularized in Europe during the 1970s [ 5 ]. It is associated with lower rates of systemic antibiotic toxicity, allowed for filling of the defect created by extensive debridement, and was considerably cheaper than prolonged courses of systemic antibiotics [ 8 ]. Polymethyl-methacrylate (PMMA) is one of the most commonly used antibiotic conduits today but requires further surgery for removal and may be associated with bead infection after elution of the antibiotic has completed [ 10 ]. Recently, synthetic calcium sulphate has gained popularity as an attractive alternative due to its predictable drug-eluting properties, osteoconductivity, biodegradability and obviating additional surgery for removal [ 11 ]. The beneficial effects of this treatment modality necessitate further study to document its efficiency in the absence of systemic antibiotic use. The aim of our study is to evaluate the resolution of infection and bone healing in patients with infected nonunion of long bones treated with extensive debridement, bone reconstruction and antibiotic-impregnated calcium sulphate pellets without subsequent use of systemic antibiotics. Materials and methods This is a retrospective cohort study of 13 consecutive patients with infected nonunion of long bone from two affiliated medical centres between 2003 and 2012. Institutional review board approval was obtained fro (...truncated)


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Karim Z. Masrouha, Michael E. Raad, Said S. Saghieh. A novel treatment approach to infected nonunion of long bones without systemic antibiotics, Strategies in Trauma and Limb Reconstruction, 2018, pp. 13-18, Volume 13, Issue 1, DOI: 10.1007/s11751-018-0303-4