Staged Treatment of Infected Tibiotalar Fusion Using a Combination Antibiotic Spacer and Antibiotic-Coated Intramedullary Nail

Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques

Background

Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use.

Methods

A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible.

Results

A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant.

Conclusion

Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted.

Level of evidence

III.

Nonunion After an Open Trimalleolar Ankle Fracture: An Extended Clinical Course and a Novel Approach to Tibio-Talo-Calcaneal Arthrodesis

Nonunion in the setting of chronic osteomyelitis after severe open ankle fractures is a feared outcome with severe loss in patient quality of life. Tibio-talo-calcaneal arthrodesis is a good salvage treatment option in this difficult patient cohort. We report a case of chronic osteomyelitis with severe destruction of the ankle joint after failed fracture fixation of an open trimalleolar ankle fracture. Fusion was ultimately achieved 5 years later using a novel-staged Masquelet technique with external ring fixator stabilization and bone graft reconstruction including femoral harvested autograft using reamer-irrigator-aspirator. This case shows that infection free arthrodesis of the ankle can be achieved even years after failed treatment. This procedure restored significant quality of life through pain relief and much improved mobility and may be a helpful technique in complex tibio-talo-calcaneal arthrodesis in the setting of chronic osteomyelitis and significant joint destruction.

Single-Stage Tibiotalocalcaneal Arthrodesis With Use of an Antibiotic-Coated Intramedullary Nail for Limb Salvage Following an Open Pilon Fracture Complicated by Osteomyelitis: A Case Report

Severe limb deformity can create a major disability, which can ultimately lead to a nonambulatory lifestyle. Limb deformities created by open fractures not only put a patient at risk for a nonfunctional lifestyle but also may lead to gross contamination and osteomyelitis of the osseous structures. At times, these deformities require amputation for better functionality. It is our belief, however, that an attempt at limb salvage should always be considered. When encountering limb deformities with osteomyelitis, most literature refers to a staged technique in which 2 procedures need to be performed: this includes external fixation and/or a temporary antibiotic spacer followed by a permanent intramedullary nail after complete resolution of the infection. Staged procedures prolong the non-weightbearing status of the patient, often decreasing quality of life. The use of a single-stage antibiotic-coated nail has rarely been discussed in the literature. Here we discuss a single-stage technique that may be an option for major deformity limb salvage in the setting of chronic osteomyelitis. This is a case report presenting a 60-year-old female who suffered an open pilon fracture resulting in osteomyelitis and was successfully treated with use of an antibiotic-coated intramedullary nail in a single stage.