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Deep infection in the presence of an implant after open reduction and internal fixation (ORIF) is usually treated with removal of the implant, serial débridement procedures, lavage, intravenously administered antibiotics, and, in some cases, placement of antibiotic-impregnated beads. If infection occurs during the early stages of bone healing, stabilization of the fractures might be compromised after removal of the implant. Although antibiotic-impregnated beads offer local delivery of antibiotics, they do not provide structural support of the fracture site. The beads often are difficult to remove after in-growth of granulation tissue. In areas of subcutaneous bone, an antibiotic bead pouch might be preferred to an open wound. Published research regarding the use of antibiotic-coated plates during the acute or chronic stages of infection is scarce. Plates offer the versatility of fracture stabilization, and the addition of antibiotic cement to the plates might aid in eradication of infection without necessitating a second surgery for removal. The patients provided written informed consent for print and electronic publication of these case reports.
Technique
After removal of implants, we perform débridement of the soft tissues with a hydroscalpel (Versajet; Smith & Nephew, London, United Kingdom), mechanical débridement of bone, and curettage with high speed burr. The wound is then irrigated with pulse pressure lavage and a minimum of 3 L sterile normal saline. The extremity is re-prepped and re-draped; the entire surgical team’s gowns and gloves are changed; and new instrumentation, including cautery and suction equipment, is used. The cement is prepared with tobramycin (3.6 g) and vancomycin (1 g) per 40-g bag of cement. The plate is placed in silicon tubing, and the antibiotic-prepared cement is injected into the tubing and molded until dry. Care is taken to mold the locations of the screw holes by making incisions in the tubing at the appropriate locations. Screws are placed through the screw holes to ensure locking capability, and Kirschner wires are placed through temporary fixation holes (Figure 1). Once dry, the screws and wires are removed from the plate, and the cement-coated plate is removed from the tubing. The antibiotic-coated plate is applied to the fracture or osteotomy site and is seated with screws as appropriate (Figure 2). The wound is closed primarily. Wound drains or vacuum-assisted closure devices are not routinely used unless there is high risk for hematoma formation. The authors prefer to have high local concentrations of antibiotic in the surrounding tissues and wound.
Clinical Series
Case 1
A 31-year-old man fell from a ladder and sustained a bimalleolar ankle fracture-dislocation that was treated with ORIF. Three weeks after initial injury, the patient presented with an infected lateral wound with purulent discharge. He was taken to the operating room for initial débridement, irrigation, and fracture stabilization with an antibiotic-coated plate and tension-band wiring of the medial malleoli. He was discharged from the hospital on day 4 after admission. Cultures of the wound grew beta-hemolytic strep group G and coagulase-negative staphylococci in broth that was sensitive to oxacillin, vancomycin, and gentamycin. The patient was treated with a 6-week regimen of Unasyn (Roerig, New York, New York), developed bony union, and has been free of clinical signs of infection for 2 years (Figures 3, 4).
Case 2
A 27-year-old male carpenter fell from a height of 12 feet and sustained a fracture of the distal radius that was treated with external fixation. The proximal pin site became clinically infected and subsequently developed osteomyelitis. The patient had a draining wound with a fracture for 2 months. He underwent débridement with partial resection of the radius and placement of an antibiotic cement–coated plate and calcium phosphate bone-void filler impregnated with antibiotics. Pathology specimens were positive for osteomyelitis, and bone cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). He received intravenously administered antibiotic therapy for 6 weeks after surgery. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 5A, 5B).
Case 3
A 44-year-old woman with insulin-dependent diabetes mellitus and venous stasis sustained a trimalleolar ankle fracture after a low-energy fall that was initially treated with ORIF. She underwent revision ORIF to treat a malunion 3 months after initial treatment. At 8 months, the patient developed a draining sinus communicating with the plate. Computed tomography revealed nonunion and indicated infection. The patient underwent resection of the osteomyelitis and repair of the fibular nonunion with an antibiotic-coated plate. Tissue cultures were positive for coagulase-negative staphylococcus, and pathology specimens were positive for osteomyelitis. She received postoperative antibiotics intravenously and 6 weeks of antibiotic therapy after discharge from the hospital. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 6, 7).
Case 4
A 48-year-old man sustained an open olecranon fracture in another country. The fracture was initially treated with 1 dose of intravenously administered antibiotics and 5 days of orally administered antibiotics. The patient returned to the United States and was treated with intravenously administered antibiotics for cellulitis of the elbow for 11 days before referral to our institution, where he underwent ORIF with placement of an antibiotic-coated plate and tension-band wiring. Soft-tissue and bone cultures had no growth. He received intravenously administered antibiotics for 6 weeks. At 5 months postoperatively, the plate was removed because of pain. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 8A-8C).
Discussion
Acute infections of fractures have recently been treated with success by Berkes and colleagues,1 who reported a 71% union rate achieved with operative débridement, antibiotic suppression, and retention of fixation until fracture union occurs. The study by Berkes and colleagues1 had a small patient population, and larger cohorts are needed to show more reliable results; however, this treatment maintains structural support for the fracture during healing but requires multiple trips to the operating room for débridements as well as the use of systemic intravenous antibiotic therapy.
A technique that was developed by the primary author (Janet D. Conway, MD) and has not been described in the literature allows for use of antibiotic cement–coated plates to treat early postoperative infections and osteomyelitic nonunions. This approach permits fracture stabilization and local delivery of high concentrations of broad-spectrum antibiotics and can reduce the number of débridement procedures required in the operating room. We present a technique that includes the use of antibiotic cement–coated plates to treat early postoperative infections associated with fractures and nonunions in order to provide eradication of infection and bony stabilization.
Our approach parallels the current theory that treating infection at a site of union is preferable to treating infection at a site of nonunion.1 Fixation devices should remain in place until osseous union is achieved. With the addition of antibiotics to the plate, removal might not be necessary unless a device is loose, nonfunctional, or, ultimately, causing pain. Other options, such as external fixation, can be burdensome to patients and can be associated with other risks. One of our 4 patients required fixation removal because of pain at the elbow; however, even noncoated olecranon plates typically are removed because of pain after fracture healing. Antibiotic cement adds bulk to the construct and can become very prominent in areas of little soft-tissue coverage (Figure 9).
Studies, assessing variables that correlate with higher likelihood of failure for primary repairs, have shown that open fracture, use of an intramedullary nail, and smoking are the highest risk factors for infected nonunion.1−4 Among our 4 patients, 3 were smokers and 1 originally had an open fracture. Smokers have been found to have a 37% higher nonunion rate and are 2 times more likely to develop wound infection and osteomyelitis.1,5 More than 60% of the time, infections are caused by S aureus or coagulase-negative staphylococci.1,5,6 In our study population, 3 of the 4 patients had coagulase-negative staphylococci grow in the cultures. Implants infected with S aureus or Candida require surgical removal. Those with less virulent coagulase-negative staphylococci might not necessitate removal; however, our population had had antibiotic therapy and continued draining sinus.5 Rightmire and colleagues7 reported that those who develop infection earlier than 16 weeks postoperatively have a 68% success rate and that smoking is a major risk factor for infection. Development of Pseudomonas in the wound has been shown to have a positive correlation with amputation.1,2 Infection with Pseudomonas, smoking, and involvement of the femur, tibia, ankle, or foot tended to result in failure.1,2 Being clinically free of signs of infection after 3 months offers a 50% cure rate, with 78% at 6 months and 95% after 1 year.2
When determining an antibiotic to use with the polymethylmethacrylate (PMMA) cement, many factors must be considered, including spectrum, heat stability, and elution characteristics.8 A synergistic effect has been seen with combinations of antibiotics (eg, vancomycin and tobramycin used together). Vancomycin concentrations increased by 103% and tobramycin by 68% when used together compared with their elution rates when used alone, showing passive opportunism.9 This will, in essence, increase concentrations of antibiotics at the site locally, which will increase the bacteriocidal potential but also create a larger antimicrobial spectrum.9
The authors used Cobalt Bone Cement (Biomet Orthopedics, Inc, Warsaw, Indiana) which been shown to have higher elution properties than Simplex P Bone Cement (Stryker, Kalamazoo, Michigan).3,10 The majority of elution occurs in the first 3 to 5 days but can continue for weeks after implantation. We place the cement on the plate allowing for its retention, hoping to eliminate a second surgery for removal.8 We recommend 3.6 g of tobramycin, and 1 g of vancomycin per 40-g bag of PMMA.3 This dose has been shown to be safe in respect to renal toxicity, plus the entire dose is not administered in a single setting because only a small portion of the cement is used when coating the plate. We close all wounds primarily, and do not regularly use drains or vacuum-assisted closures to help prevent a decrease in the local concentration of the antibiotics.11
Broad-spectrum antibiotics are used to coat the plate in order to cover as many microbial organisms as possible without knowing the final offending organism. In our experience, this current technique provides antibiotic delivery with bony stability, therefore eliminating the need for multiple sequential surgical procedures. This difficult patient problem does not occur with enough frequency to warrant a large randomized clinical trial. However, this technique has been effective in these cases and may be useful to orthopedic surgeons in the future.
Conclusion
Based on our experience, early aggressive débridement, coupled with broad-spectrum antibiotic cement–coated plate insertion, provides fracture stability and helps eradicate the infection with 1 surgical procedure.
1. Berkes M, Obremskey WT, Scannell B, et al. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92(4):823-828.
2. Tice AD, Hoaglund PA, Shoultz, DA. Risk factors and treatment outcomes in osteomyelitis. J Antimicrob Chemother. 2003;51(5):1261-1268.
3. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg. 2005;13(6):417-427.
4. Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM; LEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005;19(3):151-157.
5. Liporace FA, Yoon RS, Frank MA, et al. Use of an “antibiotic plate” for infected periprosthetic fracture in total hip arthroplasty. J Orthop Trauma. 2012;26(3):e18-e23.
6. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med. 2004;350(14):1422-1429.
7. Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: management with hardware in place. Clin Orthop. 2008;466(2):466-472.
8. Adams K, Couch L, Cierny G, Calhoun J, Mader JT. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads. Clin Orthop. 1992;(278):244-252.
9. Penner MJ, Masri BA, Duncan CP. Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty. 1996;11(8):939-944.
10. Greene N, Holtom PD, Warren CA, et al. In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos. Am J Orthop. 1998;27(3):201-205.
11. Kalil GZ, Ernst EJ, Johnson SJ, et al. Systemic exposure to aminoglycosides following knee and hip arthroplasty with aminoglycoside-loaded bone cement implants. Ann Pharmacother. 2012;46(7-8):929-934.
Deep infection in the presence of an implant after open reduction and internal fixation (ORIF) is usually treated with removal of the implant, serial débridement procedures, lavage, intravenously administered antibiotics, and, in some cases, placement of antibiotic-impregnated beads. If infection occurs during the early stages of bone healing, stabilization of the fractures might be compromised after removal of the implant. Although antibiotic-impregnated beads offer local delivery of antibiotics, they do not provide structural support of the fracture site. The beads often are difficult to remove after in-growth of granulation tissue. In areas of subcutaneous bone, an antibiotic bead pouch might be preferred to an open wound. Published research regarding the use of antibiotic-coated plates during the acute or chronic stages of infection is scarce. Plates offer the versatility of fracture stabilization, and the addition of antibiotic cement to the plates might aid in eradication of infection without necessitating a second surgery for removal. The patients provided written informed consent for print and electronic publication of these case reports.
Technique
After removal of implants, we perform débridement of the soft tissues with a hydroscalpel (Versajet; Smith & Nephew, London, United Kingdom), mechanical débridement of bone, and curettage with high speed burr. The wound is then irrigated with pulse pressure lavage and a minimum of 3 L sterile normal saline. The extremity is re-prepped and re-draped; the entire surgical team’s gowns and gloves are changed; and new instrumentation, including cautery and suction equipment, is used. The cement is prepared with tobramycin (3.6 g) and vancomycin (1 g) per 40-g bag of cement. The plate is placed in silicon tubing, and the antibiotic-prepared cement is injected into the tubing and molded until dry. Care is taken to mold the locations of the screw holes by making incisions in the tubing at the appropriate locations. Screws are placed through the screw holes to ensure locking capability, and Kirschner wires are placed through temporary fixation holes (Figure 1). Once dry, the screws and wires are removed from the plate, and the cement-coated plate is removed from the tubing. The antibiotic-coated plate is applied to the fracture or osteotomy site and is seated with screws as appropriate (Figure 2). The wound is closed primarily. Wound drains or vacuum-assisted closure devices are not routinely used unless there is high risk for hematoma formation. The authors prefer to have high local concentrations of antibiotic in the surrounding tissues and wound.
Clinical Series
Case 1
A 31-year-old man fell from a ladder and sustained a bimalleolar ankle fracture-dislocation that was treated with ORIF. Three weeks after initial injury, the patient presented with an infected lateral wound with purulent discharge. He was taken to the operating room for initial débridement, irrigation, and fracture stabilization with an antibiotic-coated plate and tension-band wiring of the medial malleoli. He was discharged from the hospital on day 4 after admission. Cultures of the wound grew beta-hemolytic strep group G and coagulase-negative staphylococci in broth that was sensitive to oxacillin, vancomycin, and gentamycin. The patient was treated with a 6-week regimen of Unasyn (Roerig, New York, New York), developed bony union, and has been free of clinical signs of infection for 2 years (Figures 3, 4).
Case 2
A 27-year-old male carpenter fell from a height of 12 feet and sustained a fracture of the distal radius that was treated with external fixation. The proximal pin site became clinically infected and subsequently developed osteomyelitis. The patient had a draining wound with a fracture for 2 months. He underwent débridement with partial resection of the radius and placement of an antibiotic cement–coated plate and calcium phosphate bone-void filler impregnated with antibiotics. Pathology specimens were positive for osteomyelitis, and bone cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). He received intravenously administered antibiotic therapy for 6 weeks after surgery. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 5A, 5B).
Case 3
A 44-year-old woman with insulin-dependent diabetes mellitus and venous stasis sustained a trimalleolar ankle fracture after a low-energy fall that was initially treated with ORIF. She underwent revision ORIF to treat a malunion 3 months after initial treatment. At 8 months, the patient developed a draining sinus communicating with the plate. Computed tomography revealed nonunion and indicated infection. The patient underwent resection of the osteomyelitis and repair of the fibular nonunion with an antibiotic-coated plate. Tissue cultures were positive for coagulase-negative staphylococcus, and pathology specimens were positive for osteomyelitis. She received postoperative antibiotics intravenously and 6 weeks of antibiotic therapy after discharge from the hospital. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 6, 7).
Case 4
A 48-year-old man sustained an open olecranon fracture in another country. The fracture was initially treated with 1 dose of intravenously administered antibiotics and 5 days of orally administered antibiotics. The patient returned to the United States and was treated with intravenously administered antibiotics for cellulitis of the elbow for 11 days before referral to our institution, where he underwent ORIF with placement of an antibiotic-coated plate and tension-band wiring. Soft-tissue and bone cultures had no growth. He received intravenously administered antibiotics for 6 weeks. At 5 months postoperatively, the plate was removed because of pain. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 8A-8C).
Discussion
Acute infections of fractures have recently been treated with success by Berkes and colleagues,1 who reported a 71% union rate achieved with operative débridement, antibiotic suppression, and retention of fixation until fracture union occurs. The study by Berkes and colleagues1 had a small patient population, and larger cohorts are needed to show more reliable results; however, this treatment maintains structural support for the fracture during healing but requires multiple trips to the operating room for débridements as well as the use of systemic intravenous antibiotic therapy.
A technique that was developed by the primary author (Janet D. Conway, MD) and has not been described in the literature allows for use of antibiotic cement–coated plates to treat early postoperative infections and osteomyelitic nonunions. This approach permits fracture stabilization and local delivery of high concentrations of broad-spectrum antibiotics and can reduce the number of débridement procedures required in the operating room. We present a technique that includes the use of antibiotic cement–coated plates to treat early postoperative infections associated with fractures and nonunions in order to provide eradication of infection and bony stabilization.
Our approach parallels the current theory that treating infection at a site of union is preferable to treating infection at a site of nonunion.1 Fixation devices should remain in place until osseous union is achieved. With the addition of antibiotics to the plate, removal might not be necessary unless a device is loose, nonfunctional, or, ultimately, causing pain. Other options, such as external fixation, can be burdensome to patients and can be associated with other risks. One of our 4 patients required fixation removal because of pain at the elbow; however, even noncoated olecranon plates typically are removed because of pain after fracture healing. Antibiotic cement adds bulk to the construct and can become very prominent in areas of little soft-tissue coverage (Figure 9).
Studies, assessing variables that correlate with higher likelihood of failure for primary repairs, have shown that open fracture, use of an intramedullary nail, and smoking are the highest risk factors for infected nonunion.1−4 Among our 4 patients, 3 were smokers and 1 originally had an open fracture. Smokers have been found to have a 37% higher nonunion rate and are 2 times more likely to develop wound infection and osteomyelitis.1,5 More than 60% of the time, infections are caused by S aureus or coagulase-negative staphylococci.1,5,6 In our study population, 3 of the 4 patients had coagulase-negative staphylococci grow in the cultures. Implants infected with S aureus or Candida require surgical removal. Those with less virulent coagulase-negative staphylococci might not necessitate removal; however, our population had had antibiotic therapy and continued draining sinus.5 Rightmire and colleagues7 reported that those who develop infection earlier than 16 weeks postoperatively have a 68% success rate and that smoking is a major risk factor for infection. Development of Pseudomonas in the wound has been shown to have a positive correlation with amputation.1,2 Infection with Pseudomonas, smoking, and involvement of the femur, tibia, ankle, or foot tended to result in failure.1,2 Being clinically free of signs of infection after 3 months offers a 50% cure rate, with 78% at 6 months and 95% after 1 year.2
When determining an antibiotic to use with the polymethylmethacrylate (PMMA) cement, many factors must be considered, including spectrum, heat stability, and elution characteristics.8 A synergistic effect has been seen with combinations of antibiotics (eg, vancomycin and tobramycin used together). Vancomycin concentrations increased by 103% and tobramycin by 68% when used together compared with their elution rates when used alone, showing passive opportunism.9 This will, in essence, increase concentrations of antibiotics at the site locally, which will increase the bacteriocidal potential but also create a larger antimicrobial spectrum.9
The authors used Cobalt Bone Cement (Biomet Orthopedics, Inc, Warsaw, Indiana) which been shown to have higher elution properties than Simplex P Bone Cement (Stryker, Kalamazoo, Michigan).3,10 The majority of elution occurs in the first 3 to 5 days but can continue for weeks after implantation. We place the cement on the plate allowing for its retention, hoping to eliminate a second surgery for removal.8 We recommend 3.6 g of tobramycin, and 1 g of vancomycin per 40-g bag of PMMA.3 This dose has been shown to be safe in respect to renal toxicity, plus the entire dose is not administered in a single setting because only a small portion of the cement is used when coating the plate. We close all wounds primarily, and do not regularly use drains or vacuum-assisted closures to help prevent a decrease in the local concentration of the antibiotics.11
Broad-spectrum antibiotics are used to coat the plate in order to cover as many microbial organisms as possible without knowing the final offending organism. In our experience, this current technique provides antibiotic delivery with bony stability, therefore eliminating the need for multiple sequential surgical procedures. This difficult patient problem does not occur with enough frequency to warrant a large randomized clinical trial. However, this technique has been effective in these cases and may be useful to orthopedic surgeons in the future.
Conclusion
Based on our experience, early aggressive débridement, coupled with broad-spectrum antibiotic cement–coated plate insertion, provides fracture stability and helps eradicate the infection with 1 surgical procedure.
Deep infection in the presence of an implant after open reduction and internal fixation (ORIF) is usually treated with removal of the implant, serial débridement procedures, lavage, intravenously administered antibiotics, and, in some cases, placement of antibiotic-impregnated beads. If infection occurs during the early stages of bone healing, stabilization of the fractures might be compromised after removal of the implant. Although antibiotic-impregnated beads offer local delivery of antibiotics, they do not provide structural support of the fracture site. The beads often are difficult to remove after in-growth of granulation tissue. In areas of subcutaneous bone, an antibiotic bead pouch might be preferred to an open wound. Published research regarding the use of antibiotic-coated plates during the acute or chronic stages of infection is scarce. Plates offer the versatility of fracture stabilization, and the addition of antibiotic cement to the plates might aid in eradication of infection without necessitating a second surgery for removal. The patients provided written informed consent for print and electronic publication of these case reports.
Technique
After removal of implants, we perform débridement of the soft tissues with a hydroscalpel (Versajet; Smith & Nephew, London, United Kingdom), mechanical débridement of bone, and curettage with high speed burr. The wound is then irrigated with pulse pressure lavage and a minimum of 3 L sterile normal saline. The extremity is re-prepped and re-draped; the entire surgical team’s gowns and gloves are changed; and new instrumentation, including cautery and suction equipment, is used. The cement is prepared with tobramycin (3.6 g) and vancomycin (1 g) per 40-g bag of cement. The plate is placed in silicon tubing, and the antibiotic-prepared cement is injected into the tubing and molded until dry. Care is taken to mold the locations of the screw holes by making incisions in the tubing at the appropriate locations. Screws are placed through the screw holes to ensure locking capability, and Kirschner wires are placed through temporary fixation holes (Figure 1). Once dry, the screws and wires are removed from the plate, and the cement-coated plate is removed from the tubing. The antibiotic-coated plate is applied to the fracture or osteotomy site and is seated with screws as appropriate (Figure 2). The wound is closed primarily. Wound drains or vacuum-assisted closure devices are not routinely used unless there is high risk for hematoma formation. The authors prefer to have high local concentrations of antibiotic in the surrounding tissues and wound.
Clinical Series
Case 1
A 31-year-old man fell from a ladder and sustained a bimalleolar ankle fracture-dislocation that was treated with ORIF. Three weeks after initial injury, the patient presented with an infected lateral wound with purulent discharge. He was taken to the operating room for initial débridement, irrigation, and fracture stabilization with an antibiotic-coated plate and tension-band wiring of the medial malleoli. He was discharged from the hospital on day 4 after admission. Cultures of the wound grew beta-hemolytic strep group G and coagulase-negative staphylococci in broth that was sensitive to oxacillin, vancomycin, and gentamycin. The patient was treated with a 6-week regimen of Unasyn (Roerig, New York, New York), developed bony union, and has been free of clinical signs of infection for 2 years (Figures 3, 4).
Case 2
A 27-year-old male carpenter fell from a height of 12 feet and sustained a fracture of the distal radius that was treated with external fixation. The proximal pin site became clinically infected and subsequently developed osteomyelitis. The patient had a draining wound with a fracture for 2 months. He underwent débridement with partial resection of the radius and placement of an antibiotic cement–coated plate and calcium phosphate bone-void filler impregnated with antibiotics. Pathology specimens were positive for osteomyelitis, and bone cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). He received intravenously administered antibiotic therapy for 6 weeks after surgery. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 5A, 5B).
Case 3
A 44-year-old woman with insulin-dependent diabetes mellitus and venous stasis sustained a trimalleolar ankle fracture after a low-energy fall that was initially treated with ORIF. She underwent revision ORIF to treat a malunion 3 months after initial treatment. At 8 months, the patient developed a draining sinus communicating with the plate. Computed tomography revealed nonunion and indicated infection. The patient underwent resection of the osteomyelitis and repair of the fibular nonunion with an antibiotic-coated plate. Tissue cultures were positive for coagulase-negative staphylococcus, and pathology specimens were positive for osteomyelitis. She received postoperative antibiotics intravenously and 6 weeks of antibiotic therapy after discharge from the hospital. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 6, 7).
Case 4
A 48-year-old man sustained an open olecranon fracture in another country. The fracture was initially treated with 1 dose of intravenously administered antibiotics and 5 days of orally administered antibiotics. The patient returned to the United States and was treated with intravenously administered antibiotics for cellulitis of the elbow for 11 days before referral to our institution, where he underwent ORIF with placement of an antibiotic-coated plate and tension-band wiring. Soft-tissue and bone cultures had no growth. He received intravenously administered antibiotics for 6 weeks. At 5 months postoperatively, the plate was removed because of pain. The patient has remained free of clinical signs of infection for more than 1 year and has achieved bony union (Figures 8A-8C).
Discussion
Acute infections of fractures have recently been treated with success by Berkes and colleagues,1 who reported a 71% union rate achieved with operative débridement, antibiotic suppression, and retention of fixation until fracture union occurs. The study by Berkes and colleagues1 had a small patient population, and larger cohorts are needed to show more reliable results; however, this treatment maintains structural support for the fracture during healing but requires multiple trips to the operating room for débridements as well as the use of systemic intravenous antibiotic therapy.
A technique that was developed by the primary author (Janet D. Conway, MD) and has not been described in the literature allows for use of antibiotic cement–coated plates to treat early postoperative infections and osteomyelitic nonunions. This approach permits fracture stabilization and local delivery of high concentrations of broad-spectrum antibiotics and can reduce the number of débridement procedures required in the operating room. We present a technique that includes the use of antibiotic cement–coated plates to treat early postoperative infections associated with fractures and nonunions in order to provide eradication of infection and bony stabilization.
Our approach parallels the current theory that treating infection at a site of union is preferable to treating infection at a site of nonunion.1 Fixation devices should remain in place until osseous union is achieved. With the addition of antibiotics to the plate, removal might not be necessary unless a device is loose, nonfunctional, or, ultimately, causing pain. Other options, such as external fixation, can be burdensome to patients and can be associated with other risks. One of our 4 patients required fixation removal because of pain at the elbow; however, even noncoated olecranon plates typically are removed because of pain after fracture healing. Antibiotic cement adds bulk to the construct and can become very prominent in areas of little soft-tissue coverage (Figure 9).
Studies, assessing variables that correlate with higher likelihood of failure for primary repairs, have shown that open fracture, use of an intramedullary nail, and smoking are the highest risk factors for infected nonunion.1−4 Among our 4 patients, 3 were smokers and 1 originally had an open fracture. Smokers have been found to have a 37% higher nonunion rate and are 2 times more likely to develop wound infection and osteomyelitis.1,5 More than 60% of the time, infections are caused by S aureus or coagulase-negative staphylococci.1,5,6 In our study population, 3 of the 4 patients had coagulase-negative staphylococci grow in the cultures. Implants infected with S aureus or Candida require surgical removal. Those with less virulent coagulase-negative staphylococci might not necessitate removal; however, our population had had antibiotic therapy and continued draining sinus.5 Rightmire and colleagues7 reported that those who develop infection earlier than 16 weeks postoperatively have a 68% success rate and that smoking is a major risk factor for infection. Development of Pseudomonas in the wound has been shown to have a positive correlation with amputation.1,2 Infection with Pseudomonas, smoking, and involvement of the femur, tibia, ankle, or foot tended to result in failure.1,2 Being clinically free of signs of infection after 3 months offers a 50% cure rate, with 78% at 6 months and 95% after 1 year.2
When determining an antibiotic to use with the polymethylmethacrylate (PMMA) cement, many factors must be considered, including spectrum, heat stability, and elution characteristics.8 A synergistic effect has been seen with combinations of antibiotics (eg, vancomycin and tobramycin used together). Vancomycin concentrations increased by 103% and tobramycin by 68% when used together compared with their elution rates when used alone, showing passive opportunism.9 This will, in essence, increase concentrations of antibiotics at the site locally, which will increase the bacteriocidal potential but also create a larger antimicrobial spectrum.9
The authors used Cobalt Bone Cement (Biomet Orthopedics, Inc, Warsaw, Indiana) which been shown to have higher elution properties than Simplex P Bone Cement (Stryker, Kalamazoo, Michigan).3,10 The majority of elution occurs in the first 3 to 5 days but can continue for weeks after implantation. We place the cement on the plate allowing for its retention, hoping to eliminate a second surgery for removal.8 We recommend 3.6 g of tobramycin, and 1 g of vancomycin per 40-g bag of PMMA.3 This dose has been shown to be safe in respect to renal toxicity, plus the entire dose is not administered in a single setting because only a small portion of the cement is used when coating the plate. We close all wounds primarily, and do not regularly use drains or vacuum-assisted closures to help prevent a decrease in the local concentration of the antibiotics.11
Broad-spectrum antibiotics are used to coat the plate in order to cover as many microbial organisms as possible without knowing the final offending organism. In our experience, this current technique provides antibiotic delivery with bony stability, therefore eliminating the need for multiple sequential surgical procedures. This difficult patient problem does not occur with enough frequency to warrant a large randomized clinical trial. However, this technique has been effective in these cases and may be useful to orthopedic surgeons in the future.
Conclusion
Based on our experience, early aggressive débridement, coupled with broad-spectrum antibiotic cement–coated plate insertion, provides fracture stability and helps eradicate the infection with 1 surgical procedure.
1. Berkes M, Obremskey WT, Scannell B, et al. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92(4):823-828.
2. Tice AD, Hoaglund PA, Shoultz, DA. Risk factors and treatment outcomes in osteomyelitis. J Antimicrob Chemother. 2003;51(5):1261-1268.
3. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg. 2005;13(6):417-427.
4. Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM; LEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005;19(3):151-157.
5. Liporace FA, Yoon RS, Frank MA, et al. Use of an “antibiotic plate” for infected periprosthetic fracture in total hip arthroplasty. J Orthop Trauma. 2012;26(3):e18-e23.
6. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med. 2004;350(14):1422-1429.
7. Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: management with hardware in place. Clin Orthop. 2008;466(2):466-472.
8. Adams K, Couch L, Cierny G, Calhoun J, Mader JT. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads. Clin Orthop. 1992;(278):244-252.
9. Penner MJ, Masri BA, Duncan CP. Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty. 1996;11(8):939-944.
10. Greene N, Holtom PD, Warren CA, et al. In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos. Am J Orthop. 1998;27(3):201-205.
11. Kalil GZ, Ernst EJ, Johnson SJ, et al. Systemic exposure to aminoglycosides following knee and hip arthroplasty with aminoglycoside-loaded bone cement implants. Ann Pharmacother. 2012;46(7-8):929-934.
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4. Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM; LEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005;19(3):151-157.
5. Liporace FA, Yoon RS, Frank MA, et al. Use of an “antibiotic plate” for infected periprosthetic fracture in total hip arthroplasty. J Orthop Trauma. 2012;26(3):e18-e23.
6. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med. 2004;350(14):1422-1429.
7. Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: management with hardware in place. Clin Orthop. 2008;466(2):466-472.
8. Adams K, Couch L, Cierny G, Calhoun J, Mader JT. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads. Clin Orthop. 1992;(278):244-252.
9. Penner MJ, Masri BA, Duncan CP. Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty. 1996;11(8):939-944.
10. Greene N, Holtom PD, Warren CA, et al. In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos. Am J Orthop. 1998;27(3):201-205.
11. Kalil GZ, Ernst EJ, Johnson SJ, et al. Systemic exposure to aminoglycosides following knee and hip arthroplasty with aminoglycoside-loaded bone cement implants. Ann Pharmacother. 2012;46(7-8):929-934.
