|Year : 2017 | Volume
| Issue : 2 | Page : 74-77
Antibiotic laden bone cement in chronic osteomyelitis
Nirmal Chandra Mohapatra, Suraj Jain
Department of Orthopaedics, S C B Medical College, Cuttack, Odisha, India
|Date of Web Publication||14-Dec-2017|
Dr. Nirmal Chandra Mohapatra
Plot No. 1360/B, Sector-6, C D A Po: Markata Nagar, Cuttack - 753 014, Odisha
Source of Support: None, Conflict of Interest: None
Background: Chronic osteomyelitis is a dreaded sequel to acute haematogenous osteomyelitis. It is also more frequent following open fracture and orthopedic surgeries. Principle in treatment of chronic osteomyelitis based on removal of devitalized tissue and filling up of dead space. Systemic antibiotic therapy may not provide minimum inhibitory concentration for prolong period. Antibiotic laden bone cement can be used in adjunct to usual treatment of debridement and systemic antibiotic therapy for local antibiotic delivery and filling dead space temporarily. Material and Method: 32 cases of chronic osteomyelitis (7 haematogenous and 25 exogenous following trauma or surgery) were included in our study which included 21 male and 9 female, age ranging from 18 to 55 year. Pre-operative culture from sinus tract, ESR, and CRP were done. All patient were treated with debridement and removal of implant if present, followed by filling the dead space by antibiotic laden bone cement beads or antibiotic laden bone cement coated nail. Control of infection was assessed by laboratory parameter. Antibiotic cement was removed at an average of 10.62 weeks. All patients were followed up for at least 2 years. Result: Infection was controlled in 28 patients out of 32 patients at the time of cement removal, secondary procedure was done in all patients of infected non union in the form of bone grafting and definite fixation except 3 patients where antibiotic cement coated nails are retained till union as there was callus formation at the end of three month. Conclusion: Antibiotic laden cement is an effective method in local control of infection in chronic osteomyelitis without any systemic side effect.
Keywords: Chronic osteomyelitis, antibiotic laden bone cement, infected non union
|How to cite this article:|
Mohapatra NC, Jain S. Antibiotic laden bone cement in chronic osteomyelitis. J Orthop Traumatol Rehabil 2017;9:74-7
|How to cite this URL:|
Mohapatra NC, Jain S. Antibiotic laden bone cement in chronic osteomyelitis. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2018 Dec 19];9:74-7. Available from: http://www.jotr.in/text.asp?2017/9/2/74/220759
| Introduction|| |
Bacterial infection is a serious complication in orthopedic surgery. Most commonly occurring orthopedic infection is soft tissue infection, necrotizing fasciitis, hematogeneous osteomyelitis, posttraumatic osteomyelitis, infected nonunion and infection around arthroplasty and internal fixation devices. This may cause increased antibiotic use, prolonged hospital stay, repeated surgical debridement, prolonged rehabilitation, morbidity and mortality.,,, They may lead to temporary impairment, long-lasting disability, or even permanent physically challenged inevitably incurring social, economic, esthetical and mental crippling, a great loss not only to the patient but to the nation as a whole, so it has been rightly said “once osteomyelitis, ever osteomyelitis.”
Systemic antibiotic therapy may not provide a minimum inhibitory concentration for prolong period and which is further worsened by decreased blood supply, other causes are bacteria are adherent to orthopedic implant and bone matrix, some bacteria may hide intracellular, and some can form slimy coat  over them that protects from antibiotic and phagocytic cells.,, In such cases, local delivery of antibiotic to surgical area may contribute to reduce infection frequency and decolonization. Bone cement may act as carrier of antibiotic for local surgical site. Hence, antibiotic laden bone cement can be used in adjunct to usual treatment of debridement and systemic antibiotic therapy for higher concentration of local antibiotic delivery. This system may release antibiotic above minimum inhibitory concentration level locally and decreases adverse effect of systemic antibiotic.,,
| Materials and Methods|| |
The present study was conducted on 32 patients who were suffering from chronic osteomyelitis from different causes. All patients were assed clinically, hematologically including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), microbiologically and radiologically. Preoperative culture was taken from sinus tract. After optimizing the host condition, all patients were treated surgically.
Thorough debridement with removal all dead tissue, infected granulation tissue, and scarred tissue was performed. Implant, if present was removed. Intramedullary reaming was done with an oversize reamer in infection following intramedullary nail. The dead space created was obliterated with antibiotic laden poly-methyl-methacrylate (PMMA) bone cement in the form of either beads or coated over a nail (k-nail or elastic nail). Nails were used in 11 cases of infected nonunion (6 cases of tibia and 5 cases of femur).
Either gentamycin PMMA cement or plain PMMA cement were used and mixed with 3 g of cefuroxime and or 2 g of vancomycin dry powder. After mixing the cement, small beads were weaved to steel wires and once the cement set they were used to pack the bony defect [Figure 1]. The regular follow-up was done with a frequent check of ESR, CRP, and wound culture. Antibiotic laden cement bead/nail was removed at 8–10th week postoperatively and wherever necessary bone graft was applied and further definitive fixation done.
|Figure 1: (a) Preoperative clinical picture, (b) CT scan, (c) Peroperative clinical picture, (d) Intraoperative bead insertion, (e) 12 week clinical picture, (f) X-ray picture after 12 weeks, (g) Bead removal, (h) 1 yr follow up clinical picture and (i) X Ray|
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Follow-up was done every 6 weeks for 1st two visit and later every 3 months till 2 years.
In each visit, patient was assessed clinically, hematologically (total leukocyte count, ESR, CRP), and radiologically and culture were sent if there was a recurrence of sinus or persistent of sinus.
Intravenous antibiotic was given for 2 weeks followed by 4 weeks of oral antibiotic based on culture and sensitivity.
The definite procedure was done for infected nonunion after cement removal in the same sitting in the form of definite fixation and bone grafting [Figure 2].
|Figure 2: (a) Preoperative X-Ray, (b) Post operative X-Ray after 3 months and © after 6 months, (d) Clinical picture after bead removal, (e) X-ray after 1 yr, (f) Clinical picture after 1 yr. (g) Clinical picture after 1 half years and (h) X-ray after one half year showing good consolidation|
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| Observation|| |
Out of 32 patients, 7 cases were hematogeneous in origin, 12 cases were associated with implant and patient 13 were secondary to a compound fracture. Intraoperative culture was positive in 30 cases out of 32, 16 were positive for Staphylococcus aureus, 6 cases for Pseudomonas, and 4 cases for coagulase negative Staphylococcus, 2 cases of Escherichia More Details coli, 1 case each of Proteus and Klebsiella. Organisms isolated were commonly resistant to penicillin, ampicillin, tetracycline, erythromycin and were sensitive to vancomycin, levofloxacin, and gentamycin.
Discharging sinus was healed by 2 weeks in 25 cases; in 2 cases, sinus was healed at 6 weeks, and in 2 cases, there was persistence of sinus and nonunion later treated by Ilizarov' method.
Hematological parameter was normalized in 28 patients at 12 weeks, and 3 patients show the persistence of sinus with high ESR and CRP showing noncompliance to treatment. In 1 case, there is the elevation of hematological parameter showing recurrence. Culture was negative in all cases during antibiotic cement removal.
In 2 cases, it was difficult to remove cement beads due to overt fibrosis.
Antibiotic cement-coated nail was left in 3 patients of infected nonunion till complete union as there was sign of callus formation at follow-up and no sign of recurrence.
| Discussion|| |
S. aureus is the most common isolate in chronic osteomyelitis followed by Gram-negative rods like Pseudomonas.,,, However, Ako-Nai et al. in 2003, observed Gram-negative rod is common isolate in their study. Increasing prominence of Pseudomonas in chronic osteomyelitis is of concern because these organisms are resistant to many antibiotics.
The combination of normal ESR and CRP is reliable for predicting the absence of infection. ESR and CRP were increased in all patients at the time of presentation which were getting normalize in most of the patients by 6 weeks after surgery, and normalize in all successfully treated patient by 3 months, this hematological parameter is correlated with clinical picture.
Zhengzhou Henan et al. in 2011, in their study, using antibiotic-impregnated cement temporary spacer for surgical treatment of osteomyelitis and nonunion, in 12 patients found similar result at 3 months by treatment with antibiotic-loaded bone cement.
Preoperative aspirate of fluid accumulation and intraoperative tissue cultures provide the most accurate specimens for detecting the infecting microorganism. At least, three intraoperative tissue areas should be sampled and paired for microbiology and histopathology. It is important to discontinue any antimicrobial therapy at least 2 weeks before tissue sampling for culture. The culture of sinus tract aspirate may be identical to intraoperative culture in 88.7% cases.
Gentamycin bone cement, vancomycin, cefuroxime were used as antibiotic as they have broad antibacterial spectrum, bactericidal, elutes from PMMA cement, chemically and thermally stable, low allergenicity, and biocompatible. In the present study, 2–3 g of either of the antibiotic were added to a pack of bone cement achieve high antibiotic concentration for a longer period at local milieu.
Klemm  was the first to use antibiotic cement beads in cases of osteomyelitis. Penner et al. found the addition of vancomycin elutes more effectively when combined with other antibiotic, called “passive opportunism.”
Many authors concluded antibiotic-loaded PMMA cement coated nails are effective, simple, and inexpensive method of treating chronic osteomyelitis following intramedullary nail.,,,
Antibiotic bone cement beads are useful in filling the dead space created by debridement, release antibiotic locally in a high concentration without any systemic side effect.
| Conclusion|| |
Meticulous debridement is the hallmark of treatment. Antibiotic-loaded PMMA beads, the only drug-delivery system which has been used successfully, provide a simple method for local treatment of infection. Drawbacks associated with the use of PMMA delivery system is the necessity of the second operation, lack of osteoconductivity, and foreign body reaction. PMMA also appears to be surface friendly to biofilm-forming bacteria. The ideal local antibiotic therapy should provide: Antibiotic choice based on antibiogram, provide high local antibiotic concentrations. It should also help in osteoconduction and/or osteoinduction without any interference in osteointegration. While bone cement antibiotic bead may not have all these properties, it still acts as a good carrier to enhance local antibiotic concentration leading to therapeutic effect.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Swiontkowski MF, Hanel DP, Vedder NB, Schwappach JR. A comparison of short-and long-term intravenous antibiotic therapy in the postoperative management of adult osteomyelitis. J Bone Joint Surg Br 1999;81:1046-50.
Cierny G 3rd
. Infected tibial nonunions (1981-1995). The evolution of change. Clin Orthop Relat Res 1999;360:97-105.
Esterhai JL Jr, Sennett B, Gelb H, Heppenstall RB, Brighton CT, Osterman AL, et al
. Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer. J Trauma 1990;30:49-54.
Gilbert DN, Dworkin RJ, Raber SR, Leggett JE. Outpatient parenteral antimicrobial-drug therapy. N Engl J Med 1997;337:829-38.
Plowman R. The socioeconomic burden of hospital acquired infection. Euro Surveill 2000;5:49-50.
Drummond MF, Richardson WS, O'Brien BJ, Levine M, Heyland D. Users' guides to the medical literature. XIII. How to use an article on economic analysis of clinical practice. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1997;21:1552-7.
Peters G, Locci R, Pulvere G. Adherence and growth of coagulase-negative staphylococci on surfaces of intravenous catheters. J Infect Dis 1982;146:479-82.
Ciampolini J, Harding KG. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often? Postgrad Med J 2000;76:479-83.
Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: A review of clinical features, therapeutic considerations and unusual aspects. N Engl J Med 1970;282:198-206.
Zimmerli W, Waldvogel FA, Vaudaux P, Nydegger UE. Pathogenesis of foreign body infection: Description and characteristics of an animal model. J Infect Dis 1982;146:487-97.
Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res 2004;427:86-93.
Seligson D, Mehta S, Voos K, Henry SL, Johnson JR. Use of antibiotic-impregnated poly methyl methacrylate beads to prevent the evoluyion of localised infection. J Orthop Trauma 1992;6:401-6.
Wahlig H, Dingeldein E, Bergman R, Reuss K. The Release of gentamicin from polymethylmethacrylate beads. An experimental and pharmacokinetic study. J Bone Joint Surg Br 1978;60:270-5.
Onche I, Adedeji O. Microbiology of post-operative wound infection in implant surgery. Niger J Surg Res 2004;6:37-40.
Bhattacharya AN, Gupta U. Changing bacterial pattern in orthopaedic infections. Indian J Orthop 1974;8:34-8.
Arora S, Ctyagi S. Bacteriological studies in osteomyelitis. Indian J Orthop 1977;31:148.
Sugandhi Rao P, Beena VK, Sripatirao P, Shivanand PG. Bacterial study of bone & joint infection with special reference to anaerobes. Indian J Orthop 1997;32:171-4.
Spangehl MJ, Masri BA, O'connell JX, Duncan CP. preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999;81:672-83.
Wang S. Antibiotic-impregnated cement temporary spacer for surgical treatment of osteomyelitis and nonunion of bone caused by intramedullary nailing. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2011;25:972-5.
Mousa HA. Evaluation of sinus-track cultures in chronic bone infection. J Bone Joint Surg Br 1997;79:567-9.
Klemm KW. Antibiotic bead chains. Clin Orthop Relat Res 1993;295:63-76.
Shyam AK, Sancheti PK, Patel SK, Rocha S, Pradhan C, Patil A. Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bone. Indian J Orthop 2009;43:396-402.
] [Full text]
Qiang Z, Jun PZ, Jie XJ, Hang L, Bing LJ, Cai LF. Use of antibiotic cement rod to treat intramedullary infection after nailing: Preliminary study in 19 patients. Arch Orthop Trauma Surg 2007;127:945-51.
Ako-Nai AK, Ikem IC, Aziba A, Ajayib AA, Onipede OA. Bacteriological examination of chronic osteomyelitis cases in Ile-Ife, Southwestern Nigeria. Afr Clin Exp Microbiol 2003;4:41-51.
Penner MJ, Masri BA, and Duncan CP, “Elution characteristics of vancomycin and tobrarnycin combined in acrylic bone-cement,” Journal of Arthroplasty 1996;11:939-44.
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