Locked Plate Impregnated with Antibiotic-Loaded Bone Cement Application as a First Stage For Managing Long Bones Infected Nonunion: A Technical Note

Abstract

Background. Infected nonunion of long bone fractures poses a dilemma for trauma surgeons, especially when accompanied by bone defects. The main goals for management are curing infection, reconstructing the bone defect, achieving union at the fracture site, and eventually obtaining acceptable functional outcomes. In these situations, the surgeon could manage the infected nonunion through single-stage surgery. However, some surgeons prefer two-stage surgical intervention, wherein in the first stage, all attention is paid to curing the infection and providing temporary stabilization till the second stage, which is the definitive fixation. Temporary fixation during the first stage after thorough debridement could be obtained by various methods, including intramedullary nails coated by bone cement or external fixators.

The aim — to describe a modification while using a locked plate impregnated with antibiotic-loaded bone cement during

the first stage of two-stage revision for managing infected nonunited distal femoral fracture.

Technique description. The method described in the current technical note is a locking plate impregnated with antibiotic-loaded bone cement. This technique provides optimal local antibiotic delivery through the bone cement and proper stability owing to the fixation using the locking plate, which could be applied as close to the bone as possible due to its function as an internal-external fixator.

Conclusion. The technique is easy and efficient and can be applied using ordinary tools without needing complex instruments.

Keywords

infected nonunion / bone cement spacer / local antibiotic therapy / antibiotic cement-impregnated locking plate

References

[1] Flores M.J., Brown K.E., O’Marr J.M., Adejuyigbe B., Rodarte P., Gomez-Alvarado F. et al. The economic impact of infection and/or nonunion on long-bone shaft fractures: a systematic review. OTA Int. 2024;7(3):e337. doi: 10.1097/OI9.0000000000000337.

[2] Metsemakers W.J., Morgenstern M., Senneville E., Borens O., Govaert G.A.M., Onsea J. et al. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg. 2020;140(8):1013-1027. doi: 10.1007/s00402-019-03287-4.

[3] Govaert G.A.M., Kuehl R., Atkins B.L., Trampuz A., Morgenstern M., Obremskey W.T. et al. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma. 2020;34(1):8-17. doi: 10.1097/BOT.0000000000001614.

[4] Bauer T., Klouche S., Grimaud O., Lortat-Jacob A., Hardy P. Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years. Orthop Traumatol Surg Res. 2018;104(1):137-145. doi: 10.1016/j.otsr.2017.10.014.

[5] Farouk O., Khalifa A.A. Tibial Bone Loss: How to Treat without Circular Fixation? J Orthop Spine Trauma. 2023;9(1):1-5. doi: 10.18502/jost.v9i1.12561.

[6] Migliorini F., Schäfer L., Simeone F., Vaish A., Bhadani J.S., Vaishya R. Management of Distal Femoral Non-union: A Systematic Review. Indian J Orthop. 2024;58(12):1686-1723. doi: 10.1007/s43465-024-01205-4.

[7] Somford M.P., van den Bekerom M.P., Kloen P. Operative treatment for femoral shaft nonunions, a systematic review of the literature. Strategies Trauma Limb Reconstr. 2013;8(2):77-88. doi: 10.1007/s11751-013-0168-5.

[8] Khalifa A.A., Fadle A.A., Elsherif M.E., Said H.G., Elsherif E., Said G. et al. Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures. Trauma. 2021;24(4):286-293. doi: 10.1177/14604086211007037.

[9] Barabash A.P., Kesov L.A., Barabash Ju.A., Shpinyak S.P. Building of extensive diaphysis defects in long bones. Traumatology and Orthopedics of Russia. 2014;20(2):93-99. (In Russian). doi: 10.21823/2311-2905-67.

[10] Yang X., Xu X., Li J., Song M., Sun H., Zhang H. et al. Management of infected bone defects of the femoral shaft by Masquelet technique: sequential internal fixation and nail with plate augmentation. BMC Musculoskelet Disord. 2024;25(1):552. doi: 10.1186/s12891-024-07681-x.

[11] Bu Z.Y., Hu L.J., Li C., Li A.J. Clinical analysis of application of antibiotic bone cement spacer combined with membrane induction technology in treatment of osteomyelitis after femoral intramedullary nail operation – A case series. J Pak Med Assoc. 2020;70(2):360-362. doi: 10.5455/JPMA.9552.

[12] Solanki T., Maurya M.K., Singh P.K. Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones. Cureus. 2023;15(8):e43421. doi: 10.7759/cureus.43421.

[13] Garabano G., Pereira S., Alamino L.P., Munera M.A., Ernst G., Bidolegui F. et al. Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails. Injury. 2023;54(Suppl 6):110650. doi: 10.1016/j.injury.2023.02.033.

[14] Romanò C.L., Bozhkova S.A., Artyukh V., Romanò D., Tsuchiya H., Drago L. Local Antibacterial Implant Protection in Orthopedics and Trauma: What’s New? Traumatology and Orthopedics of Russia. 2019;25(4):64-74. doi: 10.21823/2311-2905-2019-25-4-64-74.

[15] Jia C., Wang X., Yu S., Wu H., Shen J., Huang Q. et al. An antibiotic cement-coated locking plate as a temporary fixation for treatment of infected bone defects: a new method of stabilization. J Orthop Surg Res. 2020;15(1):44. doi: 10.1186/s13018-020-1574-2.

[16] Qiu X.S., Cheng B., Chen Y.X., Qi X.Y., Sha W.P., Chen G.Z. Coating the plate with antibiotic cement to treat early infection after fracture fixation with retention of the implants: a technical note. BMC Musculoskelet Disord. 2018;19(1):360. doi: 10.1186/s12891-018-2285-2.

[17] Wang X., Wang S., Xu J., Sun D., Shen J., Xie Z. Antibiotic cement plate composite structure internal fixation after debridement of bone infection. Sci Rep. 2021;11(1):16921. doi: 10.1038/s41598-021-96522-1.

[18] Bidolegui F., Codesido M., Pereira S., Abraham A., Pires R.E., Giordano V. Antibiotic cement-coated plate is a viable and efficient technique for the definitive management of metaphyseal septic nonunions of the femur and tibia. Rev Col Bras Cir. 2023;49:e20223060. doi: 10.1590/0100-6991e-20223060-en.

[19] Keller D.M., Pizzo R.A., Patel J.N., Viola A., Yoon R.S., Liporace F.A. Use of antibiotic-cement coated locking plates in the setting of periprosthetic infection and infected nonunion. Injury. 2022;53(7):2567-2572. doi: 10.1016/j.injury.2022.03.040.

[20] Metsemakers W.J., Morgenstern M., McNally M.A., Moriarty T.F., McFadyen I., Scarborough M. et al. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018;49(3):505-510. doi: 10.1016/j.injury.2017.08.040.

[21] Afanasyev A.V., Bozhkova S.A., Artyukh V.A. Predictors for Recurrence of Chronic Osteomyelitis Following Long Bones Cavity Defect Replacement with Synthetic Materials. Traumatology and Orthopedics of Russia. 2024;30(4):14-24. (In Russian). doi: 10.17816/2311-2905-17591.

[22] Azi M.L., Teixeira A.A.A., Cotias R.B., Joeris A., Kfuri M. Induced-Membrane Technique in the Management of Posttraumatic Bone Defects. JBJS Essent Surg Tech. 2019;9(2):e22. doi: 10.2106/JBJS.ST.18.00099.

[23] Kadhim M., Holmes L. Jr., Gesheff M.G., Conway J.D. Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis. J Orthop Trauma. 2017;31(2):111-119. doi: 10.1097/BOT.0000000000000700.

[24] Rupp M., Kern S., Walter N., Anastasopoulou L., Schnettler R., Heiss C. et al. Surgical treatment outcome after serial debridement of infected nonunion – A retrospective cohort study. Eur J Orthop Surg Traumatol. 2022;32(1):183-189. doi: 10.1007/s00590-021-02930-4.

[25] Schmidt A.H., Swiontkowski M.F. Pathophysiology of infections after internal fixation of fractures. J Am Acad Orthop Surg. 2000;8(5):285-291. doi: 10.5435/00124635-200009000-00002.

[26] Berkes M., Obremskey W.T., Scannell B., Ellington J.K., Hymes R.A., Bosse M. et al. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92(4):823-828. doi: 10.2106/JBJS.I.00470.

[27] Zhu Y., Jiang P., He Z., Qian H. Non-contact locking plate: A useful alternative to external fixation in second-stage treatment of post-traumatic tibial osteomyelitis. Exp Ther Med. 2024;27(5):230. doi: 10.3892/etm.2024.12518.

[28] Savchuk O.P., Tapalski D.V., Zinovkin D.A., Nikolaev V.I., Yarmolenko M.A., Rogachev A.A. Perifocal Soft Tissue Reactions in Response to Contaminated Implants With a Composite Antibacterial Coating: Experimental Study. Traumatology and Orthopedics of Russia. 2023;29(1): 36-45. doi: 10.17816/2311-2905-2000.

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