MR-compatible antibiotic interlocked nail fabrication for the management of long bone infections: first case report of a new technique
© Mauffrey et al.; licensee BioMed Central Ltd. 2014
Received: 3 February 2014
Accepted: 5 March 2014
Published: 17 March 2014
Successful management of intramedullary long bone osteomyelitis remains a challenge for both surgeons and patients. Patients are often immune-compromised and have endured multiple surgeries. Treatment principles include antibiotic administration (systemically +/- locally), surgical debridement of the infection site and stabilization. Since their description in 2002, antibiotic coated nails have become part of the armamentarium for the treatment of osteomyelitis allowing both local elution of antibiotics and stabilization of a debrided long bone. Limitations to their utilization have remained, in part from the technical difficulty of fabrication and MRI artifacts. We describe a new surgical technique of fabrication that has the advantages of being simple, reproducible, with an end product free of MRI artifacts.
Successful management of intramedullary long bone osteomyelitis remains a challenge for surgeon and patient alike. Patients are often immune-compromised and may have endured multiple surgeries. Treatment principles initially described by Cierny in 1983 include antibiotic administration (systemically +/- locally), surgical debridement of the infection site and stabilization. The Cierny classification includes an anatomic description of the infection and a description of the host’s resistance to infection. The anatomic description is divided into four types (I-medullary, II-superficial, III-localized full-thickness, IV-diffuse). The description of host’s resistance is divided into three classes (A-healthy, B-locally or systemically impaired, C-major systemic disorder). Since their description in 2002, antibiotic coated nails have become part of the armamentarium for the treatment of osteomyelitis allowing both local elution of antibiotics and stabilization of a debrided long bone[3–14]. Limitations to their utilization have remained due to the technical difficulty of their fabrication and presence of MRI artifacts. There is great variation in the techniques utilized to fabricate antibiotic nails. A guide wire, Enders rod or more recently an interlocked nail, provide stability to the construct. Utilization of interlocked nail has shown satisfactory results while allowing for rotational stability[12, 14]. A chest tube is often the best mold available to fabricate the cement nail. Cement nail extraction from the tubing system remains a frustrating exercise, complicated by the melting of plastic and subsequent adhesion to the cement. The technique that we describe is a rapid and reproducible exercise. In addition the utilization of a radiolucent carbon fiber interlocked nail (Carbo-Fix, Champlain, IL, U.S.A) allows for a solid, rotationally stable, MRI compatible fixation. Where inflammatory markers are not always reliable, this latter characteristic enables MRI monitoring of infection with an intramedullary implant in place.
The indication for antibiotic nailing of infected long bones should be made on a case-by-case basis. Advantages of this treatment method include early weight bearing, local antibiotic elution and stability. In addition, patients who refuse or are not candidate for long-term external fixation may benefit from antibiotic nailing. Caution is required for well-localized active infection as the reaming process may spread the infected tissues proximal and/or distal into the medullary cavity or neighboring joints.
Given the extent of the infection, the involvement of the tibia, prior diagnosis of knee joint septic arthritis and a significant risk of pathologic fracture, we elected to treat the patient with closed surgical debridement and stabilization. The risk of pathologic fracture can be estimated based on the scoring system published by Mirel. In this scoring system, points from 1 to 3 are assigned for four categories (location, size of the lesion, pain, and appearance of the lesion). In our case, a score of 9 was assigned (lower extremity 2 points, moderate pain 2 points, lytic lesion 3 points, and size 2 points). Scores >8 points are recommended for prophylactic fixation. An antibiotic intramedullary interlocked carbon fiber nail was selected to provide stability, allow elution of antibiotics and monitoring of treatment response via MRI with limited artifact. A Reamer Irrigator Aspirator (RIA) (Depuy Synthes, Paoli, PA, U.S.A) was utilized to debride the intra-osseous lesion and prevent proximal extension of the infected tissue.
Surgical technique and fabrication
The patient is placed supine on a radiolucent table with a radiolucent bump placed under the operative extremity. The approach and technique for retrograde femoral nailing is well described in the literature. We use the RIA to ream and debride the intramedullary canal preventing propagation of the infected tissue proximally in the femoral shaft. Reamings should be sent to pathology and microbiology for confirmatory diagnosis. A carbon fiber intramedullary nail (Carbo-Fix, Champlain, IL, U.S.A) with a 8.5 mm diameter is selected. Carbon fiber characteristics include MRI compatibility for monitoring of the infection. The choice of a humeral nail instead of a femoral nail allows for a thinner diameter and therefore a thicker mantle of antibiotic loaded cement.
In this manuscript, we present a novel surgical technique for the fabrication of antibiotic nails using a radiolucent antibiotic carbon fiber interlocked devise. The authors are unaware of any previous publication of this technique. In our opinion, the addition of mineral oil and dipping of the antibiotic nail in a cold saline bath ensure a rapid, easy and reproducible method of fabrication. Interlocking the nail provides excellent rotational stability. The carbon fiber nail allows a follow up of the treatment response with limited metal artifact on MRI scan and visualization of the lesion on X-ray. This is especially valuable in immune-compromised patients where inflammatory markers are rarely reliable to monitor treatment response.
The use of interlocked intramedullary nails for intramedullary infections is not a novel concept and has previously been published for infected nonunion and delayed union of the tibia. Carbon fiber nail for this indication is novel. We were unable to find any literature regarding carbon fiber nail use in long bone osteomyelitis despite the fact that carbon fiber technology use has been increasing over the last few years in Orthopaedics. Literature on carbon fiber implants in spine fusion confirms less artifact and improved evaluation of fusion compared with traditional implants[19–22]. It would logically follow that visualization would be improved in cases of bone infection.
Alternative implant options for treatment could have been a large wire coated in antibiotic cement. This method would certainly have decreased implant cost (the cost of the carbon fiber nail was $2,600) and perhaps limited the amount of exposed metallic surface for bacterial contamination. However, with our method of treatment, the patient is full weight bearing as opposed to partial weight bearing with a simple large pin and cement. In addition, the interlocking fixation minimizes the risk of migration of the construct proximally into the medullary canal and/or distally into the knee joint. Finally, although minimal, there would remain some MRI artifact created by the stainless steel pin. Given these disadvantages, this remains our preferred implant choice for this case scenario.
Our paper is by no means intended to recommend this methodology of treatment for all cases of long bone osteomyelitis or infected non-unions. The treatment of osteomyelitis is complex and needs to be individualized to each patient and problem. We believe that this novel technique adds to the armamentarium to treat these difficult cases. Weakness of our manuscript includes the lack of long-term follow up. Our current research focus is to retrospectively evaluate a series of patients with long bone infection or infected non-unions treated using this technique. The use of mineral oil to coat the inner layer of the plastic tube may alter the elution properties of antibiotics loaded in the cement. In addition, mineral oil on the surface of the nail may create a localized inflammatory response (although the cured nail is copiously irrigated prior to its insertion). We could find no reports of this occurrence in the literature.
The presented use of antibiotic nail in general is ‘off- label’ according to current FDA indications. Our patients are informed during the shared decision making process. For research purposes our research division has contacted the FDA for suggestions on how to proceed with the prospective study of such implants.
Effects of mineral oil on antibiotics elution properties of the antibiotic nail
Does the mineral oil cause a local inflammatory response?
Is the interface between cement and carbon fiber adequate
What are the elution properties of this construct and are the antibiotic eluted several weeks or months following nail insertion still active against causative organisms?
Is MRI scanning a good tool to monitor response to treatment?
Antibiotic coated intramedullary nails provide an excellent treatment modality in the treatment of certain cases of intramedullary long bone osteomyelitis. We describe a novel surgical technique using a carbon fiber interlocked antibiotic coated intramedullary nail.
The addition of mineral oil in the chest tube and dipping of the construct in cold sterile saline facilitates the fabrication of the nail
Utilization of a radiolucent interlocked implant improves MRI follow up of the infection site and X-ray visualization of the infected focus.
This surgical technique solves many of the common issues with standard antibiotic nails and, unlike treatments using non-structural components to deliver the antibiotic, will provide support to the compromised bone. Clinical trials are needed to show the results of treatment with this novel technique.
We would like to thank Ashley Schneider for all her help and support in facilitating the room set up and instruments needed for preparation of our antibiotic nails as well as her continuous help in making our job a pleasure!
- Cierny G, Mader JT: The surgical treatment of adult osteomyelitis. Surgery of the Musculoskeletal System. Edited by: C E, MD M. 1983, New York, NY: Churchill Livingstone, 4814-4834. 1Google Scholar
- Cierny G, Mader JT, Penninck J: A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003, 7-24. 414Google Scholar
- Paley D, Herzenberg JE: Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases. J Orthop Trauma. 2002, 16: 723-729. 10.1097/00005131-200211000-00007.View ArticlePubMedGoogle Scholar
- Cierny G, Mader JT: Approach to adult osteomyelitis. Orthopaedic review. 1987, 16: 259-270.PubMedGoogle Scholar
- Patzakis MJ, Wilkins J, Wiss DA: Infection following intramedullary nailing of long bones. Diagnosis and management. Clin Orthop Relat Res. 1986, 212: 182-191.PubMedGoogle Scholar
- Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg. 2005, 13: 417-427.PubMedGoogle Scholar
- Wasko MK, Borens O: Antibiotic cement nail for the treatment of posttraumatic intramedullary infections of the tibia: midterm results in 10 cases. Injury. 2013, 44: 1057-1060. 10.1016/j.injury.2013.05.001.View ArticlePubMedGoogle Scholar
- Bhadra AK, Roberts CS: Indications for antibiotic cement nails. J Orthop Trauma. 2009, 23: S26-S30.View ArticlePubMedGoogle Scholar
- Madanagopal SG, Seligson D, Roberts CS: The antibiotic cement nail for infection after tibial nailing. Orthopedics. 2004, 27: 709-712.PubMedGoogle Scholar
- 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: 945-951. 10.1007/s00402-007-0315-x.View ArticlePubMedGoogle Scholar
- 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 bones. Indian J Orthop. 2009, 43: 396-402. 10.4103/0019-5413.55468.PubMed CentralView ArticlePubMedGoogle Scholar
- Thonse R, Conway J: Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma. 2007, 21: 258-268. 10.1097/BOT.0b013e31803ea9e6.View ArticlePubMedGoogle Scholar
- Thonse R, Conway JD: Antibiotic cement-coated nails for the treatment of infected nonunions and segmental bone defects. J Bone Joint Surg Am. 2008, 90 (Suppl 4): 163-174.View ArticlePubMedGoogle Scholar
- Riel RU, Gladden PB: A simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail. Am J Orthop. 2010, 39: 18-21.PubMedGoogle Scholar
- Mirels H: Metastatic disease in long bones: a proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989, 249: 256-264.PubMedGoogle Scholar
- Ricci WM, Gallagher B, Haidukewych GJ: Intramedulary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009, 17: 296-305.PubMedGoogle Scholar
- May 2007 AAOS now.http://www.aaos.org/news/bulletin/may07/clinical7.asp,
- Miller ME, Ada JR, Webb LX: Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails. Clin Orthop Relat Res. 1989, 233-238. 245Google Scholar
- Ernstberger T, Buchhorn G, Heidrich G: Magnetic resonance imaging evaluation of intervertebral test spacers: an experimental comparison of magnesium versus titanium and carbon fiber reinforced polymers as biomaterials. Ir J Med Sci. 2010, 179 (1): 107-111. 10.1007/s11845-009-0394-5.PubMed CentralView ArticlePubMedGoogle Scholar
- Ernstberger T, Buchhorn G, Heidrich G: Artifacts in spine magnetic resonance imaging due to different intervertebral test spacers: an in vitro evaluation of magnesium versus titanium and carbon-fiber-reinforced polymers as biomaterials. Neuroradiology. 2009, 51 (8): 525-529. 10.1007/s00234-009-0537-4.PubMed CentralView ArticlePubMedGoogle Scholar
- Ernstberger T, Buchhorn G, Baums MH, Heidrich G: In-vitro MRI detectability of interbody test spacers made of carbon fibre-reinforced polymers, titanium and titanium-coated carbon fibre-reinforced polymers. Acta Orthop Belg. 2007, 73 (2): 244-249.PubMedGoogle Scholar
- Ernstberger T, Heidrich G: Postfusion magnetic resonance imaging artifacts caused by a titanium, cobalt-chromium-molybdenum, and carbon intervertebral disc spacer. J Spinal Disord Tech. 2007, 20 (2): 154-159. 10.1097/01.bsd.0000211244.52329.21.View ArticlePubMedGoogle Scholar
- Sanders J, Mauffrey C: Long bone osteomyelitis in adults: fundamental concepts and current techniques. Orthopedics. 2013, 36 (5): 368-375. 10.3928/01477447-20130426-07.View ArticlePubMedGoogle Scholar
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