Hip Pelvis.  2018 Mar;30(1):45-52. 10.5371/hp.2018.30.1.45.

Treatment of Proximal Femur Osteomyelitis Occurred after Proximal Femoral Nail Antirotation Fixation, with Antibiotic Cement-coated Tibia Intramedullary Nail: A Case Report

• Noh JH
• Koh SJ
• Lee KH

• KMID: 2408185
• DOI: http://doi.org/10.5371/hp.2018.30.1.45

Abstract

Antibiotic cement-coated intramedullary nails maintain a locally high antibiotic concentration while contributing to bone stability. We present a case of femoral subtrochanteric fracture in a patient with an infected nonunion who was successfully treated for an infection and nonunion using an antibiotic cement-coated tibial intramedullary nail. A 79-year-old woman with a right femoral subtrochanteric fracture underwent internal fixation using proximal femoral nail antirotation (PFNA). She developed osteomyelitis with nonunion at the surgical site 10 months postoperatively. We decided to insert an antibiotic cement-coated tibial intramedullary nail. After coating the nail with bone cement mixed with antibiotics, bone fixation was achieved by inserting the nail at the site of the PFNA. The patient's symptoms improved, symptoms from the infection disappeared, and bone union was confirmed. Osteomyelitis occurred because of postoperative infection following a proximal femoral fracture. Antibiotic cement-coated tibial intramedullary nails are an effective option to treat patients with osteomyelitis of the femur and achieve bone union where nonunion persists with shallow a intramedullary femoral canal.

Keyword

Osteomyelitis; Intramedullary fracture fixation; Surgical wound infection

MeSH Terms

Aged
Anti-Bacterial Agents
Female
Femoral Fractures
Femur*
Fracture Fixation, Intramedullary
Humans
Osteomyelitis*
Surgical Wound Infection
Tibia*
Anti-Bacterial Agents

Figure

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  Fig. 1 A 79-year-old with hypertension and osteoporosis presented to the emergency department with right hip pain after slipping. Radiography showed a right atypical femoral subtrochanteric fracture.

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  Fig. 2 Internal fixation was performed using proximal femoral nail antirotation (PFNA) with autologous iliac crest bone graft, simultaneously, because of a high rate of atypical subtrochanteric fracture nonunion.

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  Fig. 3 Ultrasonography revealed an abscess on the right hip.

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  Fig. 4 The 3-phase bone scan showed no definite osteomyelitis.

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  Fig. 5 At two months after discharge, a 3-phase bone scan confirmed chronic osteomyelitis at the surgical site, possibly extending to the intramedullary canal.

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  Fig. 6 The X-ray showed some callus formation at the fracture site, but still a nonunion could be observed.

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  Fig. 7 (A) The smallest tibial intramedullary nail. (B) After antibiotic impregnated cement coating.

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  Fig. 8 The nail was inserted in femur after coating the nail with bone cement (CMW bone cement, Depuy, 3 g, 2 ea) mixed with antibiotics (Vancomycin, 1 g, 2 vials). Additional cement beads (×2) were inserted.

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  Fig. 9 Bone union was achieved 4 months postoperatively.

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  Fig. 10 The patient was seen at her 4-year follow-up, the X-ray shows well maintained without osteomyelitis.

Reference

1. 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. PMID: 16224114.

2. 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.

3. Beals RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in adults. Clin Orthop Relat Res. 2005; (433):212–217. PMID: 15805960.

4. 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. PMID: 17414554.

5. Bharti A, Saroj UK, Kumar V, Kumar S, Omar BJ. A simple method for fashioning an antibiotic impregnated cemented rod for intramedullary placement in infected non-union of long bones. J Clin Orthop Trauma. 2016; 7(Suppl 2):171–176. PMID: 28053381.

6. Struijs PA, Poolman RW, Bhandari M. Infected nonunion of the long bones. J Orthop Trauma. 2007; 21:507–511. PMID: 17762489.

7. Riel RU, Gladden PB. A simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail. Am J Orthop (Belle Mead NJ). 2010; 39:18–21. PMID: 20305835.

8. Roche O, Zabée L, Sirveaux F, Villanueva E, Molé D. Treatment of septic nonunion of long bones: preliminary results of a two-stage procedure. J Bone Joint Surg Br Proc. 2005; 87-B:111–112.

9. Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004; 364:369–379. PMID: 15276398.

10. Neut D, van de Belt H, van Horn JR, van der Mei HC, Busscher HJ. The effect of mixing on gentamicin release from polymethylmethacrylate bone cements. Acta Orthop Scand. 2003; 74:670–676. PMID: 14763697.