Antibiotic cement impregnated nailing in the management of infected Non Union of Femur and Tibia: A Prospective study

INTRODUCTION: Nonunion in the presence of infection presents with the dual problems of controlling infection and providing stability. Various factors contribute to infected nonunions, including open fractures, infection after internal fixation, chronic osteomyelitis with pathological fractures, and surgical debridement of infected bone. Traditionally, the treatment strategy consists of surgical debridement with local and systemic antibiotic delivery and then a second procedure for stability, generally either internal or external fixation. Special reconstructive procedures and soft tissue procedures might also be necessary. Local antibiotic therapy is a useful technique that results in high local concentrations of antibiotics with minimal systemic levels and without systemic side effects. This method in the form of antibioticimpregnated kuntscher nails is used in the treatment of osteomyelitis and in open fractures controls infection. With the goal of avoiding more than one procedure in these patients, we present our single-procedure technique of treatment with an Kuntscher nail coated with antibiotic-impregnated bone cement, which combines local antibiotic delivery with good alignment and intramedullary fixation. Infected nonunion has been defined as a state of failure of union for 6-8 months with persistent infection at the fracture site. The incidence seems to be increasing especially in view of increasing high velocity trauma, which is more frequently treated with internal fixation. AIM: 1. To discuss the biological advantage of antibiotic cement impregnated nailing in the management of infected nonunion of femur and tibia. 2. To evaluate the clinical outcome of infected nonunion of femur and tibia managed by antibiotic cement impregnated kuntscher nail. MATERIALS AND METHODS: This is a prospective study conducted in Kilpauk Medical College Hospital between July 2008 to November 2009 in 25 cases of infected nonunions, chronic osteomyelitis (with bone defects after debridement), implant failure with nonunion and infection following plating as well as nailing. One female and twenty four male patients (age range, 21-65 years) were included in the study. Twelve of the patients were Grade IIIB compound, two were Grade II Compound, two were Gr I compound and nine were closed fractures initially. All twenty five patients had infected nonunion at presentation, and fourteen patients had bone defect ranging from 1 to 2.5cms after initial debridement. Average follow-up was 8 months (range, 4-18 months). At the latest follow-up, except for one patient all others had no clinical signs of infection. RESULTS: The clinical assessment of the union was mainly based on complete absence of pain and tenderness at the fracture site. Radiological criteria for union is evidence of bridging periosteal and endosteal callus formation as three cortical contact. Bony union recorded in twenty three cases. Two patient with nonunion did not want to undergo additional procedures to achieve bony union. Three patients required exchange nailing, seven patients needed soft tissue procedures to achieve the goals of control of infection and bony union. One case of nail bending in tibia was noted which was addressed earlier by patellar tendon bearing cast until union. Nail-cement debonding was observed in two cases of exchange nailing, and the free proximal cement mantle was removed. CONCLUSION: Antibiotic cement impregnated nailing provides effective infection control and good stability to promote union, traditionally provided by two separate procedures. • It is advantageous over external fixators, as it eliminates the complications of external fixators and has good patient compliance. • Safe, patient friendly, versatile procedure that could be adapted in hospitals easily. • The method utilises existing easily available instrumentation and materials to manage a complex problem in a highly cost effective way. “Antibiotic cement impregnated nailing is a simple, economical and very effective procedure than the traditional methods in management of infected nonunion of femur and tibia”