Tag Archive for: nailing.

Role of Antibiotic Cement-coated Nailing in Infected Nonunion of Tibia

Vol 4 | Issue 1 | May – Aug 2018 | page: 18-21 | Clevio Desouza,Vinod Nair, Amit Chaudhary, Harshal Hurkat, Shiju George.

Author: Clevio Desouza [1],Vinod Nair [1], Amit Chaudhary [1], Harshal Hurkat [1], Shiju George [1].

[1] Department of Orthopaedics, Dr D.Y.Patil Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Clevio Desouza,
Department of Orthopaedics, Dr D.Y.Patil Hospital, Pune, Maharashtra, India.
E-mail: ceviod@gmail.com


Introduction: The infection of long bones along with its nonunion is a chronic and debilitating disorder. It becomes difficult to deal with the situation in which the implant which is used for internal fixation itself becomes a potential media for infection because of the formation of biofilms and adhesions. Traditionally, this situation is managed by a two-stage procedure for controlling the infection first and then treating the nonunion. This study has been undertaken to explore antibiotic cement-coated nailing as a single stage treatment modality for achieving stability and treating of the infection at the same time.
Materials and Methods: 20 patients (above 18years of age) with nonunion of tibia associated with infection with bone gap <2 cm were managed using antibiotic cement-coated Kuntscher nail. Antibiotics used were a combination of vancomycin and teicoplanin.
Results: Infection was controlled in 95% of the patients. Bony union was achieved in 12 of 20 (60%) patients with antibiotic cement nailing as the only procedure with average time of union of 32 weeks. Bone grafting or exchange nailing type additional procedures were required in the remaining eight patients, and this was done in six patients, with union of the fracture. Two patients refused to undergo further procedures. The various complications encountered during this study were difficult nail removal in three cases, broken nail in two cases, and bent nail in 1 case. Recurrence of infection was observed in two patients. The average period of follow-up was 12 months.
Conclusion: Antibiotic cement impregnated nailing is a simple, economical, and effective single-stage procedure for the management of infected nonunion of the tibia. It has many advantages over external fixators, as it eliminates the complications and has good patient compliance. The method utilizes existing easily available instrumentation and is technically demanding and therefore can be performed at any hospital.
Keywords: Nonunion, infected, antibiotic, cement, nailing.


1. Toh CL, Jupiter JB. The infected nonunion of the tibia. ClinOrthopRelat Res 1995;315:176-191.
2. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am AcadOrthopSurg 2005;13(6):417-427.
3. Stoodley P, Ehrlich GD, Sedghizadeh PP, Stoodley LH, Baratz ME, Altman DT, et al. Orthopaedic biofilm infections. CurrOrthopPract2011;22(6):558-563.
4. Nelson CL. The current status of material used for depot delivery of drugs. ClinOrthopRelat Res 2004;427:72-78.
5. Cierny G, Mader J. The surgical treatment of adult osteomyelitis. In: CMC Evarts, editor. Surgery of the Musculoskeletal System. New York, USA: Churchill Livingstone; 1983. p. 4814-4834.
6. Court-Brown CM. Fractures of the tibia and fibula. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. p. 2080-2146.
7. Beals RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in adults. ClinOrthopRelat Res 2005;433:212-217.
8. Ueng SW, Chuang DC, Cheng SL, Shih CH. Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer. J Trauma 1996;40(3):345-350.
9. Chen CE, Ko JY, Wang JW, Wang CJ. Infection after intramedullary nailing of the femur. J Trauma 2003;55(2):338-344.
10. Wu CC, Shih CH. Distal tibial nonunion treated by intramedullary reaming with external immobilization. J Orthop Trauma 1996;10(1):45-49.
11. Paley D, Herzenberg JE. Intramedullary infections treated with antibiotic cement rods: Preliminary results in nine cases. J Orthop Trauma 2002;16(10):723-729.
12. 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(10):945-951.
13. Madanagopal SG, Seligson D, Roberts CS. The antibiotic cement nail for infection after tibial nailing. Orthopedics 2004;27(7):709-712.
14. Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma 2007;21(4):258-268.
15. Sancineto CF, Barla JD. Treatment of long bone osteomyelitis with a mechanically stable intramedullar antibiotic dispenser: Nineteen consecutive cases with a minimum of 12 months follow-up. J Trauma 2008;65(6):1416-1420.
16. Nelson CL, Hickmon SG, Harrison BH. Elution characteristics of gentamicin-PMMA beads after implantation in humans. Orthopedics 1994;17(5):415-416.
17. Nizegorodcew T, Palmieri G, Marzetti E. Antibiotic-coated nails in orthopedic and trauma surgery: State of the art. Int J ImmunopatholPharmacol 2011;24 1 Suppl 2:125-128.
18. Riel RU, Gladden PB. A simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail. Am J Orthop (Belle Mead NJ) 2010;39(1):18-21.
19. Dhanasekhar R, Jacob P, Francis J. Antibiotic cement impregnated nailing in the management of infected nonunion of femur and tibia. Kerala J Orthop2013;26(2):93-97.
20. Kim JW, Cuellar DO, Hao J, Seligson D, Mauffrey C. Custom-made antibiotic cement nails: A comparative study of different fabrication techniques. Injury 2014;45(8):1179-1184.
21. Akinyoola AL, Adegbehingbe OO, Aboderin AO. Therapeutic decision in chronic osteomyelitis: Sinus track culture versus intraoperative bone culture. Arch Orthop Trauma Surg 2009;129(4):449-453.
22. Beals RK, Bryant RE. The treatment of chronic open osteomyelitis of the tibia in adults. ClinOrthopRelat Res 2005;433:212-217.
23. Henry SL, Ostermann PA, Seligson D. The prophylactic use of antibiotic impregnated beads in open fractures. J Trauma 1990;30(10):1231-1238.
24. Chen CE, Ko JY, Wang JW, Wang CJ. Infection after intramedullary nailing of the femur. J Trauma 2003;55(2):338-344.
25. Tunney MM, Ramage G, Patrick S, Nixon JR, Murphy PG, Gorman SP. Antimicrobial susceptibility of bacteria isolated from orthopedic implants following revision hip surgery. Antimicrob Agents Chemother 1998;42(11):3002-3005.
26. Chang Y, Chen WC, Hsieh PH, Chen DW, Lee MS, Shih HN, et al.In vitro activities of daptomycin-vancomycin-and teicoplanin-loaded polymethylmethacrylate against methicillin-susceptible, methicillin-resistant, and vancomycin-intermediate strains of Staphylococcus aureus. Antimicrob Agents Chemother 2011;55(12):5480-5484.
27. Öztemür Z, Sümer Z, Tunç T, Pazarcé Ö, Bulut O. The effect of low dose teicoplanin-loaded acrylic bone cement on biocompatibility of bone cement. ActaMicrobiolImmunol Hung 2013;60(2):117-125.
28. Green SA. Complications of external skeletal fixation. ClinOrthopRelat Res 1983;180:109-116.
29. Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. ClinOrthopRelat Res 1990;250:81-104.
30. 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(4):396-402.
31. Pradhan C, Patil A, Puram C, Attarde D, Sancheti P, Shyam A. Can antibiotic impregnated cement nail achieve both infection control and bony union in infected diaphyseal femoral non-unions? Injury. 2017 Aug;48 Suppl 2:S66-S71
32. Selhi HS, Mahindra P, Yamin M, Jain D, De Long WG Jr, Singh J. Outcome in patients with an infected nonunion of the long bones treated with a reinforced antibiotic bone cement rod. J Orthop Trauma 2012;26(3):184-188.
33. Kendall RW, Duncan CP, Smith JA, Ngui-Yen JH. Persistence of bacteria on antibiotic loaded acrylic depots. A reason for caution. ClinOrthopRelat Res 1996;329:273-280.

How to Cite this article:  Desouza C, Nair V, Chaudhary A, Hurkat H, George S. Role of Antibiotic Cement-coated Nailing in InfectedNonunion of Tibia. Trauma International May-Aug 2018;4(1):18-21.


(Abstract Text HTML)   (Download PDF)