Permanent antibiotic impregnated intramedullary nail in diabetic limb salvage: a case report and literature review

Abstract

Managing complications after attempted hind foot and ankle arthrodesis with intramedullary nail fixation is a challenge. This situation becomes more problematic in the patient with diabetes mellitus and multiple comorbidities. Infection and subsequent osteomyelitis can be a devastating, limb threatening complication associated with these procedures. The surgeon must manage both the infectious process and the skeletal instability concurrently. This article provides a literature review and detailed management strategies for a modified technique of employing antibiotic impregnated polymethylmethacrylate-coated intramedullary nailing.

Keywords: Charcot neuroarthropathy; amputation; diabetic limb salvage; diabetic neuropathy; infection; intramedullary nail.

Fig. 1

Pre-operative radiographic views (A, B) showing an infected collapsed ankle and hind foot after a previous failed surgical attempt of tibiotalocalcaneal arthrodesis with an intramedullary (IM) nail. Intra-operative views showing the use of a large sagittal saw to create imperfections within the IM nail that allows increased adherence of the cement (C) and rolling of the antibiotic impregnated cement by hand onto the IM nail (D). The cement that covers the holes for the interlocking screws when placing the permanent antibiotic impregnated IM nail is removed (E). Insertion of the antibiotic coated IM nail using the insertion jig is showing in figure (F). Note that coating the IM nail with antibiotic cement precludes the use of the IM guide wire for a cannulated IM nail insertion (G). Final post-operative radiographic views (H, I) at one year follow-up. Note the density surrounding the IM nail within the tibial canal consistent with antibiotic cement.