Treatment of Periprosthetic Joint Infection and Fracture-Related Infection With a Temporary Arthrodesis Made by PMMA-Coated Intramedullary Nails - Evaluation of Technique and Quality of Life in Implant-Free Interval

Abstract

Background: Antimicrobial coating of intramedullary nails with polymethyl methacrylate (PMMA) bone cement promises infection control and stabilization for subsequent bone healing. However, when removing the implant, bone cement can debond and remain in the medullary cavity of the long bones, representing a nidus for reinfection. This work presents a technique comprising reinforcement of PMMA-coated intramedullary nails with cerclage wire to prevent such problems in patients treated for fracture-related infection (FRI) or knee periprosthetic joint infection (PJI) with a static spacer as temporary arthrodesis allowing weight-bearing in the implant-free interval. Outcomes of this surgical treatment were evaluated in terms of (i) associated complications and (ii) patient-reported quality of life.

Methods: In this retrospective case series, 20 patients with PJI (n = 14, 70%) and FRI (n = 6, 30%) treated with PMMA-coated intramedullary nails reinforced with cerclage wire between January 2021 and July 2021 were included. Quality of life during the implant-free interval was evaluated with the EQ-5D, SF-36, and an ICD-10 based psychological symptom rating and compared with previously analyzed cohorts of successfully treated PJI and FRI patients in whom eradication of infection and stable bone consolidation was achieved.

Results: Complications during the implant-free interval comprised a broken nail in one case (5.0%) and a reinfection in one case (5.0%). Coating-specific side effects and cement debonding during removal did not occur. The mean physical health component score of SF-36 was 26.1 ± 7.6, and the mean mental health component score reached a value of 47.1 ± 18.6. The mean EQ-5D index value was 0.36 ± 0.32 and the mean EQ-5D visual analogue scale rating was 47.4 ± 19.4. The scores were significantly lower than those in the successfully treated FRI cohort but not in the PJI cohort. The mean ICD-10-based symptom rating scores revealed psychological symptom burden on the depression scale and enhanced levels of anxiety in comparison with healed FRI and PJI patients.

Conclusion: Reinforcement of PMMA bone cement-coated implants seems to be a reasonable treatment option to create a temporary arthrodesis, preventing detachment of the bone cement when the implant was removed.Level of Evidence: IV.

Keywords: coated implants; fracture-related infection; periprosthetic joint infection; polymethyl methacrylate (PMMA); psychological outcomes; quality of life; temporary arthrodesis.

Figure 1

Polymethyl methacrylate (PMMA)-coated intramedullary nails. (A, B) 2-Humerus nails (Stryker, Duisburg, Germany) are wrapped with a 1.25- mm steel cerclage wire for reinforcement. (C, D) PMMA cement (Copal^®, Heraeus Medical GmbH, Wehrheim, Germany) is applied to the nails. The hardening cement is then evenly rolled out on the instrument table. (E, F) The diameter is checked with the sliding gauge according to the reamed medullary canal diameter. (G) Reinforced PMMA-coated nails are inserted into the corresponding intramedullary canal and fixed “press fit” into the bone.

Figure 2

Pre-operative x-rays of (A) an infected rotating hinge prosthesis and (B) an infected bicondylar surface replacement prosthesis are shown in the left panel. Post-operative images after explantation, debridement, and temporary arthrodesis are shown in the right panel.

Figure 3

Subdimension scores for patient-related quality of life assessed with SF-36. The results of the study cohort are shown in dark gray. For a comparison, the values of the successfully treated periprosthetic joint infection (PJI) and fracture-related infection (FRI) population are illustrated in gray and light gray, respectively. * illustrates statistical significance on a p < 0.05 level determined by an independent t-test.

Figure 4

(A) Mean EQ-5D index value on a scale 0–1 and (B) mean EQ-5D VAS (visual analogue scale) rating on a scale 0–100. For a comparison, the values of the successfully treated PJI and FRI population are illustrated in gray and light gray, respectively. * illustrates statistical significance on a p < 0.05 level determined by an independent t-test.

Figure 5

Percentage of patients showing limitations in the mobility, self-care, usual activity, pain/discomfort, and anxiety/depression of the EQ-5D subdimensions. The share of mild limitations is shown in gray, the share of severe limitations is in dark gray, and the share of no limitations is in light gray.

Figure 6

Mean values of the ISR (ICD-10-based symptom rating) total scores and depression, anxiety, obsession/compulsion, somatization, and eating disorder of the subdimensions. The values of the study cohort are shown in dark gray. For a comparison, the values of the successfully treated PJI population are illustrated in gray, and the values of the successfully treated FRI population are in light gray. * illustrates statistical significance on a p < 0.05 level determined by an independent t-test.