Evidence for Local Antibiotics in the Prevention of Infection in Orthopaedic Trauma

Abstract

Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.

Keywords: antibiotics; bone infection; bony callus; fracture-related infection (FRI); orthopaedic trauma; orthopedics fracture healing.

Figure 1

PMMA beads can be created by a hand over suture or wire, with or without the use of prefabricated templates. Beads provide no structural integrity but effectively occupy dead space and provide a higher level of antibiotic elution due to greater surface area than mono-block creations.

Figure 2

A PMMA-coated intramedullary nail can be fabricated using a chest tube or a threaded rod or guidewire. After mixing, the cement is injected into the chest tube and the rod is inserted. The tubing is then removed after the PMMA has hardened using a scalpel.

Figure 3

A clinical case of a 27-year-old woman with infected nonunion of the tibia after open fracture (A). She underwent initial irrigation and debridement with removal of hardware and placement of an antibiotic nail, antibiotic beads, and external fixation (B). The beads are ideal in this scenario for maximal surface area and antibiotic elution. At the same time, the antibiotic nail provides stability and local antibiotic delivery in the intramedullary space. A repeat debridement was performed with the placement of a mono-block spacer in the subsequent procedure (C). The mono-block spacer has the advantage of inducing a membrane for subsequent bone grafting and improved structural integrity. Healing of the fracture is shown after bone grafting with the placement of a new intramedullary nail (D).

Figure 4

Clinical images of the same patient are shown at the time of antibiotic spacer placement (A), spacer removal (B), nail placement (C), and bone grafting (D).