Prophylaxis and treatment of infection in long bones using an antibiotic-loaded ceramic coating with interlocking intramedullary nails.

Background: The study was done (1) to report on our recent experience with antibiotic-loaded calcium sulfate-coated interlocking intramedullary nails (CS-IMN) for infection prevention or infection eradication and (2) to compare the efficacy of CS-IMN versus antibiotic-loaded polymethylmethacrylate-coated IMN (PMMA-IMN) for infection eradication. Methods: We retrospectively reviewed the medical records of consecutive patients who underwent a limb salvage procedure for infection cure or infection prevention with PMMA-IMN or CS-IMN. We reviewed patient demographics, host-type, pre-operative infecting organisms, intraoperative cultures, as well as our main outcomes: infection control rate, achievement of union/fusion, and limb salvage. Results: 33 patients were treated with CS-IMN: 9 patients with goal of infection cure and 24 patients for infection prophylaxis. When used for infection prophylaxis, there was a 100 % ( 24 / 24 patients) prevention of infection rate, 95.5 % union rate ( 21 / 22 patients), and 100 % ( 24 / 24  patients) limb salvage rate. Nine patients were treated with CS-IMN to eradicate infection and were compared to a cohort of 28 patients who were treated with PMMA-IMN. The infection was eradicated in 7 / 9 patients (77.8 %) in the CS-IMN group versus 21/26 patients (80 %) in the PMMA-IMN group ( p = 0.44 ). Bone union/fusion was achieved in 8 / 9 patients (88.9 %) in the CS-IMN group versus 21/24 patients (87.5 %) in the PMMA-IMN group ( p = 0.11 ). The limb salvage rate in the CS-IMN group was 100 % ( 9 / 9  patients) versus 89 % ( 25 / 28  patients) in the PMMA-IMN group. Conclusions: CS-IMN are safe and easy to use, and we have therefore expended our indications for them. CS-IMN are very effective at infection prophylaxis in high-risk cases where infection is suspected. Early analysis suggests that CS-IMN are non-inferior to PMMA-IMN for infection eradication. This is our preliminary data that show this novel technique to be safe in a small cohort and may be as effective as the more established method. Future studies with larger cohorts of patients will be required to confirm these findings.

Attachment of a Myoelectric Prosthesis After Transulnar Osseointegration Implantation: A 2-Patient Case Study.

CASE: This report discusses 2 successful cases of traumatic transulnar amputees who underwent osseointegration implantation. After surgery, a myoelectric prosthetic equipped with Coapt (Chicago, IL) recognition software was attached directly to the implant. Patients underwent training with pattern recognition software to learn to control the myoelectric prosthetic with the multiarticulating hand and wrist. Both implants osseointegrated without signs of loosening at the most recent follow-up of 18 months and 2 years, respectively. Prosthetic control gradually improved to allow activities of daily living. CONCLUSION: These cases demonstrate what can be achieved with interdisciplinary coordination between surgeons, prosthetists, and emerging technologies.

Early Experience with Femoral and Tibial Bone-Anchored Osseointegration Prostheses.

BACKGROUND: The use of bone-anchored osseointegration implants for amputation reconstruction continues to expand throughout the world. Benefits are thought to include the elimination of socket-related problems and improved control and proprioception of the prosthetic limb. Reported outcomes have been positive, but skepticism remains with regard to the risk of infection and implant failure. Further results from early adopters are therefore needed prior to widespread acceptance and regulatory approval. METHODS: A retrospective review of the first 31 consecutive patients who underwent implantation of a press-fit osseointegration implant of the femur or tibia with follow-up of at least 6 months was performed. The primary outcome was the patient-reported Questionnaire for persons with a Transfemoral Amputation (Q-TFA) measured preoperatively and 6 to 12 months postoperatively. Patient-Reported Outcomes Measurement Information System (PROMIS) and Limb Deformity-Scoliosis Research Society (LD-SRS) scores, 2-minute and 6-minute walk tests, and complications were also recorded. RESULTS: In this study, 18 femoral reconstructions and 13 tibial reconstructions were performed, with a mean follow-up (and standard deviation) of 21.1 ± 9.2 months. Twenty-eight reconstructions were single-stage implantations. All Q-TFA domains improved significantly (p < 0.001) from preoperatively to postoperatively, including the global score (25.0 ± 17.4 to 81.2 ± 17.6 points), prosthetic use (50.2 ± 39.9 to 91.2 ± 18.7 points), prosthetic mobility (49.7 ± 26.9 to 81.4 ± 21.5 points), and prosthetic problems (46.4 ± 17.5 to 9.1 ± 6.6 points). The overall and functional outcome domains of the PROMIS and LD-SRS and the 2-minute walk test (243 ± 107 to 369 ± 151 ft [74 ± 33 to 112 ± 46 m]; p = 0.022) and 6-minute walk test (609 ± 323 to 1,054 ± 555 ft [186 ± 98 to 321 ± 169 m]; p = 0.016) also improved significantly. Serious adverse events included 2 periprosthetic hip fractures, 1 explantation for septic loosening, and 1 explantation for aseptic loosening, with an overall implant retention of 93%. The most common complication was low-grade, soft-tissue infection requiring oral antibiotics. CONCLUSIONS: Similar to the early experience of other international centers, osseointegration implants improved the overall and functional experience of patients compared with socket prosthetics. Complications were present but manageable and were not a deterrent to ongoing support of the technology. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.