Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones.

Background Fractures of long bones can sometimes lead to complications such as infection or nonunion, resulting in significant patient morbidity. Surgical intervention and antibiotics are often necessary to treat these complications. Antibiotic-impregnated cement/polymer-coated intramedullary nails have emerged as an effective surgical treatment for infected nonunion and open fractures. These implants elude high concentrations of antibiotics at the infection site while stabilizing the fracture. Extensive research has shown promising results, with success rates ranging from 60% to 100%. Benefits of these implants include stable fracture fixation, early weight-bearing, and reduced need for prolonged antibiotic therapy. However, concerns remain regarding antibiotic resistance and potential toxicity. This study aims to evaluate the efficacy and safety of these implants in managing infected nonunion and open fractures of the femur and tibia. Methods This prospective hospital-based study aimed to assess the efficacy and safety of antibiotic-impregnated cement/polymer-coated intramedullary nails for managing infected nonunion and open fractures of the femur and tibia. The study included patients aged 18 or older who received treatment with these implants between January 1, 2021 and December 31, 2022. Patients allergic to vancomycin or teicoplanin, with gap nonunion >2 cm, or lost to follow-up were excluded. Data on demographics, fracture details, previous treatment, surgery, antibiotics, and outcomes were collected using a structured proforma. Surgeries involved implant removal, debridement, culture testing, reaming, fracture reduction, and stabilization with an antibiotic-impregnated cement/polymer-coated intramedullary nail. Postoperatively, patients received antibiotics, had wound inspections, and were gradually allowed weight-bearing. Follow-up appointments and radiographic/laboratory assessments were conducted at regular intervals. The primary outcome was successful bone union, and secondary outcomes included time to union, infection rate, nonunion rate, and revision surgery. Results The majority of participants were male, with a mean age of 39.76 years. Most fractures were Gustilo-Anderson grade 3 (46.7%) and involved the tibia (73.3%). The mean bone gap after debridement was 1.3 cm. The median follow-up period was 8.21 months. Infection was controlled in 93.3% of patients, with the tibia being the most common site (70.0%). Successful bone union was achieved in 90.0% of patients, with a mean union rate of 22.13 weeks for tibial fractures and 17.21 weeks for femoral fractures. Among patients with bone union, 60.0% did not require additional procedures. Most patients had excellent bony (76.7%) and functional (70.0%) outcomes. The most common complications were the persistence of bone nonunion, impingement of proximal nail, and debonding of nail cement, each occurring in 10.0% of patients. Conclusion The study concluded that antibiotic-impregnated cement/polymer-coated intramedullary nails are effective in managing infected nonunion and open fractures of the femur and tibia. The procedure demonstrated a high success rate in controlling infections (93.3%) and achieving bone union (90.0%). Paley's criteria showed excellent bony and functional outcomes in the majority of patients. These findings support the use of this treatment option for such fractures.

Radiological and Functional Outcomes and Associated Factors After Secondary Intramedullary Nailing Among Patients With Open Fractures of the Lower Limb.

Background Open fractures of the lower limb are serious injuries caused by high-energy trauma that can lead to long-term disability. Initial treatment includes wound debridement, fracture reduction, and external fixation to stabilize bone fragments. Secondary nailing, a surgical technique to provide additional stability, has been shown to promote early mobilization and improve fracture alignment. However, there is a lack of consensus on the optimal timing and technique for secondary nailing. This study aims to evaluate the functional and radiological outcomes of patients who undergo secondary nailing for open fractures of the lower limb. Methods The study was a hospital-based prospective study of 53 patients who underwent secondary nailing for open fractures of the lower limbs. Patients aged 18 years or older, with Gustilo-Anderson classification grades 1, 2, or 3 A and B, who underwent wound debridement and external fixator application, followed by conversion to secondary intramedullary nail fixation between January 2019 and December 2021 were included in the study. The primary outcome measures were functional and radiological outcomes at follow-ups, assessed using the Lower Extremity Functional Scale (LEFS) and Radiographic Union Scale for Tibia fractures (RUST) score. Data were collected prospectively and analyzed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY). Descriptive statistics were used to summarize patient demographics and injury characteristics, and the Student's t-test and analysis of variance (ANOVA) were used to compare continuous variables between groups. The study had a final analysis of 39 patients. Results The study reports the baseline characteristics, radiological, and functional outcomes of 39 patients who underwent secondary nailing for open fractures of the lower limb. The majority of the fractures occurred in the tibia (71.8%), with most classified as grade 3 (A and B) (69.2%). At the end of the six-month period after secondary nailing, 74.4% of the fractures had a union. Radiological and functional outcomes showed significant improvement after undergoing secondary nailing. Gender and age group did not have a significant association with the radiological outcome, while the time interval between external fixation and secondary nailing was significantly associated with the radiological outcome at six weeks and three months. Conclusion According to a study, secondary nailing is effective in managing lower limb open fractures with good radiological and functional outcomes. The time interval between external fixation and secondary nailing affects radiological outcomes, with longer delays leading to lower RUST scores. Orthopaedic surgeons should consider this factor when planning surgical management. Larger sample sizes and more extended follow-up periods are needed to confirm findings and evaluate the effect of other variables on the outcome.

Lesson of the month 2: Contusion confusion.

This lesson of the month highlights that certain radiology terminology may be used to report bleeding on head computerised tomography (CT) reports. On-call junior doctors should not be expected to interpret CT head images, so often their decisions will be based on the written report. The wording used can change the clinical decision and therefore the treatment given by a junior doctor. Clinical teams and junior doctors should be educated on terminology in relation to bleeding on CT head reports.

Improving community prescribing of post-fracture denosumab after discharge.

BACKGROUND: In the UK, denosumab is usually started by hospital clinicians and continued by primary care physicians in the community, but in the authors' region denosumab is a 'green light' drug, only prescribed by the primary care team. The authors suspected that a proportion of patients who were recommended to start the drug after a neck of femur fracture were not receiving this on discharge. They aimed to improve the prescribing of denosumab by implementing a quality improvement project. METHODS: A retrospective review of electronic records and case notes in primary and secondary care was undertaken, focusing on patients who were admitted with a neck of femur fracture and recommended denosumab. Following cycle 1 of the project two interventions were implemented: Denosumab written on the inpatient prescription chart at point of treatment decision, promoting inclusion in the discharge summary A consultant letter recommending denosumab was sent separately to primary care, in addition to inclusion in the discharge summary. Following these interventions this project cycle was repeated. RESULTS: A total of 91 patients with a neck of femur fracture were identified during cycle 1 and 22/91 (24%) were recommended denosumab. However, only five of these 22 patients (22%) received the drug. Following the interventions 23/26 eligible patients (88%) were prescribed denosumab (three patients did not have a prescription with no reason given), and 17/23 (74%) had the injection given. Four patients who did not receive the denosumab injection had no obvious reason for not starting treatment. In the other two patients, one discharge summary misleadingly stated that the injection had been given as an inpatient and one patient had recurrent admissions following discharge after their neck of femur fracture so primary care had not had any opportunity to administer the injection. CONCLUSIONS: Prescribing denosumab on the inpatient drug chart and highlighting its use in a consultant-written letter to the primary care team improved prescribing and administering of denosumab in the community.

Retropharyngeal haematoma - an unusual bleeding site in an anticoagulated patient: a case report.

INTRODUCTION: Anticoagulation is used widely for the primary prevention of embolic events in patients with atrial fibrillation. Bleeding is the most common complication with oral anticoagulation. We describe the case of a patient who developed a massive retropharyngeal haematoma after a fall. Whilst the retropharyngeal space is an uncommon site for bleeding complications, it is clinically important as the development of upper airway obstruction may be life threatening. CASE PRESENTATION: We present the case of an 85-year-old Caucasian woman on warfarin, who developed a massive retropharyngeal haematoma after a fall. She initially presented with pulmonary oedema and Type 2 respiratory failure. She was commenced on treatment for this with a good clinical response. She subsequently deteriorated, developing stridor and bruising to the neck. She was urgently intubated and ventilated. Computerized Tomography scan showed a massive retropharyngeal haematoma. The baseline International Normalized Ratio (INR) was 4.9. The patients was managed conservatively and treated with Vitamin K and Prothrombin Complex Concentrates (PCCs). The INR was rapidly corrected to 1.1 and the patient made a full recovery. CONCLUSION: Retropharyngeal haematoma should be considered in anticoagulated patients presenting with abrupt respiratory distress after minor head trauma. It can develop after minor traumatic events, such as falls. It can result in upper airway obstruction, which can be life threatening. Patients should be urgently assessed for intubation and ventilation. Computerized Tomography imaging of the neck and mediastinum is diagnostic. Correction of the International Normalized Ratio with Vitamin K and Prothrombin Complex Concentrates is essential. Management is mainly supportive. However, in very large haematomas surgical drainage may be considered.