Can Antibiotic-Mixed Polymethyl Methacrylate-Wrapped Intramedullary Nail Be Used For Post Nailing Infected Tibial Non-Union As Definitive Treatment?

Introduction: Standard protocol for the management of intramedullary infected ununited fracture of tibial shaft is implantation of suitable antibiotic-impregnated bone cement-coated nail to eradicate infection followed by definitive interlocking intramedullary fixation within 6 weeks. In this study we investigate the utility of antibiotic cement coated nail to the end point.Materials and Methods: A total of 23 (M = 17, F = 6) unilateral cases of mean age 32.6 years (ranges 15-68 years) are included in this prospective study. Initially, 14 had closed and 9 had open fractures. Pre-operative culture showed Staphylococcus aureus in 21 cases, and two had mixed infection of S. aureus and Pseudomonas aeruginosa. All were sensitive to Vancomycin. About 6 mm V nail with Herzog bend was used. 4 g vancomycin in 40 g methyl methacrylate polymer was used to wrap the nail after mixing. Medullary canals are reamed and thoroughly washed and prepared nails are introduced in the medullary canal. After 2 weeks, patients are permitted to bear weight with patellar tendon bearing cast. Nails are removed with union usually 4 months after insertion.Results: Average follow- up was 30 months (range 7-63 months), and results at 1 year are produced. 20 achieve control of infection within 5 weeks, and in 2 cases, the same procedure was repeated and infection controlled. One case who failed to achieve control of infection was subjected to distraction histogenesis. Eventually, by this technique 21 of the 23 infection-free non-unions are united. However, in one case, larger-sized interlocking nail was applied. Ankle and knee joint movements show terminal 10% restrictions. According to Klemm and Borner scoring protocol, results are finally graded as 9, 12, 0, and 2 for excellent, good, fair, and poor, respectively. In initial 3 cases, final cement nail removal was a problem.Conclusion: This cost-effective protocol is very simple and can be done in any setup. Further study is proposed.