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low cost antibiotic cement nail for infected non union.pptx
- 1. LOW COST ANTIBIOTIC CEMENT NAILS AUTHOR-DR JIJU GEORGE-PROFESSOR drjijugeorge@gmail.com CO-AUTHOR-DR MOHAMED ASHRAF-PROFESSOR & HOD drashraf369@gmail.com TRAVANCORE MEDICAL COLLEGE AND MEDICITY HOSPITALS, KOLLAM. KERALA,INDIA STABILITY AND ANTIBIOTIC DELIVERY IN INFECTED NONUNIONS
- 2. • INFECTED NON-UNIONS ARE PROBABLY THE MOST LONG RUN AND FINANCIALLY DRAINING COMPLICATIONS IN ORTHOPAEDIC TRAUMA • DEVASTATING CONSEQUENCES OF FRACTURES • SUBSTANTIAL PATIENT MORBIDITY • LOSS OF FUNCTION, INCREASED PAIN, DECREASED QUALITY • SOCIO-ECONOMIC IMPACT ON PATIENT AND HEALTH CARE SYSTEM Malays Orthop J 2017,11(1);6-11
- 3. MT EVEREST CAN BE CONQUERED FROM VARIOUS SIDES
- 4. INFECTION SHOULD BE CONTROLLED TILL UNION OCCURS • IMPORTANT TO IDENTIFY THE ORGANISM • ANTIBIOTIC THAT IS SENSITIVE GIVEN ORALLY PARENTRALLY LOCALLY Drug Deliv, 2021; 28(1): 2392-2414
- 5. INFECTED DIAPHYSEAL NON-UNION AN UPHILL TASK • Microbiological, mechanical and surgical challenge to the surgeon • Mechanical instability • Repeated surgical procedures • Persistent local infection • Poor local antibiotic delivery due to avascularity Injury vol 48;sup 1;June 2017; 582-590
- 6. ANTIBIOTIC ISSUES • ‘BIOFILM’ PRODUCTION OR INTRAMEDULLARY EXTENSION OF THE INFECTION • NEED FOR PROLONGED ANTIBIOTIC COVERAGE • SCARRING AND ISCHEMIA LEAD TO POOR LOCAL AVAILABILITY • COMPLICATIONS OF PROLONGED ANTIBIOTICS Orthopedic 1994;17;415-6
- 7. INFECTED FRACTURES CURRENT TRENDS • RING FIXATOR • LRS/ EXTERNAL FIXATOR • MASQUELET TECHNIQUE • CONVENTIONAL CEMENT NAIL Injury 2022,08;005
- 8. MODIFIED LOCAL ANTIBIOTIC DELIVERY • INTRA-MEDULLARY • PERICORTICAL Drug Deliv, 2021; 28(1): 2392-2414
- 9. EXTERNAL DEVICE ISSUES Malays Orthop J 2019 Mar;13(1):36-41
- 10. CONVENTIONAL ANTIBIOTIC NAIL PROBLEMS DIAMETER INTRA OP COMPLICATIONS SURFACE AREA EXIT ISSUES COST ISSUES K-NAIL OR A V-NAIL CEMENT SURFACE AREA SMALL AND NARROW VERY THIN LAYER Clin Infect Dis 1992;14;1251-53
- 11. • DEPUY SYNTHES “EXPERT TIBIAL REAMED AND INTERLOCKED” NAIL. • A FRENCH COMPANY “SYNIMED” NAIL. • ARGENTINA “SUBITON” NAIL. • COST Rs 50 TO 60000 (specially ordered) • INDIAN MEDITEC “MATRIX” NAIL • COST Rs 30 TO 40000 (specially ordered) • CUSTOM NAILS ‘K’ OR ‘V’ OR INTERLOCKING NAIL COATED • COST Rs 15 TO 20000 • TREATMENT COST IN US $10000 TO $114000 (8 lacs to 95 lacs) • TREATMENT COST KERALA Rs 1 lac to 5 lacs (Pvt hospitals) Biomed Research International, vol 2021 Malays Orthop J 2019 Mar;13(1):36-41
- 12. AIM OF TREATMENT IN OUR SERIES • GOOD DEBRIDEMENT • RE-ESTABLISHMENT OF LOCAL VASCULARITY • LOCAL DELIVERY OF ANTIBIOTICS-MEDULLARY AND PERI- CORTICAL • MECHANICAL STABILITY OF THE FRACTURE • ……….…….AT LOW COST
- 13. OUR SERIES EXCLUSION CRITERIA • WIDE GAP, • CARDIAC / ANESTHESIA COMPLICATIONS, • ANTIBIOTIC ALLERGY, • NON-COMPLIANT AND UNRELIABLE PATIENT TOTAL CASES 20 MALE : FEMALE 14:6 PERIOD OF STUDY 2018-2022 TOTAL NAIL COST Rs 2800 – Rs 5500 RETURN TO WORK 4 – 12 MONTHS 12 7 1 EXCELLENT GOOD FAIR RESULTS
- 15. • INFORMED CONSENT FOR COMPLIANCE & TREATMENT PROTOCOL • EVALUATION AND FOLLOW UP PROTOCOL • ROUTINE & SPECIAL X RAYS • ROUTINE BLOOD TESTS CBC WITH ESR C REACTIVE PROTEINS PRO-CALCITONIN VALUES • SPECIFIC ANTIBIOTIC CULTURE AND BIOPSY REPORTS • INTRA OP CULTURE AND TISSUE CULTURES • X RAYS 3,6,9,12 WEEKS AND 6,9,12 MONTHS • FEMUR THIGH CORSET OR POP • TIBIA PTB OR POP • HUMERUS SHOULDER IMMOBILIZER OR POP • FOREARM BRACE OR POP 3
- 16. CASE 1 • 69y male with chronic discharging sinus for last 6 months • Femur fracture > 20yrs back with “k” nail • Cultures taken, debridement and removal of nail • Antibiotic specific bone cement nail • At 2 months infection settled • At 4 months walker ambulation with brace • At 6 months independent ambulator
- 17. CASE 2 • 29/m discharging sinus in the leg • Operated for open fracture with I/M nail elsewhere • Walking 6 months with continuous discharge • Implant removal, debridement and antibiotic cement nail inserted • At 2 months post op patient was independently ambulant • At 6 months patient full weight bearing and returned to work
- 18. CASE 3 • 73yrs Comminuted fracture tibia with soft tissue loss • Wound debridement and external fixation • Discharge persisting even after 6 weeks • Debridement removal of dead bone and antibiotic nail insertion • At 12 weeks nail removal • Intramedullary nail spanning ankle joint with flap coverage • At 6 months fracture united with 2 cm shortening • Patient mobilised independently with shoe raise
- 19. HOW I DO IT..…
- 20. • REFRIGIRATE THE “ SLOW “ SETTING CEMENT TILL NEED • BETTER TO HAVE TWO TEAMS • CONTINOUS SEQUENTIAL REAMING, IRRIGATION AND SUCTION • POUR CEMENT IN LIQUID STATE • PRESSUREIZE BOTH ENDS FOR EVEN DISTRIBUTION • KEEP ABOUT 4 CM NAIL EXTRA FOR EXTRACTION • CURVED TIP OF NAIL DISTALLY IN CEMENT • ROLL TUBE WITH CEMENT IN SEMI SOLID STATE • CORE DIAMETER OF ABOUT 8 TO 10 MM • WAIT FOR CEMENT TO CURE FULLY BEFORE CUTTING TUBE TECHNICAL TIPS WE PICKED UP IN OUR JOURNEY
- 21. LOW COST ANTIBIOTIC NAIL • Approximate cost to patient Tens nail 2mm Rs 1500 to 2000 Bone cement 20gm Rs 1800 to 2500 Miscellaneous Rs 1000 • The approximate cost for the nail to the patient in our series was about Rs 5000, depending on the antibiotics used. Gentamycin and Vancomycin in 18 patients. • Two patients were treated with Colistin. The cost of the nails thus shot up to 8000
- 22. DISCUSSION • ALL PATIENTS FOLLOWED UP AT 3, 6, 9,12 MONTHS THEN YEARLY FOR 2 YRS • ALL 20 FRACTURES UNITED • NO FLARE UP OF INFECTION OR REFRACTURES • ROM IN ADJACENT JOINTS WAS REDUCED ONLY BY 5-15% • ONLY 2 PATIENTS HAD SECONDARY FIXATION PROCEDURES • ALL PATIENTS RETURNED TO WORK BY 12 MONTHS • CEMENT NAIL REMOVED IN ALL BUT BOTH HUMERUS PATIENTS
- 23. CONCLUSION • COST EFFECTIVE METHOD FOR ANTIBIOTIC LEACHING CEMENT NAILS • CAN BE ASSEMBLED WITH READILY AVAILABLE THINGS IN THE O.R/O.T • THE NAILS PROVIDE STABILITY AND ANTIBIOTIC DELIVERY • APPROXIMATE COST OF NAIL Rs 2800 TO 5000 • OVER ALL REDUCTION OF HOSPITAL EXPENSE TO PATIENT BY 30 TO 40% • BETTER PATIENT COMPLIANCE
- 24. Special Thanks to • My Orthopedic Surgical team • Dr Mohammed Ashraf Dr Jiju George Dr Ayyappan Nair • Dr Suresh Pillai Dr Arun Kumar AS Dr Naiju Ajumudheen • Dr Gokul Dev Dr Jobin Jacob Job Dr Shankar S • Dr Haseeb Mukthar Dr Abdul Rehman Dr VV Ramu • Dr Shammas BM Dr Vinod VS Dr Mohammed Irshad • Dr Sinan Mohammed Dr Bidhu B Dr Vishnu S DEPARTMENT OF ORTHOPEDICS