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Implant retention with serial debridement and use of antibiotic-loaded calcium sulfate beads in acute fracture-related infection (FRI) after pelvic ring or acetabular fractures: A retrospective case series of 7 cases

Published:January 25, 2023DOI:https://doi.org/10.1016/j.injury.2023.01.045

      Abstract

      Background

      The development of a pelvic wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma and there is little literature to aid in decision-making. The purpose of this study was to describe the possibility of debridement, antibiotic pearls and retention of the implant (DAPRI) procedure to eradicate the infection.

      Methods

      Tumor-like debridement, antibiotic pearls and retention of the implant (DAPRI) aimed to remove the biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulfate antibiotic-added beads. Wound status, radiological signs of bone healing, gait and functional activity of the patient were evaluated.

      Results

      Seven patients underwent this technique. The mean follow up time was nine months (range: 6 -16 months). Complete wound healing was achieved in all the patients with no major complications. Average time of bony union was 4.3 months (range: 3–6 months) with no need for implant removal.

      Conclusion

      The DAPRI technique might represent a safe and more conservative treatment for management of early fracture-related infections (FRI) of the pelvis and acetabulum.

      Keywords

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      References

        • McCormack R.
        • Strauss E.J.
        • Alwattar B.J.
        • Tejwani N.C.
        Diagnosis and management of pelvic fractures.
        Bull NYU Hosp Jt Dis. 2010; 68: 281-291
        • Papakostidis C.
        • Kanakaris N.K.
        • Kontakis G.
        • Giannoudis P.V.
        Pelvic ring disruptions: treatment modalities and analysis of outcomes.
        Int Orthop. 2009; 33: 329-338https://doi.org/10.1007/s00264-008-0555-6
        • Kanakaris N.K.
        • Ciriello V.
        • Stavrou P.Z.
        • West R.M.
        • Giannoudis P.V.
        Deep infection following reconstruction of pelvic fractures: prevalence, characteristics, and predisposing risk factors.
        Eur J Trauma Emerg Surg. 2021; https://doi.org/10.1007/s00068-021-01618-y
      1. Tschoeke S.K., Ertel W., Franklin C.B. Immunoparalysis after multiple trauma 2007:1346–57. doi:10.1016/j.injury.2007.08.041.

        • Sagi H.C.
        • Dziadosz D.
        • Mir H.
        • Virani N.
        • Olson C.
        Obesity, leukocytosis, embolization, and injury severity increase the risk for deep postoperative wound infection after pelvic and acetabular surgery.
        J Orthop Trauma. 2013; 27: 6-10https://doi.org/10.1097/BOT.0b013e31825cf382
        • Suzuki T.
        • Morgan S.J.
        • Smith W.R.
        • Stahel P.F.
        • Gillani S.A.
        • Hak D.J.
        Postoperative surgical site infection following acetabular fracture fixation.
        Injury. 2010; 41: 396-399https://doi.org/10.1016/j.injury.2009.11.005
        • Bezstarosti H.
        • Van Lieshout E.M.M.
        • Voskamp L.W.
        • Kortram K.
        • Obremskey W.
        • McNally M.A.
        • et al.
        Insights into treatment and outcome of fracture-related infection: a systematic literature review.
        Arch Orthop Trauma Surg. 2019; 139: 61-72https://doi.org/10.1007/s00402-018-3048-0
        • Qiu X.S.
        • Cheng B.
        • Chen Y.X.
        • Qi X.Y.
        • Sha W.P.
        • Chen G.Z.
        Coating the plate with antibiotic cement to treat early infection after fracture fixation with retention of the implants: a technical note.
        BMC Musculoskelet Disord. 2018; 19: 1-6https://doi.org/10.1186/s12891-018-2285-2
        • Berkes M.
        • Obremskey W.T.
        • Scannell B.
        • Ellington J.K.
        • Hymes R.A.
        • Bosse M.
        Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation.
        J Bone Jt Surg-Am Vol. 2010; 92: 823-828https://doi.org/10.2106/JBJS.I.00470
        • Rightmire E.
        • Zurakowski D.
        • Vrahas M.
        Acute infections after fracture repair: management with hardware in place.
        Clin Orthop. 2008; 466: 466-472https://doi.org/10.1007/s11999-007-0053-y
        • Trampuz A.
        • Zimmerli W.
        Diagnosis and treatment of infections associated with fracture-fixation devices.
        Injury. 2006; 37: 59-66https://doi.org/10.1016/j.injury.2006.04.010
        • Steinmetz S.
        • Wernly D.
        • Moerenhout K.
        • Trampuz A.
        • Borens O.
        Infection after Fracture Fixation.
        EFORT Open Rev. 2019; 4: 145-152https://doi.org/10.1302/2058-5241.4.180093
        • Metsemakers W.J.
        • Morgenstern M.
        • McNally M.A.
        • Moriarty T.F.
        • McFadyen I.
        • Scarborough M.
        • et al.
        Fracture-related infection: a consensus on definition from an international expert group.
        Injury. 2018; 49: 505-510https://doi.org/10.1016/j.injury.2017.08.040
        • Calanna F.
        • Chen F.
        • Risitano S.
        • Vorhies J.S.
        • Franceschini M.
        • Giori N.J.
        • et al.
        Debridement, antibiotic pearls, and retention of the implant (DAPRI): a modified technique for implant retention in total knee arthroplasty PJI treatment.
        J Orthop Surg. 2019; 27: 1-6https://doi.org/10.1177/2309499019874413
        • Ghirardelli S.
        • Fidanza A.
        • Prati P.
        • Iannotti F.
        • Indelli P.F.
        Debridement, antibiotic pearls, and retention of the implant in the treatment of infected total hip arthroplasty.
        HIP Int. 2020; 30: 34-41https://doi.org/10.1177/1120700020929314
        • Aboltins C.A.
        • Dowsey M.M.
        • Buising K.L.
        • Peel T.N.
        • Daffy J.R.
        • Choong P.F.M.
        • et al.
        Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone.
        Clin Microbiol Infect. 2011; 17: 862-867https://doi.org/10.1111/j.1469-0691.2010.03361.x
        • Metsemakers W.-.J.
        • Fragomen A.T.
        • Moriarty T.F.
        • Morgenstern M.
        • Egol K.A.
        • Zalavras C.
        • et al.
        Evidence-Based Recommendations for Local Antimicrobial Strategies and Dead Space Management in Fracture-Related Infection.
        J Orthop Trauma. 2020; 34: 18-29https://doi.org/10.1097/BOT.0000000000001615
        • Metsemakers W.-.J.
        • Morgenstern M.
        • Senneville E.
        • Borens O.
        • Govaert G.A.M.
        • et al.
        • On behalf of the Fracture-Related Infection (FRI) group
        General treatment principles for fracture-related infection: recommendations from an international expert group.
        Arch Orthop Trauma Surg. 2020; 140: 1013-1027https://doi.org/10.1007/s00402-019-03287-4
        • Tetreault M.W.
        • Wetters N.G.
        • Aggarwal V.
        • Mont M.
        • Parvizi J.
        • Della Valle C.J.
        The Chitranjan Ranawat Award: should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?.
        Clin Orthop. 2014; 472: 52-56https://doi.org/10.1007/s11999-013-3016-5
        • Bedenčič K.
        • Kavčič M.
        • Faganeli N.
        • Mihalič R.
        • Mavčič B.
        • Dolenc J.
        • et al.
        Does preoperative antimicrobial prophylaxis influence the diagnostic potential of periprosthetic tissues in hip or knee infections?.
        Clin Orthop. 2016; 474: 258-264https://doi.org/10.1007/s11999-015-4486-4
        • Nishitani K.
        • Sutipornpalangkul W.
        • de Mesy
        • Bentley K.L.
        • Varrone J.J.
        • Bello-Irizarry S.N.
        • Ito H.
        • et al.
        Quantifying the natural history of biofilm formation in vivo during the establishment of chronic implant-associated Staphylococcus aureus osteomyelitis in mice to identify critical pathogen and host factors: QUANTIFYING IMPLANT BIOFILM IN MICE.
        J Orthop Res. 2015; 33: 1311-1319https://doi.org/10.1002/jor.22907
        • Sendi P.
        • Lötscher P.O.
        • Kessler B.
        • Graber P.
        • Zimmerli W.
        • Clauss M.
        Debridement and implant retention in the management of hip periprosthetic joint infection: outcomes following guided and rapid treatment at a single centre.
        Bone Jt J. 2017; 99-B: 330-336https://doi.org/10.1302/0301-620X.99B3.BJJ-2016-0609.R1
        • Grammatopoulos G.
        • Kendrick B.
        • McNally M.
        • Athanasou N.A.
        • Atkins B.
        • McLardy-Smith P.
        • et al.
        Outcome following debridement, antibiotics, and implant retention in hip periprosthetic joint infection—an 18-year experience.
        J Arthroplasty. 2017; 32: 2248-2255https://doi.org/10.1016/j.arth.2017.02.066
        • Chung A.S.
        • Niesen M.C.
        • Graber T.J.
        • Schwartz A.J.
        • Beauchamp C.P.
        • Clarke H.D.
        • et al.
        Two-stage debridement with prosthesis retention for acute periprosthetic joint infections.
        J Arthroplasty. 2019; 34: 1207-1213https://doi.org/10.1016/j.arth.2019.02.013
        • Buijs Ma.S
        • van den Kieboom J.
        • Sliepen J.
        • Wever K.L.H.
        • van Breugel J.M.
        • Hietbrink F.
        • et al.
        Outcome and risk factors for recurrence of early onset fracture-related infections treated with debridement, antibiotics and implant retention: results of a large retrospective multicentre cohort study.
        Injury. 2022; 53: 3930-3937https://doi.org/10.1016/j.injury.2022.10.017
        • Schmidt K.
        • Estes C.
        • McLaren A.
        • Spangehl M.J.
        Chlorhexidine antiseptic irrigation eradicates staphylococcus epidermidis from biofilm: an in vitro study.
        Clin Orthop. 2018; 476: 648-653https://doi.org/10.1007/s11999.0000000000000052
        • Chen A.F.
        • Parvizi J.
        Antibiotic-loaded bone cement and periprosthetic joint infection.
        J Long Term Eff Med Implants. 2014; 24: 89-97https://doi.org/10.1615/jlongtermeffmedimplants.2013010238
        • Aiken S.S.
        • Cooper J.J.
        • Florance H.
        • Robinson M.T.
        • Michell S.
        Local release of antibiotics for surgical site infection management using high-purity calcium sulfate: an in vitro elution study.
        Surg Infect. 2015; 16: 54-61https://doi.org/10.1089/sur.2013.162
        • Cooper J.
        • Florance H.
        • McKinnon J.
        • Laycock P.
        • Aiken S.
        Elution profiles of tobramycin and vancomycin from high-purity calcium sulphate beads incubated in a range of simulated body fluids.
        J Biomater Appl. 2016; 31: 357-365https://doi.org/10.1177/0885328216663392
        • Knecht C.S.
        • Moley J.P.
        • McGrath M.S.
        • Granger J.F.
        • Stoodley P.
        • Dusane D.H.
        Antibiotic loaded calcium sulfate bead and pulse lavage eradicates biofilms on metal implant materials in vitro.
        J Orthop Res. 2018; 36: 2349-2354https://doi.org/10.1002/jor.23903
        • McPherson MD FACS E
        • Dipane B.A .M
        • Sherif M.D .S
        Dissolvable antibiotic beads in treatment of periprosthetic joint infection and revision arthroplasty - the use of synthetic pure calcium sulfate (stimulan®) impregnated with vancomycin & tobramycin.
        Reconstr Rev. 2013; 3https://doi.org/10.15438/rr.v3i1.27