Continuous Local Antibiotic Perfusion (CLAP): A Treatment Strategy that Allows Implant Retention in Fracture-Related Infections

Abstract

BackgroundFracture-related infections (FRI) are challenging to treat because of the formation of biofilms around implants. Systemic antibiotics are notoriously ineffective against biofilms due to insufficient penetration of tissues with poor vascularity. The treatment of Fracture-related infections aims to achieve bone union while retaining the implant. As proposed by us, continuous local antibiotic perfusion (CLAP) refers to the continuous local delivery system of sufficient antibiotics to bone and soft tissue infection sites. This allows for continuous administration of antibiotics to bone marrow via needles as intra-medullary antibiotics perfusion (iMAP) and to soft-tissue via double-lumen sub tubes as intra-soft tissue perfusion (iSAP).MethodsWe examined the outcomes of FRI patients treated based on the concept of CLAP at the first author’s hospital. Forty patients treated with CLAP for FRI between 2015 and 2021 were included. CLAP was initiated as urgently as possible after the infection was diagnosed. Patient/treatment background and efficacy/safety evaluation were analyzed. Gentamicin was used in CLAP in all cases.ResultsThe mean patients’ age was 60.5 years, and the mean follow-up was 696.4 days. The affected bones were the tibia (n=17), humerus (n=6), patella (n=3), pelvis (n=3), radius (n=2), femur (n=2), calcaneus (n=2), metatarsals (n=2), ulna (n=1), proximal phalanx (n=1), and vertebra (n=1). Twelve cases were treated with iMAP alone, 11 were treated with iSAP alone, and 17 were treated with a combination of both. Implant removal was required in five patients. Two of them required toe amputation and knee arthrodesis, while fracture union was achieved in the remaining 38 patients. Only one case of transient acute renal injury was observed as a systemic side effect; however, the patient’s condition improved soon. No eighth cranial nerve neuropathy of concern was observed, and the blood concentration of gentamicin could be adjusted to an appropriate level through the combined use of iMAP and iSAP.ConclusionCLAP is a novel local drug delivery system that can potentially deliver sufficient concentrations of antibiotics with few systemic side effects and is a valuable option for FRI treatment.