Treatment of Periprosthetic Joint Infection and Fracture-Related Infection With a Temporary Arthrodesis Made by PMMA-Coated Intramedullary Nails – Evaluation of Technique and Quality of Life in Implant-Free Interval

Abstract

BackgroundAntimicrobial coating of intramedullary nails with polymethyl methacrylate (PMMA) bone cement promises infection control and stabilization for subsequent bone healing. However, when removing the implant, bone cement can debond and remain in the medullary cavity of the long bones, representing a nidus for reinfection. This work presents a technique comprising reinforcement of PMMA-coated intramedullary nails with cerclage wire to prevent such problems in patients treated for fracture-related infection (FRI) or knee periprosthetic joint infection (PJI) with a static spacer as temporary arthrodesis allowing weight-bearing in the implant-free interval. Outcomes of this surgical treatment were evaluated in terms of (i) associated complications and (ii) patient-reported quality of life.MethodsIn this retrospective case series, 20 patients with PJI (n = 14, 70%) and FRI (n = 6, 30%) treated with PMMA-coated intramedullary nails reinforced with cerclage wire between January 2021 and July 2021 were included. Quality of life during the implant-free interval was evaluated with the EQ-5D, SF-36, and an ICD-10 based psychological symptom rating and compared with previously analyzed cohorts of successfully treated PJI and FRI patients in whom eradication of infection and stable bone consolidation was achieved.ResultsComplications during the implant-free interval comprised a broken nail in one case (5.0%) and a reinfection in one case (5.0%). Coating-specific side effects and cement debonding during removal did not occur. The mean physical health component score of SF-36 was 26.1 ± 7.6, and the mean mental health component score reached a value of 47.1 ± 18.6. The mean EQ-5D index value was 0.36 ± 0.32 and the mean EQ-5D visual analogue scale rating was 47.4 ± 19.4. The scores were significantly lower than those in the successfully treated FRI cohort but not in the PJI cohort. The mean ICD-10-based symptom rating scores revealed psychological symptom burden on the depression scale and enhanced levels of anxiety in comparison with healed FRI and PJI patients.ConclusionReinforcement of PMMA bone cement-coated implants seems to be a reasonable treatment option to create a temporary arthrodesis, preventing detachment of the bone cement when the implant was removed.Level of Evidence: IV.

The Effect of Spacer Treatment of Infected Hip and Knee Arthroplasties on Patients’ Mental Health: A Narrative Review of the Literature

“…A total of 384 patients who underwent spacer placement for PJI were identified. Of 469 patients, 56% were female [3,[11][12][13][14][15][16][17][18][19][20]. The mean age ranged from 62 to 78.2 years.…”

“…The mean age ranged from 62 to 78.2 years. Of the eleven papers identified for this review, four [11][12][13][14] analyzed only hip spacers, including 119 patients; six [3,[16][17][18][19][20] only knee spacers, evaluating 238 patients; while a single [15] study included 112 patients affected by hip and knee periprosthetic joint infections. The demographic data of the selected studies are shown in Table 1.…”

“…The central defect was then filled with other antibiotate cement. Of the studies analyzed, only one case reported the rate of mechanical complications, which was attested to around 7% [17]. As for the retention time of the spacer, this varied between 45 d [3] and 210 d [18], with an average of 126 d. Two of the six papers reported [3,18] revision to the second stage, with the rates ranging between 100% and 88%, respectively.…”

“…Regarding the knee spacers, three of the six papers have evaluated different types of spacers [16,18,19]; the other three have instead studied a single kind of spacer [3,17,20]. In particular, Helito et al analyzed articulated spacers and non-articulated spacers.…”

“…In one case [3], the authors described their spacers as multi-part articulating spacers, thus providing no additional information about the nature of the components or the surgical technique. In the other case [20], the authors composed their spacers of a PS femoral component (NexGen; Zimmer Biomet, Warsaw, IN, USA) and an all-polyethylene PS tibial component or a standard PS tibial insert without a metal base-plate The static ones instead [17] were made with two humeral nails (T2, Stryker, Duisburg, Germany), which are available in small diameters and are well suited to be covered with antibiotate cement. The nails were wrapped with cerclage wire to avoid the debonding of the cement.…”