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Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized
Carlos Augusto Finelli1, Fernando Baldy Dos Reis1, Helio Alvachian Fernandes1
11Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil.
Background:
Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN).
Methods:
A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up.
Results:
After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection.
Conclusion:
This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur.
Trial Registration:
ISRCTN82233198. Retroactively registered on July 29, 2019.
Insights
The Reamer/Irrigator/Aspirator (RIA) system is as effective as conventional reaming for treating intramedullary nail infections. Both methods achieve similar infection remission rates in long bone osteomyelitis, with RIA offering better tissue collection.
Area of Science:
- Orthopedic surgery
- Infectious disease management
- Biomedical engineering
Background:
- Intramedullary nail (IMN) infections are challenging to manage, with limited retrospective studies.
- Conventional reaming and the Reamer/Irrigator/Aspirator (RIA) system are used for debridement.
- No prospective comparative studies existed between these two reaming methods.
Purpose of the Study:
- To compare the efficacy of the RIA system versus conventional reaming for treating long bone intramedullary nail infections.
- To assess infection remission rates and identify causative microorganisms.
Main Methods:
- A noninferiority randomized clinical trial involving 44 patients with IMN-associated osteomyelitis.
- Patients were randomized to either RIA alone or conventional reaming with antibiotic-loaded cement.
- Both groups received six weeks of systemic antibiotics; follow-up was at 1, 3, 6, 12, and 24 months.
Main Results:
- After 24 months, infection remission rates were similar: 87% for RIA and 95.5% for conventional reaming (p=0.60).
- Recurrence occurred in four patients between 20 days and 22 months post-treatment.
- Common pathogens included Staphylococcus aureus (40.4%) and coagulase-negative Staphylococci (22.9%); 20% of infections were polymicrobial.
Conclusions:
- The RIA system is noninferior to conventional reaming with antibiotic cement for treating IMN infections.
- RIA demonstrated superior efficacy in collecting infected medullary bone tissue, particularly for femoral retrograde nail infections.
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