Abstract
Background:
To study the feasibility and efficacy of antibiotic cement in preserving endoplants after infection in patients with early tibial plateau fracture on plate exposure.
Patients and Methods:
A retrospective analysis of 23 patients treated for post-operative infection with plate exposure after tibial plateau fracture between 2017 and 2021. They were divided into the observation group (10 patients) and the control group (13 patients). Total operation time, length of hospitalization, hospitalization cost, the number of surgeries, white blood cell (WBC) count, neutrophil (NEUT) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the post-operative evaluation index, and complications were observed during the follow-up period.
Results:
All patients were followed up for 6 to 12 months; wound healing was observed in both groups. The total operation time for patients in the control group was longer compared with the observation group. However, the length of hospitalization, hospitalization cost, and number of surgeries in the observation group were less compared with the control group. No difference in WBC, NEUT, ESR, and CRP levels was observed one day after surgery. Furthermore, WBC, NEUT, ESR, and CRP levels were higher in patients in the control group compared with the observation group 72 hours after surgery. There were no differences in the post-operative evaluation index and complications in both groups.
Conclusions:
The antibiotic cement coating used for treating early post-operative infection in patients with tibial plateau fracture could effectively control infection while retaining endoplant, thereby promoting wound healing. It could also reduce pain and the medical burden on patients.
High-energy violence often causes tibial plateau fractures and severely damages the surrounding soft tissue. The incidences of post-operative complications such as wound infection and implant exposure are nearly 5% to 23.6%.1–3 Wound infections are a catastrophic complication of orthopedic trauma and surgery. Improper wound healing after infection could lead to necrosis of soft tissue surface, defects, implant exposure, and osteomyelitis.4,5 These complications could lead to more surgeries, prolong the duration of treatment, and increase pain, cost of treatment, and doctor–patient conflict. In the worst-case scenario, the patient may require amputation, which could severely affect the patient's quality of life.
Generally, the internal fixations are removed and replaced by external fixations, with a possibility of skin flap operation, which could increase medical disputes and the burden on patients as well as their medical costs.4–8 At the same time, early replacement of internal to external fixation could lead to the displacement of fracture fragments and increase the incidence of traumatic knee arthritis. This would affect knee functions and delay recovery.6,7 Despite using this technique, a risk of soft-tissue defects after removing internal fixation and difficulties in soft-tissue closure still exists. However, therapeutic strategies for patients with tibial plateau fractures are still controversial.8–10 With the advancement in technology, antibiotic bone cement has been used widely for treating infection in patients with diabetic foot and who underwent joint replacement.11–18 However, no studies have shown the use of antibiotic cement for treating infections in patients with tibial plateau fractures on plate exposure after internal fixation.
In this study, we aimed to determine the efficacy and cost of antibiotic bone cement for treating post-operative infection in patients with tibial plateau fracture on implant exposure. The antibiotic bone cement was prepared using highly effective antibiotic agents after thorough debridement and coated using a steel plate surface for the local application of antibiotic agents. This could aid in effectively controlling local infections and one-stage wound closure.
Patients and Methods
General information and patient classification
A retrospective analysis of patients with tibial plateau fracture who underwent treatment for post-operative infections on plate exposure in our hospital from 2017 to 2021. A total of 23 patients were enrolled and divided into two groups based on their surgical procedure. In the observation group, patients underwent debridement, followed by antibiotic bone cement placement. Furthermore, the incision site was sutured and covered using vacuum sealing drainage (VSD). In the control group, the patient's wounds were closed using surface VSD coverage.
Inclusion and exclusion criteria
The inclusion criteria for patients were as follows: patients with closed proximal tibial fracture caused by trauma, incision reduction, internal fixation, infection, and necrosis at the incision site, as well as an exposed plate; patients treated surgically; and patients with complete follow-up data. The exclusion criteria for patients were as follows: patients without complete follow-up data; patients whose incision site was healed smoothly by strengthening the conservative treatment approaches like dressing replacement.
Therapeutic method
Pre-operative preparation.
The patients with wound infections were hospitalized, except for the necrotic tissues; their wounds were redressed. The discharge from the leachate was used for bacteriologic analysis and analyzing drug sensitivity. First, the patients were treated with broad-spectrum antibiotic agents such as ceftazidime. Subsequently, the patients were treated with antibiotic agents based on the type of bacterial infection and sensitivity to antibiotic agents. Magnetic resonance imaging is more useful in diagnosing changes in signal in bone marrow at an early stage, however, the interference due to the built-in system affects the imaging and accuracy. Hence, the radiograph and computer tomography scans were evaluated for osteomyelitis. We used antibiotic agents empirically until the test results were obtained. The patients with anemia, low proteinemia, and other symptoms were treated before surgery; blood sugar levels were monitored.
Surgical methods.
The patients were anesthetized, and the wound was expanded based on the principle of debridement. Next, we removed the necrotic and inflamed tissues in the wound from the plant surface and the holes created by nails. Next, the inflamed hyperplastic tissue was cleaned. The wound was washed alternately with iodine, hydrogen peroxide, and normal saline. More than 10,000 mL normal saline was used. Next, the dressings and instruments were replaced. In the observation group, the antibiotic bone cement was prepared by mixing antibiotic agents and bone cement in a 1:10 ratio. The inner plant surface was covered evenly during the formation of bone cement. The spare nail holes were also filled with bone cement. Briefly, the inner plant surface was coated with a 2-mm thick antibiotic bone cement package with a negative pressure drain. The wounds were sutured without tension, and the surface was covered with VSD. In case the soft tissue failed to cover the wound, we performed a rotating flap surgery to cover the wound once the infection was under control (Fig. 1).
Typical case. A 54-year-old female had an infection at the incision site and exposed plate after surgery for a right tibial plateau fracture.
In the control group, after thorough debridement, the site of the incision was sealed with soft tissue, and the surface was covered with VSD. If the soft tissue defect of the wound was large and difficult to suture, the wound was covered with a rotating flap once the infection was under control.
Post-operative management.
Post-surgery the patients were treated with sensitive antibiotic agents. The negative pressure drain was removed after 48 hours, and the VSD was removed after 96 hours. The bacteriologic and drug sensitivity tests were again conducted after removing the drain and VSD. The patients were no longer treated with antibiotic agents once body temperature returned to normal, the results of the bacteriologic test performed on drains were negative, and white blood cell (WBC) counts and C-reactive protein (CRP) levels returned to normal. The functional exercise was performed once the effects of anesthesia had subsided.
Post-operative evaluation index
Excellent: Post-surgery, good wound healing was observed, without any swelling and exudation, and no abnormalities in routine blood tests, CRP levels, and bacterial cultures.
Good: Swelling and exudation observed post-surgery. However, smooth wound healing was observed after appropriate dressing and drainage change. No additional surgeries were required, and the bacterial cultures were negative.
Can: Soft tissue necrosis, swelling, and exudation were observed post-surgery. The bacterial cultures were positive, and additional surgeries were required.
Poor: Recurrence of post-operative infection, skin and soft tissue necrosis, swelling, exudation, pus outflow, and osteomyelitis. The bacterial cultures were positive, and additional surgeries were required.
Statistical indicators
The operation time, length and cost of hospitalization and the number of surgeries were recorded separately for both groups. Total WBC and total neutrophil (NEUT) count, erythrocyte sedimentation rate (ESR), CRP levels, and secretion culture were measured one day before and after surgery, as well as 72 hours after surgery. The bacteriologic test was performed on drains obtained after removing the drainage tube. Next, the recurrence of infection, osteomyelitis and the number of rotary or transfer flap surgeries were recorded and analyzed statistically.
Statistical analysis
Data analysis was performed using the SPSS Statistics, version 19.0 (IBM Corp, Armonk, NY). After verifying normal distribution, the data were represented as
Results
General information
The observation group consisted of 10 patients, including six males and four females, aged 53.5 ± 5.34 years. Of these 10 patients, three suffered injuries from traffic accidents, five suffered crush injuries, and two suffered fall injuries. The patients had other medical conditions: three patients suffered from hypertension, four patients had diabetes mellitus, and four patients suffered from coronary heart disease. Based on the Cierny-Mader (C-M) osteomyelitis classification, 19 two patients were classified as C-M type IIA osteomyelitis, and eight patients were classified as C-M type IIB osteomyelitis.
The control group comprised 13 patients, of which four patients were males, and nine were females, aged 36 to 71 years, with an average age of 58.1 ± 9.8 years. Of these 13 patients, four suffered injuries from traffic accidents, four suffered from crush injuries, and five suffered from fall injuries. The patients had other medical conditions: seven patients suffered from hypertension, seven patients had diabetes mellitus, and two patients suffered from coronary heart disease. Based on the C-M osteomyelitis classification, four patients were classified as C-M type IIA osteomyelitis, and nine were classified as C-M type IIB osteomyelitis.
During the first debridement, the bacteriologic tests of 18 patients were positive, of which seven were from the observation group. Four patients had Staphylococcus aureus infection, one patient suffered from Escherichia coli infection, two patients had Pseudomonas aeruginosa infection, two patients had Acinetobacter baumannii infection, four patients had mixed infections, and 10 patients suffered a single bacterial infection in the observation group.
In the control group, seven patients had Staphylococcus aureus infection, two patients had Escherichia coli infection, two patients had Pseudomonas aeruginosa infection, four patients had Acinetobacter baumannii infection, six patients suffered mixed infection, and 13 patients had a single bacterial infection. All patients were followed up for 6 to 12 months post-surgery. No fungal infections were detected, and no difference in general data was observed in patients in both groups between the two groups (Table 1).
Comparison of the General Data Between the Two Patient Groups
Comparing the total operation time, length and cost of hospitalization, and number of surgeries in both groups
Wound healing was observed in patients in both groups. In the control group, the patients underwent more surgeries, hence, the total operation time for patients was longer compared with the observation group. In the observation group, the length and cost of hospitalization and the number of surgeries performed on patients were less compared with patients in the control group (Fig. 2).
Total operation time, length of hospitalization, hospitalization costs, and operation time in both groups.
Comparing the levels of WBC, NEUT, ESR, and CRP in both groups
An increase in the levels of WBC, NEUT, ESR, and CRP was observed on day one before surgery in patients in both groups. An increase in the levels of WBC, ESR, and CRP was observed on day one after surgery in both groups, however, the difference was not statistically significant. However, a decrease in the levels of WBC, NEUT, ESR, and CRP levels was observed 72 hours after surgery in patients in both groups. An increase in the levels of WBC, NEUT, ESR, and CRP was observed in patients in the control group compared with the observation group (Fig. 3).
White blood cell (WBC) count, neutrophil (NEUT) count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were measured one day before surgery, one day after surgery, and 72 hours after surgery in both groups.
Comparing the post-operative evaluation index in both groups
In the post-operative evaluation index, eight patients reported feeling excellent or good and two patients reported feeling can or poor in the observation group. In the control group, eight patients reported feeling excellent or good, and five patients reported feeling can or poor. No significant difference in the postoperative evaluation index, like the number of excellent and good outcomes, the recurrence of infection, and the incidence of osteomyelitis, was observed in patients in both groups (Table 2).
Complications During the Follow-Up Period in the Two Groups
Complications during the follow-up period in both groups
Due to extensive soft tissue defects, in the observation group, one patient was treated with a rotary skin flap once the infection was under control. In the control group, five patients underwent rotary or transfer skin flap surgeries once the infection was under control. The differences in the number of patients undogoing surgeries were statistically significant (Table 2).
Next, bacteriologic tests were performed on secretions obtained after removing the drainage tube. The bacterial cultures were positive in four patients. In the observation group, one patient suffered from Staphylococcus aureus and Acinetobacter baumannii infection, and one patient was infected with Acinetobacter baumannii only. In the control group, one patient tested positive for mixed Staphylococcus aureus and Acinetobacter baumannii infection, and the other patient suffered from Staphylococcus aureus and Pseudomonas aeruginosa infection. No significant differences were observed in patients in both groups (Table 2).
Re-infections were observed in one patient from both groups. Osteomyelitis was reported in one patient in the control group. No differences were observed in patients in both groups (Table 2).
Discussion
Infection is a catastrophic complication that occurs after orthopedic trauma and surgery. Built-in exposures are likely to occur if the infections are not treated adequately or if surface necrosis and defect occur in the soft tissue.2,3 High-energy violence can cause tibial plateau fractures and severely damage the surrounding soft tissue. Surgical trauma combined with local damage can increase the risk of infection at the incision site, and the treatment of infection at the incision site may easily appear on exposed plants.20–22 The necrotic tissue on the surface of plants without any biological activity and conventional therapeutic effects against infections fail to degrade, which increases infection rates, osteomyelitis, time and cost of treatment, and the doctor–patient conflict. The traditional therapeutic strategies include thorough surgical debridement, removal of infection, inactivation, and removal of necrotic tissue at the site of the wound. Further, post-operative care using antibiotic agents and replacing dressing in sterile conditions to control infections. However, frequent re-infections occur because of conventional treatment strategies, which increase tissue exposure and duration of treatment, thereby enhancing the patient's pain and the costs of treatment.
Recently, VSD has been widely used for treating orthopedic infectious wounds. However, VSD has weak antibacterial activity and should be frequently replaced. Moreover, the built-in substance has no biological activity nor soft tissue induction. Despite the repeated use of VSD, the growth of surface granulation is unsatisfactory, thus enhancing the patient's pain and the cost of treatment. Flap repair surgery can repair the wound to achieve soft tissue coverage. However, the technical requirements and the surgical risks, such as post-operative infection and necrosis, are relatively high, leading to catastrophic medical disputes.
Antibiotic bone cement is a special solvent that can resist high temperatures. It is water-soluble and stable. The rate of abnormal reaction of antibiotic bone cement is low when mixed with antibiotic agents such as gentamicin, vancomycin, and a few cephalosporins. A few advantages of antibiotic bone cement over traditional systemic antibiotic agents are as follows. 23 The antibiotic bone cement can deliver the drug precisely at the infection site in the desired quantity. It allows local, slow, and continuous release of antibacterial and antimicrobial drugs to achieve the desired antibacterial effect. It also prevents drug resistance and the generation of new drug-resistant strains, thus ensuring timely wound healing. Simultaneously, the use of local medication may not lead to systemic immune reactions. The concentration of antibiotic agents released continuously by bone cement is higher compared with the antibiotic agents administered via other routes. As a result, a low concentration of drugs enters the blood circulation at peak concentration, thereby reducing the toxicity to the other organs of the body. High concentrations of the drugs can be administered directly at the site of infection to reduce the chances of re-infection. This can also improve the effectiveness of the drugs without affecting the blood supply at the wound site. Furthermore, the antibiotic bone cement is widely used to treat infection in patients post joint replacement and chronic osteomyelitis.
Because of recent advancements, the antibiotic bone cements are now used in clinical settings for treating patients with diabetic foot infections, limb treatment, traumatic soft tissue defect wounds, open fractures, etc. Interestingly, no studies have shown the use of antibiotic bone cement for the treatment of post-operative infections in patients who underwent surgery with a steel plate exposed for tibial platform fracture. Therefore, in this study, we performed local debridement and placed antibiotic cement.
The antibiotic cement was made of clay to coat and cover the inactive plate plants. This could enhance the concentration of antimicrobials locally and control infection, thereby enhancing wound closure and healing. It can also remove the sinus tract, prevent additional surgery, and reduce the duration of hospitalization and surgery time. These positive effects can effectively shorten the duration of patient treatment and reduce the pain after surgery. It also reduces medical costs and prevents doctor–patient disputes.
The use of antibiotic cement for treating infection in patients with tibial plateau fracture after plate exposure was cost-effective and efficient. However, the sample size of this study was small, the follow-up duration was short, and there could be a few mistakes.
Conclusions and Clinical Implications
The antibiotic bone cement was made by mixing sensitive antibiotic agents and a wide range of materials. It does not require specific or special materials for preparation, surgical processes, or instruments. Furthermore, the surgical procedure is simple, can be performed by all hospitals, including those lacking advanced medical facilities, and has various applications. Additionally, it reduces the cost of treatment, can achieve satisfactory treatment outcomes, and reduces unnecessary doctor–patient conflict caused by repeated surgery. Finally, it alleviates the pain and burden of the patients and has significant social benefits.
Footnotes
Acknowledgment
We would like to thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript.
Funding Information
Natural Science Research Project of Anhui Educational Committee (KJ2021A0743)
Author Disclosure Statement
The author(s) declares no potential conflicts of interest with respect to the research, authorship, and /or publication of this article. The ethical approval for this study was provided by the Ethics Committee of the Fifth People's Hospital of Huai'an City, Jiangsu Province, China. No informed consent was required from patients due to the retrospective nature of the study.