Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.

Bone transport/limb lengthening with circular external fixation has been associated with a prolonged period of time in the frame and a significant major complication rate following frame removal. We examined the results of bone transport in fifty-one limbs using the “monorail” technique and found a dramatically improved lengthening index (24.5 days/cm. – time in frame /cm. of length gained) and an absence of refracture or angulatory deformity following fixator removal. This technique is our treatment of choice for limb lengthening/bone transport. We sought to determine patient oriented outcome and complication rates following b one transport using an external fixator placed over an intramedullary nail (the “monorail” technique). Bone transport using the monorail technique is associated with a dramatically improved lengthening index and a lower major complication rate than traditional ring fixator methods. Patient satisfaction with the procedure was high. Our study confirms the significant advantages of the monorail technique for bone transport/limb lengthening. The time in the fixator is dramatically reduced, and complications associated with earlier techniques such as angulatory deformity or refracture were not seen. We identified forty-nine patients (fifty-one limbs) who had undergone bone transport using the monorail technique (external fixator placed over an intramedullary nail). There were thirty-five men and fourteen women with a mean age of thirty-five years (range 17–50). Pre-operative diagnoses included post traumatic length discrepancy/bone defect (forty-one), congenital short stature (six) and other (four). All patients had a unilateral fixator placed over an implanted intramedullary nail. Once length correction was achieved, the fixator was removed and the nail “locked”. The mean amount of lengthening was 5.5 cm. (range 2 – 18 cm.). The lengthening index was 24.5 days /cm. (duration of external fixation/cm. bone length gained), with a range from ten to fifty days /cm. There were nineteen complications (thirty-seven percent): nine premature consolidations, four infected pin sites, two hardware failures, two osteomyelitis, one DVT, one nonunion. There were no refractures, angulatory deformities or cases of intramedullary sepsis

The December 2012 Trauma Roundup³⁶⁰ looks at: whether tranexamic acid stops bleeding in trauma across the board; antibiotic beads and VAC; whether anaesthetic determines the outcome in surgery for distal radial fractures; high complications in surgery on bisphosphonate-hardened bone; better outcomes but more dislocations in femoral neck fractures; the mythical hip fracture; plate augmentation in nonunion surgery; and SIGN intramedullary nailing and infections.