Early experience of autologous graft, hydroxyapatite & calcium sulphate antibiotic paste in revision hind-foot & ankle arthrodesis
T. Howard, J. Giddie, I. Riechert, R. Ahluwalia
1Kings College Hospital, London, United Kingdom
2Kings College Hospital, Orthopaedics, London, United Kingdom
Winner of the BOFAS 2019 2nd Best Poster Prize
Background: Revision arthrodesis on a background of infection carries high risks. We describe a new technique combining adjuvant antibiotic loaded bio-composite autologous bone graft layer technique coupled with rigid fixation in definitive surgical reconstruction.
Methods: Patients who underwent revision foot and ankle arthrodesis for proven/suspected infection were included. Standard work-up including local aspiration, bone-biopsy, definitive radiology and MDT-discussion. Definitive arthrodesis involved debridement of infected scar tissues, multiple biopsies as either part of a staged or definitive process. All bone voids were measured intra operatively and classified according to volume. At definitive arthrodesis pelvic autograft (cancellous/cortical/structural) was mixed/layered with a 40% hydroxyapatite (HA), 60% calcium sulphate (CaS) paste with appropriate antibiotic to fill the void; followed by compression fusion. Empirical/pathogen specific antibiotics were given until sample-specific-antibiotics were identified. All patients were followed up for a minimum 1 year & AOFAS scoring undertaken.
Results: 20 patients meet the inclusion criteria, and were prospectively followed up, M:F ratio (n = 1:1), mean age 52.7yrs, 25% were smokers. Surgical indications following deep sampling for revision arthrodesis: Infected non/mal-union (n=14), Aseptic-loosening (n=6). Voids defects at the time of surgery were: < 1cm3 (n=2), 1 - 1.5 cm3 (n=8), 1.5 - 2cm3, (n=8), 2 - 5cm3 (n=2). 12 pts were treated with Vancomycin, 8 with Gentamicin paste depending on bacterial advice and pre-operative sampling. No-patients were lost to follow-up; 87.5% were united on imaging and mean time to independent-ambulation was 2.9 months (functional weight bearing was reached at 1.1 months). Two-patients had radiographic evidence of non-union 1-asymptomatic, & 1-requiring revision surgery (void >3cm). Two-patients remain under review. The average AOFAS score was 82.8; no-patients were treated for post-operative-infection.
Conclusions: Layered-autologous bone-grafting, with adjuvant-antibiotic loaded bio-composite and rigid fixation has been shown to be effective and safe in revision arthrodesis with low co-morbidities in void gaps are less than 2cm3.
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