Antibiotic-coated retrograde hindfoot intramedullary nail: a reproducible technique for infection salvage with case study

Abstract

Antibiotic-coated intramedullary nails provide local antibiotic delivery while simultaneously offering stable internal fixation in complex limb salvage cases. This article describes a reproducible and cost-effective technique for construction and insertion of an antibiotic-coated retrograde hindfoot intramedullary nail utilizing readily available operating room materials for complex hindfoot and ankle infection salvage reconstruction. A representative case study with long-term follow-up demonstrating the application and outcomes of this technique is presented.

Introduction

Complex hindfoot and ankle infections remain among the most challenging conditions encountered in limb salvage surgery, particularly in patients with diabetes mellitus, charcot neuroarthropathy, peripheral neuropathy, osteomyelitis, and failed hindfoot fusion procedures. , These patients frequently present with deformity, osseous instability, compromised soft tissue envelopes, and chronic infection, significantly increasing the risk of recurrent infection, nonunion, and major lower extremity amputation. , Traditional treatment strategies often require staged procedures involving hardware removal, aggressive debridement, local antibiotic delivery, prolonged immobilization, and delayed definitive fixation. ,

Retrograde hindfoot intramedullary nails have become an important instrument in tibiotalocalcaneal (TTC) arthrodesis and complex hindfoot reconstruction due to their ability to provide stable internal fixation and maintain alignment in compromised bone. However, the presence of active or prior infection presents a significant challenge when considering internal fixation. Antibiotic-coated intramedullary nails were developed to address this issue by combining local antibiotic delivery with mechanical stability in a single construct. Pawar et al. demonstrated successful infection control and limb salvage utilizing antibiotic-coated retrograde intramedullary nails in infected Charcot ankles , while additional studies have further supported the use of antibiotic cement-coated intramedullary nails for infection eradication and stable fixation. ,,

Although antibiotic-coated intramedullary nails have been well described in the trauma literature, most published techniques focus on long bone applications involving the tibia or femur, with limited literature specifically addressing retrograde hindfoot nails. Furthermore, currently available studies often provide only brief descriptions of implant fabrication without detailed operative guidance. The purpose of this article is to present a reproducible technique for fabrication and insertion of an antibiotic-coated retrograde hindfoot intramedullary nail for complex infection salvage cases involving the ankle and hindfoot. We describe our operative setup, antibiotic cement preparation, mold fabrication utilizing readily available operating room materials, insertion technique, and technical pearls aimed at minimizing cement delamination and improving reproducibility. This technique provides a cost-effective and practical method for achieving local antibiotic delivery and stable fixation in patients undergoing complex hindfoot salvage reconstruction.

Technique guide

Attention was directed to preparation of the antibiotic-coated retrograde intramedullary nail on the back table under sterile technique. A sterile polyvinyl chloride (PVC) tube measuring 1.2 cm in diameter was selected and cut to the appropriate length to match the selected intramedullary nail. Care was taken to ensure that the most distal posterior-to-anterior interlocking screw hole remained exposed and unobstructed by the PVC tubing to allow for future fixation ( Fig. 1 ). The tube was cut to the appropriate size accordingly.

Fig. 1

PVC tubing (1.2 cm diameter) was cut to match the length of the intramedullary nail while preserving exposure of the distal posterior-to-anterior interlocking screw hole for future fixation.

The internal lumen of the PVC tube was then coated with approximately 5– 7 cc of mineral oil using a syringe in order to facilitate later removal of the cured cement-coated construct. Antibiotic-impregnated polymethylmethacrylate (PMMA) cement was then prepared according to manufacturer specifications. Once appropriate viscosity was achieved, the PMMA cement was transferred into a cement mixing gun for controlled delivery. ( Fig. 2 .)

Fig. 2

The inner lumen of the PVC tube was coated with mineral oil, and antibiotic-impregnated PMMA cement was prepared and loaded into a cement delivery gun.

The intramedullary nail was inserted into the PVC tubing and the anticipated interlocking screw hole locations were identified and marked externally on the PVC tube using a sterile marking pen. The cement mixing gun was then utilized to inject the PMMA cement into the PVC tube surrounding the intramedullary nail until the entire tube was adequately filled ( Fig. 3 ). Manual circumferential compression of the PVC tubing was then performed in order to evenly distribute the cement and ensure uniform coating of the nail throughout the construct. ( Fig. 4 ).

Fig. 3

The intramedullary nail was positioned within the PVC tube, and antibiotic-loaded PMMA cement was injected to fully surround the nail.

Fig. 4

Manual circumferential compression of the PVC tube was performed to evenly distribute the PMMA cement and create a uniform coating around the intramedullary nail.

Attention was then directed to preservation of the interlocking screw holes. Using the previously marked locations as guides, a 4 mm drill bit was utilized to drill through the cement-filled tubing at the anticipated screw hole sites. Subsequently, 4 mm Kirschner wires were inserted through each drill hole to confirm patency and ensure that no cement obstructed future screw placement ( Fig. 5 .)

Sep 5, 2026 | Posted by in ORTHOPEDIC | Comments Off on Antibiotic-coated retrograde hindfoot intramedullary nail: a reproducible technique for infection salvage with case study

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