Chronic osteomyelitis remains a challenging orthopedic illness to treat due to persistent infection, drainage, bone degradation, and poor healing .^1-2 Treatment for this condition remains complex because to biofilm formation, low antibiotic penetration, and high recurrence rates.³ Despite advances in surgical methods and antibiotic medication, this illness remains challenging to treat. Chronic disease may affect limb function, lead to several surgical treatments, and ultimately need amputation in severe cases.⁴ Conventional therapy techniques, including systemic antibiotics & surgical debridement, are often unsatisfactory for long-term infection eradication.⁵ Systemic antibiotics typically fail to restore therapeutic concentrations in damaged bones, and aggressive debridement can further damage their structural integrity.⁶ Local antibiotic delivery systems offer an alternate solution. These systems aim to address the limitations of systemic therapy by delivering high concentrations of antimicrobial medicines to the infection site while minimizing damage to other organs and tissues.⁷ Antibiotic-impregnated cement has received significant clinical attention among various local distribution strategies^.8 Cement-coated intramedullary rods can effectively address infection control and bone stabilization challenges by providing structural stability and long-term local antibiotic release.^9-10 These devices promote bone healing and reconstructive therapies by reducing bacterial load, biofilm development, and creating a favorable environment.¹¹  They do this by maintaining high local antibiotic concentrations. Cement-coated rods are a cost-effective and practical alternative for limited resources in healthcare settings due to their ease of production and adaptability during surgery.¹² Antibiotic cement-coated rods have been found to effectively eliminate infections, improve limb function, and reduce recurrences. However, due to variations in patient demographics, illness characteristics, and treatment regimens, further clinical research is needed to assess the effectiveness of this technique in different conditions. Therefore the present study was carried out to determine the effectiveness of antibiotic cement-coated rods in the management of chronic post-traumatic osteomyelitis.

The current descriptive study was carried out at the Orthopedic Department Qazi Hussain Ahmad Medical Complex and Nowshera Medical College, Nowshera from December 2025 to May 2026 after taking approval from the ethical committee of the hospital. Individuals of both genders and of different age groups (ranged 20-62 years) diagnosed with CPTO of the tibia /femur, with more than 3 months of disease duration and planned for intramedullary nailing with antibiotic cement-coated rods were enrolled in this study. Only individuals with ASA physical status I or II were eligible.13 Individuals with diabetic foot osteomyelitis, acute osteomyelitis, and malignancy involving bone and were unwilling to participate were excluded. The WHO sample size calculator was used to determine the sample size, which was based on an estimated treatment success rate of 85%, a 95% confidence level, and a 6% margin of error.14 The required sample size determined was 150. The orthopedic surgery team created a standardized proforma to collect demographic and clinical data, including age, gender, symptom duration, comorbidities (e.g. diabetes, hypertension), smoking status, and residential history. All eligible patients were enrolled with signed informed consent. Preoperative evaluations included a thorough medical history, musculoskeletal examination, and baseline laboratory tests (CBC, ESR, C-reactive protein, and radiographs of the afflicted leg). These examinations supported correct diagnosis, infection staging, and surgical planning. Orthopedic experts with at least two years of experience conducted all surgical operations under spinal or general anesthesia, according on patient fitness and surgical needs. After removing any prior implants, a cortical window was formed at the sequestrum location. Orthopedic experts with at least two years of experience conducted all surgical operations under spinal or general anesthesia, according on patient fitness and surgical needs. After removing any prior implants, a cortical window was formed at the sequestrum location. Thorough debridement removed all necrotic and diseased tissue, revealing healthy, bleeding bone. Following debridement, numerous bone specimens were taken for histological investigation and microbiological culture, with sensitivity testing. To effectively sanitize the medullary canal, it was reconstituted and washed with 6 liters of normal saline. Simplex P bone cement (40 g) was combined with vancomycin (2 g) and gentamicin (0.5 g) to create antibiotic-coated intramedullary rods under sterile circumstances during surgery. The antibiotic mixture was hand-mixed to ensure consistent dispersion and molded onto Ender or interconnecting nails according on canal diameter. Maintaining a cement coating thickness of 2-3 mm ensured good fit and elution characteristics. Following partial polymerization, the rods were molded for smooth insertion and hardened before to implantation. Participants were given ceftriaxone intravenously (1 g twice per day) & Amikacin (500 mg twice daily) for the first five days after surgery, followed by four weeks of oral levofloxacin (500 mg once daily). The antibiotic treatment was changed according to culture and sensitivity findings. Wound care and physiotherapy were started as tolerated, and weight-bearing was limited until early radiographic evidence of recovery appeared. Clinical & radiological follow-ups were performed 3 weeks, 6 weeks, and 3 months after surgery. Treatment efficacy was defined as full infection clearance, including lack of discomfort, nasal discharge, & local inflammation, as well as radiographic signs of callus development and no sequestrum or lytic alterations. SPSS Statistics version 24 was used to analyze the data. To determine the normality of continuous data such as age and disease duration Shapiro-Wilk test was applied. Normally distributed data were summarized as mean ± SD, whereas none normally distributed variables were reported as median and interquartile range (IQR). The length of sickness in this study had a skewed distribution, thus it was reported as the median (IQR) to guarantee proper data representation. Categorical factors (gender, smoking status, comorbidities, afflicted bone, and treatment success) were reported as frequencies and percentages. To eliminate confounding factors, essential demographic and clinical data were used to stratify participants. The chi-square test was used in post-stratification analysis to evaluate categorical variables' relationships. P-values < 0.05 were considered statistically significant.

In the present study over all 150 individuals with CPTO were included. Out of which males were 94(62.7%) and female were 56(37.3). The mean age of the study population was 42.3 ± 12.2 years. Majority of the participants were in the age group 31-40 years (30.7%) followed by age group 41-50 38 (25.3%), 20–30 years 34(22.7%) and 51–62 years 32(21.3%) respectively. The most prevalent bone effected was femur 109 (72.7%), followed by tibia 41(27.3%). Out of these participants 44(29.3%) of patients were smokers and most of them were from urban areas85 (56%). Diabetes mellitus was seen in 39 (19.3%) cases and hypertension was found in 24 (16.0%) individuals. as presented in table 1. Therapy with antibiotic cement-coated rods was effective in 135 (90.0%) cases, whereas 15 (10.0%) reported recurrence or persistence infection throughout the three-month follow-up period, showing  a significant overall treatment success rate as shown in table 2. Individuals with tibial osteomyelitis had 87.8% treatment success rate as compared to participants with  femoral osteomyelitis 90.8% but it was not statistically significant different (p = 0.626). Likewise, it was comparable between male (90.4%) and female (89.3%) individuals (p = 0.887). The  success rate of therapy  was somewhat greater among participants  aged 20–40 years (91.3%) as compared to  aged 41–62 years (88.6%), though the variance was not statistically significant (p =0.678). Smokers had a lower therapeutic success rate (84.1%) versus nonsmokers (92.5%), however the difference was not statistically noteworthy (p = 0.0821). Individuals who did not have diabetes mellitus had a higher rate of successful outcomes (91.7%) than those with diabetes (82.8%), however the difference was not statistically significant (p = 0.124). Similarly, hypertension had no significant correlation with the treatment result (p = 0.671). As a whole, none of the analyzed demographic or clinical characteristics exhibited a statistically significant correlation with treatment success, demonstrating that antibiotic cement-coated rods were efficacious across subgroups of the study population as shown in table 3. Clinical & radiological follow-up revealed considerable progressive improvement after therapy with antibiotic cement-coated rods. Pain reduction was observed in 93 (62.0%) individuals after 3 week, improving to 116 (77.3%) at 6 weeks to 136 (90.7%) at 3 months (p less than 0.001). In a similar vein, the number of individuals without sinus discharge increased from 98 (65.3%) at three weeks compared to 137 (91.3%) at 3 months (p less than 0.001). 90 (60.0%) individuals showed signs of wound healing at 3 weeks, 114 (76.0%) at 6 weeks, and 133 (88.7%) 3 months (p < 0.001). with the course of the follow-up period, infection recurrence remained low, occurring in 10 (6.7%), 12 (8.0%), and 15 (10.0%) & at 3 weeks, 6 weeks, and three months, respectively. There was no statistically significant increase with time (p = 0.379). Radiological evaluation also revealed significant improvement, with callus development and bone repair rising from 64 (42.7%) participants at 3 weeks to 127 (84.7%) at 3 months (p < 0.001). 112 (74.7%) patients had adequate medullary canal clearance at three weeks, and this number increased to 136 (90.7%) at three months, demonstrating borderline statistical significance (p = 0.050). During follow-up, the number of individuals without sequestrum increased from 108 (72.0%) reached 139 (92.7%) (p < 0.001). Over the course of the three-month follow-up period, antibiotic cement-coated rods were linked to a gradual clinical recuperation, successful infection prevention, and satisfactory radiological bone healing.

Chronic Post-traumatic osteomyelitis is a challenge for both surgeons as well as patients (Hake et al., 2015). This condition can arise following surgical treatment for both closed and open fractures. The reported prevalence ranges 0.7% to 33%.15 Nowadays, vigorous surgical debridement, bone stabilization, sufficient soft tissue covering, and the administration of certain antimicrobials based on the infecting microbe are all part of patient treatment procedures.16 Dead space management, which is produced by the excision of devitalized tissue, bone sequestrum, and/or the removal of prior osteosynthesis, is another crucial factor to consider. Systemic antibiotic treatment and the host immune response are often poor in this situation. Systemic antibiotic treatment and the host immune response are often poor in this situation. The use of antibiotic-loaded polymethylmethacrylate (PMMA) beads, as described by Klemm (1979), has proven successful for local application of antimicrobials; still, it is typically challenging to place and remove the beads from the medullary cavity when the infection has spread or colonized an intramedullary nail. An intramedullary metal core coated with antibiotics may be employed in these situations.15 These devices have shown up to 80%–100% infection control rates when used to treat long bone osteomyelitis.17-18 The present study was carried out to determine the effectiveness of antibiotic cement-coated rods in the management of chronic post-traumatic osteomyelitis. Our study showed that treatment with antibiotic cement-coated rods was effective in 90.0% cases. These findings are similar to the study carried out by Kanakaris et al, they reported 96% success rate after 21 months of follow-up.19 Similarly, a study done by Gabarano et al. (2021) found that 30 individuals treated using antibiotic cement-coated pins had a 91.66% success rate which support our results.20 Our findings are in line with previous studies that reported an overall satisfactory clinical outcome of 84.2% for 38 individuals with chronic osteomyelitis treated with cement rod spacers and targeted antibiotics.21 Our study revealed that none of the analyzed demographic or clinical characteristics exhibited a statistically significant correlation with treatment success, demonstrating that antibiotic cement-coated rods were efficacious across subgroups of the study population. These results are similar to the study conducted by Naqqash et al.22 This outcomes maintenances the broad applicability of this treatment modality for chronic post-traumatic osteomyelitis. Clinical & radiological follow-up revealed considerable progressive improvement after therapy with antibiotic cement-coated rods. Pain relief was observed in 90.7% cases, at 3 months. In a similar vein, the number of individuals without sinus discharge increased from 65.3% at three weeks compared to 91.3% at 3 months. 60.0% individuals showed signs of wound healing at 3 weeks, 76.0%) at 6 weeks, and 88.7% 3 months. With the course of the follow-up period, infection recurrence remained low, occurring in 6.7%, 8.0%, and 10.0% & at 3 weeks, 6 weeks, and three months, respectively. Over the course of the three-month follow-up period, our results showed that antibiotic cement-coated rods were linked to good radiographic bone healing, successful infection management, and progressive clinical recovery. These findings are consistent with other studies that reported a 100% infection control rate and complete osseous union at a 12-month follow-up in forty individuals receiving treatment with antibiotic-impregnated bone cement rods for postoperative infections following femur shaft fractures.23 The radiographic findings of our study demonstrate notable improvements in sequestrum absence and callus formation and bone repair over time. These results are comparable to the results of another study in which participants receiving cement spacers had no signs of osteomyelitis recurrence impregnated with antibiotics throughout a two-year average follow-up period.9 Our study adds to the increasing amount of evidence showing the efficacy of antibiotic-coated cement rods in the management of chronic osteomyelitis. By providing a substantial amount of antibiotics directly to the infection site, this approach not only enhances infection control but also encourages bone repair and reduces the likelihood of recurrence. Limitations of the study The lack of a control group, short follow-up period (three months), and single-center design limit the capacity to assess long-term treatment efficacy or make conclusions about causality.

The present study concluded that in individuals with chronic post-traumatic osteomyelitis antibiotic cement-coated rods is very effective in lowering pain, accelerating wound healing, and controlling infection, improving radiographic bone regeneration and accelerating wound healing. To confirm the long-term effectiveness and repeatability of this technique, more multicenter trials with standardized outcome measures and extended follow-up are necessary.

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