J. Bone Joint Infect., 7, 101–107, 2022 https://doi.org/10.5194/jbji-7-101-2022 © Author(s) 2022. This work is distributed under the Creative Commons Attribution 4.0 License. Journal of Bone and Joint Infection JBJI Open Access Original full-length article Prophylaxis and treatment of infection in long bones using an antibiotic-loaded ceramic coating with interlocking intramedullary nails Emilie-Ann Downey 1,2 , Kayla M. Jaime 2 , Taylor J. Reif 2 , Asim M. Makhdom 3 , S. Robert Rozbruch 2 , and Austin T. Fragomen 2 1 Department of Orthopaedics, Pierre-Boucher Hospital, Longueuil, QC, Canada 2 Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA 3 Department of Orthopaedics, King Abdulaziz University, Jeddah, Saudi Arabia Correspondence: Austin T. Fragomen (fragomena@hss.edu) Received: 12 January 2022 – Revised: 28 March 2022 – Accepted: 6 April 2022 – Published: 22 April 2022 Abstract. Background: The study was done (1) to report on our recent experience with antibiotic-loaded calcium sulfate-coated interlocking intramedullary nails (CS-IMN) for infection prevention or infection erad- ication and (2) to compare the efficacy of CS-IMN versus antibiotic-loaded polymethylmethacrylate-coated IMN (PMMA-IMN) for infection eradication. Methods: We retrospectively reviewed the medical records of consecutive patients who underwent a limb salvage procedure for infection cure or infection prevention with PMMA-IMN or CS-IMN. We reviewed patient demographics, host-type, pre-operative infecting organisms, in- traoperative cultures, as well as our main outcomes: infection control rate, achievement of union/fusion, and limb salvage. Results: 33 patients were treated with CS-IMN: 9 patients with goal of infection cure and 24 patients for infection prophylaxis. When used for infection prophylaxis, there was a 100 % (24/24 patients) prevention of infection rate, 95.5 % union rate (21/22 patients), and 100 % (24/24 patients) limb salvage rate. Nine patients were treated with CS-IMN to eradicate infection and were compared to a cohort of 28 patients who were treated with PMMA-IMN. The infection was eradicated in 7/9 patients (77.8 %) in the CS-IMN group versus 21/26 patients (80 %) in the PMMA-IMN group (p = 0.44). Bone union/fusion was achieved in 8/9 patients (88.9 %) in the CS-IMN group versus 21/24 patients (87.5 %) in the PMMA-IMN group (p = 0.11). The limb salvage rate in the CS-IMN group was 100 % (9/9 patients) versus 89 % (25/28 patients) in the PMMA-IMN group. Conclu- sions: CS-IMN are safe and easy to use, and we have therefore expended our indications for them. CS-IMN are very effective at infection prophylaxis in high-risk cases where infection is suspected. Early analysis suggests that CS-IMN are non-inferior to PMMA-IMN for infection eradication. This is our preliminary data that show this novel technique to be safe in a small cohort and may be as effective as the more established method. Future studies with larger cohorts of patients will be required to confirm these findings. 1 Introduction Chronic osteomyelitis is a devastating complication in or- thopedic surgery. Osteomyelitis is difficult to treat and often complicated by the presence of internal implants at the in- fected site. The health status of the host, the condition of the local soft tissues, and the infective organism all influ- ence the ability to eradicate the infection and achieve bony union. Antibiotic-loaded, polymethylmethacrylate-coated in- terlocking intramedullary nails (PMMA-IMN) have been well established for infection eradication (Conway et al., 2014; Makhdom et al., 2020). This technique allows for in- fection control with immediate stability of the bone through a single stage surgical intervention avoiding the need for ex- ternal fixation. The locally active antibiotic carrier permits early and maintained effective local tissue antibiotic concen- Published by Copernicus Publications on behalf of EBJIS and MSIS.