Что такое цемент для ногтей

Eveline cosmetics Nail Cement Укрепляющая сыворотка + база для лака

Eveline cosmetics Nail Cement — укрепляющая сыворотка, улучшает состояние ногтей. Восстанавливает и выравнивает поверхность ногтей. Можно использовать в качестве базы под лак.
Спа-Маникюр без посещения салона.

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Using antibiotic cement nail with multiple screws fixation as a single-stage salvage procedure for patient with infected tibiotalocalcaneal arthrodesis: A case report

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Shih-Chieh Yang, Department of Orthopedic Surgery, E-Da Hospital/I-Shou University, No. 1, E-Da Road, 82445 Kaohsiung. Email: [email protected]

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Abstract

Tibiotalocalcaneal (TTC) arthrodesis with retrograde nail is a widely used treatment option for severe ankle arthropathy. With inherent biomechanical benefits in axial loading and strong bending stiffness, high union rate and good clinical outcomes have been reported in the literature. However, some undesired complications, such as osteomyelitis or implant failure, can develop after this procedure. Herein, we report the case of an 86-year-old man with right ankle osteomyelitis after TTC arthrodesis with retrograde nail. After removing the previous implants and extensive debridement, we used an antibiotic cement nail with multiple screws fixation as a salvage procedure in the same operation. The patient fully recovered without further surgical treatment.

Introduction

Tibiotalocalcaneal (TTC) arthrodesis with retrograde nail is a widely used procedure that is performed in cases of severe ankle and hindfoot arhtoropathy. 1,2 In comparison to plate-and-screw constructs, the retrograde nail is a load-sharing device with improved bending stiffness and rotational stability that allows for early ambulation. 3 The inherent biomechanical advantages make it a good choice for TTC arthrodesis, and the reported outcomes were satisfactory. According to the previous literature, the union rate ranges from 76% to 96%, and the satisfaction rate could be up to 92%. 4,5 However, it is not a complication-free procedure. Various complications such as delayed wound healing, infection, pseudoarthrosis, malunion, nonunion, fracture, implant prominence, and implant failure have been reported. 2,6,7 Moreover, the management of infection after intramedullary nailing remains a challenge for orthopedic physicians. 8,9 In the presence of infection, implant removal with extensive debridement is usually needed to reduce the biofilm load and increase the cure rate. 10 However, it could result in loss of ankle and subtalar joint stability, which is essential for bony growth and union. Restabilizing the infection site after removing the nail is still controversial. 11 Furthermore, the intramedullary dead space and relatively low local antibiotics concentration make the treatment more difficult. 12 Renailing with a new retrograde TTC nail is an option, however, it could result in a high reinfection rate. 13 Some authors preferred using an external fixator, but the related complications, such as pin tract infection, make it an unfavorable option for these difficult cases. 14 Herein, we describe a case of delayed osteomyelitis after TTC fusion with retrograde nail in which the patient was successfully treated with removal of implants and extensive debridement followed by antibiotic-cemented nail insertion with multiple screws fixation.

Case report

An 86-year-old male patient presented to our institute in August 2018 because of left ankle painful swelling with sinus tract discharge ( Figure 1 ). He had a medical history of chronic atrial fibrillation, hypertension, and a myocardial infarction. The patient suffered from a left ankle fracture 6 years ago but only received conservative treatment. After that, a progression of left ankle deformity with pain was noted. He was diagnosed with advanced ankle arthritis with severe equinovarus deformity at other hospital, and TTC fusion with retrograde nail was performed in April 2018. However, 3 months after the surgery, progressive painful left ankle swelling and wound breakdown with purulent discharge from a sinus tract were noted. An imaging study revealed implant loosening and nonunion at the fusion site ( Figure 2 ). An elevated erythrocyte sedimentation rate and C-reactive protein level and leukocytosis were detected in the laboratory examinations. Surgical debridement was recommended because intramedullary osteomyelitis was diagnosed, but the patient refused. Hence, empirical intravenous antibiotics with oxacillin were given for infection control at that time. The antibiotics were changed to teicoplanin 4 days later because the wound culture examination revealed oxacillin-resistant Staphylococcus aureus (ORSA). However, the infection showed no improvement after 2 weeks of teicoplanin treatment. Therefore, the patient was referred to our hospital for further surgical management according to his request.

Figure 1. An 86-year-old male patient presented to our institute with left ankle painful swelling and sinus tract discharge for 1 month.

Figure 2. Anteroposterior and lateral view of radiography examinations demonstrated loosening of previous locked screws and intramedullary nail without solid fusion of tibiotalocalcaneal joint.

An operation was scheduled immediately because of the failure of conservative treatment. After discussion with the patient and his family, he decided to undergo a single-stage surgery rather than two-stage surgery in consideration of the risk of repeated anesthesia. During the operation, the previous implants were removed, and the soft tissue and intramedullary canal were extensively and carefully debrided. Nonunion over the fusion site was also noted during surgery. We also repeatedly reamed and irrigated the intramedullary canal with normal saline. Then, an antibiotic-loaded polymethylmethacrylate (PMMA) nail was made with a 36-French chest tube and two 2.4-mm Kirschner wires and inserted into the previous intramedullary canal. The PMMA cement was mixed with vancomycin and piperacillin, which are both sensitive to the offending pathogen, ORSA. Finally, we augmented the fixation of the TTC joint with three screws to provide immediate stability ( Figure 3 ). After the operation, intravenous antibiotic treatment with teicoplanin was prescribed for infection control.

Figure 3. The postoperative radiographs revealed that a handmade antibiotic-loaded PMMA nail was introduced into the previous intramedullary canal. Three additional cannulated screws were also inserted simultaneously to provide adequate stability. PMMA: polymethylmethacrylate.

The symptoms gradually improved with medication. The surgical wound was healed at 3 weeks postoperatively, and the stitches were removed. The erythrocyte sedimentation rate and C-reactive protein level were checked regularly to monitor the infection status. The patient was discharged after 4 weeks of intravenous antibiotic treatment. During discharge, the patient was also prescribed oral antibiotic treatment with fusidate and rifampin for continuing infection control. The inflammatory markers returned to their normal values 10 weeks postoperatively, and the antibiotics were discontinued at that time. Solid fusion was noted in a radiographic examination and pain-free walking without assistance for short distances was achieved 5 months after surgery.

Discussion

Treatment of osteomyelitis after nailing is still a challenge for orthopedic physicians even with developments in the field of medicine in recent decades. 8,9 For these cases, the treatment principles include thorough surgical debridement, stabilization of the fracture site, soft tissue coverage, and usage of adequate antibiotics. 15 In our case, infection and nonunion were the two main complications that were encountered. Although some authors recommend retaining the nail regardless of the presence of active infection, removal of the implant is still crucial in reducing the biofilm load and increasing the cure rate. 10,11 However, the stability of the fracture or fusion site, which is essential for bony union, could be lost after implant removal. However, ways to achieve stability after implant removal and surgical debridement remain unclear to date. 11

External fixation after nail removal could stabilize the nonunion site. Ueng et al. reported successful treatment of 15 patients with an infected femoral shaft nonunion using an external skeletal fixation for fracture stabilization. 16 Lin et al. proposed a staged protocol comprising Ilizarov’s technique followed by the application of an intramedullary nail to treat chronic tibia osteomyelitis that resulted in satisfactory outcomes. 17 However, external fixator-related complications, especially pin tract infection, are major concerns with such a protocol. Schalamon et al. reported that the infection rate could be up to 52% in pediatric fractures. 18 Furthermore, the cumbersome frame of an external fixator could result in a low satisfactory rate and make it an unreasonable choice for these patients.

In the treatment of osteomyelitis, extensive debridement followed by dead space management and adequate antibiotics administration is crucial for a cure. However, the local antibiotic concentration might be less than 20% of the serum level even in healthy bone. 12 In addition, debridement in cases of intramedullary infection usually requires reaming of the canal to remove the intramedullary debris and infected bone. Further, it may take approximately 4 weeks to achieve sufficient revascularization after reaming that could further decrease the local intramedullary antibiotic level. 19 Therefore, bactericidal concentration may not be achieved even with prolonged antibiotic administration.

Antibiotic-loaded cement bead chains were first introduced by Klemm for the treatment of osteomyelitis. 20 It can deliver a high concentration of drug locally even in an avascular area. Moreover, the systemic antibiotic level with this approach is very low, which could diminish the toxicity. However, although the use of antibiotic-loaded cement bead chains is a widely accepted technique with satisfactory treatment outcome, there are still some drawbacks of this procedure in terms of intramedullary osteomyelitis. First, the cement beads do not conform to the intramedullary dead space shape. Second, the beads are difficult to remove because of fibrous tissue overgrowth. Finally, they could not provide any stability for the fracture or nonunion site. Hence, additional fixation or a staged operation, removal of the cemented beads followed by reapplication of a new implant after infection control, is usually required.

The antibiotic cement nail technique was first described by Paley and Herzenberg in 2002 to solve the problems of cement bead chains. 21 This technique facilitated the delivery of high amounts of antibiotics, provided limited stability, and helped manage the intramedullary dead space. The nail could also be removed without difficulty if needed; however, its stability is not good enough for fracture healing. Therefore, the antibiotic-coated interlocking nail was introduced to provide both infection control and osseous stability, simultaneously. 22 These nails have been successfully used in various locations and have resulted in good outcomes. However, we found that it is relatively difficult to use the antibiotic-coated nail in our daily practice. With this technique, we are required to use a smaller nail to provide some space for the cement which can decrease the stability. In addition, the calcaneus bone was eroded after previous implant loosening in our case, which may decrease the stability of the interlocking screw and nail.

There is still debate whether single-stage or multiple-stage operation is preferable for osteomyelitis treatment. Staged surgery with repeated debridement followed by soft tissue and bone reconstruction procedures has been recommended to improve the outcome. 19 However, this requires a prolonged hospital stay and might increase the risk owing to multiple anesthesia procedures. Research has also proven that waiting for an operation is stressful and could cause preoperative anxiety. 23 For single-stage surgery, there is still no consensus to date regarding the treatment strategy owing to variability in the offending pathogens, clinical presentation, and host conditions. Single-stage surgery would avoid the drawbacks related to multiple surgeries although the risk of recurrent infection and treatment failure is a major concern. 24 However, some reports have found single-stage operation to be feasible for these difficult cases. 25,26

Our patient was elderly and had cardiovascular disease, which might be a relative contraindication for multiple operations. We used additional screw fixations to achieve adequate stability after antibiotic cement nail insertion. Because the space around the TTC region is much wider than the nail, applying screws is not difficult even with the nail inside. Through our technique, we were able to achieve resolution of the complications in this case in a one-stage operation, which was crucial considering the comorbidity in this case.

Conclusion

Until now, there is no consensus regarding the treatment of intramedullary infection after TTC arthrodesis with retrograde nail. We performed a single-stage operation to treat an elderly patient with cardiovascular disease and had good results. We believe that this procedure could be an alternative choice for patients who are contraindicated for or do not desire multiple surgeries. Although the outcome was satisfactory, further prospective randomized study is indicated to prove the efficacy and feasibility of our technique.

Acknowledgements

The authors would like to thank Dr Wu CH for providing technique help.

Author contributions
Y-CC and I-CC contributed equally to this work.

Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs
Shih-Chieh Yang https://orcid.org/0000-0003-2089-7399

Shyh-Ming Kuo https://orcid.org/0000-0002-3665-7181

Where is Waterworld in the UK?

Where is Waterworld in the UK?

What’s the best waterpark in the UK? WaterWorld Stoke, Staffordshire

WaterWorld Stoke is the UK’s No. 1 Indoor Tropical Aqua Park and a definite must-visit. Situated in the heart of Midlands, it has all that you can ask for from a waterpark.

Why is the water at Waterworld Green? “As for customers commenting on the green tinge – we sell ourselves as a tropical environment, and believe green is good! Much of our water comes directly from a highly eco-friendly borehole on our own site.”

What is the fastest water slide in the UK? Thrill seekers from Coventry and Warwickshire have a new high-octane option with an enormous water slide – dubbed the UK’s fastest – opening nearby. Thunderbolt, which reaches speeds of up to 39kph, is one of four new slides opening at Waterworld in Stoke-on-Trent next week.

Where is Waterworld in the UK? – Related Questions

Are theme parks open UK?

When can theme parks reopen in the UK? According to Prime Minister Boris Johnson’s lockdown roadmap, theme parks can start to reopen from April 12 in England.

Are water parks open in UK?

Pools, gyms, waterparks and sports facilities in England will reopen soon. This announcement was made by Culture Secretary Oliver Dowden who said that “normal life is slowly returning”. As well as sport facilities; beauticians and nail salons will also be able to open their doors again soon.

Can you go on water slides pregnant?

Here’s a list of some activities that can cause problems during pregnancy: Amusement park rides: Waterslides and other rides at amusement parks are a no-no, since a forceful landing or sudden start or stop could harm your baby.

What is the biggest waterpark in the world?

Tropical Islands Resort is the biggest indoor water park in the world, and manages to keep its visitors warm (though not dry) all year. The world’s largest indoor water park covers an area of more than 16 acres—that’s more than the size of six city blocks—and can host up to 6,000 guests at a time.

How long can you stay at Waterworld?

The maximum you can stay is 8 hours & it’s one set price; you get the 1st hour free, then pay £3.50 for the remaining 7 hours.

Is Water World Open 2021?

Water World Opening For The 2021 Season!

Water World is bringing back the fun for 2021 and you’re invited to join in the celebration! We’ve been given approval from county and local health officials to open fill the pools, start the slides and open the gates to welcome you back to this amazing 70-acre water park!

Does Waterworld have a shop?

Let our helpful team members assist you in picking out the perfect swimsuit, t-shirt, or surf shorts. Many other top-notch items can be found in our well-stocked shop, including jewelry, those very popular aqua socks, sunglasses, beach towels, sunscreen!

Where is the fastest water slide?

Get there: Aldeia das Aguas Park Resort is in Rodovia, about 85 miles northwest of Rio de Janeiro. At 49.9m high – 12m higher than the city’s Christ the Redeemer statue – this is not only the world’s tallest slide, it’s also reportedly the world’s fastest, with a record speed of 57mph.

When did Waterworld Stoke open?

Waterworld is a water park located in Festival Park, Stoke-on-Trent, Staffordshire, England. The park attracts 400,000 visitors per year. The park first opened in 1989 and is generally open year-round, but is closed for a few days of the week during term time.

Has anyone died Thorpe Park?

Tragic Evha, from Leicester, died in hospital after she fell into the water on the ride in front of horrified pals on a school trip. Staffordshire Police said: “Evha sadly died after falling from a water ride at the theme park.

Is Thorpe Park bigger than Alton Towers?

Thorpe Park has very little land to play with, and as a result it makes the sense that it installs major thrill rides with small surface areas. In contrast, Alton Towers has masses of space to work, but suffers from severe planning restrictions, with many flat rides exceeding its ceiling height of 65 feet.

How do you get to Alton Towers without a car?

There are three train stations near Alton Towers: Stoke-on-Trent, Uttoxeter and Derby. Guests arriving at Stafford or Uttoxeter railway station, visitors will need to contact a local taxi service for the rest of the journey to the resort.

What is the most expensive water park?

Universal’s Volcano Bay is now the most expensive water park in the world. Following Disney’s strategy of increasing prices to help regulate crowd flow, Volcano Bay has jumped up in price significantly.

What is the smallest water park in the world?

Smallest water park ever been to – Review of Parque Acuatico Aquavera, Vera, Spain – Tripadvisor.

Does water world have a lazy river?

After all, your summer won’t be complete without a few hours on this delightful lazy river. This is the first season that Waterworld is now known as Six Flags Hurricane Harbor Concord. The lazy river, called the Kaanapali Kooler, is considered the longest lazy river in Northern California!

How much does it cost to go to Waterworld?

$49.99 General Admission (48″+), $44.99 Child (under 47″). $14.99 Seniors (ages 60+). Tots under 40″ in height are free of charge. * Ticket prices do not include tax.

Where is the biggest water park in Europe?

Alpamare – Bad Seedamm, Switzerland

Alpamare (an hour and a half from Basel) is Europe’s biggest covered waterpark, so it’s not affected by the weather and it’s open all year round.

Can you ride roller coasters 1 month pregnant?

Avoid amusement park rides, water slides and roller coasters. Forceful landings and sudden sharp stops can hurt your baby. Staying away from rides like these might be challenge if you already have other rugrats that may want to go, or friends that invite you out.

Can I jump off a diving board pregnant?

Diving into the water off a diving board while pregnant is not recommended due to two things: Force of impact: The impact of the water hitting your body while diving, especially if you don’t dive professionally, can hurt your body and cause stress to your uterus and baby.

Where is the biggest waterpark in America?

Noah’s Ark is America’s Largest Waterpark®, located in the Waterpark Capital of the World. Situated on 70 sprawling acres in the heart of Wisconsin Dells, Noah’s Ark is the best place for family vacations.

Is Waterworld still open?

Waterworld season closure

Thank you for visiting Waterworld during the 2020-2021 season. Waterworld is closed and will reopen in October. Bring the family and enjoy our heated pools, whiz down the curly slide or challenge your friends on the two racing slides.

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