Management of Infection After Intramedullary Nailing of Long Bone Fractures: Treatment Protocols and Outcomes

Abstract

Implant related sepsis is a relatively unusual complication of intra-medullary nail fixation of long bone fractures. Depending on the extent of infection, timing of diagnosis and progress of fracture union, different treatment strategies have been developed. The aim of this review article is to collect and analyze the existing evidence about the incidence and management of infection following IM nailing of long bone fractures and to recommend treatment algorithms that could be valuable in everyday clinical practice. After searching the P u b M e d /Medline databases, 1270 articles were found related to the topic during the last 20 years. The final review included 28 articles that fulfilled the inclusion criteria.Only a few prospective studies exist to report on the management of infection following IM nailing of long-bone fractures. In general, stage I (early) infections only require antibiotic administration with/without debridement. Stage II (delayed) infections can be successfully treated with debridement, IM reaming, antibiotic nails, and administration of antibiotics. Infected non-unions are best treated with exchange nailing, antibiotic administration and when infection has been eradicated with graft implantation if it is needed. Debridement, exchange nailing and systemic administration of antibiotics is the best indication for stage III (late) infections, while stage III infected non-unions can successfully be treated with nail removal and Ilizarov frame, especially when large bone defects exist.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model

“…Clinically, the development of infection after intramedullary nailing may progress as far as sepsis. Even in the event of sepsis, it has been reported that union can still occur in a fracture that has stable fixation with intramedullary nailing [16]. In the current study, a high number of S aureus (1 9 10 8 ) was used to create a local infection rate of 100% with low morbidity.…”

“…Torque to failure and stiffness both were lower in the infection group than in the control group at 6 weeks, but with the numbers available for testing, they were not different at 3 weeks (p = 0.615 and p = 1, respectively; Table 2 [3][4][5][6][7][8][9][10][11][12][13][14][15][16]; p = 0.004) both were greater in the control group than in the group with infection. Maximum torque to failure was lower in the infection group than in the control group at all time points.…”

“…Results Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 ; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3][4][5][6][7][8][9][10][11][12][13][14][15][16]; p = 0.004) both were greater in the control group than in the group with infection.…”

Increased risk of adverse events in management of femur and tibial shaft fractures with plating: An analysis of NSQIP data

“…Advanced age has been shown to be a risk factor for postoperative complications such as nonunion as well as a risk factor for developing a long bone fracture. 5,8,9,27 ASA score was significantly predictive of postoperative complications, in which each unit increase was associated with a 2-fold increase in developing a postoperative complication. Knowing the risk factors for postoperative complications of lower extremity long bone fractures, surgeons will be able to better risk stratify patients based on fracture type and be able to better prevent acute postoperative complications.…”

“…[4][5][6][7] Older individuals also face an increased risk of long-bone fractures due to a decrease in bone density associated with age and increased risk of falling. 5,8,9 Management of long bone fractures varies from conservative methods including casting and bracing to surgical, encompassing open reduction internal fixation (ORIF) with plates or intramedullary nailing (IMN). 2,3 Optimal treatment for long-bone fractures is still debated among orthopaedic surgeons and depends on various factors.…”