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

Overview

Journal Open Orthop J

Publisher Bentham Open

Specialty Orthopedics

Date 2013 Aug 7

PMID 23919097

Citations 25

Authors

Kostas G Makridis

Theodoros Tosounidis

Peter V Giannoudis

Affiliations

Soon will be listed here.

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.

Citing Articles

Treatment of Infection After Tibial Intramedullary Nailing With Bone Distraction Combined With Free Anterolateral Thigh Flap for Concomitant Soft-tissue Defect.

Zhou Z, Qin H, Marei A, Wen J, Yu L, Meng F Plast Reconstr Surg Glob Open. 2024; 12(12):e6346.

PMID: 39687414 PMC: 11649285. DOI: 10.1097/GOX.0000000000006346.

Impact of Surgical Timing on Fracture Healing in Tibial Shaft Injuries: A Comparative Review of Intramedullary Nailing Techniques.

Kashyap S, Ambade R, Landge S, Salwan A Cureus. 2024; 16(10):e70978.

PMID: 39507186 PMC: 11539009. DOI: 10.7759/cureus.70978.

Infection complicating locked intramedullary nailing of open lower-extremity fractures: incidence, associated risk factors, and lessons for improving outcome in a low-resource setting.

Adesina S, Amole I, Akinwumi A, Adegoke A, Owolabi J, Adefokun I J Bone Jt Infect. 2024; 8(1):71-79.

PMID: 38774303 PMC: 11106765. DOI: 10.5194/jbji-8-71-2023.

Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections.

Ann Azad M, Patel R Clin Microbiol Rev. 2024; 37(2):e0010423.

PMID: 38506553 PMC: 11237642. DOI: 10.1128/cmr.00104-23.

Antibiotic-Coated Intramedullary Nailing Managing Long Bone Infected Non-Unions: A Meta-Analysis of Comparative Studies.

Ghaseminejad-Raeini A, Azarboo A, Pirahesh K, Sharafi A, Hoveidaei A, Nwankwo B Antibiotics (Basel). 2024; 13(1).

PMID: 38247628 PMC: 10812602. DOI: 10.3390/antibiotics13010069.

References

Hiesterman T, Shafiq B, Cole P . Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011; 19(11):690-700. DOI: 10.5435/00124635-201111000-00005. View

Court-Brown C, Keating J, McQueen M . Infection after intramedullary nailing of the tibia. Incidence and protocol for management. J Bone Joint Surg Br. 1992; 74(5):770-4. DOI: 10.1302/0301-620X.74B5.1527132. View

Changulani M, Jain U, Keswani T . Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop. 2006; 31(3):391-5. PMC: 2267584. DOI: 10.1007/s00264-006-0200-1. View

Henley M, Chapman J, Agel J, Harvey E, Whorton A, Swiontkowski M . Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma. 1998; 12(1):1-7. DOI: 10.1097/00005131-199801000-00001. View

Motsitsi N . Management of infected nonunion of long bones: the last decade (1996-2006). Injury. 2008; 39(2):155-60. DOI: 10.1016/j.injury.2007.08.032. View

Lowenberg D, Feibel R, Louie K, Eshima I . Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects. Clin Orthop Relat Res. 1996; (332):37-51. DOI: 10.1097/00003086-199611000-00007. View

Shah R, Moehring H, Singh R, Dhakal A . Surgical Implant Generation Network (SIGN) intramedullary nailing of open fractures of the tibia. Int Orthop. 2004; 28(3):163-6. PMC: 3474498. DOI: 10.1007/s00264-003-0535-9. View

Bong M, Kummer F, Koval K, Egol K . Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007; 15(2):97-106. DOI: 10.5435/00124635-200702000-00004. View

Petrisor B, Anderson S, Court-Brown C . Infection after reamed intramedullary nailing of the tibia: a case series review. J Orthop Trauma. 2005; 19(7):437-41. DOI: 10.1097/01.bot.0000161542.93624.8d. View

10.

Stannard J, Harris H, McGwin Jr G, Volgas D, Alonso J . Intramedullary nailing of humeral shaft fractures with a locking flexible nail. J Bone Joint Surg Am. 2003; 85(11):2103-10. DOI: 10.2106/00004623-200311000-00007. View

11.

Karadimas E, Papadimitriou G, Theodoratos G, Papanikolaou A, Maris J . The effectiveness of the antegrade reamed technique: the experience and complications from 415 traumatic femoral shaft fractures. Strategies Trauma Limb Reconstr. 2009; 4(3):113-21. PMC: 2787205. DOI: 10.1007/s11751-009-0071-2. View

12.

Romano C, Romano D, Logoluso N, Drago L . Bone and joint infections in adults: a comprehensive classification proposal. Eur Orthop Traumatol. 2011; 1(6):207-217. PMC: 3150792. DOI: 10.1007/s12570-011-0056-8. View

13.

Megas P, Saridis A, Kouzelis A, Kallivokas A, Mylonas S, Tyllianakis M . The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method. Injury. 2010; 41(3):294-9. DOI: 10.1016/j.injury.2009.09.013. View

14.

Aderinto J, Keating J . Intramedullary nailing of fractures of the tibia in diabetics. J Bone Joint Surg Br. 2008; 90(5):638-42. DOI: 10.1302/0301-620X.90B5.19854. View

15.

Tsourvakas S, Alexandropoulos C, Papachristos I, Tsakoumis G, Ameridis N . Treatment of humeral shaft fractures with antegrade intramedullary locking nail. Musculoskelet Surg. 2011; 95(3):193-8. DOI: 10.1007/s12306-011-0126-7. View

16.

Simpson A, Wood M, Athanasou N . Histological assessment of the presence or absence of infection in fracture non-union. Injury. 2002; 33(2):151-5. DOI: 10.1016/s0020-1383(01)00078-x. View

17.

Keating J, OBrien P, Blachut P, Meek R, Broekhuyse H . Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997; 79(3):334-41. DOI: 10.2106/00004623-199703000-00003. View

18.

Uhlin B, Hammer R . Attempted unreamed nailing in tibial fractures: a prospective consecutive series of 55 patients. Acta Orthop Scand. 1998; 69(3):301-5. DOI: 10.3109/17453679809000935. View

19.

Tang P, Gates C, Hawes J, Vogt M, Prayson M . Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?. J Orthop Trauma. 2006; 20(5):317-22. DOI: 10.1097/00005131-200605000-00004. View

20.

Giannoudis P, Xypnitos F, Dimitriou R, Manidakis N, Hackney R . "Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature". J Orthop Surg Res. 2012; 7:39. PMC: 3554551. DOI: 10.1186/1749-799X-7-39. View