infection after intramedullary nailing of the femur

Infection after Intramedullary Nailing of the FemurChin-En Chen, MD, Jih-Yang Ko, MD, Jun-Wen Wang, MD, and Ching-Jen Wang, MD

Background: The management of in-fection after intramedullary nailing of thefemoral shaft fracture remains a challengeto orthopedic surgeons. The dilemma con-fronting surgeons concerns the removal orretention of the nail in the presence ofinfection.

Methods: The authors treated 23 in-fections after intramedullary nailing forfemoral fractures. All fractures were un-healed at presentation. All patients werefollowed for at least 1 year after the infec-tion. Acute infection occurred in 13 pa-tients, subacute infection in 5, and chronicinfection in 5. The patients were dividedinto two groups on the basis of the methodof the initial treatment. In group I (12patients), the intramedullary nails were

retained, and there were 11 men and 1woman, with an average age of 36 years(range, 1555 years). In group II (11 pa-tients), the nails were removed at the timeof debridement and the fractures werestabilized with external fixation, and therewere nine men and two women, with anaverage age of 44 years (range, 2569years).

Results: In group I, all fractureshealed within an average period of 9months (range, 515 months) after surgi-cal debridement. There was no recurrenceof infection at an average follow-up of 25months (range, 1276 months). In groupII, seven fractures healed within an aver-age of 10 months (range, 424 months)after treatment. At an average follow-up

of 33.8 months (range, 1279 months), in-fected nonunion was noted in two patients.More complications occurred in group IIpatients in comparison with group I pa-tients. Limited range of motion of the kneejoint was usually encountered if a fracturewas stabilized with external fixation for aprolonged period of time.

Conclusion: Retention of the in-tramedullary nail is performed if the fix-ation is stable and the infection is undercontrol. External fixation is most suitablefor uncontrollable osteomyelitis or in-fected nonunion. Staged bone grafting isusually necessary when a bone defect ispresent.

Key Words: Infection, Intramedul-lary nailing.

J Trauma. 2003;55:338344.

The management of infection after intramedullary (IM)nailing of the femoral shaft fracture remains a challengeto orthopedic surgeons. The dilemma confronting thesurgeons concerns the removal or retention of the nail in thepresence of active infection. Several authors have suggestedretaining the nail for fracture stabilization despite theinfection.13 Barquet et al.4 recommended antibiotic suppres-sion treatment until the fracture healed in stable nailing, andremoval of the nail in unstable nailing. Stabilization of thefracture after removal of the nail is also controversial andshould be individualized. After sequestrectomy, rinsing, andantibiotic treatment, the fracture could be renailed using aninterlocking nail, which provides stable fixation for the in-fected long bone.4 The fracture can also be stabilized with anexternal fixation device after removal of the nail. In infectednonunion of the femur shaft fracture, some authors preferexternal skeletal fixation for fracture stabilization, antibioticbeads as local therapy, and early bone grafting.5,6 However,the role of external fixation for infection after IM nailing of

the femoral shaft fracture is unclear. The purpose of thisstudy was to retrospectively analyze the clinical results oftreatment of infection after IM nailing and focus on the latecomplications after treatment.

MATERIALS AND METHODSA retrospective study of 23 patients who developed in-

fection after IM nailing of the femoral shaft at the authorshospital between 1993 and 1998 was conducted. All patientswere followed for at least 1 year after the onset of infection.There were 20 men and 3 women. The average age at the timeof fracture was 36 years (range, 1567 years). The onset ofinfection after nailing ranged from 5 days to 10 years. Pain,swelling, and local heat were present in all acute infections. Adischarging sinus was usually noted in chronic infection.

According to Seligson and Klemms classification forosteomyelitis after IM nailing, acute osteomyelitis occurswithin the first 30 days, subacute osteomyelitis occurs from 1to 6 months, and chronic osteomyelitis occurs for more than6 months.7 Infected nonunion of the femur was defined as thefracture site being ununited 6 months after treatment with IMnailing.8 In the current series, acute infection occurred in 13patients, subacute infection occurred in 5, and chronic osteo-myelitis occurred in 5. Infected nonunion after nailing wasnoted in five cases at presentation.

According to the initial treatment, the patients were di-vided into two groups. The individual treatment program wasdetermined by the surgeon on the basis of the clinical symp-toms of the patient and the duration of infection. In group I,

Submitted for publication March 2, 2002.Accepted for publication August 9, 2002.Copyright 2003 by Lippincott Williams & Wilkins, Inc.From the Department of Orthopedic Surgery, Chang Gung Memorial

Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan, Republic ofChina.

Address for reprints: Chin-En Chen, MD, Department of OrthopedicSurgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123,Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien 83305, Taiwan, Republicof China; email: [email protected].

DOI: 10.1097/01.TA.0000035093.56096.3C

The Journal of TRAUMA Injury, Infection, and Critical Care

338 August 2003

12 patients were treated with retention of the nail (Fig. 1).There were 11 men and 1 woman, with an average age of 36years (range, 1555 years). The right femur was involved infive patients and the left in seven. The fracture was located inthe proximal third of the femur in four patients, the middlethird in six patients, and the distal third in two patients. Tenpatients had an associated injury at the time of injury. Allwere closed fractures. The initial treatment included opennailing in seven, closed nailing in one, and plating in four.

Five patients received a secondary nailing for reasons otherthan infection, which included open nailing and bone graftingfor aseptic nonunion after plate fixation in four, and correc-tive osteotomy for malunion in one. An acute osteomyelitiswas noted in eight, and subacute osteomyelitis was noted infour. The treatment in this group included debridement anddrainage in eight cases, debridement followed by reinsertionof the nail in two cases, and external fixation after failure ofdebridement and nail retaining in two cases. Antibiotic beads

Fig, 1. (A and B) Radiographs of the femur in a 38-year-old man showing interlocking nailing and local antibiotic beads for nonunion offemoral shaft fracture. (C and D) After local debridement and antibiotic suppression treatment, staged bone grafting was performed topromote bone union. Radiographs of the femur showing bone union 9 months postoperatively. (E and F) Anteroposterior and lateralradiographs showing solid union of the fracture after removal of IM nail. There was no recurrence of infection.

Infection after Intramedullary Nailing

Volume 55 Number 2 339

were placed at the fracture site after the debridement in sevencases.

In group II, the nails were removed and the fractureswere stabilized with an external fixator after irrigation anddebridement (Fig. 2). There were nine men and two women,with an average age of 44 years (range, 2569 years). Theright femur was involved in seven patients and the left infour. The fracture was located in the proximal third of thefemur in one patient, the middle third in four patients, and thedistal third in four patients; segmental fractures occurred intwo patients. Seven patients had an associated injury. Therewas closed fracture in nine and open type I fracture in two

patients. The initial treatment included open nailing in 10 andplating in 1. One patient received open nailing and bonegrafting for aseptic nonunion after plate fixation failure. Inthis group, there was acute infection in five, subacute infec-tion in one, and chronic infection in five. Antibiotic beadswere placed at the fracture site after debridement for localtherapy for all patients. Exchange to internal fixation wasperformed in two patients after the infection was under con-trol. No patients in either group required a flap to reconstructa soft tissue defect.

In acute infection, intravenous antibiotic therapy withoxacillin and gentamicin was given immediately after wound

Fig. 2. (A) Radiographs of the femur in a 25-year-old man showing upper-third fracture of the right femur treated with open reduction andinternal fixation with Kntscher nail and wires. (B) The infection developed 8 months postoperatively. After debridement and removal of thenail, the fracture was stabilized with an external fixation device. (C and D) The fracture was united after staged cancellous bone grafting.


340 August 2003

culture was performed. The antibiotic therapy was thenchanged according to the sensitivity test of the cultured mi-croorganism. Erythrocyte sedimentation rate and C-reactiveprotein were measured weekly to monitor the infection con-trol. The duration of antibiotic treatment was determined onthe basis of the clinical response of the patient and bacteriaspecies. The use of antibiotics was usually longer if theinfected microorganisms included multiple flora or gram-negative infections. The patients received regular follow-upat our outpatient clinic at 4- to 6-week intervals for clinicalevaluation and to assess the healing process of the fracture byobtaining radiographs of the femurs. Nonunion was definedas the fracture persistently ununited after 1 year of treatment.

RESULTSIn group I, the number of operative procedures after

infection ranged from one to seven (range, 3.2). Five casesreceived bone grafting to promote bone union. The infectingmicroorganism in this group included oxacillin-resistantStaphylococcus aureus in five, oxacillin-sensitive S. aureusin one, Escherichia coli in one, Acinetobacter in one, groupD Streptococcus in one, and mixed infection in three (Table1). Parenteral antibiotic therapy was used for 2 to 3 weeksfollowed by oral antibiotics for 4 to 6 weeks. All fracturesunited between 5 and 15 months (average, 9 months). Thenail was removed in five patients after the fracture healed.Five complications in four patients were noted, which in-cluded limited range of motion (ROM) of knee joints of lessthan 120 degrees in four, and leg-length discrepancy 1 cmin one. There was no recurrence of infection at an averagefollow-up of 25 months (range, 1276 months).

In group II, the number of operative procedures afterinfection ranged from two to nine (average, 4.5), and allpatients received staged bone grafting to promote bone unionif the infection was under control. The infecting microorgan-isms included oxacillin-resistant S. aureus in five, oxacillin-sensitive S. aureus in two, and mixed infection in four.Parenteral antibiotics were given for 10 to 14 days and then

oral antibiotics were given for 2 to 3 weeks. The patients inthis group were followed for an average of 34 months (range,1279 months). Seven fractures healed between 4 and 24months (average, 10 months). Two patients underwent above-knee amputation because of a nonfunctional limb as a sequelaof head injury. Excluding the pin-track infection, nine com-plications in seven patients were noted in this group. Therewas limited ROM of the knee joint in seven patients andleg-length discrepancy more than 1 cm in two. No angulardeformity in this group was noted, even after long-term use ofthe external fixator. Two persistent cases of infected non-union of the femoral shaft fracture were noted at the latestfollow-up (Tables 2 and 3).

DISCUSSIONThe goal of treatment for infection after IM nailing of the

femur is to eradicate infection, achieve bone healing, andimprove the functional result. The basic principles of treat-ment included debridement, fracture stabilization, soft tissuereconstruction, and systemic and/or local antibiotic treatment.Stable fixation of the fractures is essential for bone union.However, as long as there is an intramedullary nail in place,infection may spread along its path.9 With systemic antibiotictherapy alone, although the purulent infection may diminish,the infection cannot be completely eradicated when the im-plant is in place.10 The dilemma confronting surgeons con-cerns the removal or retention of the nail in the presence ofinfection. In acute infection, several authors have advocatedretaining the nail despite the infection and then nail removaland reaming debridement after the fracture has healed.11

Patzakis et al.11 reported 30 patients with infection oflong bone fractures after intramedullary nailing and sug-gested that nail stabilization for fracture healing after debride-ment and appropriate antibiotic therapy were the critical fac-tors in the orthopedic management of infection after IMnailing. They recommended that prompt surgical irrigationand debridement should be performed after infection wasdocumented. In 17 of 30 fractures, the infection was localized

Table 1 Infecting Microorganism after IM NailingBacterial Culture No. of Cultures Nail-Retaining Group Nail-Removal Group

Gram-positive cocciORSA 13 5 8OSSA 4 2 2Group D Streptococcus 2 2Staphylococcus hemolyticus 2 1 1

Gram-negative rodsEscherichia coli 2 2Acinetobacter 4 2 2Pseudomonas aeruginosa 3 1 2Enterobacter cloacae 1 1Citrobacter diversus 1 1Proteus mirabilis 1 1Klebsiella pneumonia 1 1

Total isolates 34 17 17

ORSA, oxacillin-resistant S. aureus; OSSA, oxacillin-sensitive S. aureus.



to the fracture site and adjacent medullary cavity with abscessformation, and in two patients the infection was only local-ized at the protruding tip of the nail. The abscess was locatedin the distal screw hole in one of our patients. After localdebridement and antibiotic treatment, the infection was undercontrol and the fracture healed. The nail was removed afterthe fracture healed. There was no recurrence of infection atthe time of follow-up.

Barquet et al.4 recommended retaining the nail until thefracture healed in stable fractures without radiologic seques-trum, and reaming the canal 2 or 3 months after fracturehealing. In an unstable fracture or in the presence of radio-logic sequestrum, refixation with interlocking nailing wasperformed. In our series, the nail was retained in 12 patients(group I). Of these, the infections were acute or subacuteosteomyelitis. The IM nails were used for acute fracturefixation or secondary nailing for aseptic nonunion. Two ofthe 12 nails (group I) were shifted to external fixation. Bothwere acute and multiple flora infections. We decided toremove the nail because of uncontrollable infection afterdebridement twice, even when the nail was stable.

Klemm et al. stated that the hallmark of infection afterIM nailing was longitudinal spread of sepsis into the medul-lary canal along the entire length of the nail and that reamingwas the only way to loosen and remove the small lamellarsequestra that cling to the endosteum.9 Lidgren and Torholm

reported on their successful experience, which added IMreaming to conventional local eradication of sequestrum toimprove the treatment of chronic osteomyelitis of diaphysealbone.12 In our series, only five nails were removed after thefracture healed and reaming of the medullary canal wasperformed. Although reaming of the medullary canal afternail removal was recommended, it was difficult to determineits usefulness.1113 Nail removal is advisable in young pa-tients if the fracture has healed. Routine nail removal is notsuggested. The necessity for nail removal and the usefulnessof reaming the canal after fracture healing require longerclinical experience and larger series.

In infected nonunion of the long bone, there are twobasic strategies of treatment: the union first strategy, andthe infection elimination first strategy. Ueng et al. reportedexternal fixation for infected nonunion of the long bone witha good result.5 However, there are many problems that maybe encountered with external fixation for femoral fractures.Pin-track infection often occurs because of poor drainage ofdischarge from the femur. It usually takes too long for im-mobilization because of the risk of refracture or angulationsafter premature removal of the external fixator. Motion of thethigh is unavoidable with external fixation. Therefore, exter-nal fixation of the femur increased the risk for pin-trackinfection and restriction of motion of the knee by bindingdown the quadriceps muscle and should be used only inselected cases. MacAusland14 emphasized that if fracturestability was dependent on the nail, the nail should not beremoved prematurely. Besides, in acute osteomyelitis, thepossibility of bony union is better than in infected nonunion.The principle of treatment should be different from that forinfected nonunion of the femoral fracture.

Klemm et al.9 had suggested that it might be necessary tochange from an interlocking nail to an external fixation de-vice to control the infection when there was persistent puru-lent drainage or segmental bone loss. However, the result wasunpredictable and the treatment was too long. In their recent

Table 2 Comparison of the Data and Result between Nail-Retaining Group and Nail-Removal GroupNail-Retaining Group (range) Nail-Removal Group (range)

Age (yr) 36 (1555) 44 (2569)Sex (M:F) 11:1 9:2Side (R:L) 5:7 7:4Location (U/3:M/3:L/3:segmental) 4:6:2:0 1:4:4:2Initial treatment (nailing:plating) 8:4 10:1Osteomyelitis (acute:subocute:chronic) 8:4:0 5:1:5Antibiotic beads (cases) 7 11Bone grafting (cases) 5 9No. of operative procedure 3.2 (17) 4.5 (29)Duration of antibiotic treatment (wk) 68 34Bone union (mo) 9 (515) 10 (424)Infection control (%) 100 82Fracture union (%) 100 82Complications (patients) 4 11Follow-up (mo) 25 (1276) 34 (1279)

M, male; F, female; R, right; L, left; U/3, upper-third; M/3, middle-third; L/3, lower-third.

Table 3 Comparison of the Complications betweenNail-Retaining Group and Nail-Removal Group

Complications Nail-RetainingGroupNail-Removal

Group

Limited motion of knee joint(120 degrees)

4 7

LLD 1 cm 1 2AK amputation 2Infected nonunion 2

LLD, leg-length discrepancy; AK, above-knee.


342 August 2003

report, Seligson and Klemm suggested renailing the femurafter the infection was under control.7 In our series, 11 pa-tients had nails (group II) removed because of infection, and9 patients had received staged cancellous bone grafting topromote bone union. At the time of follow-up, two patientshad a persistent infected nonunion despite external fixationtreatment or intramedullary nailing. One case with chronicosteomyelitis of the femur presented with discharging sinusof 10 years duration. Removal of the intramedullary nail,stabilization with external skeletal fixation, and vascularizedfibular bone grafting to reconstruct the segmental defect wereperformed. Unfortunately, infected nonunion persisted de-spite the treatment. The other case was a diabetic patient. Thenail was removed and the femur was stabilized with externalfixation because of purulent discharge and uncontrollablesepsis. After infection was under control, secondary nailingwas performed to stabilize the fracture. However, the infec-tion has persisted despite repeated debridement and externalfixation after 1 year of treatment.

It was also noted that there was a very high incidence ofinfection when the external fixators were replaced by in-tramedullary nails.15,16 Two of our patients were treated withthis method. Indications for pin-track infection were notpresent, and the patients could not tolerate the treatment withan external fixation device because of cosmetic reasons. Bothpatients had a complex treatment course. One patient re-ceived IM nailing and bone grafting because of treatmentfailure with external fixation. Recurrence of infection wasnoted after nailing. The nail was removed and the canal wasreamed and debrided after the fracture healed. At 3-yearfollow-up, there was no recurrence of infection. The otherpatient was a diabetic patient in whom the infection wasuncontrollable even with external fixation. Infected nonunionpersisted at the latest follow-up of 2 years after treatment.The patient died of a medical condition unrelated to thefemoral osteomyelitis.

The most common infecting microorganism in bothgroups was oxacillin-resistant S. aureus (Table 1). Becauseclosed-suction irrigation might be associated with increasedrisk for superinfection, closed drainage tubes were used inpatients in whom the wound was closed. A polymethyl-methacrylate antibiotic chain was very useful as a local an-tibiotic in the treatment of osteomyelitis.17,18 In this series,only five fractures in group I did not receive local antibiotictreatment because there was no bone defect after the debride-ment. Local antibiotic treatment after debridement is ourroutine procedure in the management of infection after IMnailing. Treatment with local antibiotic beads is indicatedwhen there is a significant bone defect in which later bonegrafting is planned. The bone grafting was usually performed4 to 6 weeks later, after treatment with local antibiotic beads.Removal of the local antibiotic beads and replacement withcancellous bone grafting was performed in 12 patients.

Because the external fixation pins hinder the placementof antibiotic beads, Klemm et al.9 had suggested using anti-

biotic sticks that are flexible enough to pass by externalfixation pins into the narrow cavity for its entire length. Noneof the patients in our series has received these antibioticsstick. The antibiotic beads were placed and filled the bonedefect at the fracture site after the debridement was per-formed. The alternatives for reconstruction of bone defectsafter infection are cancellous grafting, vascularized bonetransfer, and bone transport.

Systemic antibiotic treatment was determined by theresult of culture and sensitivity testing. The often recom-mended standard length of antibiotic administration is 4 to 6weeks, but there is no evidence that this regimen is superiorto treatment for shorter periods.19 Although the duration ofparenteral antibiotic therapy must be individualized, mostpatients in this series received 2 to 3 weeks of treatment. Inthe nail-retaining group (group I), oral antibiotics were givenfor an additional 4 to 6 weeks until the erythrocyte sedimen-tation rate and C-reactive protein became normal.

In our series, 4 of 12 cases (30%) had limited motion ofthe knee in group I, and all cases in group II had limited ROMof the knee joints, which was consistent with the observationof MacAusland. All cases in group I had bone union and norecurrence of infection at the time of follow-up. In group II,seven patients achieved fracture union and no infection. Twopatients received amputation because of a nonfunctional limbattributable to sequelae of head injury. Two cases showed apersistent nonunion at follow-up. There were more compli-cations in group II compared with group I. Limited range ofmotion of the knee joint was usually encountered if a fracturewas stabilized with an external fixator. Bone grafting wasusually necessary in group II to promote bone union.

The shortcoming of this study is the fact that it is un-controlled and retrospective. The treatment course was morecomplicated in most of the patients compared with the treat-ment for a simple femoral shaft fracture. The decision-mak-ing was sometimes difficult because the treatment result wasunpredictable and the treatment course always long. Thetreatment choice was individualized for each patient, and nostrict principle can be followed. The compliance of the pa-tient was important, especially under treatment with externalfixation and to prevent the possibility of pin-track infection.

In conclusion, adequate debridement, antibiotic treat-ment, and stabilization of the femoral shaft fracture are themainstays of treatment for infection and enhancement offracture healing. Despite different methods of fixation usedafter infection of IM nailing of the femur, most fracturesachieved union eventually. Limited motion of the knee jointand leg-length discrepancy were common, especially afterprolonged treatment with external fixation. We suggest thatretention of the IM nail be performed if the fixation is stableand the infection is under control. External fixation may bemost suitable for uncontrollable osteomyelitis or infectednonunion. Staged bone grafting is usually necessary when abone defect is present.



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infection after intramedullary nailing of the femur

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