-
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.
The Journal of TRAUMA Injury, Infection, and Critical Care
340 August 2003
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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.
Infection after Intramedullary Nailing
Volume 55 Number 2 341
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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.
The Journal of TRAUMA Injury, Infection, and Critical Care
342 August 2003
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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.
Infection after Intramedullary Nailing
Volume 55 Number 2 343
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344 August 2003