OTA 1999 Posters

Infected Ununited Fractures of the Tibia: Results of Treatment with Intramedullary Nailing

William L. Craig, III, MD; Jordan B. Renner, MD; Laurence E. Dahners, MD,

University of North Carolina at Chapel Hill, Raleigh, NC

Infected ununited fractures of the tibia present a complicated problem to the orthopaedic surgeon. The goals of treatment include bony union, eradication of the infection, and restoration of function. Concern over spreading the infection and reports of amputation have led some to suggest that intramedullary (IM) nails not be used in this setting. However, some studies have suggested that IM nails may provide a good treatment option. It has been the practice of the senior author to reconstruct infected ununited fractures of the tibia with an IM nail. We believe that IM nails provide the most stable fixation and therefore the best opportunity for bony union in addition to allowing for earlier weight bearing and restoration of function. The purpose of this study was to retrospectively evaluate the outcome of patients with infected ununited fractures of the tibia treated with an IM nail at our institution.

The charts of all patients who underwent intramedullary nailing for an infected ununited tibia fracture at our institution between 1985 and 1996 were reviewed retrospectively. A patient was considered infected if they had had a positive culture or a history of purulent drainage. Charts were reviewed to determine mechanism of injury, treatment history, history of infection, and follow-up data. Follow-up radiographs were reviewed by a musculoskeletal radiologist to determine bony union.

Sixteen patients with infected ununited fractures of the tibia were treated with intramedullary nails. The condition most commonly followed an open fracture (87%) of the tibia initially treated with external fixation (63%). The intramedullary nailing for the treatment of the infected nonunion was performed on average 21.2 months after the initial injury. Staphylococcus was the most common organism isolated (56%). Five patients (31%) had the nail placed at a staged procedure (separate operative procedure following a debridement). Eleven patients (69%) had the nail placed at the time of the debridement. Intramedullary antibiotic irrigation was used for 3 to 7 days postoperatively in 9 patients (56%). Average follow-up was 36 months. Fifteen of sixteen fractures healed at an average of 35 weeks. All patients were permitted full weight bearing at an average of 22 weeks. Three patients (19%) had persistent wound drainage at last follow-up. Staging the procedure or using intramedullary antibiotic irrigation postoperatively produced no improvement in outcome. There were 4 (25%) significant complications; one guide wire penetration into the ankle, two refractures after nail removal, and one broken nail. There were no amputations.

Although the use of intramedullary fixation for the treatment of an aseptic nonunion is well accepted, its use in the presence of infection is controversial. Concern over worsening infection and amputation has led some to favor other methods of treatment. However, clinical studies have described good results with the use of IM nails in the treatment of infected nonunions. Miller reported on 19 infected nonunions of the tibia treated with irrigation and debridement, intramedullary nailing and open wound management. Eighteen of nineteen fractures healed at an average of 6.6 months. Four fractures (21%) had persistent drainage. No patient required an amputation. Klemm reported on 27 patients with an infected nonunion of the tibia treated with IM nail, closed wound management and intramedullary irrigation with Ringer's lactate. Seventy percent (19 of 27) of the fractures healed. One patient required an amputation. Lottes also reported the successful treatment of infected nonunions of the tibia with an intramedullary nail.

The results of this study provide further evidence that an IM nail may be an effective and safe treatment option for selected infected nonunions of the tibia. Most importantly, we believe that the functional level the intramedullary nail allows the patient to achieve prior to union is a significant advantage. Although good results can be obtained with this treatment method, there appears to be a significant risk for complication (25%). The procedure is technically demanding and should be reserved for bony injuries amenable to intramedullary fixation. The decision as to when to remove the nail should be given careful consideration.