Management of infected tibial intramedullary nailing using an organized treatment protocol

Twenty cases of osteomyelitis, following intramedullary nailing of tibial shaft fractures, were managed with a prospective treatment protocol, comprising intramedullary reaming debridement, antibiotic-bead depot, external skeletal fixation, microvascular muscle flap and early cancellous bone grafting. The follow-up period ranged from 25 to 48 months (average, 34.3 months). Pseudomonas aeruginosa (37.5%) and Staphylococcus aureus (20.8%) were the organisms most commonly involved. There were eight united and 12 ununited fractures after reaming debridement surgery. Nineteen infections were initially arrested by one debridement. One infection was arrested by two Sequential debridements. All 12 ununited fractures were stabilized by Hoffmann unilateral external fixation until the fracture healed. The time spent in external fixation ranged from three to seven months (average, 5.2 months). Early cancellous bone grafting was successfully accomplished for nine ununited fractures with major debridement bone loss. The average union time of the nine fractures with bone grafting was 6.5 months (range, from six to eight months). We believe that this treatment protocol gives a predictable and rapid recovery. The complications were infection recurrence in two cases at the old tibial shaft fracture sites, minor Hoffmann pin tract infection in two cases and stiffness in two ankles and one knee.