Management of infected femoral nonunions with a single-staged protocol utilizing internal fixation

There are no reported series that specifically deal with repair of infected nonunions of the femur with revision internal fixation. We sought to determine whether a standardised treatment protocol we have used for 13 patients since 1992 results in a high union rate, resolution of infection, and a good functional outcome.

The study cohort included seven male and six female patients who presented to the senior author with an infected nonunion of the shaft of the femur. Eleven patients with a minimum of 2-year follow-up and between the ages of 19 and 75 years (mean 53.2 years) were included and evaluated. All patients underwent a single-staged protocol that includes an antibiotic "holiday", then treating the infected nonunion with surgical debridement and hardware removal, local and systemic antibiotics, revision open reduction and internal fixation, and use of supplemental bone grafting. Great emphasis at the time of surgery is placed upon aggressive debridement, correction of any deformity, and obtaining stable internal fixation. We sought to report our success rate of nonunion repair, number of re-interventions, complication rate, final knee range of motion, and the ability to eradicate the infection using this treatment regimen.

At most recent follow-up (mean 5.6, range 2-12 years), all patients had united and resolved their infections. Ten of the patients healed their nonunions with the fixation placed at the time of initial revision by us. Five patients required re-interventions to ultimately attain fracture union. Four patients had additional bone grafting procedures at the time of antibiotic bead removal. One of these four patients, who was later diagnosed with a nickel allergy, required three subsequent revision open reduction and internal fixations with bone grafting for hardware failure and persistent nonunion. A final patient underwent nail dynamisation with achievement of osseous union. Only one patient had less than 90 degrees of knee flexion, although he previously had an extensor mechanism disruption and had only 15 degrees of flexion noted at the time of initial surgery performed by us.

The results of this study indicate that our standard protocol for treatment of infected nonunion of the shaft of the femur is reliable at obtaining fracture union with a good functional result, while resolving infection despite the reliance upon internal fixation.