Early definitive internal fixation for infected nonunion of the lower limb

The management of an infected nonunion of long bones is difficult and challenging. A staged procedure comprising radical debridement followed by definitive internal fixation was favored. However, no standard treatment has been established to determine the appropriate waiting period between initial debridement and definitive internal fixation. We propose a management method that incorporates early definitive internal fixation in infected nonunion of the lower limb.

Thirty-four patients (28 men and 6 women; mean age 46.09 years; range 25-74 years) with infected nonunion of the tibia or femur were included. Initial infected bone resection and radical debridement were performed in each patient in accordance with the preoperative plans. Definitive surgery was performed 2-3 weeks after the resection (4 weeks after flap surgery was required), and a third surgery was performed to fill the bone defect through bone grafting or transport (three-stage surgery). In cases of unplanned additional surgery, the reason for the requirement was analyzed, and radiological and functional results were investigated in accordance with the Association for the Study and Application of the Method of Ilizarov criteria.

Bone union was achieved in all patients, and treatment was conducted as planned preoperatively in 28 patients (28/34, 82.35%). The mean interval between primary debridement and secondary definitive fixation was 2.76 weeks (range 2-4 weeks). Six unplanned additional surgeries were performed, and the infection relapsed in two cases. The radiological and functional outcomes were good or better in 32 and 31 patients, respectively.

Early definitive surgery can be performed to treat infected nonunion by thorough planning and implementation of radical resection, active response to infection, restoration of defective bones, and soft tissue healing through a systemic approach.