Infection after intramedullary nailing for femur and tibia fractures - characteristics and outcome analysis

Infection is one of the major complications associated with intramedullary nailing. Aim of this study is to analyze the outcome of infection after fixation of tibia and femur with intramedullary nailing and to compare the outcome in patients treated with nail retention versus removal.

This is a retrospective cohort study including consecutive adult patients treated at our institution between 01/2015 and 03/2022 for infection involving the intramedullary nail used for fixation of femur or tibia fractures. Characteristics of infection and outcome data were evaluated by actively contacting the patients with a standardized questionnaire. Uniform predetermined definitions were used. The probability of infection-free survival was estimated using the Kaplan-Meier method and compared between the groups using log-rank test.

Fifty-one patients (37 males, 14 females) with infection associated with femur (n = 37) or tibia (n = 14) nail were included. The pathogen was identified in 45 (88 %) episodes, including 30 monomicrobial and 15 polymicrobial infections. The predominant pathogens in monomicrobial infections were coagulase-negative staphylococci (n = 11) and in polymicrobial infections gram-negative bacteria. The intramedullary nail was removed in 35 (69 %) patients and retained in 16 (31 %) patients. At follow-up (median follow-up 28 months; IQR 21-38 months), 19 of 31 (61 %) evaluable patients were infection-free. In patients with nail removal, 14 of 22 (64 %) were infection-free, whereas those with nail retention, 5 of 9 (56 %) were infection free.

The fact that patients in the nail retention group were of higher age, experienced earlier infection after surgery, and were mainly caused by high virulent pathogens suggest a potential selection bias. Nevertheless, it appears that certain infections may be treated successfully with nail retention, reducing the number of interventions for the patient, and increasing cost effectiveness.

Overall cure of infected intramedullary nails was 61 %. No significant difference in the infection eradication of infected intramedullary nails were observed, irrespective of the time of occurrence after nail implantation. These results should be confirmed in a larger prospective cohort.