Management of Infected Intramedullary Nail Femur

Abstract

SUMMARY R eamed IM nailing has become the gold standard for the treatment of diaphyseal femoral fractures requiring surgical stabilization. The load-sharing nature of IM nails allows for earlier mobilization and weight bearing of the trauma patient. Factors affecting the biomechanical characteristics of the nail include its material properties, diameter, cross-sectional shape, anterior bow, and the presence of locking screws. Although IM reaming has a negative effect on endosteal blood supply, it allows for insertion of a larger, stiffer nail with increased cortical contact. In addition, reaming stimulates local extraosseous and periosteal blood flow, which is the most important source of nutrient flow during fracture healing. Although it is clear that reaming causes embolization of marrow contents and alters levels of immune mediators, it has not been shown in either animal models or clinical human studies to increase mortality or alter pulmonary function. Major complications following this procedure include infection, compartment syndrome, venous thrombo-embolic events, fat embolism syndrome, neurovascular damage and non-union. All these complication could have a significant impact on the functional outcome of patients. The incidence of infection following closed long-bone fractures is approximately 1-2%.This incidence isconsiderably higher in open fractures (for Gustilo-Anderson Type I fractures 5%, for Type II 10% and for Type III over 15%, respectively). A meticulous clinical evaluation, a detailed diagnostic workup, and a specific treatment strategy are critical factors in diagnosing the presence of infection after IM nailing of femoral fractures. Criteria for clinical infection include an open wound with a draining sinus, fever, persistent pain and local signs of inflammation. The laboratory workup includes a full blood cell count, C-reactive protein and erythrocyte sedimentation rate which along imaging studies can lead to an accurate diagnosis of an underlying infection. The culture of the infected tissue provides the final diagnosis. Depending on the extent of infection, timing of diagnosis and progress of fracture healing, different treatment options have been developed. There is no hard and fast rule for the treatment of osteomyelitis related to implant. Still now it is a big challenge for orthopedic surgeons to handle such cases. A useful tool is to classify infection according to timing of presentation and fracture state. In general, acute infections only require antibiotic administration with debridement. subacute infections can be successfully treated with antibiotic nails, exchange nailing or removal of the nail after fracture union and IM reaming with/without grafting at a later stage if nonunion occurred. chronic infected nonunions can successfully be treated with removal of implant, external fixator and bone graft if no gab present but if gab present bone transport used by ilizarov or monolateral external fixator or combined technique between IM nail and monolateral external fixator.