Management of femoral diaphyseal infected nonunion with antibiotic beads local therapy, external skeletal fixation, and staged bone grafting

Background: Fifteen patients with femoral shaft fractures complicated by in fected nonunions were treated with a two-stage protocol. Methods: In the first stage, radical debridement was performed along with a ntibiotic bead chains local therapy and external skeletal fixation. In the second stage, the debrided nonunion site was repaired with bone grafting an d the external skeletal fixator was used until bony union was achieved, The time between the first and second stages of treatment was 2 to 6 weeks, Th e debrided bone defects ranged from 0.5 to 15 cm, Autogenous iliac cancello us bone grafting was performed in II patients, and microvascularized osteos eptocutaneous fibular transfer was performed in 4 patients. Results: Wound healing and bone union were achieved in all 15 cases. The du ration of external fixation of these patients ranged from 7 to 15 months, w ith an average of 9 months. Minor pin-track infection was seen in seven pat ients, Postoperative infection after the second-stage bone grafting occurre d in three patients. These three infections were arrested by limited debrid ement along with 2 to 4 weeks of parenteral antibiotic therapy. In one case , stress fracture occurred at 11 months after microvascularized fibular tra nsfer; this was managed with another 5 months of external skeletal fixation , With an aggressive physical therapy program, 10 patients achieved nearly full range of knee motion and 5 patients had relevant knee flexion deficits . The follow-up averaged 58 months (range, 40-76 months); no recurrence of osteomyelitis was observed even at 76 months. Conclusion: We have found that our two-stage treatment with antibiotic bead s local therapy, definitive external skeletal fixation, and staged bone gra fting is an acceptable treatment protocol for the management of femoral dia physeal infected nonunion. It results in rapid recovery from osteomyelitis and a predictable recovery from nonunion.