The Hip: Preservation, Replacement and Revision

Infected Femoral IM nails 

- Discussion:
    - see: femoral non unions / osteomyelitis
    - three types of infection:
           - infection of the soft tissues;
           - infection of the fracture site
           - infection of the entire marrow cavity:(rare but serious and may require AKA);
     - infection usually develops with in 3 weeks of IM nailing;
     - look for continuous deep thrombing pain, which is worse at night and persisting beyond usual period of postop discomfort;
           - intermittent fever, redness, warmth, tenderness, and marked swelling of the thigh are common;

- Management: Infection following IM nailing:
    - once a deep infection is diagnosed - the question is whether to remove nail;
    - 4 to 6 months is required for frx healing;
    - pt must be protected from septicemia, by thorough debridment of sequestra, infected tissue, open wound care and ATB
    - acutely infected IM nails should be irrigated and debridded at the frx site as well as the IM canal;
    - consider making a hole in distal medial aspect of femur to allow thorough irrigation of the canal;
    - stable intramedullary nail:
         - there is no gross motion is present, then leave nail in place if - at debridment of infection;
         - nail is usually left in place as long as frx fixation is maintained;
         - nail is removed if subsequent x-rays show evidence of bone resorption and lossening of the nail;
    - unstable intramedullary nail:
         - consider whether to add interlocking screws;
         - consider whether to add a larger diameter exchange nail;
         - it has been shown that rigid stabilization of frx site is imperative in infected nonunions;
         - larger nail may be necessary to compensate for the extra reaming;
         - after frx union, which can be expected despite the infection, nail can be removed;
         - nail is removed, canal overreamed to remove infected granulation tissue from the canal, canal is irrigated thoroughly, & larger nail is inserted;
         - drainage hole in the distal medial aspect of the femur may be created to allow thorough irrigation and drainage of the canal;
         - after fracture union, IM nail may then be removed & any residual infection is adressed;
    - aggressive infection:
         - more extensive infection may require external fixation;

- Examples:
    - 35 yo male who developed extensive chronic osteomyelitis following IM nail insertion


- Maintenance of Hardware After Early Postoperative Infection Following Fracture Internal Fixation

- Staged Bone Grafting Following Placement of an Antibiotic Spacer Block for the Management of Segmental Long Bone Defects

- Fatal pulmonary embolization after reaming of the femoral medullary cavity in sclerosing osteomyelitis: a case report.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, September 7, 2012 9:10 am