Multi-regional debridement and staged reconstruction for fracture-related infection after intramedullary nailing

Late fracture-related infection (FRI) after intramedullary nailing may extend beyond the fracture site to involve the medullary canal, nail entry site, and locking screw tracts. This retrospective cohort study evaluated a staged protocol incorporating systematic multi-regional debridement of the entire nail-related infection pathway. We reviewed 47 patients treated between January 2017 and January 2025, all of whom had fracture nonunion and an interval of at least 3 months from the first documented confirmation of FRI to admission. Stage I included intramedullary nail removal; systematic multi-regional debridement of the fracture/nonunion site, nail entry site, entire medullary canal, and proximal and distal locking screw tracts; locking plate fixation; and temporary vancomycin-loaded polymethyl methacrylate cement placement for dead-space management and induced membrane formation. Definitive Stage II reconstruction included the removal of the temporary plate construct and cement, repeat debridement, bone grafting, and definitive fixation with a new internal locking plate after clinical and laboratory infection quiescence and intraoperative reassessment. The cohort included 21 tibial and 26 femoral cases, with a mean follow-up of 25.3 ± 14.1 months. Two patients had confirmed persistent infection requiring repeat debridement before definitive Stage II reconstruction. No confirmed recurrence or unplanned surgical debridement for suspected recurrence occurred after definitive reconstruction. Union after the index Stage II reconstruction was achieved in 44 of 47 patients (93.6 %). The remaining three patients achieved union after further surgery, resulting in a final union rate of 100 %. The mean times to radiographic union and full weight-bearing were 9.7 ± 2.1 and 11.3 ± 3.8 months, respectively. Median (interquartile range) WBC count, ESR, and CRP decreased from 7.2 (6.2–9.0) × 10 ⁹  L ⁻¹ , 39.0 (12.5–65.0) mm h ⁻¹ , and 26.5 (10.3–43.2) mg L ⁻¹ to 5.9 (5.0–7.7) × 10 ⁹  L ⁻¹ , 17.0 (8.0–29.5) mm h ⁻¹ , and 6.3 (3.7–8.9) mg L ⁻¹ , respectively. LEFS and SF-36 scores increased from 47.0 (37.0–65.5) and 417.0 (335.0–439.0) to 70.0 (61.0–75.5) and 491.0 (480.0–516.5), whereas VAS and SAS scores decreased from 4.0 (4.0–4.0) and 45.0 (42.0–50.0) to 1.0 (0.0–1.0) and 32.0 (29.5–37.0), respectively (all p ≤0.001). These findings support the feasibility of this staged protocol in selected patients with late post-intramedullary-nailing FRI and nonunion.