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Peer-reviewedCC BY 4.0Journal of Bone and Joint Infection

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

  • Xingyu Chen1,2
  • Junyi Li1
  • Yunan Li1
  • Hangyu Li1
  • Kehan Lv1
  • Yueliang Zhu3
  • Muguo Song1,2
  • Jian Shi1,2
  1. 1Department of Orthopaedics, 920th Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032, China
  2. 2Yunnan Province Key Laboratory of Microsurgical Medical Technology, 212 Daguan Road, Kunming 650032, China
  3. 3Department of Orthopaedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Abstract

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) × 109 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) × 109 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.

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Cite

BibTeXRIS
BibTeX
@article{chen2026multiregional,
  title = {{Multi-regional debridement and staged reconstruction for fracture-related infection after intramedullary nailing}},
  author = {Xingyu Chen and Junyi Li and Yunan Li and Hangyu Li and Kehan Lv and Yueliang Zhu and Muguo Song and Jian Shi},
  journal = {Journal of Bone and Joint Infection},
  year = {2026},
  month = oct,
  doi = {10.5194/jbji-11-655-2026},
  url = {https://doi.org/10.5194/jbji-11-655-2026},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Multi-regional debridement and staged reconstruction for fracture-related infection after intramedullary nailing
AU  - Xingyu Chen
AU  - Junyi Li
AU  - Yunan Li
AU  - Hangyu Li
AU  - Kehan Lv
AU  - Yueliang Zhu
AU  - Muguo Song
AU  - Jian Shi
PY  - 2026
DA  - 2026/10/29
JO  - Journal of Bone and Joint Infection
DO  - 10.5194/jbji-11-655-2026
UR  - https://doi.org/10.5194/jbji-11-655-2026
AB  - 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) × 109 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) × 109 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.
SN  - 2206-3552
ER  -