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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 29-37

Infected nonunion with implant in situ in long bone fractures, managed by retention of implant-our experience

Department of Orthopaedics, UP University of Medical Science, Saifai, Etawah, Uttar Pradesh, India

Date of Web Publication29-May-2017

Correspondence Address:
S. P. S. Gill
Department of Orthopaedics, UP University of Medical Science, Saifai, Etawah, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-7341.207164

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Introduction: Early Internal fixation of any fracture now days given us great advantage with relation to early mobilization and early returns to daily activity. Rate of infection related to implant surgery reported by numerous study ranges from 0.5% to 4-5% in closed fractures and up to 10% in cases of compound fractures. Post operative infection with implant in place is one of the most difficult conditions to manage. In our study we tried to retain the implants in these cases and evaluated long term result in these cases. Material and Method: We selected total 108 cases of infected implant without union from regular follow cases of operated post operative cases of upper and lower limb long bones managed by nailing and plating 2006 to 2014. Out of 108 cases 94 cases completed their follow up duration. We managed these cases with retention of implant for as long as possible with regular debridement, incision and drainage, pus culture and sensitivity and antibiotics accordingly off and on till attainment of bony union. Final results were evaluated and any implant failure and other revision surgery rates recorded. Results: Out of 94 cases bony union were achieved in 76 cases (81%) with retention of same implant with proper antibiotic coverage, regular follow up and guarded weight bearing. 8 of our cases shows implant failure due to delayed and non union. In 10 cases, removal of implant was required before bony union. Infection related to implant was also cured once implant were removed after attaining bony union without any long term complications. Conclusion: This increase incidence of infection related to implant also aggravated by various drug resistant microorganism. In most of these cases of infected implant, implants can be retained in situ till bony union achieved. Low grade infection with implant didn't have any severe negative consequence on bony union. This infection can be cured with removal of implant once bony union achieved.

Keywords: Infected implant, long bone infected implants, postoperative infection, retention of infected implant

How to cite this article:
Gill S, Raj M, Singh P, Kumar D, Singh J, Rastogi P. Infected nonunion with implant in situ in long bone fractures, managed by retention of implant-our experience. J Orthop Traumatol Rehabil 2017;9:29-37

How to cite this URL:
Gill S, Raj M, Singh P, Kumar D, Singh J, Rastogi P. Infected nonunion with implant in situ in long bone fractures, managed by retention of implant-our experience. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2023 Mar 27];9:29-37. Available from: https://www.jotr.in/text.asp?2017/9/1/29/207164

  Introduction Top

Infection after any orthopedic surgery is one of the most serious complications.[1] In recent past years with a better understanding of asepsis and operative conditions, the incidence of infection declines rapidly after any orthopedic surgery. With the increase in the frequency of high-energy trauma globally and going trend toward the early internal fixation of compound fractures of all bone, the incidence of infection related to orthopedic implant is again showing increasing incidence.[2] This increasing incidence also associated with the emergence of multi-drug resistant microorganism prevalent in hospitals.[3] Infection after any orthopedic surgery is associated with a high morbidity and increase the cost of treatment due to revision surgeries. Till now most of these cases of the infected implant with nonunion managed by removal of that implant with any cement and other foreign material from infected site followed by regular debridement and long-term antibiotics.[4] This leads to unstable fracture site with infection. These cases further required secondary procedures such as ring fixation.[5] These lead to very long morbidity and the high cost of treatment.

Numerous study of retention of the implant with antimicrobial drugs has reported recurrence rate of 69–97% after a variable period of follow-up.[6] In recent past, several studies reporting a high rate of success rate with regular debridement and retention of the implant with controlled infection and shows success rate up to 80% of cases. Main concern with implant-related infection is of biofilm.[7],[8] With a better understanding of biofilm and antimicrobial agents that can penetrate this biofilm prolonged retention of this implant could be possible till union can be achieved. In this study, postoperative cases of fracture with the infected implant in situ selected and prospectively followed-up at regular interval and intervened accordingly. The outcome is recorded and analyzed.

The purpose of the current study was to see that whether infected implant can be retained for the enough duration in situ till the bony union can be achieved without any serious limb- and life-threatening complications. We also aimed to identify other variable related to the success of retention of infected implants such age of the patient, grade of initial soft tissue injury, relation with smoking and tobacco chewing of, the time delay between injury and surgery, fracture communition.

  Materials and Methods Top

This study was performed in 1000 bedded multispecialty tertiary case specialized Medical Collage UPRIMS and R, Saifai, Etawah, located in North Central India in a rural setup. The patients were selected from the regular follow-up cases of internal fixation done in Department of Orthopedics, which shows sign of infection from internal fixation site from August 2008 to August 2013. Early postoperative follow-up cases with the implant in situ with the sign of infection within 6 weeks of surgery during regular early postoperative follow-up were selected and further evaluated for inclusion in the current study. During this period, totally 118 cases of the infected implant were selected. These cases were investigated and intervention such as local wound debridement, incision, and drainage done and we tried to retain the implant till bony union achieved. Of these 118 cases, 108 cases came under our study inclusion criteria for retention of the implant. Totally 108 cases were included in the study, of these 94 cases completed this regular follow-up with our department. 14 cases did not turned-up during regular follow-up and their final results were not known; hence, they were also excluded from the study. Of 118 cases, only 94 cases were followed-up till the end of follow-up from our side.

Inclusion criteria

  • Postoperated case of fracture of long bones managed by internal fixation either nailing or plating showing sign of infection during early follow-up without any bone union
  • Cases with radiological and clinical stable internal fixation of fracture site
  • Clinical evidence of infection from operated limb before attainment of bony union
  • Healthy fracture ends without any bone lyses due to infection.

Exclusion criteria

  • Patients with Other systemic disease leading to increase susceptibility to infection like uncontrolled diabetes, HIV and other immunocompromised conditions excluded
  • Known cases of multidrug-resistant cases with high-grade infection also excluded
  • Unstable fixation or loose fixations cases to start with also not included in this case series
  • Radiologically seen bone lysis around fracture and implant also excluded indicating severe infection
  • Other systemic conditions with contraindication to the use of long-term antibiotics also excluded.

Postoperative infection defined as redness, swelling, erythema around fracture site and implant insertion site with the collection of pus in tissue, sinus pus discharge, local tenderness and other systemic symptoms of infection like fever. This is further confirmed by pus culture and sensitivity. Cases with negative or sterile pus and culture sensitivity report but giving clinical signs of infection also included in this study.

108 cases were selected from a routine follow-up from 2008 August to 2014 August from orthopedics Out Patient Department of our institution UPRIMS and R, Saifai, Etawah. The cases were followed-up till bony union was achieved and cases were taken for removal of the implant after bony union. 94 cases completed their follow-up. End of follow-up decided by either attainment of bony union followed by implant removal and early removal of the implant before the union. Any removal of the implant before bony union counted as failure case. The cases were selected and further evaluated radiologically, and routine investigations carried out such as complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serum protein with albumin to globulin ratio, local pus microscopy, culture, and sensitivity.[9],[10],[11],[12] Baseline parameters recorded and antibiotics started according to culture and sensitivity. Every case of early postoperative implant-related infection was taken to operation theater for local wound irrigation and debridement. Local aspiration and tissue sampling was done for histopathological investigation. Local aspiration was sent for culture and sensitivity investigation. Every measure was taken to prevent any cross or local contamination during aspiration and tissue sampling. During this early irrigation and debridement, the stability of fixation also assessed and cases with good stable internal fixation only selected for further continuation of retention of the implant. All these cases were kept on intravenous antibiotics for 15 days according to culture and sensitivity report followed by oral antibiotics. Regular follow-up of cases done weekly to assess the effectiveness of given antibiotics. The weekly amount of pus discharge assessed and compared to an earlier visit. Biweekly ESR and CRP of cases also done to see any change of to see the effectiveness of given antimicrobials. Cases responding to drugs further managed on the same line. Those not responding to antimicrobials, reassessment of pus culture done and change in antibiotics carried out. Any collection of superficial of deep pus was watched carefully, and immediate incision and drainage carried out. Radiograph of limb obtained every 4 weeks. During each follow-up, not weight bearing exercise was advised, and joints were mobilized. Partial weight bearing was allowed once there was radiological sign of union seen on follow-up radiograph. Full weight bearing allowed once complete bony union seen on radiograph. The need of dynamization also assessed during follow-up and in some cases dynamization also carried out from the far end of the fracture site. Some of the tibial cases also required fibulectomy as fibula shows early union and now allowing the compression at the fracture site. Cases during follow-up also carefully assessed and evaluated for any sign of implant loosing, failure of fixation, osteolysis at the fracture site and screw site. Any loose fixation and lost reduction seen during follow-up were further managed by other methods such as implant removal, debridement, and external fixation and in some cases delayed revision internal fixation and counted in failure group.

The antimicrobial protocol used was depending on culture and sensitivity of pus collected from the infected site. These antimicrobial were also according to our institutional antimicrobial policy. Response to these antimicrobial also assessed by reduction in swelling and reduction of pus coming out of sinus and also by laboratory investigations such as ESR and CRP. Cases not responding to systemic antimicrobials were further managed by local wound irrigation and local antibiotics beads and repeat culture and sensitivity. These cases were closely monitored and the need for implant removal assessed accordingly. In all of our case, we given oral tab rifampicin 600 one a day for at maximum 3 months or till bony union whichever is earlier. Rifampicin was added for better penetration of antibiotics in biofilms around the implant and its action against Stapylococcus aureus (methicillin resistant).[13],[14] All cases were evaluated radiologically every 4 weeks and progression of callus formation noted carefully. Furthermore, a sign of bone destruction, bone resorption, and fracture end lysis also noticed. Cases were followed-up to the achievement of the bony union. Bony union determined by radiological bridging callus and no pain over fracture site on weight bearing in lower limb cases.

Of 118 cases, 108 cases fulfilled the inclusion criteria were continued with the same implant and followed-up and intervened in our study as mentioned earlier. Of these 108 cases, 94 cases completed their follow-up with our department. Of 94 cases, 64 were males and 30 were females with an age range from 18 years to 68 years and average age of 36.8 years. Follow-up duration of these cases were range from 15 months to 36 months with an average follow-up duration of 30 months. Of 94 cases, 76 cases were of the lower limb, 46 tibial and 30 femoral implants with the sign of early infection. 18 cases were of upper limb internal fixation and out of these 18 cases 12 were of humerus internal fixation and 6 were of forearm internal fixation. 16 cases of upper limb internal fixation 16 cases were of plating and two cases were of humerus interlocking with infected implant. Of 76 lower limb cases, 55 cases were of locked intramedullary nailing and 21 cases were of plating.

According to Gustilo and Anderson classification,[15],[16] out of 94 cases 34 were of compound Grade I, 24 cases were of compound Grade II and 20 cases were of compound Grade III group. Rest 16 cases were a closed fracture to start with and acquired infection either per operatively or early postoperatively. All cases of the upper limb infected implant were a closed fracture to start with.

We also recorded the history of smoking and tobacco chewing [17] from our study group. Out of 94 cases, 40 cases were having history of smoking and tobacco chewing.

Ethical clearance was taken from institutional ethical committee and written informed consent was obtained from each patient. Statistical analysis was performed by our Institutional Statistician from Department of SPM. Chi-square and Fisher's exact tests were performed to identify variable association with the outcome of implant retention. The level of significance was set at P < 0.05.

  Results Top

Most of earlier studies with postoperative infection with the implant in situ advocated the removal of implants. In our study, we try to retain the implant with controlled infection for as long as possible. We carefully selected 94 cases for this study for retaining the infected implant which full fills our inclusion criteria. Of 94 selected, 46 cases were of tibia fracture with the infected implant and 30 cases were of femur fracture with the infected implant. 18 cases of the infected implant were of upper limb, 12 humerus and 6 forearm cases.

Out of 94 cases, we were able to achieve good to excellent outcome in 76 (81%) cases. During follow-up, of these 94 cases 18 (19%) cases show failure and continuation of the infected implant could not be possible of these cases were immediately discontinued, and other measures were taken to treat these cases such as removal of internal fixation and debridement and external stabilization. Of these 18 failure cases in 10 cases, there was a loss of fixation and loosening of the implant were seen with due course of time due to uncontrolled infection. These cases were come as multidrug resistant cases. In eight cases, implant failure was noted before the union. There was strong association between failure of infected implant retention and grading of soft tissue injury during initial injury. Of 18 failure of implant retention, 15 cases were of Compound Grade III and compound Grade II to starts with which were treated by primary internal fixation.

Out of 46 tibial cases of infected implant 37 cases achieved complete bony union without any serious consequences [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]. 9 cases gone into failure out of 46 tibia fixation with the infected implant. Of these nine cases, five cases were of loosing of the nail with unstable fracture site noticed during follow-up. These cases were further managed by removal of the implant and other methods of fixation like external fixation. In rest four cases implant failure seen due to the delayed union. These cases were also managed by removal of the implant, local debridement, and external fixation. Implant removal were done in 30 of these successful tibial 37 cases after attaining bony union and canal washed thereafter and infection also cured. Other seven cases did not turn up and not given consent for implant removal as they have a little or negligible problem with still implant in situ and in these cases infection also cured after attainment of union. The average duration of implant retention in tibia with bony union cases was 18 weeks with a range from 15 weeks to 27 weeks. All of these cases were advised as soon as there was bony union. These cases were further protected by below knee walking Plaster of Paris (POP) cast for 6 weeks after removal of the implant. Seven cases of failure were further managed by removal of the implant before the bony union, and two of these cases were managed by POP cast with window and other five by external stabilization. All these cases also attained union by other methods without any serious consequences.
Figure 1: (a) Communited fracture upper end of tibia. (b) Fracture managed by lateral tibia plating by minimally invasive percutaneous plate osteosynthesis method. (c) Infection noticed during regular follow-up in case of tibia plating, managed by local cleaning and proper antibiotics and retention of plate. (d) Infected implant managed by retention of implant and in follow-up radiograph callus formation seen. (e) Final outcome with retention of infected plate

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Figure 2: (a) Fracture both bone leg distal end. (b) Fracture both bone leg managed by plating. (c) Plate insertion site of both bone fracture got infected with skin slough and pus discharge. (d) Follow.up radiograph at 10. weeks with union in progress with retention of same infected implant

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Figure 3: (a) Case of tibia interlocking. (b) Tibia nail got infected with sinus discharge, managed by retention of implant. (c) Union seen after 14 weeks with retention of infected tibia nail implant

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Figure 4: (a) Compound Fracture bone bone leg. (b) Fracture both bone leg managed by interlocking nail. (c) During follow.up, pus discharging sinus noticed, nail got infected. (d) Follow.up radiograph at 12. weeks, union achieved with retention of infected tibia nail

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Figure 5: (a) Fracture both bone leg. (b) Case of fracture both bone leg managed by interlocking nail. (c) Interlocking nail got infected with swelling and subcutaneous pus collection. (d) Union achieved with retention of same infected implant

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Out of 30 femur cases of the infected implant, 26 cases shows complete bony union during follow-up with retained implant without any further complications [Figure 6],[Figure 7],[Figure 8]. In two cases implant loosing seen and two cases of implant failure seen in femur nailing cases. These four cases were further managed by implant removal and delayed secondary nailing. Out of 26 of these cases, 20 cases agreed for removal of the implant after bony union. Rest cases not given the consent for the removal of the implant as again they have a little or negligible problem with still implant in situ and in these cases infection also cured after attainment of union The average follow-up duration of femur cases were 32 weeks. The average union time in femur cases with the infected implant in situ were 18 weeks and ranged from 14 weeks to 22 weeks. Four failure cases were of compound Grade III supracondylar fracture of the femur to start with, two treated by retrograde nailing and two by distal femur LCP. These four cases were managed by removal of implant, debridement, high tibial skeletal traction, and delayed internal fixation once the infection was controlled.
Figure 6: (a) Supracondylar fracture of femur. (b) Supracondylar fracture of femur managed by retrograde femoral nailing. (c) Supracondylar nail of femur got infected with pus discharging sinus. (d) Follow-up radiograph of retrograde femoral nail 12 weeks with retention of infected implant.
(e) Follow-up radiograph at 16 weeks with retention of infected implant, complete union achieved

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Figure 7: (a) Femur fracture managed by open K nail. (b) Infection noticed with nail of femur. (c) Callus seen during follow.up at 8. weeks with infected implant in. situ. (d) Final outcome at 12. weeks, bony union seen, with infected implant in situ

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Figure 8: (a) Supracondylar fracture of Femur with bone loss. (b) Supracondylar fracture managed by primary plating. (c) During follow.up of plating case, sinus discharge noticed. (d) Case of infected plating managed by retention of same implant. (e) Continuation with infected implant retention, bony union achieved

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Out of 18 cases of the upper limb with retained infected implant, 13 cases show bony union without any other serious complications [Figure 9] and [Figure 10] and in all of these cases infection was cured after removal of the implant once the union was achieved. Rest five cases of upper limb show failure in retention of the infected implant. Out of 5 failures, 3 were of both bone forearm plating with retained infected implant and two cases were of the humerus with retained infected impact. Out of two humerus failure cases, one was of plating and one was of nailing. These five failure cases of upper limb were further managed by removal of the implant and local control of infection and external fixation. None of these cases gone to any serious complications such as neurovascular damage or amputation. Average union time of 12 successful cases was 15 weeks with a range from 13 weeks to 24 weeks.
Figure 9: (a) Case of humerus fracture managed by plating. (b) During follow.up implant got infected, managed by retention of implant. (c) Union achieved with retention of infected implant

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Figure 10: (a) Supracondylar fracture of humerus. (b) Supracondylar fracture of humerus managed by elbow reconstruction plating. (c) Postoperative sinus discharge with implant in place (d) Infected implant managed by retention of implant and in follow-up radiograph callus formation seen. (e) Final outcome with retention of infected plate

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Other factors associated with failure of the infected implant were also analyzed. These are an association with tobacco chewer and smoking, socioeconomical status, and nutritional status of patients, patient's compliance with the treatment protocol, patient's apprehension with retention of the infected implant.

About 40% of cases of successful implant retention were smokers to start with and were advised to stop smoking and there compliance of stopped smoking cannot be assessed. About 60% of cases of failure group were smokers to start with. There were an overall relation of smoking and tobacco chewing wit delayed union and nonunion, but in our follow-up, a strong relation between failure of implant retention and smoking and tobacco chewing cannot be stabilised. There was a strong association between severity of compounding to the failure of retention of implant group. 85% (15 cases) of cases of implant retention failure were of compound Grade III or compound Grade II group to start with.

There was also a strong association between levels of antimicrobial resistance to the success of retention of the implant. 90% cases of multidrug-resistant microorganism case gone into failure group. Methicillin resistant S. aureus (MRSA) was one of the constant microorganisms seen in long-term failure cases.

  Discussion Top

Traditionally, management of postoperative infection includes a prolonged course of an antimicrobial agent, aggressive debridement, and most importantly, removal of the infected implant. Steckelberg and Osmon.[18] in his study found the success rate of more than 80% in cases of prosthetic infections but had its own complication including prolonged immobilization, unstable fracture site, and poor patient compliance. Recently, several investigators suggest that the fracture will heal in the presence of infections as long as the fixation material remains stable.

Rightmire et al.[19] in their study on acute infections after fracture repair: Management with hardware in place showed 47 (68%) were successful and 22 (32%) were unsuccessful. They also said that smoking was a major risk factor with a 3.7 times greater likelihood of procedures being unsuccessful, thus treating infected fractures with hardware in place is less successful than widely believed.

In 1996, Tsukayama, Estrada and Gustilo [20] reported a success rate of 68%, but debridement with retention of the implant was limited only to infections of short duration <1 month after surgery. In 2003, Meehan et al.[21] reported 1 year recurrence-free rate of 89%, but only infections with penicillin-susceptible streptococci were included.

The stability provided by the implants has been proved to reduce the incidence of infection after internal fixation, and to aid in the clearance of established infections, thus making the maintenance of fixation a top priority.

Berkes et al.[22] retrospectively analyzed 123 postoperative wound infections that had developed within 6 weeks after internal fixation of a fracture and found that 87 patients (71%) had fracture union with operative debridement, retention of hardware, and culture-specific antibiotic treatment.

In an experimental study, Warlock et al.[23] fixed diaphyseal fractures of the tibia with a stable compression plate or with an unstable endomedular pin, and inoculated S. aureus in the fracture zone. They found out that in the unstable group there were 2 times more infections than in the stable compression plate group (71% vs. 35%).

As literature does not suggest any guidelines to dictate whether implant should be removed or retained in the presence of an acute infection, the management requires flexibility in the treatment plan while trying to avoid a poor outcome such as infected nonunion. According to the available literature, it is recommendable to maintain the hardware in place till osseous union has occurred. This study suggests it is possible to achieve union and resolve infection with the implant in place.

Chen et al.[24] in their work on Infection after intramedullary nailing of the femur postulated that retention of the intramedullary nail can be performed if the fixation is stable and the infection is under control.

Viol et al.[25] worked on soft tissue defects and exposed hardware and identified parameters for the potential salvage of exposed hardware with soft tissue coverage. If stable hardware, time of exposure <2 weeks, control of infection, and location of hardware salvage of the hardware with plastic surgical soft tissue coverage is possible.

Zych and Hutson [26] in their work on diagnosis and management of infection after tibial intramedullary nailing showed 20 patients with an infection after intramedullary nailing of the tibia, treatment protocols were based on the time of onset of infection (acute, subacute, and chronic) and the status of bone healing. Acute infection group managed successfully with nail retention, debridement, soft tissue coverage, and IV antibiotics.

Gristina,[27] on their work on mechanisms of musculoskeletal sepsis shows clinical infection is multifactorial and may include the formation of a biofilm. Due to the adsorption of proteins, sugars, and other macromolecules onto the implant surface; possible changes in the material itself attributable to the host or the bacteria; the effects of the implant on the local environment; and the systemic effects of the implant in the host.

Merritt and Dowd [28] worked on the role of internal fixation in infection of open fractures studies with S. aureus and Proteus mirabilis and noticed that Infection rates in fixed and unfixed fractures were compared, the infection rate at 2 weeks was lower in the internally fixed fractures than in the unfixed fractures. However, g negative proteus infections worse in the internally fixed group. Stability lowers incidence of S. aureus infection.

Friedrich and Klaue [29] worked on Mechanical stability and post-traumatic osteitis: An experimental evaluation of the relation between infection of bone and internal fixation and seen that abscesses, sinuses, and sequestra developed in 45% of the unstable fractures, whereas clinically manifest osteitis did not occur after rigid fixation. With rigid fixation, there was no significant difference in the time to bony union between the infected and uninfected fractures.

In this study, our main aim was to retain the infected implant in situ as long as possible to attain bony union without any serious complications. There is great apprehension among patients and also in treating regarding infection after any orthopedic surgery. Numerous studies have proven that there is no significant difference in the time of bony union between the infected and uninfected fracture, but the mail concern is fracture stability. This infection may convert initial rigid internal fixation into loose internal fixation. This is the main concern with relation to retained infected implant. To prevent this loosing of initial stable internal fixation we take every measure to control the infection with proper debridement, drainage of any collection and proper antimicrobials. This was also seen in previous studies that stable fixation is also associated with low infection rate. Out of 108 cases included in our study, 94 cases completed our full study follow-up duration. We were able to achieve 81% success rate with relation to the bony union. All of these cases we were succeeded to retain implant for enough duration with a regular timely intervention like debridement, incision and drainage and antimicrobial suppression so that these cases can achieve bony union. We added tab rifampicin 600 mg daily in the morning in every cases of the infected implant as a universal positive factor for action against biofilm and MRSA. There were also difficulties in explaining regarding the retention of the implant with infection till bony union. But with proper counseling and explanation we were able to obtain consent from all of these cases. There were great apprehensions in society regarding discharging sinus and infection after orthopedic implant surgery and also for retaining of these implants in situ.

Cases from low socioeconomical status given poor outcomes of retention of infected implant. Causes are multifactorial as they are generally not strict to nonweight bearing protocol so prone to implant loosing, also difficult for them in continuation of long-term antibiotics. Poor nutrition also contributes to failure in these cases. Of 94 cases, 70% cases were from low socioeconomic status as our institute is government hospital located at rural setup. Out of 18 failure cases, 90% (16 cases) were of low socioeconomic status.

Most of our cases after attaining bony union gone for implant removal surgery and in all of these cases infection were cured within few days to weeks of removal of the implant.

In 18 failure cases, the most common cause of failure was loosing of implant and loss in stable fixation. This leads to further increase in grade of infection and infection further loosens the implant. These all cases were further managed by implant removal, thorough debridement, repeat culture, external stabilization, and delayed secondary procedures such as external fixation and delayed internal fixation. In all of these cases, bony union achieved without any limb-threatening of live-threatening complications.

  Conclusion Top

Postoperative implant-related infection of long bones fracture can be well-managed by retention of same primary internal fixation till the bony union under proper antimicrobial suppression of infection, repeated minor interventions such as debridement, incision, and drainage, and also it should make sure that internal fixation is stable. Any sign of implant loosing and loss of stable fixation should be discontinued from implant retention protocol and should be further managed by removal of implant and other delayed internal or external fixation.

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Conflicts of interest

There are no conflicts of interest.

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