Post-Intramedullary Nailing Osteomyelitis among Closed Femoral Shaft Patients from 2015 to 2020

Femoral shaft fractures are high-energy injuries usually due to road traffic accidents and treated with intramedullary nailing with osteomyelitis after intramedullary nailing in closed femoral fractures being a dreaded complication. This descriptive study utilized a cross-sectional case-series to determine the demographic, clinical, and bacteriologic profile, and the incidence of osteomyelitis in closed femoral shaft fracture patients from January 1, 2015, to December 31, 2020. Out of 581 cases who underwent intramedullary nailing for a closed femoral fracture, 20 patients developed osteomyelitis (3.4%). Results show that males aged 18 – 25 years with right middle third femoral fracture caused by motor vehicular accident comprised the majority of cases.  Preoperative Cefazolin and postoperative Cefuroxime were given with an average of 4-6 weeks operative delay after injury. Open reduction and intramedullary (IM) nailing using either a locked nail or a Kuntscher nail was used averaging 3-4 hours to complete by orthopedic resident surgeons. All patients received at least 2 units of packed RBCs with average of 800 ml blood loss. All the patients were healthy with a normal immune system, and all cases had localized osteomyelitis with no systemic signs of infection. The patients with osteomyelitis were readmitted 1–2-years for debridement, sequestrectomy, saucerization, and application of antibiotic beads. Exchange nailing was done in 4 patients, and one fracture was re-fixed with distal compression screw. Isolates were gram positive, with Staphylococcus aureus being the most prevalent. Bony union was seen in 15 patients within 6 months while 5 patients were lost to follow-up.  The infection rate of 3.4% after intramedullary femoral nailing in this tertiary hospital is higher than established infection rates after nailing of closed femoral fractures in developed countries. The delayed surgery, blood loss and blood transfusions are factors that have contributed in the development of osteomyelitis in these immunologically healthy patients. 

Keywords: Closed femoral shaft fracture; Descriptive, cross-sectional case-series; Intra-medullary nailing patients; and Osteomyelitis.