Initial peri- and postoperative antibiotic treatment of infected nonunions: results from 212 consecutive patients after mean follow-up of 34 months

Figures & data

Figure 1 Distribution (in %) of localizations of infected nonunions.

Figure 2 Distribution (in %) of fracture types causing infected nonunions.

Table 1 Detected species from tissue samples of all 171 infected nonunions with positive microbial evidence

Species	Number of positive tissue samples (N=171), n (%)
Coagulase-negative Staphylococcus spp.	76 (44.4)
Mixed infection	32 (18.7)
Staphylococcus aureus	18 (10.5)
Enterobacter cloacae	10 (5.8)
Bacillus spp.	8 (4.7)
Proprionibacterium spp.	5 (2.9)
Streptococcus spp.	4 (2.4)
Candida parapsilosis	3 (1.8)
Citrobacter freundii	2 (1.2)
Escherichia coli	2 (1.2)
Pseudomonas stutzeri	2 (1.2)
Acinetobacter lwoffii	1 (0.6)
Finegoldia magna	1 (0.6)
Proteus mirabilis	1 (0.6)
Clostridium tertium	1 (0.6)
Peptoniphilus harei	1 (0.6)
Clostridium clostridioforme	1 (0.6)
Enterococcus faecalis	1 (0.6)
Serratia marcescens	1 (0.6)
Micrococcus luteus	1 (0.6)

Figure 3 Successful nonunion treatment after Masquelet technique.

Notes: Nonunion of the distal tibia 18 months after fracture with microbiological evidence of coagulase-negative Staphylococcus spp. (A). Postoperative image after changing the osteosynthetic material together with extensive debridement and implantation of a bone cement spacer according to Masquelet technique step 1 (B). Final image after Masquelet step 2 with spacer removal, metaphyseal locking compression plate re-osteosynthesis and implantation of cancellous bone of the femur into the fracture gap. The patient showed complete fracture healing after 16 months (C).

Figure 4 Unsuccessful nonunion treatment after Masquelet technique.

Notes: Nonunion of the distal tibia 20 months after fracture with microbiological evidence of a mixed infection (A). Postoperative image after changing the tibial nail and extensive debridement with implantation of a bone cement spacer according to Masquelet step 1 and additional implantation of a locking compression plate at the fibula (B). Masquelet step 2 was performed 6 weeks later with spacer removal and re-osteosynthesis using an Expert Tibial Nail PROtect^® at the tibia together with cancellous bone. At 22 months after Masquelet step 2, the patient did not show fracture healing in X-rays (C) and computed tomography scan (D), yet.

Figure 5 Fusion rates (in %) of cases with infection with the 3 most frequently detected bacteria and cases without detected microbial infection compared to all 171 cases of infected nonunion with positive microbial evidence.

Note: Lower part of each row shows complete bone fusion rate with absent fracture line, upper part depicts rate of incomplete bone fusion with partial fracture line.

Figure 6 Schematic algorithm of Masquelet step 1 and 2 with peri- and postoperative antibiotic treatment.