Efficacy of Antibiotic-Coated Intramedullary Nails for Septic Shaft Nonunion: Surgical Technique and Outcomes
Antibiotic cement nail, Septic non-union, Shaft nonunion, Long bone infection, Intramedullary nailing, Fracture-related infection
Published online: Apr 20 2026
Abstract
Objective: To evaluate the efficacy of a staged protocol using an antibiotic-impregnated cement-coated intramedullary nail (ACCIN) for achieving infection eradication and bone consolidation in the treatment of septic shaft non-union of long bones.
Methods: A retrospective cohort study was conducted on 18 patients treated for septic nonunion of the humerus, femur, or tibia at a single tertiary referral center between January 2018 and January 2024. All patients were managed with a standardized staged protocol involving radical debridement and first-stage stabilization with a custom-made ACCIN, followed by definitive fixation and bone grafting after infection control after an additional spacer Masquelet augmentation and later bone grafting. Data on demographics, injury characteristics, microbiology, and treatment outcomes were collected. The primary outcomes were infection eradication and radiographic union.
Results: The cohort consisted of 14 males (78%) and 4 females (22%) with a mean age of 43 years. The tibia was the most common location (50%). Staphylococcus aureus was the most frequently isolated pathogen (44.4%). Following the staged protocol, both infection eradication and bone union were successfully achieved in 16 of the 18 patients, for an overall success rate of 88%. The mean time to consolidation was 7 months. Unfavorable outcomes were significantly associated with advanced age. Long-term functional complications were significantly associated with advanced age, tobacco use, and failure to control the infection after the first stage.
Conclusion: The use of an antibiotic-impregnated cement nail as part of a staged protocol is a highly effective and reliable strategy for managing septic shaft non-union. This technique successfully addresses the dual challenges of infection and instability, leading to high rates of limb salvage and bone union. Patient-specific factors, particularly age and smoking, remain important predictors of the final outcome.
