Three-year outcomes following retained intramedullary nails (DAIR) in early fracture related infections: A prospective case series.

Abstract

To evaluate whether early implant retention using the Debridement Antibiotics Implant Retention (DAIR) protocol results in sustained infection remission at three years in patients with early fracture related infection (FRI) following intramedullary nailing of diaphyseal femoral and tibial fractures. Design: Prospective observational cohort study. Single-center, academic Level I trauma centre. Patient selection criteria: Patients with early FRI (≤ 2 weeks from index surgery) following intramedullary nailing for OTA/AO classified femoral or tibial diaphyseal fractures (32 and 42), open and closed, treated between 2015 and 2017. Exclusion criteria included infections > 2 weeks post-surgery or less than three years follow-up. Outcome measure and comparisons: Primary outcome was infection remission, defined as the absence of clinical, radiographic, or surgical signs of infection at one, two, and three years. Statistical analysis assessed association between recurrence and demographic, surgical, or microbiological variables. Secondary outcome included fracture healing. Analyses were descriptive and exploratory due to the small cohort size. Eleven patients (9 male; mean age 42.3 ± 14.1 years) were included. The tibia was affected in seven patients (63.6%) and the femur in four (36.4%). At one year, all patients achieved infection remission. However, six patients (54.6%) had infection recurrence by year two, requiring nail removal. At three years, four of these six were infection-free, two had persistent infection, with remission after treatment. At six months, fracture union was observed in nine patients: two required secondary procedures for delayed union. All eleven patients achieved fracture union by 12 months. No statistically significant associations were found between infection recurrence and any measured variables, including age, BMI, OTA/AO classification, closed or open, microbial species, or antibiotic duration (all p > 0.05). DAIR achieved complete infection remission at one year in patients with early FRI after intramedullary nailing; however, more than half of the patients developed late recurrence during longer follow-up. Despite these recurrences, fracture union was achieved in all cases. These findings suggest that early remission may overestimate the long-term effectiveness of nail retention and that prolonged follow-up is essential when evaluating treatment success. Level II, prospective case series.