Managing Nonunions and Fracture-Related Infections-A Quarter Century of Knowledge, and Still Curious: A Narrative Review

Abstract

Nonunions and fracture-related infections represent a significant complication in orthopedic and trauma care, with their incidence rising due to an aging, more comorbid global population and the escalating threat of multi-resistant pathogens. This narrative review highlights pivotal advancements in diagnostics and therapeutic approaches, while also providing an outlook on future directions. Diagnostic methodologies have significantly evolved from traditional cultures to sophisticated molecular techniques like metagenomic next-generation sequencing and advanced imaging. Simultaneously, therapeutic strategies have undergone substantial refinement, encompassing orthoplastic management for infected open fractures and the innovative application of antibiotic-loaded bone substitutes for local drug delivery. The effective integration of these possibilities into daily patient care critically depends on specialized centers. These institutions play an indispensable role in managing complex cases and fostering innovation. Despite considerable progress over the past 25 years, ongoing research, interdisciplinary collaboration, and a steadfast commitment to evidence-based practice remain crucial to transforming management for the future.

Keywords: allografts; bone graft substitutes; fracture-related infections; low-grade infections; nonunion; orthoplastic surgery.

Figure 1

Milestones in the diagnosis of nonunions and fracture-related infections during the last half century (MRI: magnetic resonance imaging; FDG-PET/CT: fluorodeoxyglucose positron emission tomography/computed tomography; CEUS: contrast-enhanced ultrasound; mNGS: metagenomic next-generation sequencing).

Figure 2

Illustrative imaging of nonunions and fracture-related infections: (a) T2-weighted MRI of a patient with traumatic lower leg amputation, showing an intraosseous abscess and soft tissue changes indicative of chronic infection; (b) Coronal and sagittal CT views of an atrophic femoral nonunion, a condition often linked to low-grade infection.

Figure 3

Illustrative orthoplastic management of a soft tissue defect following a distal lower leg fracture: (a) Clinical appearance of the chronic defect after initial debridement; (b) Intraoperative view of the same site after reconstruction with a gracilis free flap.

Figure 4

PerOssal^® as part of the treatment of chronic osteomyelitis in a distal femur: (a) Postoperative X-Ray image; (b) Follow-up X-Ray 2 years later. The PerOssal^®-Beads are largely resorbed. No recurrence of infection was detected clinically.