Infection rate of intramedullary nailing in closed fractures of the femoral diaphysis after temporizing external fixation in an austere environment

Objectives: To determine the infection rate of intramedullary (IM) nailing of closed diaphyseal femur fractures after temporary stabilization with external fixation in an austere combat environment. Design: Retrospective case series. Setting: Iraq and Afghanistan Theater and Military Medical Treatment Centers in the United States and Landstuhl, Germany. Patients: Military personnel who underwent temporizing external fixation of a closed diaphyseal femur fracture (OTA 32) with later conversion to an IM nail between 2003 and 2012. Intervention: Patients were identified from the Joint Theater Trauma Registry and Department of Defense electronic medical record, and a retrospective review was performed. Main Outcome Measurements: Variables measured included age, gender, mechanism of injury, Injury Severity Score, associated injuries (to include thoracic and abdominal injuries), base deficit, history of massive transfusion, date of injury, date and place of external and IM fixations, time to conversion procedure, report of superficial or deep infection, report of fracture union, and date of last follow-up. Results: One hundred twenty-two patients, mean age 25 (18-43) years, sustained 125 closed femoral diaphyseal fractures from May 2003 to July 2012. External fixation was performed at a mean of 0.2 days (median of the day of injury) and a range of 0-3 days. Mean time to IM nail conversion procedure was 6.9 (1-20) days. Infection rate was 2.5%, with a P of 0.188. Average follow-up was 41.4 (12-119) months. Conclusions: Acceptable low infection rates can be achieved after IM nailing of closed diaphyseal femur fractures treated with initial external fixation in an austere combat environment. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.