Arthrodesis in the Charcot foot: a systematic review

Treatment Options of Prosthetic Joint Infections Following Total Ankle Arthroplasty: A Systematic Review

Background: This comprehensive systematic review aims to explore and discuss existing treatment modalities for infections in total ankle arthroplasty (TAA), providing insights that may contribute to the establishment of a "standard of care" for these challenging cases. The study analyses the intricate landscape of infected TAA, addressing gaps in the current literature and emphasizing the need to refine treatment strategies. With the reported incidence of periprosthetic joint infection after TAA surpassing rates observed in total hip and knee replacements, the research navigates through various treatment modalities, underscoring the lack of a universally accepted standard of care. Methods: In this systematic review, following PRISMA guidelines, PubMed, Scopus, and Google Scholar, we identified 15 papers addressing the management strategies for infected TAA (162 infected ankle arthroplasty cases).These databases were chosen for their extensive coverage, strong relevance to the research topic, and ease of access, ensuring a thorough and focused retrieval of pertinent literature on the treatment of infected ankle prostheses. The review involved the identification and evaluation of articles providing insights into complications, treatment outcomes, and risk factors. Extracted data were summarized and reported. A descriptive analysis was performed, and when feasible, a statistical analysis was conducted. Results: Treatment modalities included irrigation and debridement (48.8%), revision total ankle arthroplasty (36.3%), primary arthrodesis (7.9%), spacer arthroplasty (4.5%), and primary amputation (3.9%). Complication rates varied, with 46.5% for irrigation and debridement, 20% for two-stage revision, 7.14% for primary arthrodesis, and 25% for spacer arthroplasty. Conclusions: The rising prevalence of TAA underscores the need for a definitive treatment protocol due to severe complications. This review emphasizes careful patient selection and accurate diagnosis. Irrigation and debridement are effective for acute infections, while two-stage revision is a valid alternative for chronic infections. High-quality randomized controlled trials are important for establishing an evidence-based treatment protocol.

Predictive Factors of Amputation in Diabetic Foot

Background: Diabetic foot ulcers are a common complication of diabetes mellitus, often leading to progressive sensory deficits, impaired vascularization, and a predisposition to ulceration and gangrene. Untreated ulcers may cause recurrent infections that endanger a patient's life. Amputation of part of the limb up to a well-vascularized level is one of the treatments employed for untreated ulcers. Objectives: Laboratory data were analyzed with the aim of identifying risk factors related to surgical amputation treatment of diabetic foot. We believe it is useful to identify risk factors that can be altered from a reversible condition in the clinical decision-making of treatment, thus manifesting themselves in a timely manner to provide the patient with an alternative to surgical amputation of the lower limb. Methods: Our retrospective study was conducted by the Department of Orthopedics and Traumatology at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome. We recruited 200 patients who underwent lower limb amputation for diabetic foot between 2017 and 2021 and had blood tests both 30 days and within 5 days before the first surgery. Results: This case-control study revealed a significant negative correlation between hemoglobin (Hb) levels and the occurrence of leg amputations. In contrast, C-reactive protein (CRP) levels, the neutrophil-to-lymphocyte ratio (NLR), and the platelet-to-lymphocyte ratio (PLR) showed significant positive correlations with leg amputations. A 3-year follow-up of the cases also revealed a significative positive correlation between age, white blood cells (WBC) count, NLR, PLR, and death at 3 years. Conclusions: Our findings suggested that lower Hb levels and elevated CRP, NLR, and PLR levels in patients with diabetic foot disease may be associated with a higher risk of lower-limb amputation. Unexpectedly, this study also demonstrated that elderly age, WBC, CRP, NLR and PLR levels may be associated with a negative prognosis for these patients. These findings highlighted the importance of monitoring these laboratory values in diabetic patients to identify individuals at higher risk of leg amputations and implement appropriate interventions to prevent or minimize the occurrence of this severe complication.

Locally obtained autologous bone grafts are effective for achieving arthrodesis while managing foot and ankle charcot's neuroarthropathy: short to mid-term results from a specialized north African foot and ankle surgery unit

PURPOSE

We aimed to report the union rate after only utilizing a locally obtained autologous bone graft while correcting the deformity and performing joint arthrodesis in patients with foot and ankle Charcot neuropathy (CN) and to report on the radiographic, functional, complications incidence outcomes at a minimum of two years of follow up.

METHODS

We included 24 patients having a mean age of 55.4 ± 10.1 years diagnosed with CN of the foot, ankle, or both. Seven (29.2%) cases were classified as Brodsky type 1, 11 (45.8%) as type 3 A, and six (25%) were type 4. Hindfoot and Midfoot bi-columnar arthrodesis was performed in 70.8% and 29.2% of the patients, respectively. Eight (33.3%) cases had preoperative ulcers. Functional outcomes were evaluated using a modified AOFAS score. Arthrodesis site union was assessed clinically and radiographically. All patients were available for a mean follow up of 35.7 ± 9.5 (24-54) months.

RESULTS

Arthrodesis site union was achieved in 23 (95.8%) cases after a mean of 4 ± 1.7 (2-7.5) months. The mean modified AOFAS score was 72.4 ± 10.41 (46-83) points; 79.2% achieved excellent and good scores. Ulcers healed in 87.5% of the patients. Twenty-two (91.7%) patients were satisfied with their functional results. Infection incidence was 12.5%, and no patients required revision or amputation.

CONCLUSION

Foot and ankle Charcot neuroarthropathy deformity correction by arthrodesis of the affected joint as a salvage management option resulted in acceptable clinical and radiological outcomes. To enhance the local environment for arthrodesis consolidation, locally obtained autografts led to higher union rates and avoided the drawbacks of using other graft types.

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint

INTRODUCTION

Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge.

METHODS

This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score.

RESULTS

Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002).

CONCLUSION

This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.

Functional outcomes of tibiotalocalcaneal arthrodesis using a hindfoot arthrodesis nail in treating Charcot's arthropathy deformity

Background

Tibiotalocalcaneal arthrodesis or hindfoot fusion is a salvage surgical option used to treat symptomatic or severe deformity as a result of Charcot's arthropathy. It is an internal fixation that utilizes nails to stabilize the hindfoot after surgical correction of the deformity. This study intends to measure the change in functional outcomes of patients with Charcot's arthropathy using this technique and the time taken to achieve fusion.

Method

This study presents a series of 40 cases of Charcot's arthropathy where hindfoot fusion was done using a hindfoot arthrodesis nail. A retrospective analysis was done where these patients' functional scores had been evaluated preoperatively and postoperatively (serially) with the Short-Form Health Survey 36 (SF-36), American Orthopedic Foot and Ankle Society (AOFAS), Foot and Ankle Outcome Score (FAOS), and Foot Function Index (FFI). Along with its complication, the length of time required for the fusion is also reported.

Results

This study consists of 40 patients (13 men, 27 women; mean age 60.5 years; age range 52-68 years) with a mean follow-up of 64 months (range 24-108 months). The mean time taken for fusion was 5.1 months. All patients showed improvement in functional scoring (SF-36, AOFAS, FFI, and FAOS) postoperatively. We establish that the improvements were gradual over 2 years. Approximately 37.5% of patients had a minor complication and 2.5% had a major complication.

Conclusion

Hindfoot fusion using a hindfoot arthrodesis nail results in improved functional outcome with an acceptable fusion time and acceptable complication rate.

Level of evidence

Level III.

High rate of complications after corrective midfoot/subtalar arthrodesis and Achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3

PURPOSE

Corrective midfoot resection arthrodesis is the standard treatment of Charcot arthropathy type Sanders 2 and 3 with severe dislocation. In order to critically evaluate the effect of surgical correction, a retrospective analysis of our patient cohort was performed. Hereby, special emphasis was set on the analysis of the pre- and post-operative equinus position of the hindfoot.

METHODS

Retrospectively, all patients (n = 82) after midfoot resection arthrodesis in Charcot type Sanders 2 or 3 were included. Complications were recorded, and the mean complication-free interval was calculated. Additionally, the calcaneal pitch as well as Meary's angle were measured pre- and post-operatively and in case of complications.

RESULTS

Overall complication rate was 89%. Revision surgery was necessary in 46% of all patients. The mean complication-free interval was 285 days (0-1560 days). Calcaneal pitch and Meary's angle significantly improved after operation but returned to pre-operative values after onset of complications. Achilles tendon lengthening showed no significant effects on the mean complication-free interval.

CONCLUSION

Operative treatment of Charcot arthropathy remains a surgical challenge with high complication rates. Surgical correction of equinus position has been highlighted for successful treatment but was not able to prevent complications in this study, which is demonstrated by the recurrent decrease of the calcaneal pitch in cases of reoperation. Therefore, as a conclusion of our results, our treatment algorithm changed towards primarily addressing the equinus malpositioning of the hindfoot by corrective arthrodesis of the hindfoot.

Validation of the Ischaemia Severity Scale (ISS) Based on Non-Invasive Vascular Assessments (SEWSS) for Predicting Outcomes of Diabetic Foot Attack

Assessment of ischaemia severity includes a variety of measures, such as pedal pulse palpation, the ankle/brachial index (ABI), and the toe/brachial index (TBI), but there is a lack of consensus regarding which ischaemia scale is the most effective for determining outcome prognosis. The purpose of this study is to validate the application of the ischaemia severity scale (ISS) in the effective prediction of wound healing, amputations, and mortality for diabetic foot wounds (DFW). This prospective study included 235 consecutive patients graded according to the Saint Elian Wound Score System (SEWSS). The ISS is part of this system, with patients being scored as non-ischaemic (0) or having mild (1), moderate (2), or severe (3) ischaemia. Age, diabetes duration in years, and ulcer size were found to be associated with a longer mean ischaemia of increasing severity. A trend of reduction in the pulse palpation rates (70.4%, 50%, 8.5% to 0%; p < 0.01), ABI (1.1 ± 0.1, 0.86 ± 0.3, 0.68 ± 0.2, 0.47 ± 0.2, p < 0.01), TBI average values (0.90 ± 0.35, 0.62 ± 0.52, 0.50 ± 0.33, 0.10 ± 0.42, p < 0.01), wound healing success (88.7%, 57.7%, 40.7%, 12.9%; p < 0.01), and delay in weeks (Kaplan−Meier: log-rank 44.2, p < 0.01) was observed with increasing values of the ISS (0, 1, 2, and 3). The odds ratio for adverse outcomes increased for each additional level of ischaemia severity. Thus, we demonstrate that the ISS is useful in effectively predicting adverse outcomes for DFW.

Predictive Factors of Poor Outcome in Sanders Type III and IV Calcaneal Fractures Treated with an Open Reduction and Internal Fixation with Plate: A Medium-Term Follow-Up

BACKGROUND

Consensus on the treatment for severely comminuted calcaneus fractures has yet to be found. This study aims to analyze the functional and radiological short- and medium-term outcomes of displaced calcaneus fractures of type III and IV treated with ORIF, and to identify, if present, the early predictors of unfavorable outcomes.

METHODS

Thirty-three calcaneal fractures were included, 23 type III and 10 type IV, according to Sanders classification. AOFAS scales for ankle and hindfoot and SF-12 were used. Böhler and Gissane angles were analyzed before and after surgery.

RESULTS

The minimum follow-up was six years. The mean AOFAS score at six months was 16.5 points (24.2 ± 10.8 vs 10.8 ± 9.5; p = 0.03) with better outcomes in patients with Sanders type III fractures. This difference decreased in the subsequent follow-up. Likewise, the mental and physical score of SF-12 had the same trend. Two wound infections and no deep infections were recorded in the Sanders type III fracture group. Instead, in the Sanders type IV group, there were four wound infections and one deep infection.

CONCLUSIONS

Clinical and radiological outcomes in Sanders Type III and Type IV calcaneus fractures treated with plate and screws were very similar in long-term follow-up. If ORIF provided better short- to medium-term follow-up in Sanders type III fracture, these benefits have been lost in six years. Polytrauma and psychiatric patients showed significantly lower clinical outcomes in long-term follow-up, appearing as the most reliable negative predictors.

Colchicine versus Physical Therapy in Knee Osteoarthritis

Background: The treatment of osteoarthritis remains a major challenge due to the unavailability of a disease-modifying medication and the limitations of current therapeutic perspectives, which mainly target the symptoms, not the disease itself. The purpose of our study is to compare the efficacy of colchicine treatment versus physical therapy. Methods: The study included 62 patients diagnosed with knee osteoarthritis (KOA) according to the American College of Rheumatology (ACR) criteria, hospitalized within the time frame of October 2020−March 2022 in the Department of Rehabilitation Medicine and Physical Therapy of the Emergency Clinical County Hospital of Craiova. The participants were randomly divided into two groups. The observation period was 16 weeks long. The first group (31 patients) received colchicine at a dosage of 1 mg/day together with analgesics (acetaminophen < 2 g/day), while the second group (31 patients) received analgesics (acetaminophen < 2 g/day) together with a 16-week plan of physiotherapy. Results: Group II, in which patients underwent physical therapy, demonstrated a statistically significant decrease in both left (p < 0.001) and right (p = 0.012) knee VAS and WOMAC (p = 0.038) scores at 16 weeks, compared to the group treated with colchicine. Regarding the MSUS examination at 16 weeks, there were no significant changes in the structural abnormalities and no improvement in cartilage aspect or thickness. Higher BMI was associated with higher WOMAC score (p = 0.012), but not with higher VAS score (p = 0.062). Cholesterol and triglyceride levels were associated with high WOMAC (p < 0.001; p = 0.021) and high VAS (p = 0.023; p < 0.001) scores. Conclusions: Our study monitored VAS and WOMAC scores in two groups of patients with KOA, showing that physical therapy is more effective than colchicine in reducing symptoms. We found no statistically significant difference in musculoskeletal ultrasound (MSUS) feature improvement during the 16-week study.

Midterm outcomes of midfoot and hindfoot arthrodesis with strut allograft for Müller-Weiss disease

Background

Müller–Weiss disease (MWD), a rare dysplastic disorder of the foot, is characterized by deformity, sclerosis, and fragmentation of the lateral part of navicular bone. Arthrodesis is the mainstay treatment for MWD. Generally, arthrodesis can be achieved through internal fixation with metallic implants, and morselized chip bone may be packed into the gap for better bone union. However, with this procedure, the original foot size is not maintained and support for the foot arch is not provided. Sequela of short foot, or flatfoot is commonly observed even though these complications of surgery had not been reported with cases of MWD treated by arthrodesis. Herein, we present a retrospective analysis of treating MWD through midfoot and hindfoot arthrodesis combined with strut allograft.

Methods

From August 2006 to June 2019, 20 patients with MWD (mean age, 59.6 years; range, 40–80 years) underwent midfoot and hindfoot arthrodesis with strut bone allograft and were followed for at least 24 months. The patients were able to ambulate and participate in rehabilitation programs 3 months postoperatively.

Results

The used four radiographic parameters (Meary’s angle in anteroposterior and lateral view, talonavicular coverage angle, calcaneal pitch) demonstrated significant differences (P < .05) preoperatively and postoperatively, but those between the postoperative values and the values at the last follow-up session did not, indicating that strut allograft was able to maintain normal alignment. The mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scores at 2 years postoperatively revealed significant improvement from baseline, from 60.2 to 84.2 (P < .05). The 12-item Short Form Health Survey scores also improved significantly (P < .05). All patients reported substantial pain relief and exhibited improved functional outcomes and gait patterns.

Conclusions

For advanced-stage MWD, arthrodesis with a precisely shaped, size-matched strut allograft provided strong support for biomechanical alignment and enhanced functional performance.

Does Demineralized Bone Matrix Affect the Nonunion Rate in Arthroscopic Ankle Arthrodesis?

Demineralized bone matrix (DBM) has been shown to have positive effects on union rates in many orthopedic subspecialties; however, minimal evidence exists about bone graft substitutes in foot and ankle surgery. The purpose of this study is to compare nonunion rates in arthroscopic ankle arthrodesis in patients receiving DBM with those without. We hypothesized DBM to be associated with a decreased risk of nonunion. This retrospective review includes 516 consecutive ankle arthrodesis cases from March 2002 to May 2016. Of these, 58 ankles (56 patients) that underwent primary arthroscopic ankle arthrodesis met the inclusion criteria, and 31 of these ankles received DBM, while 27 did not. Nonunion was assessed by clinical examination and routine postoperative radiographs. If nonunion was suspected, a computed tomography (CT) scan was performed. The primary outcome measure was nonunion rate. Secondary outcome measures included wound complications, return to operating room (OR), and rate of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). From the study cases, 58 were available for final follow-up. The average age was 55.9 years (±17.4), and mean follow-up was 43.0 months (range 6.3–119.4). There was no difference in nonunion rate in patients who received DBM (4/31, 12.9%) versus those who did not (4/27, 14.8%) (p = 0.83). Similarly, when comparing the two groups, there were no statistically significant differences in superficial wound complications (6.5% vs. 3.7%, p = 1.0) or rate of return to OR (29% or 0.037/person-years vs. 37% or 0.099/person-years; p = 0.20). No major complications including deep wound infections, DVTs, or PEs occurred. This is the largest study to directly compare nonunion rates and complications for patients receiving DBM versus those who did not in primary arthroscopic ankle arthrodesis. No significant association was found between DBM usage and risk of nonunion, wound complications, return to OR, or postoperative DVT or PE development.

Lisfranc complex injuries management and treatment: current knowledge

Lisfranc complex injuries are a spectrum of midfoot and tarsometatarsal (TMT) joint trauma, more frequent in men and in the third decade of life. Depending on the severity of the trauma can range from purely ligamentous injuries, in low-energy trauma, to bone fracture-dislocations in high-energy trauma. A quick and careful diagnosis is crucial to optimize management and treatment, reducing complications and improving functional outcomes in the middle and long-term. Up to 20% of Lisfranc fractures are unnoticed or diagnosed late, above all low-energy trauma, mistaken for simple midfoot sprains. Therefore serious complications such as post-traumatic osteoarthritis and foot deformities are not uncommon. Clinically presenting with evident swelling of the midfoot and pain, often associated with joint instability of the midfoot. Plantar region ecchymosis is highly peculiar. First level of examination is X-Ray performed in 3 projections. CT scan is useful to detect nondisplaced fractures and minimal bone sub-dislocation. MRI is the gold standard for ligament injuries. The major current controversies in literature concern the management and treatment. In stable lesions and in those without dislocation, conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks. Displaced injuries have worse outcomes and require surgical treatment with the two main objectives of anatomical reduction and stability of the first three cuneiform-metatarsal joints. Different surgical procedures have been proposed from closed reduction and percutaneous surgery with K-wire or external fixation (EF), to open reduction and internal fixation (ORIF) with transarticular screw (TAS), to primary arthrodesis (PA) with dorsal plate (DP), up to a combination of these last 2 techniques. There is no superiority of one technique over the other, but what determines the post-operative outcomes is rather the anatomical reduction. However, the severity of the injury and a quick diagnosis are the main determinant of the biomechanical and functional long-term outcomes.

Individual Surgical Treatment of Stage IV Müller-Weiss Disease According to CT/MRI Examination: A Retrospective Study of 12 Cases

Background

This study reported the individual surgical treatment of 12 cases with stage IV Müller-Weiss disease (MWD) according to CT/MRI examination.

Methods

In total, 12 cases diagnosed with stage IV MWD in our hospital from 2015 to 2019 were included in the retrospective study. Relevant clinical outcomes were evaluated preoperatively and postoperatively.

Results

The follow-up results showed satisfactory outcomes in all cases. All the cases were presented with tenderness and chronic pain on the midfoot dorsum, and three cases were also presented with tenderness and pain on the lateral side of the midfoot, in which calcaneal cuboid arthritis was revealed by CT/MRI. The American Orthopedic Foot and Ankle Society (AOFAS) scores elevated from 62.5 ± 6.8 (range: 53–74) preoperatively to 95.3 ± 7.2 (range: 73–100) postoperatively (P &lt; 0.005). The Visual Analog Scale (VAS) scores declined from 4.2 ± 0.9 (range: 3–5.5) preoperatively to 0.5 ± 0.3 (range: 0–2) postoperatively (P &lt; 0.001). On the weight-bearing lateral view of the foot, the Tomeno-Méary angle (TM lat) changed from −11.2 ± 4.2 (range: −17.2 to −2.8) degrees preoperatively to −2.4 ± 3.9 (range: −10.2 to 5.2) degrees postoperatively (P &lt; 0.001).

Conclusions

The fusion of the talus-navicular joint and the adjacent affected joint provide good clinical outcomes. The CT/MRI scans are helpful to identify the adjacent joint arthritis and provide indications for individual treatment for Stage IV MWD.

High Reoperation Rate in Mobile-Bearing Total Ankle Arthroplasty in Young Patients

Background and Objectives: Due to inferior survival rates compared to hip and knee arthroplasty, total ankle arthroplasty (TAA) was previously mainly recommended for older and less active patients. However, given the encouraging survival rates and clinical outcomes of modern generations of TAA, some authors have also advocated TAA in young patients. Thus, the aim of this study was to evaluate age related reoperation, revision and survival rates of third-generation mobile-bearing TAAs. Materials andMethods: In this retrospective study, 224 consecutive TAA patients with a minimum follow up (FU) of 2 years were analyzed. Patients were retrospectively assigned to two study groups (Group A: age < 50 years; Group B: age ≥ 50 years). Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle. Results: After a mean FU of 7.1 ± 3.2 years, the reoperation rate (Group A: 22.2%; Group B: 5.3%; p = 0.003) and revision rate (Group A: 36.1%; Group B: 13.8%; p = 0.003) were higher within Group A. An age of under 50 years at time of surgery was associated with higher reoperation (odds ratio (OR): 6.54 (95% CI: 1.96–21.8); p = 0.002) and revision rates (OR: 3.13 (95% CI: 1.22–8.04); p = 0.018). Overall, lower patient age was associated with higher reoperation (p = 0.009) and revision rates (p = 0.001). Conclusions: The ideal indication for TAA remains controversial, especially regarding patient age. The findings of this study show high reoperation and revision rates in patients aged under 50 years at time of surgery. Therefore, the outcomes of this study suggest that the indication for TAA in young patients should be considered very carefully and that the association between low patient age and high reoperation rate should be disclosed to all eligible patients.

Antibiotic-Coated Nail in Open Tibial Fracture: A Retrospective Case Series

Implant-associated infections still represent one of the main problems in treatment of open fracture. The role of systemic antibiotic prophylaxis is now agreed and accepted; however, recent literature seems to underline the importance of local antibiotic therapy at the fracture site, and antibiotic nails have been shown to play a role in the treatment of open fractures in terms of fracture healing and lower risk of infection. We retrospectively analyzed our results, from January 2016 to March 2020, with the use of coated nails in the treatment of open tibial fractures, evaluating the rates of infection and fracture healing as primary outcomes and the rate of reoperations, time from trauma to nailing and hospital stay as secondary outcomes. Thirty-eight patients treated with coated nail (ETN ProtectTM, Synthes) were included in the study. Minimum follow-up was of 18 months. Thirty-four of 38 patients achieved bone union and 2 patients underwent septic non-union. In our series, no systemic toxicity or local hypersensitivity to antibiotics were recorded. From this study, use of antibiotic-coated nails appears to be a valid and safe option for treatment of open tibial fractures and prevention of implant-related infections, particularly in tibial fractures with severe soft tissue exposure and impairment.