Aim: The aim of the project was to discover if bacteria were implicated in non-union of fractures of the tibia and femur, which had been treated with intramedullary nailing.

Method: 40 intramedullary nails removed from tibial and femoral fractures were retrieved for the purpose of the study. 20 of these nails were from fractures, which had successfully united and were removed for mainly anterior knee pain or discomfort at screw sites. These nails formed the control group for the project. 20 nails were removed from fractures which had failed to unite prior to further operative intervention such as exchange nailing or the application of an Ilizarov frame. These fractures had no clinical evidence of infection and formed the study group for the project. The nails were subjected to ultrasound in the research laboratory to dislodge adherent bacterial formed as biofilm from the surface of the nail. Using both standard culture techniques and non-culture techniques, any dislodged bacteria were isolated and identified. Non-culture techniques involved the use of specific monoclonal antibody labelled immunofluorescence microscopy. Isolated bacteria were tested for the sensitivities of commonly used antibiotics in orthopaedic practice according to NCCLS guidelines.

Results: We discovered that bacteria were detected in up to 70% of the nails removed from fractures, which had failed to unite, using both standard culture and non-culture techniques. Also, we discovered that bacteria were detected in up to 30% of the nails removed from fractures that had united. The organisms identified were mainly the coagulase negative staphylococcus epidermidis and the gram-positive anaerobe proprionibacterium acnes. The antibiotics gentamicin, erythromycin, cefotaxime and cefomandole performed poorly against the isolated bacteria. Vancomycin, ciproxin and fucidin however performed better.

Conclusion: Bacteria formed as biofilm on intramedullary nails may have a significant role in the development of non-union fractures treated by this method. The bacteria isolated showed worrying resistance to commonly used antibiotics in orthopaedic practice, in particular, those used as prophylaxis.