JOT - 2026-08-13 - Journal Article
Outcomes of Aseptic, Septic, and Occult Infected Index Nonunion Repair: A Retrospective Comparative Study.
Rossbach K, Mau M, Marchand L, Higgins T, Rothberg D, Haller J
Topics
Key Takeaway
Occult infected nonunions (culture-positive but FRI-criteria-negative) achieved successful union after index surgery in 79.3% of cases, comparable to aseptic nonunions (72.8%) and significantly better than septic nonunions (50.0%, p=0.004).
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Summary
This study compared index nonunion surgery outcomes across three groups—aseptic, occult infected (culture-positive but not meeting FRI major criteria), and septic—classified using EBJIS/ICM 2018 FRI criteria in 208 patients over 10 years at a single Level I center. Successful union without additional surgery was 79.3% (occult infected), 72.8% (aseptic), and 50.0% (septic), with postoperative infection rates of 10.3%, 16.0%, and 35.2%, respectively. Septic nonunions carried significantly worse outcomes on both primary and secondary endpoints (p=0.004 and p=0.005).
Key Limitation
Retrospective single-center design with a small occult infected cohort (n=29) precludes controlling for fracture location, fixation construct, and antibiotic management heterogeneity across groups.
Original Abstract
OBJECTIVES
To compare nonunion surgery effectiveness for occult infected, aseptic, and septic nonunions in patients identified using the FRI criteria.
METHODS
Design: Retrospective Review.
SETTING
Single Level I Tertiary Academic Center.
PATIENTS SELECTION CRITERIA
All skeletally mature patients over a 10-year period with nonunions and inflammatory labs at the time of index surgery were evaluated. Patients were classified using fracture-related infection (FRI) criteria as septic (SP) or aseptic. Aseptic patients were further stratified by intraoperative cultures into aseptic (AP, culture-negative) and occult infected (OP, culture-positive) groups. Exclusion criteria were pathologic fractures.
OUTCOME MEASURE AND COMPARISONS
Primary outcome measured was successful union after index nonunion surgery without need for additional surgical interventions.
RESULTS
A total of 208 patients with nonunion fractures were included (OP: 29; AP: 125; SP: 54). Mean age was similar between groups (OP: 47.6 ± 21.2 years, range 19.9-79.9 years; AP: 54.5 ± 25.6 years, range 15.4-93.4; SP: 54.9 ± 23.5 years, range 16.5-81.3, p=0.854). Male sex distribution in occult infected patients, aseptic patients, and septic patients was 65.5%, 66.4%, and 46.3%, respectively (p=0.035). Occult infected patients had the highest rate of successful union after index surgery without need for additional operative intervention (79.3%), followed by aseptic patients (72.8%) and septic patients (50.0%) (p=0.004). Postoperative infections following index nonunion surgery were significantly lower in aseptic patients (16.0%) and occult infected patients (10.3%) compared to septic patients (35.2%) (p=0.005).
CONCLUSIONS
Index nonunion surgery in septic patients, as defined by FRI criteria, was associated with worse outcomes compared to aseptic and occult infected patients. The success of surgery in occult infected nonunion is comparable to aseptic cases, suggesting that subclinical fracture related infection does not significantly compromise outcomes.
LEVEL OF EVIDENCE
Prognostic Level III.