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Volume 14
Issue 21
10.3390/jcm14217767
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This is an early access version, the complete PDF, HTML, and XML versions will be available soon.
Review

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

by
Jonas Armbruster
1,
Benjamin Thomas
2,
Dirk Stengel
3,
Nikolai Spranger
4,
Paul Alfred Gruetzner
1 and
Simon Hackl
5,*
1
BG Klinik Ludwigshafen, Department for Orthopaedics and Trauma Surgery at Heidelberg University, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
2
BG Klinik Ludwigshafen, Department of Hand, Plastic, and Reconstructive Surgery, Burn Center at Heidelberg University, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
3
BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117 Berlin, Germany
4
Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, 12683 Berlin, Germany
5
Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Straße 8, 82418 Murnau, Germany
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2025, 14(21), 7767; https://doi.org/10.3390/jcm14217767 (registering DOI)
Submission received: 27 July 2025 / Revised: 30 September 2025 / Accepted: 31 October 2025 / Published: 1 November 2025
(This article belongs to the Special Issue Evidence-Based Clinical Management of Orthopaedic Trauma: 25 Years in Retrospect, and a Forecast of 25 Years to Come)
Versions Notes

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

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MDPI and ACS Style

Armbruster, J.; Thomas, B.; Stengel, D.; Spranger, N.; Gruetzner, P.A.; Hackl, S. Managing Nonunions and Fracture-Related Infections—A Quarter Century of Knowledge, and Still Curious: A Narrative Review. J. Clin. Med. 2025, 14, 7767. https://doi.org/10.3390/jcm14217767

AMA Style

Armbruster J, Thomas B, Stengel D, Spranger N, Gruetzner PA, Hackl S. Managing Nonunions and Fracture-Related Infections—A Quarter Century of Knowledge, and Still Curious: A Narrative Review. Journal of Clinical Medicine. 2025; 14(21):7767. https://doi.org/10.3390/jcm14217767

Chicago/Turabian Style

Armbruster, Jonas, Benjamin Thomas, Dirk Stengel, Nikolai Spranger, Paul Alfred Gruetzner, and Simon Hackl. 2025. "Managing Nonunions and Fracture-Related Infections—A Quarter Century of Knowledge, and Still Curious: A Narrative Review" Journal of Clinical Medicine 14, no. 21: 7767. https://doi.org/10.3390/jcm14217767

APA Style

Armbruster, J., Thomas, B., Stengel, D., Spranger, N., Gruetzner, P. A., & Hackl, S. (2025). Managing Nonunions and Fracture-Related Infections—A Quarter Century of Knowledge, and Still Curious: A Narrative Review. Journal of Clinical Medicine, 14(21), 7767. https://doi.org/10.3390/jcm14217767

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