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Objectives: To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture related infections (FRIs) occurring within 90 days of initial IMN placement. Design: Retrospective case-control Setting: Four academic, level 1 trauma centers Patients: 66 patients that subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN Intervention: DAIR versus IMN removal pathways Main Outcome Measurements: Fracture union Results: Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was seen in ultimate bone healing (p=.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN (p<.001), McPherson systemic host grade B (p=.046), as well as increasing open fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst (p=.009). Fewer surgeries following initial FRI treatment were positively associated with ultimate bone healing (p=.029). Conclusions: Treatment of FRI within 90 days of tibial IMN with either DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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