If the infection is late, or due to resistant organisms, external fixation is preferable to renailing.
An alternative is to insert temporarily a reinforced, antibiotic-containing polymethylmethacrylate (PMMA) “nail” into the medullary canal, after reaming out the infective membrane and thorough lavage of the IM canal, also excising any sinus tract and any sequestra. An antibiotic-loaded PMMA nail is prepared by injecting liquid bone cement, pre-mixed with antibiotics (e.g. tobramycin 1 g per cement batch) into both ends of an appropriately sized chest tube which is vented in the middle to allow complete filling.
A small-diameter flexible rod (e.g., nailing guide wire) is inserted before the cement hardens. The chest tube is then cut off.
The “nail” can be left in situ until the fracture has healed, or until the infection is under control, and then replaced with a solid metallic nail – a solid nail is used in order to avoid the hollow nail’s becoming a hiding place for bacteria.