Strategic considerations in the treatment of infected nonunion in the lower extremity: a narrative review

The treatment of infected nonunion in the lower extremity remains one of the most demanding and nuanced challenges in orthopedic surgery, requiring not only infection eradication but also thoughtful reconstruction of bone and soft tissue in a compromised biological environment. Despite the availability of numerous surgical techniques, clinical decision-making in these cases often lacks standardization and is influenced by surgeon experience, institutional protocols, and variable patient factors. This narrative review aims to synthesize current evidence and expert consensus into a unified, stepwise treatment algorithm that supports individualized, context-driven care. The proposed framework emphasizes the importance of initial patient and limb assessment and soft tissue condition as a basis for determining surgical eligibility and guiding the sequence of intervention. Infection control is prioritized as the cornerstone of management, followed by stable fixation and timely soft tissue coverage. Bone reconstruction is then tailored according to defect size and local tissue viability, with strategies ranging from acute shortening to complex biological or implant-based solutions. The algorithm also integrates adjunctive medical, nutritional, and psychosocial support measures, recognizing their critical role in overall success. By promoting a structured yet adaptable clinical approach, this review offers a practical roadmap for managing infected nonunion and achieving durable limb salvage across diverse clinical scenarios.