S04.KL3 WHY DO WE FAVOUR EXTERNAL FIXATION IN DIAPHYSEAL INFECTED NON-UNION AND WHAT COULD BE THE REASONS TO TURN BACK TO INTERNAL FIXATION IN ADEQUATE CASES

Abstract

Based on the analysis of Rittmann and Matter the AO advocated to leave stable implants after osteosynthesis in place and to remove them only when a sufficient bridging of the fractured would have happened. In opposition it generally became accepted to remove instable implants to be replaced by an external fixateur. Using local antiseptics such as Lavasept (Willlenegger) and intravenous antibiotics efficient against the proven bacteria one was able to cure the infection. Additional measures of osteoinduction (mainly cancellous autograft and decortication) favoured bridging of the non-union area. With the help of callus distraction after segmental resection of dead bone areas using more sophisticated external fixateurs marvellous reconstructions of big bone areas became possible.

On the other hand we have to realize, that in the upper extremities external fixation is frequently a clumsy installation inhibiting function. Because of delay of union not unfrequently secondary stabilazation of non-union or refracture areas had to be stabilized with secondary internal fixation. This was possible because the infection was already cured.

The knowledge of implant related infection did learn us, that the elimination of bacteria linked to a biofilm, which are at rest, frequently are resistant against antibiotics otherwise successful against planctonic bacteria of the same species. Be it by higher concentrations, be it by the use of antibiotics efficient against resting bacteria such as Rifampin ant once other possibilities are developed to be able to treat infections even in presence of internal osteosyntheses. When the success rate of intramedullary nails as they were used by Klemm was distinctly lower compared with external fixateurs at that time, today it becomes possible to us internal fixation in infections with bacteria with a known antibiotic treatment in presence of implants. This opens important doors for the combination of internal fixation, vascular bone grafts and antibiotic treatment accelerating the treatment of infected non-union in adequate cases.Stepwise it became possible to get to better functional results within a shorter time in adequate cases.