Current concepts in the management of infected non-union of the femur: internal versus external fixation

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Introduction The management of infected non-unions continues to be a herculean task for the orthopaedic surgeon due to the emergence of microbial resistance, failure of fixation, frequent re-fractures and resurgence of previously treated infection.The aim of the paper was to structure the approach to the management of patients with infected femoral non‑union based on the literature review and surgeons’ experience.Material and methods A detailed literature review, including current updates on the management of fracture‑resistant infections (FRI) and non-union of the femur was conducted. Search words and phrases used for navigation in the international medical literature platforms were: osteomyelitis, non-union, diagnostic solutions, local antibiotics, biomechanical stability.Results and Discussion The principles of surgical management of infected non-union of the femur remain the same: (a) adequate soft tissue sampling; (b) thorough debridement; (c) fracture stabilization; (d) dead space and defect management; (e) delivery of local antibiotics and (f) soft tissue coverage. The goal of surgery is to get rid of infection. There is no place for empirical treatment of suspected infection. Therapy should be initiated based upon microbial cultures of deep tissue specimens. While selecting the type of hardware for non-union of the femur, one often encounters a dilemma concerning the most appropriate surgical tool for stabilization. Internal fixation with bone grafting would depend on the size of the gap; commonly defects < 6 cm are treated with this modality. External fixation becomes indispensable in certain scenarios such as poor local skin and soft tissue conditions, associated limb length discrepancy > 2 cm, large defect gaps ≥ 6 cm, concomitant deformity, small fragments or osteopenic bone.Conclusion Based on this review of current concepts, the authors conclude that there is no ideal or universal approach for management of infected non-union of the femur, and the approach may vary depending on the technical expertise available and the institutional practices. Irrespective of the modality used, the golden rules of fixation remain the same, alignment, preservation of biology, contact of fragments, stability and early restoration of function.