Femur osteomyelitis following medullary nailing.

Abstract

The publication is based on a group of 29 patients with infected medullary nail osteosyntheses. They are part of a completed and controlled series of 96 cases of infected femur pseudarthroses of different genesis. The characteristic anamnestic, clinical, and therapeutic features of femur osteomyelitis following medullary nailing are shown. The analysis shows that infection complications can frequently be traced to dubious or false indications for nail osteosynthesis or to an imperfect nailing technique. Compared to infected pseudarthroses following plate osteosynthesis, the formation of osseous defects due to sequestration is less following infected medullary nailing, thus bony support of the main fragments is usually maintained. Spreading of the infection in the sense of a medullary space phlegmon and endosteal sequestration are characteristic. The basic forms of therapy are described: A nail which reliably stabilizes can remain in place despite the presence of infection; with the assistance of such additional measures as debridement, osteoplasty, local chemotherapy, and continuous drainage, bony bridging can be achieved. Unstable intramedullary supports require removal of the medullary nail, reaming of the medullary space for the purpose of endosteal debridement, and stable reosteosynthesis. Due to the danger of osseous circulatory disturbance, fixateur externe osteosynthesis must be preferred for the femur despite its biomechanical disadvantages. Differentiated selection of the specific external fixation arrangement depends on the infection activity, extent, and anatomic location of the osteomyelitic focus and the function of the joints. In individual cases sufficiently dimensioned internal plate osteosynthesis is appropriate, despite the danger of possibly provoking disruption of the periosteal vascularity of the cortical bone. We reject renewed medullary nailing following previous infected medullary nail osteosynthesis. Long-term results are satisfactory with respect to subjective symptoms, the function of adjacent joints, bone consolidation, and loading. In the chronic stage, however, widely branching fistula systems and defective osseous cavities can lead to therapy-resistant problems.