[Reported malpractice after postoperative infection of the locomotor system. Analysis of 261 expert testimony evaluations]

[Principles of surgical therapy concepts for postoperative and chronic osteomyelitis]

Infection of the bone is one of the most serious complications in the field of orthopedic and trauma orthopedic surgery. Sufficient treatment protocols not only contain complex surgical procedures but also sophisticated diagnostic tools, proper use of antibiotics, and intensive physical therapy right from the beginning. Even in light of these advanced treatment protocols, which have great impact on both patients and health care systems, persisting infection and residual functional deficits of the extremities are not rare. In cases of early (acute) infection, the main objective is to avoid chronification by diligent surgical interventions. The surgical principle is the meticulous debridement and lavage of the situs. Revision of only the epifascial layers is as inadequate as the simple reopening of the wound without excision of the whole wound including all tissue layers. In cases of chronic soft tissue and bone infection, radical debridement of all infected and scar tissue is also the basic requirement of treatment. Reconstruction of the soft tissue envelope is done by local or free flap surgery. Because of they are better resistant to infection, musculo(cutaneous)flaps are preferred. Bony reconstruction is done by autologous cancellous bone grafting (partial defects), segment transport (full thickness defects), or freely transplanted vascularized bone grafts (large partial defects). Both soft tissue and osseous reconstruction take a relatively long period of time requiring several operations and periods of hospitalization. These have to be discussed and explained to the patients extensively. If the required amount of resection and the capability of reconstruction do not coincide, the surgeon and the patient have to decide whether restoration of function without definitive infection care, symptomatic infection therapy, or amputation is the most proper treatment option according to the patient's everyday needs and lifestyle. Because each treatment protocol is a composition of orthopedic trauma surgeons, plastic surgeons, radiologists, microbiologists, and physical therapists, reliable cooperation and communication is essential.

[Why do osteosyntheses fail? The problem with biomechanics and biology]

Avoidance of complications in the course of fracture treatment is of essential importance not only for patients but increasingly from an economic point of view. In the past 15 years emphasis has been placed on the development and fine-tuning of minimally invasive reduction techniques with suitable implants. The main objectives were avoidance of surgical site infection and uneventful fracture healing. This facilitated the solving of long-standing problems but created new sources of error. Minimally invasive, dynamic forms of osteosynthesis were found to fail with extensive open reduction or neglect of biomechanics. Additionally, it appeared that some traditional techniques and basic rules of operative fracture treatment fell into oblivion. The majority of complications are determined already preoperatively by the choice of treatment or implant. After exact analysis of the biomechanics and biological etiology, nonunion is dealt with by an imperative increase in mechanical stability. Additional procedures, i.e., bone graft or debridement, are incorporated into the therapeutic regime. Increasing mechanical stability should be attempted with a minimum of added trauma to avoid local biological impairment. Further improvement of outcome depends on innovative and adapted teaching concepts. Training exclusively with one implant, even under the guidance of the producing company, is insufficient to grasp the various fundamentals of operative fracture treatment indispensable for a successful day-to-day routine.