Introduction

The authors’ experience in the treatment of infected defect nonunions has been acquired over 40 years. In the early period the basic principles were:

1. 
   

   Stabilization (external fixator)

   
   
2. 
   

   Debridement

   
   
3. 
   

   Open wound treatment and repeated debridement (wait for granulation tissue)

   
   
4. 
   

   Soft-tissue covering

   
   
5. 
   

   Cancellous bone grafting

The basic principles concerning debridement and stabilization are still the same but local muscle flaps and microsurgical interventions, such as free vascularized skin-muscle flaps have made it possible to carry out soft-tissue coverage at an earlier stage after radical debridement and successful treatment of the infection.

This does not mean that under special conditions a more conservative, less invasive approach would not be still appropriate. After meticulous debridement smaller bone and soft-tissue defects can be filled with pure autogenous cancellous bone, followed by open wound treatment, awaiting granulation tissue to be covered by split-skin transplantation.

The indication for an open cancellous bone graft is especially given whenever the small defect is not suitable for a local flap coverage and would need a rather invasive vascularized flap with possible local- and donor-site problems.

The authors’ conclusion is that not every coverage of a soft-tissue defect needs the help of the plastic-reconstructive surgeon.

Technique

The first step is the excision and careful debridement of dead soft tissue and bone. To judge the vitality of the tissues the use of methylene blue is recommended. Dead-bone sequesters can easily be recognized and other dead tissue will remain blue after irrigation with physiological NaCl-solution. This dead tissue can thus be easily removed. This first step is performed under use of the tourniquet.

After opening the tourniquet, bleeding bone and soft tissue should be present everywhere. Bleeding sclerotic bone should not be removed; drilling of small holes will stimulate further revascularization. Such an extensive debridement as recommended when flap coverage is performed, is not necessary.

A redon-suction drain is placed at the deepest point of the bone defect before pure autogenous cancellous bone is impacted. In the first series, the open cancellous bone grafts were covered with humid gauzes for a week with an exchange of dressing every third day, debriding necrotic cancellous bone fragments when necessary. Finally, granulation tissue will cover the cancellous bone graft allowing split-skin grafting.

Later on, the open graft was covered with gentamicin beads—again in combination with humid gauzes. Using this coverage the authors saw a much faster and more extensive granulation tissue appear, leading to a shortening of the open treatment.

The favorable effect of gentamicin beads covering an open cancellous bone graft is demonstrated by two examples of posttraumatic osteitis of the calcaneus.