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Fractures of the medial malleolus usually occur in association with fractures of the lateral and, less commonly, posterior malleolus. Nonetheless isolated fractures of the medial malleolus have been recorded in sufficient numbers.

The avascular necrosis (AVN) or osteonecrosis of the femoral head is a pathologic process, with many etiological factors, that results from interruption of blood supply to the bone and if not managed timely it leads to the collapse of the femoral head. A number of different classification systems have been developed to evaluate patients with osteonecrosis, nonetheless there is no standard unified classification system for determining the extent and location of the necrotic area in the femoral head. Perhaps the most established classification is the Ficat classification which combines plain film, MRI and clinical features.

The midtarsal joint includes the talonavicular and calcaneocuboid joints. It carries the eponym of Chopart, who described an amputation at this level. Main and Jowett in 1975 classified midtarsal injuries by the direction of the deforming force.

Heterotopic ossification is the abnormal formation of mature lamellar bone within extraskeletal soft tissues where bone does not exist. Heterotopic ossification has been classified into posttraumatic, non-traumatic or neurogenic, and myositis ossificans progressiva or fibrodysplasia ossificans progressive. The Brooker classification was proposed in 1973. Since then it has been used broadly for radiographic rating and for reporting the results of different prophylactic treatments for HO. It is a four class system based on Anteroposterior radiographic views.

Hip osteophyte formation consist late osteoarthritic changes. The changes involving the femoral head are usually more advanced than those seen in the acetabulum. Jeffery in 1973 performed a study describing the topography, morphology and growth of osteophytes in a series of femoral heads removed from patients presenting with advanced osteoarthritis of the hip. Major osteophyte formation patterns appeared to be influenced by the direction, degree and rate of displacement of the femoral head in relation to the acetabulum. Four principal patterns of growth were noted.

The best method for measuring bone mass nowadays is the DEXA (dual energy X-ray absorptiometry) because of its high accuracy and low precision error. Nonetheless it is an expensive method. A less precise but more widely available and less expensive screening tool is conventional radiography. The Singh index describes the trabecular patterns in the bone at the femoral neck and head. X-rays are graded 1 through 6 according to the disappearance of the normal trabecular pattern. Studies have shown a link between a Singh index of less than three and fractures of the hip, wrist, and spine.

Paget disease is a localized disorder of bone remodelling which begins with excessive bone resorption followed by an increase in bone formation concluding to a structurally disorganized mosaic of bone (woven bone) [1]. The structurally affected bone is mechanically weaker, less compact, more vascular and more susceptible to fracture than normal adult lamellar bone. Paget disease which is the second most common bone disorder (after osteoporosis) in elderly people was first described by an English surgeon, James Paget, in 1877 as a chronic inflammation of the bone named osteitis deformans. The disease evolves in three stages

The development of percutaneous techniques of fixation of the superior pubic rami has led to the introduction of a topographic type of classification of these fractures in 2008 by Nakatani et al.

Acute tibial tubercle avulsion fractures typically occur in adolescent boys involved in certain sports. It mainly happens by a strong quadriceps contraction during knee extension or by a rapid passive flexion of the knee against the contracting quadriceps. Ogden et al. described three histological zones in the tibial tubercle growth plate. There is a progressive change from fibrocartilage to columnar cartilage from proximal to distal just before physiologic epiphysiodesis. The physiologic epiphysiodesis occurs in the same direction.

Distal radial fractures, represent a group of the commonest injuries managed by the orthopedic trauma clinicians. Multiple classification systems have developed attempting to reflect fracture severity, define prognosis and guide treatment decision making. Four of the most commonly used classification systems are described to this chapter.

Many classifications apply to fracture of the fifth metatarsal. In general fractures of the proximal end of the fifth metatarsal are categorised as (1) those of the tuberosity and (2) those of the proximal metatarsal within 1.5 cm of the tuberosity. On this anatomical scheme are based some early classifications such as Lawrence’s (1993) and Dameron’s (1972).

Osteonecrosis is by restriction of osseous circulation that leads to necrosis of osseous tissue. The knee is the second most common site for osteonecrosis after the hip. Osteonecrosis of the knee may be spontaneous osteonecrosis or secondary osteonecrosis (related to several risk factors such as alcohol abuse, sickle cell disease, systemic lupus erythematosus, Gaucher disease, Fat Embolism). Spontaneous osteonecrosis involves only the medial femoral condyle whereas secondary osteonecrosis may affect both condyles.

The tarsometatarsal joint carries the eponym of Lisfranc, who described an amputation at this level. In 1909 Quenu and Kuss presented a classification for tarso-metatarsal joint injuries which was modified in 1982 by Hardcastle. In 1986 Myerson relabeled this classification presenting its final form. The patterns described by this classification typically include combined fractures-dislocations. The dislocations involved in this type of injuries may be either monolateral or divergent. In monolateral dislocations the metatarsals are dislocated towards one direction (medial or lateral). In divergent dislocations the first metatarsal shifts medially and the remainder of the forefoot shifts laterally. Most commonly Lisfranc injuries involve the first, second metatarsals and the medial cuneiform, however more complicated patterns can be seen. Soft tissue Injuries of the Lisfranc joint (sprains) are classified by the Burroughs classification which was introduced in 1998.

The navicular plays an important role in maintaining the medial longitudinal arch of the foot. Navicular fractures may not be initially evident on plain radiographs and this may lead to delayed diagnosis and poor outcome. There are four types of navicular fractures namely: (1) cortical avulsion fractures, (2) tuberosity avulsion fracture, (3) body fractures, and (4) stress fractures.

In 1935 Pauwels presented a classification for femoral neck fractures which mainly refers to intracapsular fractures and which relies on the angle of obliquity of the fracture line in relation to the horizontal plane.

A percentage of 15–20 % of major long-bone fractures in childhood refers to growth plate injuries. Salter-Harris classification which was presented in 1963 is a commonly used method of describing fractures through the physis (growth plate) of skeletally immature individuals. Outcome worsens as the number describing the fracture increases.

The Evan's classification system for intertrochanteric fractures is described as well as the recommended treatment strategy, and relevant references as to their outcome.

A challenging case of a nonunion of the proximal femur complicated by infection attributed to microbial and fungal pathogens requiring a combination of novel surgical techniques to achieve eradication of infection, preservation of the native hip joint, and restoration of function.

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.Cite this article: Bone Joint J 2014; 96-B:783–8.

Background This study aims to determine the incidence of pulmonary embolism (PE) in trauma and orthopedic patients within a regional tertiary referral center and its association with the pattern of injury, type of treatment, co-morbidities, thromboprophylaxis and mortality. Methods All patients admitted to our institution between January 2010 and December 2011, for acute trauma or elective orthopedic procedures, were eligible to participate in this study. Our cohort was formed by identifying all patients with clinical features of PE who underwent Computed Tomography-Pulmonary Angiogram (CT-PA) to confirm or exclude the clinical suspicion of PE, within six months after the injury or the surgical procedure. Case notes and electronic databases were reviewed retrospectively to identify each patient’s venous thromboembolism (VTE) risk factors, type of treatment, thromboprophylaxis and mortality. Results Out of 18,151 patients admitted during the study period only 85 (0.47%) patients developed PE (positive CT-PA) (24 underwent elective surgery and 61 sustained acute trauma). Of these, only 76% of the patients received thromboprophylaxis. Hypertension, obesity and cardiovascular disease were the most commonly identifiable risk factors. In 39% of the cases, PE was diagnosed during the in-hospital stay. The median time of PE diagnosis, from the date of injury or the surgical intervention was 23 days (range 1 to 312). The overall mortality rate was 0.07% (13/18,151), but for those who developed PE it was 15.29% (13/85). Concomitant deep venous thrombosis (DVT) was identified in 33.3% of patients. The presence of two or more co-morbidities was significantly associated with the incidence of mortality (unadjusted odds ratio (OR) = 3.52, 95% confidence interval (CI) (1.34, 18.99), P = 0.034). Although there was also a similar clinical effect size for polytrauma injury on mortality (unadjusted OR = 1.90 (0.38, 9.54), P = 0.218), evidence was not statistically significant for this factor. Conclusions The incidence of VTE was comparable to previously reported rates, whereas the mortality rate was lower. Our local protocols that comply with the National Institute for Health and Clinical Excellence (NICE) guidelines in the UK appear to be effective in preventing VTE and reducing mortality in trauma and orthopedic patients.

dissection of the tissues, causing a collection in the perivascular area, which subsequently distended into the uterine cavity. There was then rupture, with sudden intractable blood loss. Diagnosis is difficult, requiring color Doppler ultrasound, CT scan, or angiography. Being a rare cause of secondary postpartum hemorrhage, a high degree of suspicion is required to anticipate this diagnosis. Uterine artery embolization is a safe and effective method to control hemorrhage under these circumstances. References

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

To provide evidence on the midterm sexual-function- and health-related quality-of-life outcome of patients with a traumatic pelvic fracture, as recorded at least 12 months after their surgery.Prospective noncomparative study.Tertiary referral centre for pelvic-and-acetabular reconstruction.Cohort of patients attending a dedicated pelvic-and-acetabular reconstruction clinic because of blunt pelvic trauma, at a minimum of a year after their injury.Operatively treated pelvic fractures and concomitant surgical interventions for associated injuries, if any, sustained by the patients after blunt trauma.Sexual function questionnaires: IIEF (international index of erectile function) and FSFI (female sexual function index). Quality of life was assessed with the EuroQol-5D questionnaire.Of a cohort of 110 patients, 80 patients (48 males and 32 females) consented to participate with a median age of 46 years (range, 19-65 years). Of the above cohort, 62.5% were a result of road traffic accidents and 52.5% were classified as lateral compression type fractures. Assessment occurred at a median period of 36 months after injury (range, 12-96). Overall, significant decrease of their quality of life (P0.0001) and sexual function were recorded (males, P0.00014; females, P0.001). Sexual dysfunction was identified in 43.8% of the female and 52.1% of the male patients, as per the validated gender-specific sexual function scores (female sexual function index and international index of erectile function, respectively). Regression analysis identified the presence of urinary tract injury (P0.049) and open surgical treatment (P0.047) as independent risk factors for sexual dysfunction. A near significant association with injury severity score (P = 0.05) was seen. Male gender (P0.006), abdominal injury (P0.0001), pelvic fracture severity (P0.049), pain (P0.0001), and sexual dysfunction (P0.034) were identified as significant independent risk factors for decreased quality of life.All domains of female and male sexual function were significantly decreased at a minimum of a year after pelvic fracture. Quality of life was also significantly decreased in this group with sexual dysfunction shown to be an independent risk factor for decreased quality of life after injury. Further pivotal clinical studies should follow based on the provided evidence. High clinical suspicion and prompt engagement of appropriate multidisciplinary pathways, including urological, gynecological, and psychiatric consultations, is recommended.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Cigarette smoke has negative effects on bone metabolism and fracture repair. However, no study has reviewed effects of nicotine on bone and fracture repair independent of other constituents of cigarette smoke. The authors review the existing evidence of the effect of nicotine on 'bone' and 'bone cells' and fracture repair, drawing conclusions relevant to clinical practice and future research.A literature review was conducted using PRISMA guidelines and PubMed, Cochrane, MEDLINE/OVID, EMBASE, NHS Evidence and Google scholar databases. Articles were included if they specifically investigated the effects of nicotine on 'bone' or fracture repair in animal or human models or in vitro effects on 'bone cells'. A total of 64 papers were included in this review, of which 15 were human in vitro studies and 49 animal studies wherein 9 were in vitro and 40 in vivo. In vivo studies of the effects of nicotine in animals demonstrated widespread effects on bone including osteoneogenesis, osseointegration, steady-state skeletal bone and genes and cytokines relevant to bone cell physiology and bone homeostasis. In these studies, nicotine's effects are predominately negative, inhibiting bone cell metabolism and fracture repair, whereas most in vitro studies reported biphasic responses in all bone cells except osteoclastic cells.The review suggests that nicotine has effects on osteoneogenesis, osseointegration and steady-state skeletal bone in animal in vivo models, as well as effects on all 'bone cells', via several mechanisms in both animal and human cell in vitro studies. The effect of nicotine is dose-dependent, with higher concentrations having predominantly negative effects, whereas at low concentrations a stimulatory effect is seen. Stimulatory effects on certain cells may indicate a possible, limited therapeutic role; advice regarding smoking cessation perioperatively should remain due to the other harmful components of cigarette smoke, but there may be scope for allowing the use of nicotine patches instead of complete abstention. Further research into clinical outcomes is required before the exact response of bone and fracture repair in humans to nicotine is known.

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements. Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients. Cite this article: Bone Joint J 2013;95-B:230–8.

The current available evidence for the use of bone graft substitutes in the management of subchondral bone defects associated with tibial plateau fractures as to their efficiency and safety has been collected following a literature review of the Ovid MEDLINE (1948-Present) and EMBASE (1980-Present). Nineteen studies were analysed reporting on 672 patients (674 fractures), with a mean age of 50.35 years (range 15-89), and a gender ratio of 3/2 males/females. The graft substitutes evaluated in the included studies were calcium phosphate cement, hydroxyapatite granules, calcium sulphate, bioactive glass, tricalcium phosphate, demineralised bone matrix, allografts, and xenograft. Fracture healing was uneventful in over 90% of the cases over a variant period of time. Besides two studies reporting on injectable calcium phosphate cement excellent incorporation was reported within 6 to 36 months post-surgery. No correlation was made by any of the authors between poor incorporation/resorption and adverse functional or radiological outcome. Secondary collapse of the knee joint surface ≥ 2 mm was reported in 8.6% in the biological substitutes (allograft, DBM, and xenograft), 5.4% in the hydroxyapatite, 3.7% in the calcium phosphate cement, and 11.1% in the calcium sulphate cases. The recorded incidence of primary surgical site and donor site infection (3.6%) was not statistically significant different, however donor site-related pain was reported up to 12 months following autologous iliac bone graft (AIBG) harvest. Shorter total operative time, greater tolerance of early weight bearing, improved early functional outcomes within the first year post-surgery was also recorded in the studies reporting on the use of injectable calcium phosphate cement (Norian SRS). Despite a lack of good quality randomised control trials, there is arguably sufficient evidence supporting the use of bone graft substitutes at the clinical setting of depressed plateau fractures.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Two incidences of late diaphyseal stress fracture due to unsuccessful targeting during intramedullary nailing are presented. Distal interlocking in the diaphysis must be performed meticulously to avoid the appearance of this significant complication.

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures, which are not specifically defined by any current classification system. Their incidence is increasing due to the rising number of elderly osteoporotic fractures. They have always been notoriously difficult fractures to treat. We present a systematic review of conservative and operative management and their respective outcomes over the last century.

Introduction: Aim of this study is to present the clinical profile and outcomeof complexmultifragmented/segmental femoral fractures, comparing their outcome following different management strategies. Materials and methods: Retrospective single centre cohort study of complex femoral fractures classified as AO types 32-C.1/2/3. Pathologic, paediatric fractures were excluded. Demographics, mechanism of injury, type of fracture, associated injuries (AIS05), ISS and NISS, treatment method, secondary procedures, complications and final clinical outcome were recorded. Descriptive statistical methods were utilised comparing early-total-care (ETC) protocols versus damage-control-orthopaedics (DCO). Results: 22-patients (24-fractures) were identified over a 4year period. Young males represented the majority (75%), with median age 32 years (18–71). Road-traffic-accidents were responsible for all of these injuries. Therewere 12 32-C.2 (segmental), and 12 32-C.3 (multifragmented) fractures (4 open grades 3A/B). The median length of the segment or, of the comminution was 13.1 cm (3.9–26.6).There was bone loss in 5cases (ranging 7.8–13.6 cm). Median ISS was 22 (9–41), median NISS was 27 (13–43). Half were managed according to ETC and half in stages (DCO). Deep local sepsis complicated 6 cases, 1 thromboembolism, 1 femoral head AVN, and 2 systemic complications. Three months post-injury mortality was 18%. The rest 9/19 fractures united after median period of 8 months (6–9). There were 2delayed-unions (healed at 11 and 12months) and 8 nonunions. Secondary interventions were necessary for 9 cases (6 healed, 3 still under treatment). DCO was associated with higher ISS/NISS, mortality, while the clinical outcome of either treatment protocol was comparable. Discussion: Severe femoral fractures represent an index injury of severe trauma, are associated with multiple other injuries. Their mortality, complication rate and final clinical outcome remain suboptimal irrespective of different management strategies.

Introduction Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario. Materials and methods Prospective collection of data related to infected cases treated with the use of the RIA in a tertiary referral centre referring to a 3 year period. Peri-operative details, microbiology results, and follow-up outcome over a minimum period of 12 months post-surgery are reported. Results Twenty patients (13 men), with average age 44.8 years (18–75), suffering from 7 tibial and 13 femoral infections represent the study cohort. There were 19 surgical-site-infections, and 1 spontaneous haematogenous infection in non-previously operated extremity. The canal was stabilised using an antibiotic-loaded-cement-nail in 18 cases. The antibiotic nail was subsequently removed after 6–8 weeks. The most commonly isolated organism was staphylococcus aureus. There were followed-up regularly (2,6, 12 weeks, and then at 6 months and 12, 24, 36 months). At 6 months follow up (range 12–43 months) no recurrence was observed. Two patients died during the course of the study. One patient at the day after surgery due to septic shock, and another one at 2 years due to irrelevant causation. Another patient had a below knee amputation after debriding of the canal for pan-medullary osteomyelitis. However, there was no recurrence in the stump at the latest follow up after 1 year. Conclusion The usage of this new device shows promising results in the treatment of intramedullary osteomyelitis. Reaming under simultaneous irrigation and suction appears to be an effective and safe alternative for debridement of the intra medullary infections of femur and tibia. Long term follow up is essential, as post traumatic osteomyelitis can occur at any time after surgical treatment although the majority of recurrences are seen within 2 years.

The aim of this study was to evaluate the safety and efficiency, as well as the incorporation characteristics of a specific type of xenograft used for iliac crest defects post-harvesting tri-cortical iliac crest bone graft.Sixteen patients diagnosed with chronic anterior pelvic pain were operated for pubic symphysis fusion. The tri-cortical graft harvested from the iliac crest was inserted into the pubic symphysis and compressed with a reconstruction plate. The defect in the iliac crest was filled with a block of cancellous bovine substitute (Tutobone®). The length of iliac crest defect, time to fusion of pubic symphysis, time to incorporation of the graft and complications were recorded. The postoperative pain and patients' satisfaction were evaluated.The median age of patients was 36.5 years (range 27-75). Fusion was obtained in 15 patients (94 %). The median time to fusion was four months (range three to seven). The length of the iliac crest bone defect ranged from 40 to 70 mm. Integration of the bovine substitute was achieved in 15 patients (94 %) over a median period of three months (range two to six). The postoperative median pain score was 2 (range 1-5). Twelve patients (75 %) reported good satisfaction. No major complications or allergic reactions were observed.The xenograft used in this study provided a safe and effective method of reconstruction of iliac crest donor site defects. It has satisfactory incorporation, high biocompatibility and no signs of inflammatory reactions. This new technique is simple and easily reproducible in routine clinical practice.

Bone infection in adults is a potentially devastating complication following trauma or surgery. The clinician should diagnose osteomyelitis based on certain clinical manifestations and on laboratory and imaging findings. For pathogen identification, the treating surgeon should take appropriate tissue samples. Close collaboration with microbiologists is of paramount importance to dictate the appropriate duration and type of antibiotics to be administered. Treatment of acute osteomyelitis requires surgical debridement and prolonged course of antibiotics. Debate exists regarding the maintenance or the removal of any internal fixation device. Treatment of chronic osteomyelitis is more complicated. For its eradication the treatment course is often prolonged and frustrating. Based on the current literature an algorithm of treatment for both acute and chronic bone infections is recommended.