The treatment and healing process can be divided into three phases: preoperative, intraoperative, and postoperative.

In all three phases, the reduction of soft-tissue damage, the prevention of contamination, and the improvement of blood perfusion are necessary [6–8]. Therefore, the fracture should be reduced as early as possible, sufficient blood pressure should be reached, a examination of open fractures should be performed under sterile conditions in the operating room, and antibiotic drugs must be administered in the emergency room. The radical removal of dead tissue is required on open fractures. Additionally, the type of osteosynthesis and operative procedure chosen should prevent a decrease of local and systemic conditions for wound healing. In critical soft-tissue conditions, the method of choice is a temporary covering of the wound with a vacuum closure. Time plays a vital role in the third phase. By the time the surgeon reflects whether a revision procedure is necessary, the revision should be done.

The majority of severe infections and development of osteitis can be prevented with early and consequent management of complications in the third postoperative phase.

The usual principles for diagnosis of osteitis are valid.

In the clinical presentation of open fractures, operative fracture treatment, complications during wound healing, diabetes mellitus, and signs of general inflammation-like fever, swelling, and redness are indicative of osteitis.

Local signs of infection on clinical examination depend on the level of infection. The spectrum of local symptoms ranges from pain under stress to redness and swelling, up through the existence of fistula with purulent secretion, and in severe cases, systemic sepsis.

A specific laboratory parameter for detecting osteitis does still not exist.

In clinical practice, C-reactive protein (CRP) seems to be reliable parameter for evaluation of the activity of an inflammatory process [9, 10].

There are different imaging methods for diagnosing acute postoperative and the chronic osteitis. For the diagnosis of acute osteitis, the imaging methods are less helpful [9, 11].

For chronic osteitis, plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) are methods of diagnosis. Thus, enclosed gas in a bone formation seen on CT scans is a strong argument for chronic osteitis. The uptake of contrast medium in the adjacency of a bone sequester is deemed to be strong evidence of chronic osteitis.

Ultrasound imaging is not appropriate for the diagnosis of osteitis because it is not highly specific. In recent years, results using fluorodeoxyglucose positron emission tomography (FDG-PET) have shown to be a valid method for the diagnosis of osteitis. Available studies report sensitivity with an of average 96 % and specificity of 91 % compared with bone scintigraphy (82 %/25 %), leukocyte scintigraphy (61 %/77 %), and MRI (84 %/60 %) [12]. Using FDG-PET CT should show an improvement of expressiveness (Fig. 18.2).

A positive microbiological culture shows the highest evidence for the diagnosis of osteitis. The bacterial probes must be taken from the intraoperative situs. The tests must be representative for aerobe and anaerobe bacteria. The time between extraction of the material and the beginning of processing the microbiological investigation is important for the significance of the probes. If incubation of the probes begins too late, a false negative result can present for noninfected tissue. The same is essential for the extraction of the probes from the wound. Using gloves and instruments for avoiding contamination from the skin and other tissue areas is indispensable. In clinical cases with a high suspicion of infection without a positive microbiological result, specific infections must be excluded (e.g., tuberculosis, Lues).