Der Nutzen einer adjuvanten lokalen Antibiotikagabe bei der Therapie offener Frakturen

Abstract

Seven hundred and four compound fractures —198 (28%) grade l, 259 (37%) grade ll, 247 (35%) grade 111 (86 IIIA, 119 11113, 42 IIIC) — were treated in 590 patients between May 1983 and May 1989 at the University of Louisville. Of these fractures, 157 (22%, group 1) received systemic antibiotic prophylaxis only, whereas 547 (78%, group 2) were treated with additional local application of aminoglycoside beads (tobramycin). Comparison of factors (fracture grades, age, sex, fracture location, follow up) revealed no significant differences between the two groups. All fractures underwent timely irrigation, debridement and skeletal stabilization. In group 1, 52 wounds were primarily closed, 53 underwent delayed primary closure and 52 were left open. In group 2 283 wounds were primarily closed, 229 were managed with the bead pouch technique and 35 were adapted loosely (delayed closure). Forty-nine (6.96%) of the 704 compound fractures became infected (acute wound infection and/or chronic osteomyelitis). Group 1 showed an infection rate of 16.6% (26/157), group 2 a rate of 4.2% (23/547). The difference was statistically highly significant (P < 0.001). Comparison of the infection rates, whether on an acute or a chronic basis, showed that infection rates were lower in group 2 than in group 1 for all fracture grades. A statistically significant difference was established only for type 11113 fractures, where the wound infection rate was 39.1 % (9/23) in group 1 and 7.3% (7/96) in group 2 (P < 0.001). The rate of chronic osteomyelitis was 26.1% (6/23) in group 1 and 6.3% (6/96) in group 2 (P < 0.025). Prophylactic use of antibiotic-bearing polymethylmethacrylate beads in addition to systemic antibiotics was of benefit in preventing infectious complications in compound fractures, in particular in type IIIB fractures.

Zusammenfassung

704 komplizierte Bruche [198 (28%) erstgradige, 259 (37%) zweitgradige, 247 (35%) drittgradige Bruche (Gustilo-Anderson-Klassifikation)] wurden zwischen Mai 1983 und Mai 1989 behandelt. Bei den Frakturen mit drittgradigem Weichteilschaden waren 86 IIIA-, 11911113- und 42 IIIC-Typen vorhanden (GustiloMendoza-Williams-Klassifikation). 157 offene Brüche (Gruppe 1) erhielten eine alleinige systemische Antibiotikagabe (Dreierkombination für 5 Tage), während in die Wunden von 547 komplizierten Frakturen (Gruppe 2) zusätzlich Aminoglykosid-PMMA-Ketten eingebracht wurden. Alle Frakturen wurden radikal debridiert, lavagiert und stabilisiert. Die Infektrate (akute Wundinfektion und/oder Osteomyelitis) betrug 16,6% in Gruppe 1 (26 von 157) und 4,2% in Gruppe 2 (23 von 547). Ein Vergleich der Infektionsraten zeigte eine Reduktion in Gruppe 2 gegeniiber Gruppe 1 bei alien Frakturgraden. Die Senkung der Infektionsrate war nur für den Frakturtyp 11113 statistisch significant: Die Wundinfektion betrug 39,1% in Gruppe 1 und 7,3% in Gruppe 2 (p < 0,001), die Osteomyelitisrate war 26,1 % in Gruppe 1 und 6,3 % in Gruppe 2 (p < 0,025). Der adjuvante lokale Antibiotikaeinsatz im Therapiekonzept offener Frakturen ist sinnvoll, insbesondere bei Brüchen vom Typ 11113.