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Management von frakturassoziierten Infektionen

Management of fracture-related infections

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Zusammenfassung

Frakturassoziierte Infektion („fracture-related infections“, FRI) stellen eine Herausforderung für die unfallchirurgische Versorgung dar. Die Probleme in der Behandlung solcher Infektionen sind vielfältig. Insbesondere bei noch nicht abgeschlossener Frakturheilung sind neben der Infektsanierung zusätzlich die Widerherstellung der knöchernen Kontinuität zu adressieren. Das Ausmaß der begleitenden Weichteilschädigung ist von besonderer Relevanz, da eine reduzierte Vaskularisation zu Einschränkungen in der Frakturheilung führt. Während akute Infektionen häufig einfach zu erkennen sind, können die Symptome bei chronischen Infektionen unspezifisch sein und sich der Diagnostik entziehen. Diese Tatsache macht die Behandlung solcher Infektionen kompliziert und erfordert z. T. ein interdisziplinäres Vorgehen. Aus diesem Grund hat die „Fracture-related Infection Consensus Group“ einen Algorithmus entwickelt, der erstmals 2017 publiziert sowie 2018 und 2020 erneuert wurde. Bei den FRI handelt es sich um biofilmassoziierte Infektionen, sodass die aktuellen Richtlinien sich an die bereits etablierten Therapiealgorithmen für periprothetische Infektionen anlehnen. Trotz der Analogien zu periprothetischen Infektionen bestehen auch Unterschiede bei der Behandlung, da die Aspekte der Frakturheilung und Knochendefektsanierung einen determinierenden Faktor in der Therapie der FRI darstellen. Im Folgenden werden die Besonderheiten von FRI herausgestellt sowie die Klassifikationen und ein Leitfaden zur Behandlung erörtert.

Abstract

Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.

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Abbreviations

AO:

Arbeitsgemeinschaft für Osteosynthesefragen

CRP:

C‑reaktives Protein

FDG-PET:

18F‑Fluordesoxyglucose-Positronen-Emissions-Tomographie

FRI:

„Fracture-related infection“ (frakturassoziierte Infektion)

HPF:

„High power field“

pAVK:

Periphere arterielle Verschlusskrankheit

PMN:

„Polymorphonuclear cells“

RT-PCR:

„Real-time polymerase chain reaction“ (Echtzeit-Polymerase-Kettenreaktion)

SIRS:

„Systemic inflammatory response syndrome“ (systemisches inflammatorisches Response-Syndrom)

SPECT:

Singlephotonen-Emissionscomputertomographie

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Authors and Affiliations

  1. Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    Jan-Dierk Clausen, Philipp Mommsen, Tarek Omar Pacha, Marcel Winkelmann, Christian Krettek & Mohamed Omar

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  1. Jan-Dierk Clausen
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  2. Philipp Mommsen
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  3. Tarek Omar Pacha
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  6. Mohamed Omar
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Correspondence to Jan-Dierk Clausen.

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J.-D. Clausen, P. Mommsen, T. Omar Pacha, M. Winkelmann, C. Krettek und M. Omar geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Clausen, JD., Mommsen, P., Omar Pacha, T. et al. Management von frakturassoziierten Infektionen. Unfallchirurg 125, 41–49 (2022). https://doi.org/10.1007/s00113-021-01116-1

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