133. Die posttraumatische Osteitis nach schweren Weichteil- und Skeletverletzungen am distalen Unterschenkel und Fuß

Zusammenfassung Die Komplikationsrate schwerer Weichteil- und Skeletverletzungen am distalen Unterschenkel und Fuß ist hoch. Die Infekthäufigkeit wird aufgrund verfügbarer Daten der AO-Dokumentations-Zentrale, Bern präsentiert. Bei Infekt ist eine großzügige Entfernung von nekrotischem Gewebe und Stabilität der infizierten Fraktur nötig. Der Zeitpunkt für Spongiosaplastiken, mikrovasculäre Lappen, systemische und lokale Antibiotica und lokale Spülungen mit Desinfizientien werden diskutiert und auch auf mögliche Wechselbeziehungen von Allergien auf Implantate und Infekte eingegangen.     

Osteitis

Trauma und Berufskrankheit - Grundsätzlich ist das Therapiekonzept bei akuten und chronischen Osteitiden mittlerweile allgemein anerkannt und verbreitet. Die Behandlung durch multiresistente...     

Osteitis

In principle, the therapy concept of acute and chronic osteomyelitis has generally been accepted and widely applied. However, the treatment of osteomyelitis caused by multi-resistant bacteria (MRB) requires a series of additional measures to ensure lasting therapeutic success. Depending on the transmission method of the bacteria and the mechanism of becoming resistant, some patients with multi-resistant viruses (e. g. MRSA, methicillin-resistant Staphylococcus aureus infection; VRE, vancomycin-resistant enterococcus) should be treated in isolation. Isolation itself makes additional measures necessary, such as sluices, eradication/decontamination, psychological care etc. While MRB osteomyelitis remains a relatively rare disease, its complexity and long clinical course require an intensive, special and interdisciplinary therapeutic approach in order to achieve the desired outcome. This is clearly demonstrated by our own statistical data. For example, the transmission of MRSA in our clinic decreased between 2000 and 2007 from 50 to 4, although the number of admissions of MRSA patients increased from 18 to 92.     

Osteitis

Infections of the locomotive system appear in many different forms such as acute inflammation of joints or bone following injury or surgical or chronic processes, often lasting for years. They demand an exact treatment plan not only to remove necrotic tissue but also for reconstruction of defects. A special problem is infection following alloplastic reconstruction of joints or spine. Multiple surgical procedures are required to hinder reinfection, restore function, and assure acceptable patient quality of life.     

Benignes desmoplastisches Fibroblastom am Unterschenkel

Desmoplastic fibroblastoma (“collagenous fibroma”) is a benign fibrous soft tissue tumor. We report a rare case of a “collagenous fibroma” located in the proximal lower leg in 56-year-old man. The clinical, radiological, and pathological-morphological findings are documented. The operative treatment was performed according to general principles of surgical management of benign soft tissue tumors.     

Posttraumatische Osteitis

Identification and antibiotic susceptibility testing of the infecting microorganism in posttraumatic osteitis is the major concern for an efficient therapy. Tissue samples and aspirates are the most appropriate specimens for microbiological testing. An empiric antimicrobial therapy without microbiological testing should be given only in exceptional cases. Antimicrobial selection and duration of therapy are based on clinical findings and the local epidemiology of antimicrobial susceptibility. In the special case of prosthesis-related infections, only total replacement can achieve complete recovery.     

Bakterielle Osteitis

Zusammenfassung Mit zunehmender Lebenserwartung der Bevölkerung und stetig steigender medizinischer Kompetenz steigt auch die Zahl älterer, häufig abwehrgeschwächter Patienten. Immunkompromittierte Patienten bedürfen sowohl bei der Diagnosestellung als auch der Therapie der bakteriellen Osteitis besonderer Beachtung.     

Therapiekonzepte bei Osteitis

Despite constant improvements in medical care, osteitis—posttraumatic infection of bone—is still encountered. It develops as a postoperative complication or after open injuries of the extremities and requires a treatment schedule that is tailored to the findings. The main pathogens are staphylococci. Osteitis cannot be controlled unless an adequate therapy is implemented early in its course. Once the initial diagnosis has been made—various psychological mechanisms make this difficult—and the first surgical revision carried out the further surgical therapy can be planned. This will depend on the findings, and the options range from simple debridement through switching to a different treatment method to soft tissue transplantation. The treatment should be carried out by experienced surgeons in specialist centres. A good outcome of treatment for the injured person is only possible if the surgical interventions are closely dovetailed with subsequent rehabilitation. If function remains restricted, specially adapted aids must be prescribed, which must be checked frequently to see whether further adaptations are needed. The treatment of osteitis is far more costly than that of uncomplicated fractures.     

Begutachtung der Osteitis

Chronic posttraumatic osteomyelitis remains a major topic of expert discussion concerning infections of the bones and joints. Trauma-induced haematogenous osteomyelitis is rare in Europe. The two main determinants for the degree of disability are the degree of functional loss and the clinical examination. The degree of functional loss is analysed according to the standards of medical opinion in orthopaedic and trauma surgery. The clinical examination should address the activity of the osteomyelitis, i.e. the existence of a draining sinus. The combination of both defines the degree of disability and thus the compensation.     

Mikrobiologie bei Osteitis

The present article discusses the scientific principles and reliability of the “gold standards” in osteomyelitis diagnosis and microbiological methods of tissue biopsies. Currently, only Level III and IV studies can be found in the literature, while Level I and II studies are lacking. Diagnosis of early and acute periprosthetic infection/acute osteomyelitis is usually straightforward; problems arise in the case of chronic infection. Reliable diagnosis by means of joint puncture to identify the pathogen is not possible; in addition to cell culture, the aspirate should be further analysed cytologically using cell counting and differentiation. Additional diagnostic methods include arthroscopic synovial biopsy. Regardless of the findings, duration of the implant’s position, and the patient’s general condition, individual therapy is initiated. The lack of robust evidence in septic surgery needs to be rectified urgently; the formation of the working group on septic surgery represents a first step in this direction.     

Plastische Weichteildeckung bei Defektfrakturen am Unterschenkel

Zusammenfassung. Mit der konsequenten Einführung eines sequentiellen radikalen Débridements und der postprim?ren Weichgewebsrekonstruktion konnte die Amputationsrate, der Hospitalaufenthalt, die chronische Osteitis, die Rehabilitationsperiode und die Zahl sekund?rer rekonstruktiver Eingriffe bei drittgradig offenen Unterschenkelfrakturen deutlich reduziert werden. Durch die Distraktionscorticotomie und biologische Osteosyntheseverfahren wurde die Knochenrekonstruktion deutlich verkürzt. Es werden die Indikation, taktisches Vorgehen und technische iatrogene Probleme der aktuellen interdisziplin?ren Verfahren geschildert, die eine Modifikation auch bei der Weichgewebsrekonstruktion erfordern.      

Akute posttraumatische Osteitis

The consequences of an incorrect action by a doctor while exercising his or her medical practice are manifold. For errors in treatment, civil and criminal liability is especially important. Here a close cooperation with the liability insurer is essential. For criminal proceedings, whether for errors in treatment or for fraudulent invoicing, retaining a lawyer early on is necessary. In case of fraudulent invoicing, there is always the danger of losing the contract status with the insurance company. Furthermore, the return of not insubstantial medical fees is to be anticipated. In the case of errors treatment as well as fraudulent invoicing, professional conduct proceedings are to be expected, and the suspension or even loss of accreditation is possible.