Schmidt A H, Swiontkowski M F
University of Minnesota School of Medicine, Minneapolis, USA.
J Am Acad Orthop Surg. 2000 Sep-Oct;8(5):285-91. doi: 10.5435/00124635-200009000-00002.
Infection complicating internal fixation of fractures is a serious complication that is difficult to treat. Whenever metallic devices are implanted in vivo, successful biointegration requires that host cells colonize the highly reactive implant surface. Bacteria such as staphylococci can also become adherent to metallic or polymeric implants and will compete with host cells for colonization of the implant surface. Once adherent, these bacteria form a biofilm and undergo phenotypic changes that make them resistant to the normal host immune response as well as to antibiotics. Furthermore, metallic implants themselves cause specific deficits in the function of the local immune system that may render the host response to infection inadequate. Any associated soft-tissue injury causes even greater impairment of local immune function. Despite the potentially detrimental impact of internal fixation, fracture stability is of paramount importance in achieving fracture union and in preventing infection. It has been demonstrated in animal models that contaminated fractures without internal fixation develop clinical infection more commonly than similar fractures treated with internal fixation at the time of colonization. Because of the potential for infection whenever internal fixation is utilized, appropriate prophylactic antibiotic coverage for staphylococci and Gram-negative organisms should be provided. Open wounds and severely damaged soft tissues require aggressive management so that a viable soft-tissue envelope is maintained around the implant. Host factors such as smoking and malnourishment should be corrected. Early diagnosis and aggressive treatment of implant-related infection with antibiotics, debridement, and maintenance of stable internal fixation are essential to successful treatment.
骨折内固定术后感染是一种严重且难以治疗的并发症。每当金属器械植入体内时，成功的生物整合要求宿主细胞在高反应性的植入物表面定植。葡萄球菌等细菌也可附着于金属或聚合物植入物上，并会与宿主细胞竞争植入物表面的定植。一旦附着，这些细菌就会形成生物膜并发生表型变化，使其对正常的宿主免疫反应以及抗生素产生抗性。此外，金属植入物本身会导致局部免疫系统功能出现特定缺陷，这可能使宿主对感染的反应不足。任何相关的软组织损伤都会导致局部免疫功能进一步受损。尽管内固定可能有不利影响，但骨折稳定性对于实现骨折愈合和预防感染至关重要。动物模型已证明，在细菌定植时，未进行内固定的污染骨折比接受内固定治疗的类似骨折更易发生临床感染。由于使用内固定时存在感染风险，应给予针对葡萄球菌和革兰氏阴性菌的适当预防性抗生素覆盖。开放性伤口和严重受损的软组织需要积极处理，以便在植入物周围维持有活力的软组织包膜。吸烟和营养不良等宿主因素应予以纠正。早期诊断并通过使用抗生素、清创以及维持稳定的内固定对植入物相关感染进行积极治疗，对于成功治疗至关重要。
