Diefenbeck M, Mennenga U, Gückel P, Tiemann A H, Mückley T, Hofmann G O
Klinik für Unfall-, Hand-und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena.
Z Orthop Unfall. 2011 Jun;149(3):336-41. doi: 10.1055/s-0030-1270952. Epub 2011 Apr 27.
Vacuum-assisted closure is used frequently for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. However, no objective parameters describe the time point for secondary wound closure. Our thesis was that negative microbiological results from bone specimens can indicate the time for secondary wound closure. Moreover, treatment course and clinical outcome after 3.4 years should be compared to those of other surgical approaches for acute postoperative osteomyelitis from the literature.
43 patients with acute postoperative osteomyelitis of the extremities and the pelvis were treated by serial bone and soft tissue debridements and VAC therapy and analysed prospectively. Debridements were repeated until the wounds were macroscopically free from signs of infection (good granulation/no necrosis). During each revision a bone specimen was taken for microbiological analysis. Number of revisions, bacterial cultures, type of wound closure and recurrence of infection after 3 years and 5 months on average after the last surgery was analysed.
9.8 debridements on average were performed until eradication of infection and secondary wound closure. Despite the absence of macroscopic infection, bacteria were still found in bone samples from 15 of 43 patients. Three biopsies were free of bacteria for the first time right before wound closure, 25 samples had become negative during the treatment. Six recurrences (19.3 %) were noted after 3.4 years on average. Four patients from the group of negative bone biopsies (19 %) and two patients from the group of persisting bacteria before secondary closure (20 %) had a recurrence of infection.
In about one third of the bone biopsies bacteria persisted. This bacterial load had no correlation to wound healing and rate of recurrence after over 3 years. In conclusion, microbiological bone samples are not suitable as an indicator for the time point of secondary wound closure. Compared to other treatment options in acute postoperative osteomyelitis from the literature (especially implantation of local antibiotics), no advantage of vacuum-assisted closure could be shown concerning number of debridements and rate of recurrences.
负压封闭引流术常用于治疗四肢创伤后骨髓炎。在清创及反复更换负压封闭引流敷料后，伤口通过二期缝合、中厚皮片移植或局部皮瓣进行闭合。然而，尚无客观参数描述二期伤口闭合的时间点。我们的论点是，骨标本微生物学结果为阴性可指示二期伤口闭合的时间。此外，应将3.4年后的治疗过程和临床结果与文献中其他治疗急性术后骨髓炎的手术方法进行比较。
对43例四肢及骨盆急性术后骨髓炎患者进行了系列骨与软组织清创及负压封闭引流治疗，并进行前瞻性分析。反复进行清创，直至伤口在肉眼下无感染迹象（肉芽良好/无坏死）。每次清创时取骨标本进行微生物学分析。分析了平均在最后一次手术后3年零5个月时的清创次数、细菌培养结果、伤口闭合类型及感染复发情况。
平均进行9.8次清创直至感染消除及二期伤口闭合。尽管肉眼下无感染，但43例患者中有15例的骨标本中仍发现细菌。3例活检标本在伤口闭合前首次无菌，25份标本在治疗过程中转阴。平均3.4年后发现6例复发（19.3%）。骨活检阴性组的4例患者（19%）及二期闭合前细菌持续存在组的2例患者（20%）出现感染复发。
约三分之一的骨活检标本中细菌持续存在。这种细菌负荷与伤口愈合及3年多后的复发率无关。总之，微生物学骨标本不适合作为二期伤口闭合时间点的指标。与文献中急性术后骨髓炎的其他治疗选择（尤其是局部抗生素植入）相比，负压封闭引流术在清创次数和复发率方面未显示出优势。
