One of the most serious complications in orthopedics and trauma surgery is infection in the field of inset implants. The rehabilitation of the focus of infection and the reconstruction of function is the daily challenge faced by the staff of Septic / Reconstructive Department. the interdisciplinary coordination of the various necessary diagnoses and therapeutic interventions is essential for treatment to be successful.
Continuous education and training are also part of daily work, such as participation and implementation of scientific research projects in order to continuously improve the quality of patient care. Publications, standard procedures and research projects are presented below.
Osteitis is the infection of a bone. In Germany, more than 12,000 patients a year are hospitalized because of osteitis. Causes of this disorder often include open fractures or operations through which bacteria or fungi pass from outside into the bone. However pathogens can also spread via the bloodstream from other sources of infection in the body (e.g. infected sinuses, athlete's foot), are passed on and trigger a bone infection. In a bone infection, the treatment is almost always surgical, through removal of the infected tissue. In addition, appropriate antibiotics are administered and applied locally for the pathogen in the form of antibiotic-coated sponges. If an infection occurs after a breakage and there is still a plate or a nail in the affected bones, this must be removed in most cases to achieve an infection remediation. When there are no more signs of infection exhibited and smear tests no longer demonstrate the presence of the pathogen, reconstruction can begin. If there is a major bone defect, this can be compensated for via a callus distraction. Soft tissue defects can be covered by a flap surgery (transplantation of muscle and skin tissue from another part of the body).
In patients with an inset prosthesis an infection can result around the prosthesis. Here also the pathogen may have entered either from outside or via the bloodstream to the bone. If a prosthesis is infected, it must almost always be removed in order to achieve infection remediation. During the infection remediation a spacer is used, with antibiotic-blended bone cement, which prevents shortening of soft tissues. After infection remediation either a new prosthesis can be be implanted or immobilisation of the joint can be opted for (arthrodesis).
With an osteitis, it may be necessary to remove infected and dead bone, whereby a shortening results. A large difference in leg length can cause problems, so that callus distraction is used. For this purpose, the bone which is to be lengthened is surgically cut through, and the two halves are placed in traction over weeks or months (depending on bridgeable defect extent) slowly and continuously along its longitudinal axis. In this way one can extend by about 1 mm per day. the new bone material develops between the two halves of the bone but still has to mature before it is loaded. The callus distraction can be done via various methods, the ring fixator and intramedullary nail extension being the most common.
The classical form of infection remediation is debridement. Here, the infected tissue is radically removed. For better wound base granulation, a sponge is inserted into the wound and a vacuum seal is performed in the in the wound cavity where a vacuum is generated.
When there are implants or prostheses, it may also be necessary to remove them for infection remediation. Infected and dead bone must also be removed, with the resultant defect closed via a callus distraction, after infection remediation. Debridement is repeated until the intraoperative smears taken show no pathogen detection.
Flap surgery as the technique normally used for covering small or large soft tissue defects. Here, muscle and skin tissue is transplanted from a nonessential site on the patient to the site where the defect has been removed.
The intramedullary nail extension provides another method for callus distraction. Above all, during extension of the thigh bone an externally attached fixator can distinctly impede hip flexion and the patient sitting so that an intramedullary process (nail located inside the bone) is preferable.
The intramedullary nail extension is also available for the lower leg. The intramedullary nail extension used by us consists of a two-part telescopic rod. During the operation the bone to be extended is severed surgically. Then the nail is inserted.
After surgery, the distal part (farthest from the body) of the telescope moves out from the proximal (close to the body).For this purpose, the patient has to perform certain movements of the leg. Sliding the telescopic units apart increases the distance between the two bone halves, and the leg is extended. This method offers a high degree of stability but requires a reliable patient participation going forwards.
The ring fixator is a method for callus distraction, ie for lengthening bones.
With an osteitis, it may be necessary to remove infected and dead bone, whereby a shortening of the limb results. A large difference in leg length can cause problems, and so callus distraction is used. For this purpose, the bone which is to be lengthened is surgically cut through and the two halves are placed in traction over weeks or months (depending on the extent of the bridgeable defect) slowly and continuously along the longitudinal axis.
New bone material then develops between these two halves and has to mature before it is loaded. This callus distraction can be accomplished via the so-called Ilizarov ring fixator. In this case, wires or half-pins are introduced into the bone and the whole is stabilized using rings which are interconnected by longitudinal members.
Misalignments can be corrected secondarily with the three dimensional fixation. The callus distraction process is also very easy for the patient to apply.
Germs which are resistant to a variety of antibiotics necessitate isolation in the hospital.
Examples of multiresistant pathogens are MRSA (methicillin-resistant staphylococcus aureus) or MRSE (methicillin-resistant Staphylococcus epidermidis). Increasingly, germs such Eschereichia coli, Pseudomonas aeruginosa, Acinetobacter and Klebsiella are becoming resistant.
In this respect, we have set up a special isolation ward with beds for these patients. This serves on the one hand to protect the patient himself, as an interdisciplinary team of doctors and nurses specifically takes care of and tries to "decontaminate" these patients. On the other hand, we also protect other patients and personnel against transfers of these difficult to treat germs.
In front of each patient's room is an airlock in which the staff or visitors can move in order to prevent spread and propagation of germs. The isolation unit also provides a monitor for watching patients who no longer require intensive care.