Das biologische Skalpell I – Frakturheilung und patientenbezogene Einflussfaktoren

 

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Zusammenfassung

Trotz unseres zunehmenden Wissens über die Mechanismen der Frakturheilung kommt es im klinischen Alltag bei 5–10 % der Patienten zu einer verzögerten oder ausbleibenden Frakturheilung. Die biomechanischen Voraussetzungen zur adäquaten Frakturheilung sind gut untersucht und finden Anwendung in aktuellen Implantatsystemen und Osteosynthesetechniken. Oftmals wird für die verzögerte Frakturheilung eine schlechte „Biologie“ verantwortlich gemacht. Die zugrunde liegenden „biologischen“ Ursachen sind multifaktoriell und die einzelnen Aspekte oft nur unzureichend in Studien höheren Evidenzgrads untersucht. Dennoch sollte es Aufgabe des behandelnden Arztes sein, neben einer adäquat durchgeführten Osteosynthese oder Retention bei konservativer Behandlung, alle Faktoren zu berücksichtigen, welche die Frakturheilung negativ beeinflussen. Die vorliegende Übersichtsarbeit soll in einem 1. Teil einen Überblick geben über patientenbezogene Faktoren, die die Frakturheilung beeinflussen. Hierzu zählen Komorbidität des Patienten und persönliche Gewohnheiten (Rauchen, Alkohol, Ernährung). In klinischen Studien sind für jeden einzelnen dieser Faktoren nur schwer signifikante Einflüsse auf die Frakturheilung nachweisbar, da hierzu sehr hohe Patientenzahlen und homogene Kollektive erforderlich wären. Dennoch ermöglicht uns die Kenntnis dieser Einflussfaktoren, die Bedingungen für eine optimale Frakturheilung zu optimieren. Ebenso wie der Chirurg während eines chirurgischen Eingriffs präzise Schnitte durchführt, ist auch eine präzise Analyse und Optimierung der „biologischen“ Gegebenheiten möglich und zu empfehlen.

Abstract

Despite our growing knowledge about the mechanisms of fracture healing, about 5 to 10 % of all fractures show impaired healing or non-union formation. We have learned about the biomechanical requirements for adequate fracture healing, leading to sophisticated osteosynthesis techniques and specific implant systems. A poor “biology” is often made responsible for the failure of bone healing. However, the underlying “biological” mechanisms are multifactorial and poorly understood. There is a lack of knowledge and clinical evidence about specific biological factors which influence fracture healing. However, it is the responsibility of the medical practitioner to address all factors that could negatively influence fracture healing, while respecting general principles of conservative or operative fracture management. The current review aims to summarise patient-related factors that influence fracture healing including co-morbidities of the patient just as well as life style-related factors such as smoking, nutrition and alcohol consumption. It is hardly possible to prove a significant influence for each of these factors in clinical studies, because homogeneous cohorts and very high patient numbers would be needed. Nevertheless, a deeper knowledge about these factors potentially influencing fracture healing could help us to improve fracture healing and decrease the number of non-unions in our patients. Just as well as the surgeons performs precise incisions with a knife, a precise analysis and improvement of the “biology” are possible and recommended.

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