Acute post traumatic & postoperative infection_present management.ppt

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    Toru Sato, M.D.Toru Sato, M.D.

    cute posttraumat cpostoperative infection

    present management

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    Debridement of necrotic tissue and flapand

    antibiotics Debridement of necrotic tissue and flap and

    implant removal and antibiotics

    Antibiotics only

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    Closed fracture .!"

    Open fracture #.$" %ustilo type &&&

    '.$"

    AO documentation

    !(') !((

    AO documentation

    !(') !((

    &nfection rate

    Closed fracture *$" Open fracture

    %ustilo type ) &&&A +*(" %ustilo type &&&B ~ &&&C '*+ "

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    -ound contamination

    acteria

    umber

    0irulence

    Circulation ecrosis

    Alien bodies 1eamatoma &nstability 2esistance

    &nfection

    Organism

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    Contamination Coloni3ation

    &nfection

    4e can e5plain these definition, but it6s difficult tograsp in clinical situation, because 4e can6t seebacteria and situations change every moment.

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    iofilm of Staphy.aureus

    Once bacteria adhere a foreign body, they produceglyycocaly5 and a biofilm is built. acteria in thebiofilm are protected from antibiotics ormacrophages or immunoglobulin.

    iofilm

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    iofilm

    - Minimal inhibitory concentration 7M&C8 iniofilm is several ) several hundred times higher

    than floating situation.- So, in these situations, Surgical debridement must

    be done as soon as possible.

    http://ja.wikipedia.org/wiki/%E3%83%95%E3%82%A1%E3%82%A4%E3%83%AB:Staphylococcus_aureus_biofilm_01.jpg
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    Discipline in patient management is essential : - wearing face masks - repeated hand disinfection - type and time of hair removal

    - correct skin disinfection - no small talk during surgery - sterile gloves for dressing changes

    1o4 to reduce the ris9 of contamination

    Strict isolation if M S! is suspected

    Staphylococcus aureus are everywhere in our hospitalStandard precaution "#$

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    Medium :Medium : hematomahematoma seromaseroma fluid collection around implantfluid collection around implant

    DeadDead softsoft tissues:tissues: skin necrosisskin necrosis

    muscle%periosteummuscle%periosteum thermal damagethermal damage

    Dead hard tissue:Dead hard tissue: devasculari&ed 'onedevasculari&ed 'one

    foreign 'odiesforeign 'odies

    Circumstances favorable for bacteria

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    :iving tissue is best protectionagainst infection

    one is a plant 4ith its rootin the soft tissue

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    1ost related

    AgeDisease

    DM. 2A. Obesity. Malnutrition.Malignancy.

    Dialysis. etc8Drugs Steroid. &mmunosuppressant. etc:ong hospitali3ation&nfection at another region

    2is9 factors for surgical site infection

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    2is9 factors for surgical site infection

    * emergency operation* duration of surgery

    * surgical techni;ue

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    !( * !(>one defect

    Deep soft tissue in=uryacteria contamination

    S9in defectCompartment syn.?5. patternS9in condition&schemia

    !(+* !(!&schemia Comp. syn.

    Soft tissue infectionacteria contamination

    S9in condition

    S9in defect

    Deep soft tissue in=ury

    Open fracture

    2is9 factors for surgical 7fracture8 site infection

    ?actors influenced in=. site

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    +@( closed fracture!!>/@* !!+/#

    /@* !!+/#

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    Closed fracture

    !!>* !!+

    Soft tissue infection @.!" vs '.$"Compartment syn. '. " vs '.!"

    Op. time > 1rs '. " vs '.!"

    erve in=ury @.@ " vs . "?5. . " vs '.#"

    Soft tissue in=ury +. " vs '.@"

    2is9 factors for surgical 7fracture8 site infection

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    Analysis of accurate in=ury

    no4ledge of ris9 factor

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    ?actors contributing to acute infection

    * Contamination 4ith pathogenic organisms

    Staphylococcus aureus #+"

    *

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    Dead tissue debridementEnstable fracture fi5ation1ematoma /seroma drainage

    1igh tissue pressure tension free s9in

    Management to protect infection

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    ( :ab. data F Clinical findings

    ( Surgeons tend to ma9e optimistic =udgments

    a bout their o4n operations .(Clear diagnosis : disturbance of wound healing,

    necrosis of wound edge, Hematoma in the wound.

    Garly diagnosis of acute infection

    &f the infection is doubtful, re*opening of the 4oundshould be done as soon as possible.

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    *+y male*+y male

    ,all from height .m/

    AO+>*C>

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    0.days after in1ury2#3-clover4 ", articular surface/ 5 M"34

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    6ound edge necrosis

    3ost op 0w 3ost op 7w 3ost op +w

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    CDC Center for Disease Control and

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    - 6ash-out with lots of fluid- 6ash-out with lots of fluid

    - De'ridement repeated/ of all dead tissue8- De'ridement repeated/ of all dead tissue8

    fi'rin or pusfi'rin or pus

    - #hecking sta'ility of fi9ation and implants:- #hecking sta'ility of fi9ation and implants:

    - #ement 'eads with anti'iotic - #ement 'eads with anti'iotic

    - 6ound closure depending on local situation- 6ound closure depending on local situation- !nti'iotics for + weeks according to culture test/- !nti'iotics for + weeks according to culture test/

    Wound revision in acute Wound revision in acute

    infectioninfection

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    -ith infection in the presence of a fracturefi5ation implant, the goal of treatment is

    fracture healing and the prevention ofchronic osteomyelitis

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    +0y male+0y male

    $rafficaccident

    DM

    AO+>*C>%ustilo

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    )mergent op days after in1ury Skin graft

    07 days after in1ury 4 ", articular surface/5 M"34 locking plate/

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    3ost op 7m

    Distur'ed wound healing

    coloni&ation

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    Antibiotic prophyla5is reduces a ris9 of infection * efore op. 7before tourni;uet II -ithin$hours8

    * Single dose 7 st/$nd generat. Cefalosporin8 ma5. $+hours

    ur9e J?!# , SurgeryAntibiotic prophyla5is is not a substitute for careful

    surgical techni;ue.odo9i et al l!!>,

    o5ma et al !!#

    2ole of antibiotics in fracture surgery

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    Conclusions

    * &ncidence of infection after operative fi5ation ofclosed fractures should be K *$"

    * &n case of acute infection immediate action ismandatory

    * Thorough debridement of all dead tissue* &mplants providing stability may remain Lin situ

    * Mechanical stability and vital tissues are essential to obtain bony union

    *

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    Than9 you for your attentionThan9 you for your attention