Diaphyseal Osteomyelitis (Indications for Bone Transport) SALEH WASLALLAH ALHARBY KING SAUD...
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Transcript of Diaphyseal Osteomyelitis (Indications for Bone Transport) SALEH WASLALLAH ALHARBY KING SAUD...
Diaphyseal Osteomyelitis (Indications for Bone Transport)
SALEH WASLALLAH ALHARBYKING SAUD UNIVERSITY
AO COURSE RIYADH, MAY 2005
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
An incidence of infection
> 1–2 % for closed fractures> 6–7 % for open fractures
(except Gustilo type IIIB & IIIC)
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
OUTLINES
1-CAUSES AND CONTRIBUTING FACTORS.
2-WHEN TO BONE TRANSPORT.
3.TYPES OF BONE TRANSPORT.
4.CLINICAL EXAMPLES.
5.DIFFICULTIES.
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
1-CAUSES AND CONTRIBUTING FACTORS.
1-OPEN FRACTURESwith or without bone loss.
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
1-CAUSES AND CONTRIBUTING FACTORS.
2-UNCOTRLLED INFECTION FOLLOWING INTERNAL
FIXATION
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
1-CAUSES AND CONTRIBUTING FACTORS.
3-MULTIPLE SURGERIES FOR OSTEOMYELITIS
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
1-CAUSES AND CONTRIBUTING FACTORS.
4-POOR SURGICAL SKILLS
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
1-CAUSES AND CONTRIBUTING FACTORS.
5-IMPROPER TIMING FOR INTERNAL FIXATION
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
1-CAUSES AND CONTRIBUTING FACTORS.
OPEN FRACTURES
UNCOTRLLED INFECTION FOLLOWING INTERNAL FIXATION
MULTIPLE SURGERIES FOR OSTEOMYELITIS
POOR SURGICAL SKILLS
IMPROPER TIMING FOR INTERNAL FIXATION
BONE DEFECT
PESUDARTHROSES
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Risk factors for surgical site infection
Host related:- old age- co-morbidity (diabetes, obesity, arteriosclerosis, malnutrition,
nicotine etc)- drugs (steroids, immuno-suppression, antibiotics)- remote infections (dental etc)- preoperative hospitalization
Procedure related:- emergency operation - duration of surgery- surgical technique
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
BONE DEFECTCan be addressed by:
Bone graft
Bone transport
Acute or gradual shortening
Amputation
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
2-WHEN TO BONE TRANSPORT
Defect 2 cm and above
Can’t bone graft
no or limited source
can’t reach site
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
3.TYPES OF BONE TRANSPORT.
MAIN GOALS
1 -Restore osseous integrity (continuity)
2 -Maintain mechanical axis
3 -Restore length and normal rotation
4 -Eradication of infection
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
3.TYPES OF BONE TRANSPORT.
You can’t Eradicate infection in presence of:
Instability
Spaces for pus to collect
Dead soft and hard tissues
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
3.TYPES OF BONE TRANSPORT.
Distraction osteogenesis using Ex Fix
a. monolocal (monofocal) 1-logitudinal
2-side to side
b. bilocal (bifocal) compression/ distraction osteogenesis
Example
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Distraction Osteogenesis
Neo-osteogensis
Tension stress
Encourage bone healing
Restore bone length
Restore bone thickness
Activates biosynthetic processes
Thus Increase local resistance to infectionInfection is eaten away by the flames of regenerates ( G A Ilizarov)
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Bone sepsis can be eliminated by:
1-Cotrolled osteogenesis filling cavities by new bone tissues
2-Resection of infected bone followed by bone transport
3-Cavity oblitaration by transporting segment of bone into the cavity
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Docking site
End to end
Side to side
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Factors contributing to acute infection
- Contamination with pathogenic organismsStaphylococcus aureus > 64%
- Presence of a medium for bacteria to grow- Rough soft-tissue handling, periosteal stripping- Mechanical instability of fracture
We can influence all of them
Acute posttraumatic infection starts locally with or without general symptoms
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
How to reduce the risk of contamination
- Staphylococcus aureus are everywhere in our hospitals
- 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
Strict isolation if MRSA (methicillin-resistant Staphylococcus aureus)is suspected (referrals)
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Circumstances favorable for bacteria to grow:
Medium: hematoma hemostasisseroma suction drains
fluid collection surface structure around implant of implant
Dead “soft” tissues:skin necrosis debridement ofmuscle/periosteum all necrotic tissue
thermal damage cautery, drilling?
Dead “hard tissue”:devascularized bone debridementforeign bodies
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Clinical signs of acute infection
Local: - swelling- inflammation- tenderness/pain- fluctuation
General: - fever- CRP (C-reactive
protein)- Leucocyte
if in doubt agressive wound revisionDr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Important factors influencing bone defect treatment
A) PATHOLOGY PERSONALITY1-Shape of bone fragments (quantity)
2-Thickness of bone fragments (quality)3-Degree and type of displacement
4-Degree of mobility between the fragments5-Presence or absence of shortening
6-Degree of bone defect7-Charactristics of soft tissue changes including skin
8-Presence of purulent process B) PATIENT PERSONALITY
Amputation VS long staged procedures
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Any implant/device providing mechanical stability should stay in place
Loose implants must be removed or replaced to optimize the fixation
A rigidly fixed fracture will unite in spite of infection
W. W. Rittmann & S. Perren, 1974
Infection and implants for fracture fixation
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Role of antibiotics in fracture surgery
Prophylactic antibiotics reduce risk of contamination:- perioperative (before tourniquet !!)- single dose (1st/2nd generat. Cefalosporin) max. 24 hours
Burke JF 1961, Surgery
Prophylactic antibiotics are not a substitute for a careful surgical technique
Bodoki et al l993, Boxma et al 1996
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby
Conclusions
- Incidence of infection after operative fixation of closed fractures should be < 1-2%
- Appropiate “behaviour” helps to reduce the risks- In case of acute infection immediate action is mandatory- Thorough debridement of all dead tissue- Implants providing stability may remain “in situ”- Mechanical stability and vital tissues are essential to obtain bony union- Prophylactic single dose antibiotics are effective, but cannot replace poor surgery
Dr Saleh W Alharby [email protected] http://faculty.ksu.edu.sa/DrSalehAlharby