diaphyseal osteomyelitis (indications for bone transport) saleh waslallah alharby king saud...
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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
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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
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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