Diaphyseal Osteomyelitis (Indications for Bone Transport) SALEH WASLALLAH ALHARBY KING SAUD UNIVERSITY AO COURSE RIYADH, MAY 2005 Dr Saleh W Alharby [email protected]

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)


AVOIDABLE?


OUTLINES

1-CAUSES AND CONTRIBUTING FACTORS.

2-WHEN TO BONE TRANSPORT.

3.TYPES OF BONE TRANSPORT.

4.CLINICAL EXAMPLES.

5.DIFFICULTIES.



1-OPEN FRACTURESwith or without bone loss.



2-UNCOTRLLED INFECTION FOLLOWING INTERNAL

FIXATION



3-MULTIPLE SURGERIES FOR OSTEOMYELITIS



4-POOR SURGICAL SKILLS



5-IMPROPER TIMING FOR INTERNAL FIXATION



OPEN FRACTURES

UNCOTRLLED INFECTION FOLLOWING INTERNAL FIXATION

MULTIPLE SURGERIES FOR OSTEOMYELITIS

POOR SURGICAL SKILLS

IMPROPER TIMING FOR INTERNAL FIXATION

BONE DEFECT

PESUDARTHROSES


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


BONE DEFECTCan be addressed by:

Bone graft

Bone transport

Acute or gradual shortening

Amputation


2-WHEN TO BONE TRANSPORT

Defect 2 cm and above

Can’t bone graft

no or limited source

can’t reach site



MAIN GOALS

1 -Restore osseous integrity (continuity)

2 -Maintain mechanical axis

3 -Restore length and normal rotation

4 -Eradication of infection



You can’t Eradicate infection in presence of:

Instability

Spaces for pus to collect

Dead soft and hard tissues



Distraction osteogenesis using Ex Fix

a. monolocal (monofocal) 1-logitudinal

2-side to side

b. bilocal (bifocal) compression/ distraction osteogenesis

Example


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)


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


Docking site

End to end

Side to side


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


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)


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


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


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


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


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


Documents

Diaphyseal Osteomyelitis (Indications for Bone Transport) SALEH WASLALLAH ALHARBY KING SAUD UNIVERSITY AO COURSE RIYADH, MAY 2005 Dr Saleh W Alharby [email protected]