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7/24/2019 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 *$" Open fracture
%ustilo type ) &&&A +*(" %ustilo type &&&B ~ &&&C '*+ "
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-ound contamination
acteria
umber
0irulence
Circulation ecrosis
Alien bodies 1eamatoma &nstability 2esistance
&nfection
Organism
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Contamination Coloni3ation
&nfection
4e can e5plain these definition, but it6s difficult tograsp in clinical situation, because 4e can6t seebacteria and situations change every moment.
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iofilm of Staphy.aureus
Once bacteria adhere a foreign body, they produceglyycocaly5 and a biofilm is built. acteria in thebiofilm are protected from antibiotics ormacrophages or immunoglobulin.
iofilm
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iofilm
- Minimal inhibitory concentration 7M&C8 iniofilm is several ) several hundred times higher
than floating situation.- So, in these situations, Surgical debridement must
be done as soon as possible.
http://ja.wikipedia.org/wiki/%E3%83%95%E3%82%A1%E3%82%A4%E3%83%AB:Staphylococcus_aureus_biofilm_01.jpg7/24/2019 Acute post traumatic & postoperative infection_present management.ppt
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Discipline in patient management is essential : - wearing face masks - repeated hand disinfection - type and time of hair removal
- correct skin disinfection - no small talk during surgery - sterile gloves for dressing changes
1o4 to reduce the ris9 of contamination
Strict isolation if M S! is suspected
Staphylococcus aureus are everywhere in our hospitalStandard precaution "#$
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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.
7/24/2019 Acute post traumatic & postoperative infection_present management.ppt
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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