开放骨折课件

Infectionsin

OrthopaedicTrauma

开放骨折GUSTILO&ANDERSON19761Types1,2,3Updated19842Types3A,3B,3C1.GustiloRB,AndersonJT.“PreventionofInfectionintheTreatmentofOneThousandandTwenty-fiveOpenFracturesofLongBones.”JBJS-A1976.58(4):453-458.2.GustiloRB,MendozaRM,WilliamsDN.“ProblemsintheManagementofTypeIII(Severe)OpenFractures:ANewClassificationofTypeIIIOpenFractures.”JTrauma1984.24(8):742-746.开放骨折Classification—

Whydowecare?ClassificationcorrelateswithprognosisGRADEIIIIIIAIIIBIIICINFECTION0-2%2-7%10-25%10-50%25-50%FRACTUREHEALING21-28WKS26-28WKS30-35WKS30-35WKS开放骨折Antibioticsin

OpenFracturesTheuseofantibioticsinopenfractureshasaprotectiveeffectagainstearlyinfectioncomparedwithnoantibioticsorplacebo(Relativerisk0.41)GosselinRA,RobertsI,GillespieWJ.“Antibioticsforpreventinginfectioninopenlimbfractures.”CochraneDatabaseSystemReview2004.1:CD003764.开放骨折Choiceof

Antibioticsin

OpenFracturesNodifferenceininfectionratesbetweenclindamycinandcefazolin(anythingvsS.aureuswillwork)

BensonDR,RigginsRS,LawrenceRM,HoeprichPD,HustonAC,HarrisonJA.“TreatmentofOpenFractures:AProspectiveStudy.”JTrauma1983.23:25-30.开放骨折Choiceof

Antibioticsin

OpenFracturesDuetogramnegativecontamination,addaminoglycosideforGrade3FarminjuriesandVascularinjuries,giveampicillinorpenicillinDon’tforgettetanus开放骨折Durationof

Antibioticsin

OpenFracturesInadoubleblind,prospectivetrial,nodifferenceininfectionratesbetween1and5daysofpostoperativeantibioticsinopenfracturesDellingerEP,CaplanES,WeaverLD,WertzMJ,DroppertBM,HoytN,BrumbackR,BurgessA,PokaA,BenirschkeSK.“Durationofpreventiveantibioticadministrationforopenextremityfractures.”ArchSurg.1988Mar.123(3):333-339.开放骨折InitialI&DTimingClassic:within6hoursRecentlybeingchallengedNoinfectionsin91isolatedopenType1fracturestreatedwithoutI&D(exceptattimeoffixationonavg5daysafterinjury)1Nodifferenceininfectionrateinchildrenwillalltypesofopenfracturestreated0-6hoursand7-24hoursfromtimeofinjury2IstillconsiderallopenfracturesemergenciesYangEC,EislerJ.“TreatmentofIsolatedType1OpenFractures:IsEmergentOperativeDebridementNecessary?”CORR2003.410:289-294.SkaggsDL,FriendL,AlmanB,ChambersHG,SchmitzM,LeakeB,KayRM,FlynnJM.“TheEffectofSurgicalDelayonAcuteInfectionFollowing554OpenFracturesinChildren.”JBJS-A2005.87:8-12开放骨折TheIrrigationAmountNogooddataAnimalstudiesshowimprovedremovalofparticulatematterandbacteriabuteffectplateausataleveldependentonthesystemAnglenrecommends3LforGr1,6LforGr2,9LforGr3AnglenJO.“WoundIrrigationinMusculoskeletalInjury.”JAAOS2001.9:219-226.开放骨折TheIrrigationTheDeliveryMethodBulbSyringevs.PulsatileLavageAnimalstudyshowspulsatilelavagehasadetrimentaleffectonearlybonehealing,butthiseffectisnolongerpresentat2weeks1Animalstudyshowsmoresofttissuedestructionwithpulsatilelavage2Animalstudyshowspulsatilelavagetobemoreeffectiveinremovingparticulatematterandbacteria3Lowpressurepulsatilelavagemayresultinfewerinfections(ongoingstudy)DirschlDR,DuffGP,DahnersLE,EdinM,RahnBA,MiclauT.“HighPressurePulsatileLavageIrrigationofIntraarticularFractures:EffectsonFractureHealing.”JOT1998.12(7):460-463.BoydJI,WongworawatMD.“High-PressurePulsatileLavageCausesSoftTissueDamage.”CORR2004.427:13-17BhandariM,SchemitschEH,AdiliA,LachowskiRJ,ShaughnessySG.“HighandLowPressurePulsatileLavageofContaminatedTibialFractures:AninvitroStudyofBacterialAdherenceandBoneDamage.”JOT1999.13:526-533.开放骨折TheIrrigationTheAdditiveAntibiotics(typicallybacitracinand/orneomycin)MixedanimalandhumanresultsCostly(forbacitracinalonearound$500/washout)??CausingresistanceReportedcases(few)ofanaphylaxisAnglen:“Noprovenvalueinthecareofopenfracturewounds…somerisk,albeitsmall.”开放骨折TheIrrigationTheAdditiveSurfactants(i.e.Soaps)InterferewithbacterialadhesionEmulsifyandremovedebrisNosignificantdifferenceininfectionorbonehealingcomparedtobacitracinsolution,butmorewoundhealingproblemsinbacitracingroupAnglenJO.“ComparisonofSoapandAntibioticSolutionsforIrrigationofLower-LimbOpenFractureWounds:AProspective,RandomizedStudy.”JBJS-A2005.87(7):1415-1422.开放骨折TheDebridementRemovealldevitalizedtissue4CsofmuscleviabilityColorContractilityConsistencyCapacitytoBleedHighVelocityParallelFluidFlowComparedtoscalpelandpulsatilelavage,“equallyeffectiveinremovingbacteriaandparticulatematterfromthewoundsasdeterminedbyquantitativebacteriology,x-rayandhistologicanalysis.”WebbLX,MorykwasMJ,SmithTL,BanwellPE,BapstJ,WaiteAM.“HighVelocityParallelFluidFlowforDebridementofContaminatedWoundsinaPigModel.”PosterPresentation2000OTAAnnualMeeting.开放骨折Implantsin

OpenFracturesSiteSpecificForearms–immediateplatingOK1Femur–inadults,reamedIMNail2Tibia–somecontroversyJonesJA.“ImmediateInternalFixationofHigh-EnergyOpenForearmFractures.”JOT1991.5(3):272-279.LhoweDW,HansenST.“ImmediateNailingofOpenFracturesoftheFemoralShaft.”JBJS-A1988.70(6):812-820.开放骨折Implantsin

OpenFracturesTibiaUnreamednail(UTN)versusExfixinGradeII,IIIA,andIIIBUTNwithfewersubsequentprocedures,lessinfectionsNodifferenceinhealingratesReamed(RTN)vs.Unreamed(UTN)forGradeI,II,andIIIARTNwithtrendtowarddecreasednumberofsecondaryprocedureswithnoincreasedcomplicationsHenleyMB,ChapmanJR,AgelJ,HarveyEJ,WhortonAM,SwiontkowskiMF.“TreatmentofTypeII,IIIA,andIIIBOpenFracturesoftheTibialShaft:AProspectiveComparisonofUnreamedInterlockingIntramedullaryNailsandHalf-PinExternalFixators.”JOT1998.12(1):1-7.FinkemeierCG,SchmidtAH,KyleRF,TemplemanDC,VareckaTF.“AProspective,RandomizedStudyofIntramedullaryNailsinsertedwithandwithouthReamingfortheTreatmentofOpenandClosedFracturesoftheTibialShaft.”开放骨折TimingofWound

Coverage/ClosureASAPafterwoundadequatelydebridedOnly18%ofinfectionscausedbysameorganismisolatedininitialperioperativecultureSuggestshospitalacquiredetiologyofinfection“FixandFlap”ForTypeIIIB&IIICopentibiafractures,6%deepinfectionwithflapsperfomed<72hours,30%deepinfectionwithflapsperformed>72hoursWoundVACmayplayaroleuntilcoveragePatzakisMJ,BainsRS,LeeJ,etal.“Prospective,randomized,double-blindstudycomparingsingle-agentantibiotictherapy,ciprofloxacin,tocombinationantibiotictherapyinopenfracturewounds.”JOT2000.14:529-533.GopalS,MajumderS,BatchelorA,KnightS,DeBoerP,SmithRM.“Fixandflap:theradicalorthopaedicandplastictreatmentofsevereopenfracturesofthetibia.”JBJS-B2000.82(7):959–966.DedmondBT,KortesisB,PungerK,SimpsonJ,ArgentaA,KulpB,MorykwasM,WebbL.“TheuseofNegativePressureWoundTherapyintheTemporaryTreatmentofSoftTissueInjuriesassociatedwithHighEnergyOpenTibialShaftFractures.”JOT.2007开放骨折TheLatestWord…BMPsApprox40%decreasedinfectionratewithuseofBMPinTypeIIIop