1. Diaphyseal Osteomyelitis (Indications for Bone Transport) SALEH WASLALLAH ALHARBY KING SAUD UNIVERSITY AO COURSE RIYADH, MAY 2005 Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

2. An incidence of infection > 1–2 % for closed fractures > 6–7 % for open fractures (except Gustilo type IIIB & IIIC) Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

3. AVOIDABLE? Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

4. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

5. 1-CAUSES AND CONTRIBUTING FACTORS. 1-OPEN FRACTURES with or without bone loss. Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

6. 1-CAUSES AND CONTRIBUTING FACTORS. 2-UNCOTRLLED INFECTION FOLLOWING INTERNAL FIXATION Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

7. 1-CAUSES AND CONTRIBUTING FACTORS. 3-MULTIPLE SURGERIES FOR OSTEOMYELITIS Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

8. 1-CAUSES AND CONTRIBUTING FACTORS. 4-POOR SURGICAL SKILLS Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

9. 1-CAUSES AND CONTRIBUTING FACTORS. 5-IMPROPER TIMING FOR INTERNAL FIXATION Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

10. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

11. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

12. BONE DEFECT Can be addressed by: Bone graft Bone transport Acute or gradual shortening Amputation Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

13. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

14. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

15. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

16. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

17. Distraction Osteogenesis Neo-osteogensis Tension stress Encourage bone healing Restore bone length Restore bone thickness Activates biosynthetic processes Thus Increase local resistance to infection Infection is eaten away by the flames of regenerates ( G A Ilizarov) Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

18. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

19. Docking site End to end Side to side Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

20. Factors contributing to acute infection - Contamination with pathogenic organisms Staphylococcus 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

21. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

22. Circumstances favorable for bacteria to grow: Medium:hematomahemostasis seromasuction drains fluid collectionsurface structure around implant of implant Dead “soft” tissues: skin necrosisdebridement of muscle/periosteumall necrotic tissue thermal damagecautery, drilling? Dead “hard tissue”: devascularized bonedebridement foreign bodies Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

23. Clinical signs of acute infection Local:- swelling - inflammation - tenderness/pain - fluctuation General:- fever - CRP (C-reactive protein) - Leucocyte if in doubt agressive wound revision Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

24. Important factors influencing bone defect treatment A) PATHOLOGY PERSONALITY 1-Shape of bone fragments (quantity) 2-Thickness of bone fragments (quality) 3-Degree and type of displacement 4-Degree of mobility between the fragments 5-Presence or absence of shortening 6-Degree of bone defect 7-Charactristics of soft tissue changes including skin 8-Presence of purulent process B) PATIENT PERSONALITY Amputation VS long staged procedures Dr Saleh W Alharby alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

25. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

26. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby

27. 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 alharby@ksu.edu.sa http://faculty.ksu.edu.sa/DrSalehAlharby