Acute posttraumatic /

postoperative infection
present management

Toru Sato, M.D.

 Debridement of necrotic tissue and flap

and
antibiotics
Debridement of necrotic tissue and flap and
implant removal and antibiotics
Antibiotics only

Infection rate
AO documentation

1980~1988

Closed fracture
1.9%
Open fracture
6.2%
Gustilo type III
Closed fracture 110.2%
2%
Open fracture
Gustilo type ~ IIIA 4-8%
Gustilo type IIIB ~ IIIC 10-45%

Wound contamination
Bacteria

Organism
Circulation
Necrosis
Alien bodies
Heamatoma
Instability
Resistance

Number
Virulence

Infection

 Contamination
Colonization
Infection
we can explain these definition, but its difficult to
grasp in clinical situation, because we cant see
bacteria and situations change every moment.

Biofilm
Once bacteria adhere a foreign body, they produce
glyycocalyx and a biofilm is built. Bacteria in the
biofilm are protected from antibiotics or
macrophages or immunoglobulin.

Biofilm of Staphy.
aureus

Biofilm
- Minimal inhibitory concentration (MIC) in
Biofilm is several ~ several hundred times higher
than floating situation.
- So, in these situations, Surgical debridement must
be done as soon as possible.

How to reduce the risk of contamination

Staphylococcus aureus are everywhere in our hospital
Standard precaution ICT

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 is suspected

Circumstances favorable for bacteria

Medium : hematoma

seroma
fluid collection around implant
Dead soft
tissues:

skin necrosis

muscle/periosteum

Dead hard tissue:

thermal damagebone

devascularized

foreign bodies

Living tissue is best protection

against infection
Bone is a plant with its root
in the soft tissue

Risk factors for surgical site infection

Host related
Age
Disease
DM. RA. Obesity. Malnutrition.
Malignancy.
Dialysis. etc)
Drugs Steroid. Immunosuppressant. etc
Long hospitalization
Infection at another region

Risk factors for surgical site infection

Procedure related

- emergency operation
- duration of surgery
- surgical technique

Risk factors for surgical (fracture) site infection

Injured site related

948 Open fracture
(1981 1989)
Retro-/prospective study

Risk factors for surgical (fracture) site infection

Open fracture
1981-1983
Bone defect
Deep soft tissue injury
Bacteria contamination
Skin defect
Compartment syn.
Fx. pattern
Skin condition
Ischemia

Factors influenced inj. site

1984-1989
Ischemia Comp. syn.
Soft tissue infection
Bacteria contamination
Skin condition
Skin defect
Deep soft tissue injury

Risk factors for surgical (fracture) site infection

Injured site related

478 closed fracture
1993/7-1994/6
Prospective study
Virchow Berlin

Risk factors for surgical (fracture) site infection

Closed fracture
1993-1994
Soft tissue infection

17.9% vs 0.2%

Compartment syn.

10.5% vs 0.9%

Op. time>3 Hrs

10.5% vs 0.9%

Nerve injury

7.7 % vs 1.1%

Fx. Pattern: type C

3.5 % vs 0.6%

Soft tissue injury

4.5 % vs 0.7%

Improvement of infection rate

Analysis of accurate injury

Knowledge of risk factor
Proper protocols

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

Management to protect infection

Dead tissue
debridement
Unstable fracture
fixation
Hematoma /seroma
drainage
High tissue pressure tension free skin

Clinical signs of acute infection

local: - swelling
- inflammation
- tenderness/pain
- fluctuation
general: - fever
- CRP
- Leucocyte

if in doubt

agressive wound revision

Early diagnosis of acute infection

Lab. data Clinical findings
Surgeons tend to make optimistic judgments
a bout their own operations .
Clear diagnosis : disturbance of wound healing,
necrosis of wound edge, Hematoma in the wound.
If the infection is doubtful, re-opening of the wound
should be done as soon as possible.

 76y male

AO43-C3

Fall from height (2m)

Emergent op

12days after injury

LCP-clover
ORIF (articular surface) & MIPO

Wound edge necrosis

Post op 1w

Post op 4w

Post op 6w

Post op 6m

CDC Center for Disease Control and Prevention)

Detection of surgical site infection (SSI)

Careful observation of the wound

Wound revision in acute

infection
- Wash-out with lots of fluid
- Debridement (repeated) of all dead tissue,
fibrin or pus
- Checking stability of fixation and implants:
- Cement beads with antibiotic ?
- Wound closure depending on local situation
- Antibiotics for 6 weeks (according to culture test)

Infection and implants for fracture fixation

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

With infection in the presence of a fracture

fixation implant, the goal of treatment is
fracture healing and the prevention of
chronic osteomyelitis

 61y male
Traffic
accident
DM

AO43-C3
Gustilo

Emergent op

days after injury Skin graft

14 days after injury ORIF (articular surface)
& MIPO (locking plate)

Disturbed wound healing

colonization

Post op 4m

Role of antibiotics in fracture surgery

Antibiotic prophylaxis reduces a risk of infection
- Before op. (before tourniquet !! Within
2hours)
- Single dose (1st/2nd generat. Cefalosporin) max. 24
hours
Burke JF
1961,
Surgery
Antibiotic
prophylaxis is not a substitute for 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%
- 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

Thank you for your attention

Thank you for your attention