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Principles of Fracture Related Infections: Surgery
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Principles of Fracture Related Infections: Surgery
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T00H10M33S
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Upload Date:
2024-08-23T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BILAL JAMAL: With Stimulan [INAUDIBLE] that implies I know how to use a computer. I think my screen should be visible, hopefully but on the wrong side, so apologies. So I was going to give a quick five minute presentation [MUSIC PLAYS] to identify the Stimulan which is manufactured by our corporate supporters.
BILAL JAMAL: And I wanted to discuss through fracture related infection. This is a slide from Biocomposites from a regulatory point of view and I'll let you all read that at your leisure. And in terms of my conflicts of interest, they are there as per on the screen. I don't think they particularly impact on the content of the talk I'll give this evening.
BILAL JAMAL: So I suppose for me, the things that I want to cover are the principles of surgery within fracture related infection, recognizing that Hamish is going to speak on this in significantly more detail and will be much more erudite around the matter. I'll also cover database management and I have a quick case history to illustrate the point. So I think for me, fracture related infection surgery is all about the debridement.
BILAL JAMAL: I think historically this is an operation that [MUSIC STARTS] was left for the most junior member of the surgical team which I think is a mistake because in actual fact, I think that debridement of fracture you do for me and that looks like the excision of all infected bone soft tissue. It can be very difficult to identify what bone is infected and then have the courage to excise it.
BILAL JAMAL: But I think it needs to be excised such that you're then left with bone, which has normal morphology and bleeds in a normal fashion as well. And the photographs there demonstrate an example of segmental excision of bone. If there is evidence of pan medullary infection, I think that requires reaming as well to try and clear that infection. There is now a vogue towards the use of a reamer irrigator aspirator,
BILAL JAMAL: however, that's not necessary. I think sequential reaming is just as good. My favorite instrument in actual fact is a curette because I think that helps address infection and helps clear it both within bone and soft tissues to a very high level. Another element of that all is to use fluids to wash out and sterilize the soft tissues and bone. And I tend to go for low pressure saline rather than the use of pulsatile lavage because of my concern of seeding infection into native non infected tissues.
BILAL JAMAL: Orthopaedics, for the most part, is lifestyle surgery. There's very little of what we do that actually saves lives. However, I think it's fair to say that this is pseudo oncological debridement because the kind of surgery that we do here is much more than just simple lifestyle surgery. It's something that can save lives and requires the skill and determination that is seen more in an oncological practice. After a debridement,
BILAL JAMAL: it's vital that any resected bone is provided with mechanical stability because we know that mechanical stability in and of itself helps to settle down infection. And there are various philosophical arguments that can be entered into around the role of internal fixation or external fixation in that circumstance and I won't rehearse those arguments this evening. Whichever soft tissue defect is left needs to be reconstructed and therefore a fracture related infection
BILAL JAMAL: surgery is the paradigm of joint working between orthopedics and plastic surgery. And again, whatever bone defect is left that must be reconstructed. And these days, there are multiple ways in which to manage that. But I'm going to move on to the focus of today's talk, which is around dead space management. This is vital because if we don't address dead space, that situation is left with a hematoma
BILAL JAMAL: and that can act as a nidus for infection. And therefore, to my mind, we need to address that so that we're not left with a hematoma, which can become infected. But also I think there's value in having a product which can provide high dose local antibiotic delivery to try and address some of the systemic side effects from systemic [MUSIC PLAYS] antibiotics and Stimulan is one such option. Now this is a calcium sulphate hemi-hydrate.
BILAL JAMAL: It's biodegradable and tends to to the sort of installations for use with Vancomycin, Tobramycin but I think it's fair to say that it's commonly used off license with a mixture, with a large mixture of antibiotics and antifungal agents. Wound discharge has commonly been a felt to be a problem with void fillers. However, this is much less of a concern with Stimulan than with other products.
BILAL JAMAL: And you can see here the antibiotic elution sits way above the typical MIC of most organisms for up to six weeks and that is hugely useful from an infection eradication point of view. And these three lines represent gentamycin, vancomycin and tobramycin. I think from my point of view, tips for use are to pick antibiotics carefully, and therefore I tend to, on an empirical basis, use vancomycin and gentamicin and mix both into Stimulan.
BILAL JAMAL: If there are previous culture results, I use those, and should the situation be anything more than moderately complicated, I'd discuss it with the microbiology and ID colleagues. I think a two layer repair is hugely useful to try and mitigate against the risk of significant wound discharge and if that's not possible, I tend to get early involvement with my plastic surgery team to ensure that flap coverage is considered.
BILAL JAMAL: And I wanted to quickly demonstrate one case where I had a patient with fracture related infection. This is a chap who's 52 years old who presented with relatively poor physiology. He'd had nine DVT's within his right leg previously. He'd had three previous DVT's and had a past history of hepatitis C, and the thing which was driving all of this was a history of drug misuse
BILAL JAMAL: and he was currently on methadone. He'd sustained a closed right ankle fracture, which was bimalleolar in nature, and two and a half weeks down the line had proceeded onto internal fixation. Sorry, apologies, had proceeded on to internal fixation at time of injury and had then represented two and a half weeks down the line with this picture where radiographs for the most part looked satisfactory. We might quibble about the choice of fixation in a relatively high risk individual, but I think these clinical photographs would highlight some of the concerns.
BILAL JAMAL: He had evidence of early wound failure and as Deepa had proposed, there was a real concern of deeper infection in this circumstance. He went on to have debridement by the local team who removed the lateral metalwork and as you can see, there had applied a back dressing. And therefore he was left with a large lateral sided soft tissue defect.
BILAL JAMAL: There was an attempt to treat this with a vac dressing over the course of a few days, but the situation didn't improve as is relatively predictable I guess. He was discussed within the infection MDT and was demonstrated to have a polymicrobial infection, which was multidrug resistant and therefore was started up on a mixture of IV and oral antibiotics. He went on to come under my care and had further surgery approximately a week following debridement, at which point his findings were fairly typical.
BILAL JAMAL: I tend to find in these patients that there is gross infection within the perineal tendon sheath and that needs excision, as does the fibula along the length of where the plate sat. The ankle joint itself tends to be infected and tends to sit as a mode of introduction of infection into the medial malleolar fracture, and therefore I removed the medial malleolar screws and the fracture itself.
BILAL JAMAL: I inserted Stimulan into that posterior lateral defect that is often left following this level of debridement, and that was impregnated with vancomycin and gentamycin. And for soft tissue cover, the plastic surgical team proceeded with a peroneus brevis turndown. And as I say, there are multiple conversations that can be had about internal or external fixation, but in this circumstance, I proceeded with an Ilizarov frame to help achieve an ankle fusion.
BILAL JAMAL: And these are radiographs, image intensification views from theater. You can see there that the Stimulan sits posterior laterally, that the ankle joint has been prepared and compressed and fixed with the Ilizarov frame. These were radiographs after a month and a half or so, at which point, you can see that the Stimulan has resorbed, which is clearly encouraging, as that would suggest that it's not going to act as a long term nidus for infection.
BILAL JAMAL: Radiographs a year down the line would suggest that his ankle joint had fused, and at that point, the frame was removed. And thereafter he represented about 16 to 18 months after the fact, at which point you can see that his ankle joint has quite successfully fused. You can see that he had evidence of venous insufficiency within this lower limb, which isn't surprising considering the past history of DVT
BILAL JAMAL: and he had venous ulceration, which settled with compression dressings. So I think to my point of view, dead space management is vital and local antibiotic elution has a role to play in the eradication of infection. And these are the principles that we have covered today. I'm happy to take questions on that basis.
Segment:0 .
BILAL JAMAL: With Stimulan [INAUDIBLE] that implies I know how to use a computer. I think my screen should be visible, hopefully but on the wrong side, so apologies. So I was going to give a quick five minute presentation [MUSIC PLAYS] to identify the Stimulan which is manufactured by our corporate supporters.
BILAL JAMAL: And I wanted to discuss through fracture related infection. This is a slide from Biocomposites from a regulatory point of view and I'll let you all read that at your leisure. And in terms of my conflicts of interest, they are there as per on the screen. I don't think they particularly impact on the content of the talk I'll give this evening.
BILAL JAMAL: So I suppose for me, the things that I want to cover are the principles of surgery within fracture related infection, recognizing that Hamish is going to speak on this in significantly more detail and will be much more erudite around the matter. I'll also cover database management and I have a quick case history to illustrate the point. So I think for me, fracture related infection surgery is all about the debridement.
BILAL JAMAL: I think historically this is an operation that [MUSIC STARTS] was left for the most junior member of the surgical team which I think is a mistake because in actual fact, I think that debridement of fracture you do for me and that looks like the excision of all infected bone soft tissue. It can be very difficult to identify what bone is infected and then have the courage to excise it.
BILAL JAMAL: But I think it needs to be excised such that you're then left with bone, which has normal morphology and bleeds in a normal fashion as well. And the photographs there demonstrate an example of segmental excision of bone. If there is evidence of pan medullary infection, I think that requires reaming as well to try and clear that infection. There is now a vogue towards the use of a reamer irrigator aspirator,
BILAL JAMAL: however, that's not necessary. I think sequential reaming is just as good. My favorite instrument in actual fact is a curette because I think that helps address infection and helps clear it both within bone and soft tissues to a very high level. Another element of that all is to use fluids to wash out and sterilize the soft tissues and bone. And I tend to go for low pressure saline rather than the use of pulsatile lavage because of my concern of seeding infection into native non infected tissues.
BILAL JAMAL: Orthopaedics, for the most part, is lifestyle surgery. There's very little of what we do that actually saves lives. However, I think it's fair to say that this is pseudo oncological debridement because the kind of surgery that we do here is much more than just simple lifestyle surgery. It's something that can save lives and requires the skill and determination that is seen more in an oncological practice. After a debridement,
BILAL JAMAL: it's vital that any resected bone is provided with mechanical stability because we know that mechanical stability in and of itself helps to settle down infection. And there are various philosophical arguments that can be entered into around the role of internal fixation or external fixation in that circumstance and I won't rehearse those arguments this evening. Whichever soft tissue defect is left needs to be reconstructed and therefore a fracture related infection
BILAL JAMAL: surgery is the paradigm of joint working between orthopedics and plastic surgery. And again, whatever bone defect is left that must be reconstructed. And these days, there are multiple ways in which to manage that. But I'm going to move on to the focus of today's talk, which is around dead space management. This is vital because if we don't address dead space, that situation is left with a hematoma
BILAL JAMAL: and that can act as a nidus for infection. And therefore, to my mind, we need to address that so that we're not left with a hematoma, which can become infected. But also I think there's value in having a product which can provide high dose local antibiotic delivery to try and address some of the systemic side effects from systemic [MUSIC PLAYS] antibiotics and Stimulan is one such option. Now this is a calcium sulphate hemi-hydrate.
BILAL JAMAL: It's biodegradable and tends to to the sort of installations for use with Vancomycin, Tobramycin but I think it's fair to say that it's commonly used off license with a mixture, with a large mixture of antibiotics and antifungal agents. Wound discharge has commonly been a felt to be a problem with void fillers. However, this is much less of a concern with Stimulan than with other products.
BILAL JAMAL: And you can see here the antibiotic elution sits way above the typical MIC of most organisms for up to six weeks and that is hugely useful from an infection eradication point of view. And these three lines represent gentamycin, vancomycin and tobramycin. I think from my point of view, tips for use are to pick antibiotics carefully, and therefore I tend to, on an empirical basis, use vancomycin and gentamicin and mix both into Stimulan.
BILAL JAMAL: If there are previous culture results, I use those, and should the situation be anything more than moderately complicated, I'd discuss it with the microbiology and ID colleagues. I think a two layer repair is hugely useful to try and mitigate against the risk of significant wound discharge and if that's not possible, I tend to get early involvement with my plastic surgery team to ensure that flap coverage is considered.
BILAL JAMAL: And I wanted to quickly demonstrate one case where I had a patient with fracture related infection. This is a chap who's 52 years old who presented with relatively poor physiology. He'd had nine DVT's within his right leg previously. He'd had three previous DVT's and had a past history of hepatitis C, and the thing which was driving all of this was a history of drug misuse
BILAL JAMAL: and he was currently on methadone. He'd sustained a closed right ankle fracture, which was bimalleolar in nature, and two and a half weeks down the line had proceeded onto internal fixation. Sorry, apologies, had proceeded on to internal fixation at time of injury and had then represented two and a half weeks down the line with this picture where radiographs for the most part looked satisfactory. We might quibble about the choice of fixation in a relatively high risk individual, but I think these clinical photographs would highlight some of the concerns.
BILAL JAMAL: He had evidence of early wound failure and as Deepa had proposed, there was a real concern of deeper infection in this circumstance. He went on to have debridement by the local team who removed the lateral metalwork and as you can see, there had applied a back dressing. And therefore he was left with a large lateral sided soft tissue defect.
BILAL JAMAL: There was an attempt to treat this with a vac dressing over the course of a few days, but the situation didn't improve as is relatively predictable I guess. He was discussed within the infection MDT and was demonstrated to have a polymicrobial infection, which was multidrug resistant and therefore was started up on a mixture of IV and oral antibiotics. He went on to come under my care and had further surgery approximately a week following debridement, at which point his findings were fairly typical.
BILAL JAMAL: I tend to find in these patients that there is gross infection within the perineal tendon sheath and that needs excision, as does the fibula along the length of where the plate sat. The ankle joint itself tends to be infected and tends to sit as a mode of introduction of infection into the medial malleolar fracture, and therefore I removed the medial malleolar screws and the fracture itself.
BILAL JAMAL: I inserted Stimulan into that posterior lateral defect that is often left following this level of debridement, and that was impregnated with vancomycin and gentamycin. And for soft tissue cover, the plastic surgical team proceeded with a peroneus brevis turndown. And as I say, there are multiple conversations that can be had about internal or external fixation, but in this circumstance, I proceeded with an Ilizarov frame to help achieve an ankle fusion.
BILAL JAMAL: And these are radiographs, image intensification views from theater. You can see there that the Stimulan sits posterior laterally, that the ankle joint has been prepared and compressed and fixed with the Ilizarov frame. These were radiographs after a month and a half or so, at which point, you can see that the Stimulan has resorbed, which is clearly encouraging, as that would suggest that it's not going to act as a long term nidus for infection.
BILAL JAMAL: Radiographs a year down the line would suggest that his ankle joint had fused, and at that point, the frame was removed. And thereafter he represented about 16 to 18 months after the fact, at which point you can see that his ankle joint has quite successfully fused. You can see that he had evidence of venous insufficiency within this lower limb, which isn't surprising considering the past history of DVT
BILAL JAMAL: and he had venous ulceration, which settled with compression dressings. So I think to my point of view, dead space management is vital and local antibiotic elution has a role to play in the eradication of infection. And these are the principles that we have covered today. I'm happy to take questions on that basis.
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