早期应用抗生素与清创冲洗术对大鼠开放骨折模型感染控制的影响

目的 观察早期应用抗生素与清创冲洗术对大鼠开放骨折模型感染控制的影响.方法 建立SD大鼠开放骨折金黄色葡萄球菌感染模型.动物模型建立后2、6、24 h分别给予清创冲洗手术和全身性抗生素(头孢唑林钠,5 mg/kg)治疗.14 d后取骨及内固定物标本分别行细菌培养定量分析.结果 损伤后2h行清创冲洗术及抗生素处理的大鼠标本未见细菌生长.2h应用抗生素的大鼠,随着实施清创冲洗术时间由2h延迟到6h[骨标本菌培养,4.25×105菌落形成单位(CFU),标本细菌定量检测水平明显增加(P＜0.05),但延迟清创手术至24 h时菌落数却未见显著增加(骨标本菌培养,4.12 ×105 CFU;P ＞0.05).抗生素的应用时间显著影响标本的细菌阳性培养结果,早期应用抗生素对感染控制的影响效应大于单纯早期清创手术.无论何时实施清创冲洗手术,抗生素应用时间从6h延迟至24h,清创冲洗手术对感染控制的效果都会降低.结论 早期应用抗生素或实施清创手术均可在一定程度降低感染的发生,早期应用抗生素对感染控制的影响效应大于早期清创手术,但早期应用抗生素不能抵消延迟手术时间对感染控制的影响.     

Effect of repeated irrigation and debridement on fracture healing in an animal model.

The initial management of open fractures often requires repeated irrigation and debridement of the open wound and stabilization of the fracture. However, washing out the fracture hematoma could delay the early healing process of stable fractures. Because delayed union and non-union are serious complications, the effect of repeated irrigation and debridement on the fracture healing process was investigated. Twenty-four rabbits received unilateral, transverse. mid-tibial open osteotomies with a 3 mm gap. The osteotomy site was thoroughly irrigated and stabilized with double-bar external fixators. The osteotomy sites in the study groups underwent repeat irrigation and debridement on either the third day (Group II), the fourth day (Group III), or consecutively on the first and second days (Group IV) after the index procedure. The bone healing was assessed with weekly radiographs and peripheral quantitative computerized tomographs. In Group I (control), all osteotomies healed radiographically before the tenth week. In Group II, five out of six osteotomies healed radiographically before the tenth week. In Group III, only two of five osteotomies healed before the tenth week. In Group IV, none of the osteotomies had healed by week fifteen. All of the non-healed osteotomies exhibited atrophic non-unions at fifteen weeks. Compared to the control group at the tenth week, the average bone mineral content at the osteotomy site and the area of high mineral density callus (> or = 890 mg/cm3) were significantly lower in Groups III (63%, p = 0.002 and 95%, p = 0.05, respectively) and IV (99%, p < 0.001 and 100%, p = 0.05, respectively). The results of this study suggest that repeated irrigation and debridement, associated with persistent rigid immobilization, may contribute to the development of delayed unions or atrophic non-unions.     

一期清创加内固定治疗开放性跟骨骨折的临床体会

目的 探讨一期清创加内固定治疗开放性跟骨骨折的临床效果.方法 回顾性分析我院2001年2月至2007年12月对25例27足开放性跟骨骨折行一期清创加内固定术治疗的临床资料.男18例,女7例;年龄14～65岁,平均43.6岁.24例为高处坠落伤,1例为机器绞伤,开放伤口为GustiloⅡ型,骨折均为Sanders Ⅲ～Ⅳ型.手术清创内侧开放伤口,同时外侧扩大L型切口切开复位H或Y型钢板内固定跟骨骨折.结果 跟骨高度宽度、Bohlers angle、Gissane angle、跟骨外翻角均得到良好恢复,内侧均伤口一期愈合.21例患者获得随访,随访时间1.2～8.7年,平均6.4年,除1例外侧手术伤口术后2周仍渗液,细菌培养无细菌,经换药后愈合.结论 内固定一期用于开放性跟骨骨折的治疗,安全、有效.     

保留假体清创术治疗假体周围感染疗效的影响因素

假体周围感染(PJI)是人工关节置换术后的灾难性并发症,严重影响患者的生活质量,给家庭和社会造成了沉重的负担。保留假体的清创术由于创伤小、花费少,目前仍被推荐作为急性PJI的首选治疗。但文献报道的成功率差异极大,如何提高保留假体清创术的成功率,本文对该问题作一综述。     

开放性骨折清创术中与感染后细菌培养的调查与分析

目的 调查分析开放性骨折急诊清创术中与伤口感染后创面细菌种类及其药敏情况,并观察两者之间的关系.方法 分析2010年10月至2011年12月急诊行清创固定且术后伤口发生感染的61例四肢开放性骨折患者的细菌培养及药敏试验结果,男43例,女18例;年龄4～ 72岁,平均37.3岁.受伤至入院时间为1～14h,平均5.3h.将每例患者清创术中及感染后创面细菌培养及药敏结果进行比较.结果 清创术中创面的细菌培养阳性率较低(22.9％,14/61),清创术中和创面感染后培养出相同病原菌的仅有2例,一致率(3.3％,2/61)很低.61例伤口感染后共培养出69种病原菌株.造成开放性骨折术后感染的病原菌多为革兰阴性菌(91.3％,63/69),主要是鲍曼不动杆菌(49.3％,34/69).60.8％ (42/69)的术后感染病原菌是由多重耐药菌(MDR)造成,80.9％ (34/42)的MDR是鲍曼不动杆菌,其对头孢哌酮舒巴坦的耐药率相对较低(44.1％,15/34),多介于敏感和中介之间.结论 清创术中的细菌培养结果无法预测造成术后感染的病原菌.开放性骨折的感染多为院内感染,以革兰阴性菌为主,MDR占很高比例,应该给予足够重视.     

Three-vessel view debridement of the open tibial fracture: a surgical technique

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the “three-vessel view”. Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

     

Comparison of bacteria isolated from open fractures following debridement and subsequent infection

BackgroundOne of the major objectives for the management of open fractures is to prevent bone and soft tissue infection. Here, we identified species and drug sensitivities of bacterial isolates recovered during open fracture debridement and after infection and compared the results between the two time points.MethodsA total of 61 hospitalized patients with open fractures who developed post-operative wound infection between October 2016 and December 2017 were included in this study. The cohort included 43 males and 18 females aged between 4 and 72 years. Patients were admitted to hospital 1–14 h after injury. Samples were collected after debridement and after infection and submitted for bacterial culture. Resulting isolates were identified using a VITEK 2 Bacterial Identification System and tested for drug sensitivity using the disc diffusion method. Results from the two time points were then compared.ResultsThe positive bacterial culture rate following debridement was relatively low (14/61, 22.9%). In addition, bacteria cultured after debridement were generally inconsistent with those cultured after wound infection, with a concordance rate of only 3.3% (2/61). Gram-negative bacteria accounted for 91.3% (63/69) of isolates recovered from wound infections following surgery, among which Acinetobacter baumannii was baumannii was the predominant pathogen, accounting for 49.3% (42/69) of all isolates. Overall, 60.8% (42/69) of postoperative infections were caused by multi-drug resistant bacteria, with A. baumannii isolates accounting for 80.9% (34/42) of these cases. Rates of cefoperazone/sulbactam resistance were relatively low among the isolates (15/34, 44.1%), and most isolates showed a sensitive or intermediate resistance phenotype.ConclusionsResults of bacterial culture after debridement could not predict pathogenic bacteria causing postoperative infection. Therefore, we propose that open fracture infections are predominantly nosocomial and are mainly caused by multidrug-resistant Gram-negative bacteria. Further attention should be paid to the control of these pathogens in clinical settings.     

Factors influencing infection rate in open fracture wounds

Seventy-seven infections in 1104 open fracture wounds were evaluated to identify those factors that predisposed to infection. Factors could be placed into three categories: (1) increased risk, (2) no effect, and (3) inconclusive. The single most important factor in reducing the infection rate was the early administration of antibiotics that provide antibacterial activity against both gram-positive and gram-negative microorganisms. In this study, surgical debridement was performed on all open fracture wounds.     

Clostridium perfringens infection following intramedullary nailing of an open femur shaft fracture

In a 47-year old patient, clostridial bacteraemia and local gas gangrene developed following osteosynthesis of a penetrating femoral fracture by a medullary nail. The operation had been performed in a post-injury interval of 14 days. The first clinical symptoms did not appear until 6 days after surgery. Operative treatment by large local incisions, debridement and drainage with the medullary nail left in situ accompanied by administration of penicillin G resulted in recovery. In the case presented here, local haematoma and debris due to the osteosynthesis procedure had probably induced a proliferation of clostridia leading to gas gangrene. The delay in development of signs and symptoms and the benign appearance of the wound resulted in delay in early diagnosis and appropriate treatment of this potentially life-threatening entity. Ultrasound proved to be a valuable tool in the evaluation of local changes. Even in performed in an appropriate postinjury interval, medullary nailing bears a potential risk of inducing a clostridial infection, so that the indication must be very strict.     

关节镜和开放清创治疗人工膝关节置换术后感染的疗效比较

目的对比分析膝关节镜和开放手术两种方法治疗人工膝关节置换术后感染的临床疗效。方法从本组收治的人工膝关节置换术术后感染的患者中，选取没有窦道形成，没有明显骨质感染、破坏，假体没有松动并且能找到敏感抗生素的患者13例13个膝。治疗前抽取关节液行细菌培养和药敏试验，随机分成两组，A组6例关节镜下关节腔清创术，B组7例开放手术关节腔清创术，术后用敏感抗生素液持续闭式灌冼2～4周，待冲洗液变清后3～5天拔管。结果选取的两组病例资料无显著性差异（P〉0．05），滑膜组织病理分析示炎性改变。13例患者经治疗后局部及全身症状、体征消失，血液和关节液检查结果正常，X线照片基本正常。13例患者平均随诊1．5年（6个月～3年），A组2例、B组1例术后3个月感染复发，均行关节镜清创术后感染治愈。B组1例术后半年感染复发，并出现明显的假体松动，施行清创及二期翻修术，术后感染治愈，无复发。A、B两组感染治愈率分别为66．7％和71．4％，差异无统计学意义（P〉0．05）。术后A组优良率100％，B组优良率为85．7％，有显著性差异（P〈0．05），A组术中出血量少于B组（P〈0．05）。结论对人工膝关节置换术后感染没有窦道形成，无明显骨质破坏，假体没有松动，可找到敏感抗生素的患者，选择关节镜手术治疗可以获得较好的疗效，关节功能恢复比开放手术有明显优势，是一种创伤小、治疗效果较好的方法。     

Early versus late reduction of a physeal fracture in an animal model

This study was designed to determine whether delayed reduction of physeal fractures in an animal model causes growth disturbance, and whether final alignment is better in delayed or malreduced fractures. Salter 1 fractures of the proximal tibia were created in 41 immature rats randomized into five groups. The fractures were reduced as follows: group 1, immediately; group 2, 6 hours; group 3, 24 hours; group 4, 48 hours; and group 5, left malreduced. Both legs were analyzed for leg-length discrepancy, angular deformity, and evidence of radiographic bar. No radiographic physeal bar or leg-length discrepancy was seen among any of the groups. Angular deformity was greatest in group 5 and least in group 1. Immediate reduction resulted in the least angular deformity. Delayed reduction showed no evidence of physeal damage, physeal growth disturbance, or radiographic bar formation. Alignment was not improved in delayed reduction versus malreduced fractures.     

Sclerostin monoclonal antibody enhanced bone fracture healing in an open osteotomy model in rats

Sclerostin is a negative regulator of bone formation. Sclerostin monoclonal antibody (Scl‐Ab) treatment promoted bone healing in various animal models. To further evaluate the healing efficiency of Scl‐Ab in osteotomy healing, we investigated the time course effects of systemic administration of Scl‐Ab on fracture repair in rat femoral osteotomy model. A total of 120 six‐month‐old male SD rats were subjected to transverse osteotomy at the right femur mid‐shaft. Rats were treated with vehicle or Scl‐Ab treatment for 3, 6, or 9 weeks. Fracture healing was evaluated by radiography, micro‐CT, micro‐CT based angiography, 4‐point bending mechanical test and histological assessment. Scl‐Ab treatment resulted in significantly higher total mineralized callus volume fraction, BMD and enhanced neovascularization. Histologically, Scl‐Ab treatment resulted in a significant reduction in fracture callus cartilage at week 6 and increase in bone volume at week 9, associated with a greater proportion of newly formed bone area at week 6 and 9 by fluorescence microscopy. Mechanical testing showed significantly higher ultimate load in Scl‐Ab treatment group at week 6 and 9. This study has demonstrated that Scl‐Ab treatment enhanced bone healing in a rat femoral osteotomy model, as reflected in increased bone formation, bone mass and bone strength. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:997–1005, 2014.     

Comparison of healing process in open osteotomy model and closed fracture model

OBJECTIVE: Comparison of the healing process in open osteotomy and closed fracture models that were used to study fracture healing. DESIGN: Randomized, prospective study in experimental animals, with a recovery duration of two and four weeks. SETTING: Unrestricted cage activity with weight bearing as tolerated. ANIMALS: Thirty-four skeletally mature, female New Zealand White rabbits. INTERVENTIONS: Closed fractures and open osteotomies of the tibial diaphysis were reduced and immobilized with four-pin, double-bar external fixators. MAIN OUTCOME MEASUREMENTS: Callus circumference was measured with a tape measure, bridging callus was assessed on biplane radiographs and evaluated histologically, and torsional stiffness and maximum torque were measured. RESULTS: Periosteum damage was more severe and hematoma formation was smaller in the osteotomy model, resulting in a delay in biological healing and restoration of the biomechanical properties. CONCLUSIONS: Investigators should consider the difference between the closed fracture and open osteotomy models when selecting an animal model to investigate fracture healing.     

The relationship between time to surgical debridement and incidence of infection in grade III open fractures

Objective  

The purpose of this study was to determine the association between time to initial debridement and infection rate in high-energy (grade III) open fractures of tibia.     

Delayed debridement of an open total talar dislocation reimplanted in the emergency room

Open total talar dislocation is a rare but well known injury. Its management is controversial and fraught with complications such as infection, avascular necrosis, and post-traumatic osteoarthritis.We report the case of a woman sustaining a pure open talar dislocation reduced in the emergency room. Debridement was done three days after the injury in the operating room. There was no infection. One year after surgery she complained of occasional pain. Ambulation was normal. She wore regular shoes. The overall alignment of the ankle, hindfoot, and midfoot was normal. Movements of the tibiotalar and subtalar joints were not impaired. She has resumed her regular activities. Radiographs showed no signs of avascular necrosis. All components of the treatment strategy of open total dislocation should be carried out in emergency. This results in environment close to the original biological state. Good results can be achieved if infection is avoided.     

Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection prevention in type II and III open injuries

The aim of this study was to retrospectively evaluate the clinical and culture-positive infection rates of open Gustilo/Anderson type II and III fractures using a protocol nanocrystalline silver wound dressing and hydrosurgical debridement. Retrospective case series through chart review on all type II and III open fractures were treated using a novel protocol from December 2005 to March 2008 (N = 17). All Gustilo/Anderson grade II and III open fractures were treated with a novel protocol at a Level I trauma centre. Open Gustilo/Anderson grade II and III fractures were acutely stabilised in the trauma centre/emergency department, while a nanocrystalline silver dressing was placed within the wound. Debridement using a hydrosurgical scalpel and gravity irrigation was performed within 6-8 hours of injury. Cultures were obtained prior to definitive fixation. The primary outcome measurements were positive cultures and clinical infection rates. Seventeen patients met inclusion criteria. Mean age (33·5) and injury severity score (12·7) were gathered. There were 4 grade II open fractures (23·5%), 11 grade IIIA (64·7%) and 2 grade IIIB open fractures (11·8%). The mean time to intravenous antibiotics was 61·5 minutes. The mean time to initial debridement/irrigation was 222·1 minutes. The average number of surgical procedures was 2·35 with a mean length of stay of 11·8 days. Six patients developed positive cultures from the traumatic wounds, five were contaminants. One clinical infection was found (methicillin-resistant Staphylococcus aureus). The overall clinical infection rate in this series was 5·9% (1/17). The only infection was in a Gustilo/Anderson grade II fracture. There were no infections in the more high-energy Gustilo/Anderson grade IIIA and IIIB fractures compared with the Gustilo/Anderson control of 4-42%. We conclude that this novel protocol for open-fracture treatment is a promising intervention. A further prospective randomised clinical study is warranted.     

The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1 degrees (sd 27.8) pre-operatively to 75.7 degrees (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1 degrees (sd 33.5) to 79.5 degrees (sd 43.2) (p = 0.0003), and mean external rotation from 10.2 degrees (sd 18.7) to 25.4 degrees (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.