Operative Environment

Postoperative SSIs are believed to occur via bacterial inoculation at the time of surgery or as a result of bacterial contamination of the wound via open pathways to the deep tissue layers.1–3 The probability of SSI is reflected by interaction of parameters that can be categorized into three major groups.2 The first group consists of factors related to the ability of bacteria to cause infection and include initial inoculation load and genetically determined virulence factors that are required for adherence, reproduction, toxin production, and bypassing host defense mechanisms. The second group involves those factors related to the defense capacity of the host including local and systemic defense mechanisms. The last group contains environmental determinants of exposure such as size, time, and location of the surgical wound that can provide an opportunity for the bacteria to enter the surgical wound, overcome the local defense system, sustain their presence, and replicate and initiate local as well as systemic inflammatory reactions of the host. The use of iodine impregnated skin incise drapes shows decreased skin bacterial counts but no correlation has been established with SSI. However, no recommendations regarding the use of skin barriers can be made (see this Workgroup, Question 27)

No Job Name

Abstract Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome

Treatment of long bone intramedullary infection using the RIA for removal of infected tissue: indications, method and clinical results.

Treatment of intramedullary infections of long bones is based upon the principles of surgical debridement, irrigation, fracture site stabilization, soft tissue coverage, and antibiotic administration. Reaming of the medullary canal is an essential component of surgical debridement because it removes intramedullary debris and infected bone surrounding the removed intramedullary device and within the intramedullary canal. The Reamer-Irrigator-Aspirator (RIA) has distinct features that appear to be beneficial for management of intramedullary infections. It allows reaming under simultaneous irrigation and aspiration, which minimizes the residual amount of infected fluid and tissue in the medullary canal and the propagation of infected material. The disposable reamer head is sharp, which combined with the continuous irrigation may attenuate the increased temperature associated with reaming and its potential adverse effects on adjacent endosteal bone. The disadvantage of the RIA is increased cost because of use of disposable parts. Potential complications can be avoided by detailed preoperative planning and careful surgical technique. The RIA should be used with caution in patients with narrow medullary canals and in infections involving the metaphysis or a limited part of the medullary canal. Reaming of the canal is performed with one pass of the RIA under careful fluoroscopic control. Limited information is available in the literature on the results of the RIA for management of intramedullary infections of long bones; however preliminary results are promising. The RIA device appears to be an effective and safe tool for debridement of the medullary canal and management of intramedullary infections of the long bones. Further research is needed to clarify the exact contribution of the RIA in the management of these infections