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Re: Огнестрельный перелом бедра в аппарате
Bill Burman 05 Май 2002, 11:19
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Watson and Kuldjanov said they had an 88% infection rate with late, non-staged exfix-IM nail exchanges - even with *pristine* pin sites.
With confirmed osteomyelitis of the pin sites, Rudel et al had no deep infections with late exfix-IM nail exchanges if staged pre-nailing
pin-tract biopsies were negative.
(http://www.hwbf.org/ota/am/ota01/otapa/OTA01533.htm)
In four cases you discussed 5/2/2002, there was apparent avoidance of infection with late exfix-IM nail exchanges (2 non-staged, 2 staged)
treated with 4-5 days of oral ciprofloxacin.
You wrote:
"Now i think either it was incredible luck, or staphyllococci at your side are much more angry, if also solid unreamed nails were used. "
The question I am trying to raise is that if there is any doubt as to the possibility of pin tract colonization, why not take the added precaution of staged pre-nailing pin tract biopsies?
Bill Burman, MD
HWB Foundation
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Re: Огнестрельный перелом бедра в аппарате
Отправитель: Alexander Chelnokov 05 Май 2002, 11:31
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BB> Watson and Kuldjanov said they had an 88% infection rate with late,
BB> non-staged exfix-IM nail exchanges - even with *pristine* pin sites.
Don't you know what nails were used in their series - solid or hollow?
BB> possibility of pin tract colinization, why not take the added precaution of
BB> staged pre-nailing pin tract biopsies?
Do you mean to take a culture with fixator in place? Or you ask why not operate after a period of time to allow pin sites to heal? I wouldn't trust too much our bacteriology reports.
In view of so discouraging infection rates as reported Dr Watson for the non-staged group definitely the lag period is necessary.
The only problem is what to do with the leg (and patient) after external device removal before nailing. If the patient has been mobile recent weeks, he would not be too enthusiastic about bed traction.
Maybe it is worth to insert new pins/wires prior to remove the old ones, to keep external fixator in place and allow the level of activity?
Our modest exchange experience was more optimistic so i proceed with the nailing (UFN 11 mm) before i read answers :-(
So 5th day i am about a nervous breakdown. After the surgery except the cold shower from the group a laboratory report was received that he is also HIV and hep. C infected. So i keep fingers crossed. I attached xrays and current view of the leg. All looks calm at the moment... How long to proceed with antibiotics and heparin?
The patient feels fine, no fever, ambulates with crutches, knee ROM is 0/90, and he is going to leave for home tomorrow.
Comments and moral support are welcome... THX in advance.
--
Best regards,
Alexander N. Chelnokov
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Re: Огнестрельный перелом бедра в аппарате
Отправитель: Tom DeCoster 05 Май 2002, 11:36
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I'm happy to provide moral support. I know for a fact that it is possible to obtain good healing with an intramedullary nail after external fixation as I've seen dozens of successful cases. So in this instance you should watch
and wait and if this patient has a problem with infection then treat it. If he doesn't, great for everyone. Intramedullary nailing is fundamentally an excellent technique (mechanically and physiologically) and will overcome many (but not all) technical and situational problems.
That doesn't mean that you should keep nailing them until you experience an unacceptable infection rate. Especially with HIV + etc.
TD
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Re: Огнестрельный перелом бедра в аппарате
Отправитель: Manuel Sotelo 05 Май 2002, 11:40
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Meaning that you don't nail a HIV+?
Regards
Manuel
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Re: Огнестрельный перелом бедра в аппарате
Отправитель: Tom DeCoster 06 Май 2002, 08:51
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Meaning I expect a significant infection rate if performing IM nail after XF and I expect it would be even higher with IM nail after XF in cases with HIV + and would seek out
alternative treatments with lower or more acceptable infection rates.
TD
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Re: Огнестрельный перелом бедра в аппарате
Отправитель: DR T I GEORGE 05 Май 2002, 11:37
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I feel that there may be some point in Alex's statement though yet to be proved scientifically.
"Now i think either it was incredible luck, or staphyllococci at your side are much more angry, if also solid unreamed nails were used. "
From what I know during the original work of Ilizarov the role of antibiotics was minimal which is not the case in my experience. Of course
HIV was unknown in those days. May be this is a food for thought and some work in future- to do an intercontinental study on the virulence of the same organism.(I am unaware of such a study if already published).
DR T I GEORGE,
Cosultant Orthopaedic surgeon,
Polytrauma, Microvascular Surgery and Hand Surgery Unit,
Metropolitan Hospital,
Trichur, South India.
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