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SYNOPSIS
Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore
“ STUDY OF POSTOPERATIVE WOUND INFECTIONS AND ITS
OUTCOME IN ORTHOPAEDIC SURGERIES”
Name of the candidate
: Dr. Karen Maria D’sa.
Guide
: Dr. K. Raghuveer Adiga.
Course and Subject
: M.S. (Orthopaedics)
DEPARTMENT OF ORTHOPAEDICS
FR. MULLER MEDICAL COLLEGE HOSPITAL
KANKANADY, MANGALORE – 575 002.
2010
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
ANNEXURE – II
PROFORMA FOR REGISTRATION OF THE SUBJECT FOR
DISSERTATION
1.
Name of the Candidate
DR. KAREN MARIA D’SA
and Address
POST GRADUATE RESIDENT
[in block letters]
DEPARTMENT OF ORTHOPAEDICS
FR. MULLER MEDICAL COLLEGE
KANKANADY
MANGALORE 575 002
2.
Name of the Institution
FR. MULLER MEDICAL COLLEGE
HOSP ITAL KANKANADY,
MANGALORE 575 002
3.
Course of study and
M.S (ORTHOPAEDICS)
subject
4.
Date of admission to
01-04-2010
Course
5.
TITLE OF THE TOPIC:
“ STUDY OF POSTOPERATIVE WOUND INFECTIONS AND ITS
OUTCOME IN ORTHOPAEDIC SURGERIES”
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6.
BRIEF RESUME OF THE INTENDED WORK :
6.1 NEED FOR STUDY :
In 1862, Louis Pasteur’s ingenious experiments into the nature of putrefaction
were officially endorsed by the Paris Academy of Science. The endorsement
signalled an end to the long-held belief that the exposure of organic material to air
brought about the “spontaneous generation” of microorganisms, and the concepts of
“sepsis” and “asepsis” became firmly established. A scant three years later, in what
must be regarded as a paradigm of applied science, Joseph Lister demonstrated the
incredible implications of antisepsis in his practice of Orthopaedic surgery. For the
first time in recorded history, major surgical procedures could be performed with a
reasonable expectation of primary wound healing and recovery. Essential
enhancements for preventing and controlling wound “sepsis” were provided by the
antibiotic revolution of the 1940s, ushering in the highly technical, highly invasive,
and highly successful era of modern surgery. As noted by McDermott and Rogers,1
the greatest impact of the antibiotic revolution may be related, in the long run, to its
essential role in supporting the advancements of modern surgery. Indeed, surgery as
we know it today would be impossible in an environment in which infection was
likely or, once established, untreatable.
In reviewing the principles underlying the prevention and control of surgical
wound infections, it is axiomatic to appreciate the inevitability of bacterial
contamination of the surgical wound. Infection in Orthopaedic surgery is a disaster
both for the patient and surgeon. Pre and postoperative infections have been shown to
significantly increase the use of antibiotics, prolong the hospital stay, conduct
repetitive debridements, prolong rehabilitation, and finally even increase the
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morbidity and mortality of patients. It drastically increases the cost to the medical
system, and causes severe physical limitations and diminishes the quality of life.
With such serious implications of postoperative infections, it is imperative that
measures, including the use of prophylactic antibiotics, be given to prevent infection.
The pathogenesis of infection in fractures fixation devices is related to
microorganisms, which grow in bio-film, and therefore its eradication is difficult.
These infections are classified into three stages :early, delayed and late infections . A
preliminary report on the study of wound infections reported the infection rates of
39% in postoperative patients that was reduced to 0.2% with proper aseptic measures
in recent times2.
At the beginning of the 21st century, the rate of infection was reduced due to
basic aseptic measures and antibiotic use. Sterile surgical technique and intravenous
administration of antibiotics such as Ceftriaxone, Cefixime, or Clindamycin prior to
incision are the current standard of care in Orthopaedic Surgery.
As early as 1946, a correlation between the amelioration of infection and the
interval between the contamination of the wounds and the administration of
antibiotics had been established. The most common infecting organism in
Orthopaedic surgeries is Staphylococcus aureus. Ketcham and others3
,noted a
significantly high correlation between the presence of nasal carriage of
Staphylococcus aureus and incidence of postoperative Staphylococcus aureus
surgical wound infections. The ability of tissues to contain the contaminating bacteria
, thereby avoiding an infecting process , is related to existing local and systemic
immune processes. The milieu of the surgical wound may be viewed as a balance of
opposing forces. As the number and virulence of contaminating bacteria increases ,
so does the chance for development of a postoperative infection .The importance of
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microbial load in determining whether a wound becomes infected or not has been
appreciated for years.
Figure taken from Mandel: Infectious Diseases: Chapter 285, Postoperative
Infections and Antimicrobial Prophylaxis10
Hence the objective of this study is to find out the effectiveness of surgical
asepsis in preventing wound infection and its final outcome on Orthopaedic
surgeries.
6.2 REVIEW OF LITERATURE:
In 1896 Brewer2 reported the infection rates of 39% in postoperative patients
that was reduced to 0.2% with proper aseptic measures in recent times, 29
Staphylococcus aureus wound infections among the 108 nasal carriers versus 15
infections among 249 non carriers, p <0.0001.
Khan4 said that the surgeon hand scrub is probably the most ritualized step in
the preparation for surgery. Clocks and timers have been installed and used to
mandate the traditional ten minute scrub, and the use of nail cleaner and scrub brush
for a full ten minutes has often been mandated. Current recommendations when an
antimicrobial soap is used include scrubbing the hands and forearms for the length of
time recommended by the manufacturers, usually two to six minutes. Alcohol based
agents show an immediate reduction of 95% of the resident flora and a 99%
reduction with repeated applications. Chlorhexidine can be left on the hands, and it
will continue to lower bacterial counts during the procedure.
4
Roth5 compared wound irrigation with and without betadine, the infection rate
was 0.5% and 2.9%, respectively. This difference was significant. Antibiotics are
often added to the irrigant.
Cruse6, stated shaving of the hair about the surgical area and the use of the
surgical scrub of the patient is another factor steeped in tradition, however he
stipulated that these two measures can cause grave wound infections ; the use of
razors more than 24hours prior to surgery carries a 21% risk and the use of razors
exactly 24hours prior to surgery carries just 3.1 % risk
6.3
OBJECTIVES OF THE STUDY:
1. To study the incidence of postoperative wound infections and the toll it takes
on orthopaedic surgeries by evaluating :

The effectiveness of usage of preoperative and postoperative systemic
and local antibiotics.

The role of sterile measures such as scrub suits, masks, sterile gloves,
gowns and drapes in reducing the surgical site infection
2. To assess the efficacy of surgical asepsis in Orthopaedic surgeries
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7.
MATERIALS AND METHODS:
7.1 SOURCE OF DATA:
We shall be taking a diverse group of individuals between 18-50 years of age,
who shall be undergoing surgeries with and without implant insertion at Father
Muller Medical College, Mangalore between 2010 – 2012 and follow up these cases
using the data obtained from case records maintained with Medical records
department and individual patients proforma obtained on admission and on out
patient basis to Father Muller Medical College, Mangalore between 2010–2013.
7.2 METHOD OF COLLECTION OF DATA:
The diagnosis for wound infection will be done by clinical examination,
laboratory investigations such as ESR, CRP, microbiology- multiple swabs from the
wound site. A swab will be taken first before the surgery, then after the surgery on
the 3rd day, 12th day and then after 3 months of surgery .We shall be concentrating on
whether the chosen patients show signs of infection such as redness, pus discharge,
fever, loosening of implant, raised ESR levels or raised CRP levels.
Study type :
A prospective follow up of the outcome of the patient following operation.
A sample size of 50 patients will be selected using purposive sampling technique. All
50 patients will undergo a surgery with or without the insertion of an implant.
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Inclusion criteria:
1. Patients taken up for elective surgeries(major or minor procedures) .
2. Patients who are known cases of Diabetes mellitus and Hypertension on
regular treatment for the same .
3. Patients aged 18 years and above.
Exclusion criteria :
1. Immunocompromised patients.
2. Patients on long term cortico-steroids and immunosuppressive treatment.
3. Patients with open fractures.
Plan for data-analysis :
Collected data will be analysed by ‘t’-test and Chi-Square test. About 100
adult patients who are taken up for elective procedures, either major procedures such
as DHS fixation or minor procedures such as incision and drainage at Father Muller
Medical College Hospital will be evaluated and assessed pre-operatively, intraoperatively and post-operatively for a period ranging 6-24months.
On the 3rd, 6th and 21st day following surgery, post-operative culture and
sensitivity swabs shall be taken .Investigations in terms of recording ESR and CRP
levels shall be done.
7.3 Does the study require any investigations or intervention to be conducted on
patients or other human or animals? If so please describe briefly.
Yes
7.4 Has ethical clearance been obtained from your institution in case of 7.3
Yes
7
8.
LIST OF REFERENCES:
1. McDermott W, Rogers DE. Social ramifications of control of microbial disease.
Johns Hopkins Med J. 1982; 151: 301-12.
2. Brewer GE. Operative surgery at city hospital with a preliminary report on the
study of wound infections. Surgery of musculoskeletal system. Evarts M,
1990;5:4316
3. Ketcham AS, Lieberman JE, West JT. Antibiotic prophylaxis in cancer surgery
and its value in staphylococcal carrier patients. Surg Gynecol Obstet. 1963; 117:
1-6.
4. Khan A, Mclaren SG, Nelson CL. Surgical hand scrub practices in orthopaedic
surgery. Clin Orthop Relat Res .2003;414:65-8
5. Roth RM, Gleckman RA, Gantz NM, Kelly N. Antibiotic irrigations. A plea for
controlled clinical trials .Pharmacotherapy .1985;5:222-7.
6. Cruse PJ, Foord R. The epidemiology of wound infection. A 10 year prospective
study of 62,939 wounds. Surg Clin North Am .1980 ;60:27-40.
7. Sands K, Vineyard G, Platt R. Surgical site infections occurring after hospital
discharge. J Infect Dis 1996;173:963-70.
8. Weigelt JA, Dryer D, Haley RW. The necessity and efficiency of wound
surveillance after discharge. Arch Surg 1992;127:77-82.
9. Lilani SP, Jangale N, Chowdhary A, Daver GB. Surgical site infection in clean and cleancontaminated cases. Indian J Med Microbiol 2005; 23: 249-52.
10. Mandel: Infectious Diseases: Chapter 285, Postoperative Infections and
Antimicrobial Prophylaxis
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SIGNATURE OF THE CANDIDATE:
10 REMARK OF THE GUIDE:
APPROVED
11 NAME AND DESIGNATION OF (in
block letters):
DR. K.RAGHUVEER ADIGA
11.1 GUIDE
ADDITIONAL PROFESSOR
DEPARTMENT OF ORTHOPEDICS
FATHER MULLER MEDICAL COLLEGE,
KANKANADY
MANGALORE-575002
11.2 SIGNATURE
11.3 HEAD OF THE
DR. JACOB CHACKO
DEPARTMENT
PROFESSOR AND HOD
DEPARTMENT OF ORTHOPAEDICS
FATHER MULLER MEDICAL COLLEGE,
KANKANADY
MANGALORE-575002
11.4 SIGNATURE
12 12.1 REMARKS OF THE
CHAIRMAN AND DEAN
12.2 SIGNATURE
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