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Wheeless' Textbook of Orthopaedics

Wheeless' Textbook of Orthopaedics

C.R. Wheeless MD

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Wheeless' Textbook of Orthopaedics

Addition of Antibiotics to Cement:

- See: Wound Management: - Cement Bead Pouch: - after fracture stabilization has been completed, osseous defects may be filled with antibiotic-impregnated methylmethacrylate beads; - these beads provide local depot administration of antibiotic and maintain space for subsequent bone graft; - as noted by Keating et al 1996, bead pouches help reduce the infection rate in open tibia fractures from 16% to 4%; - add 2.4 gm of tobramycin per cement package, and fashion small beads attached to a O silk suture; - once cement no longer sticks to the surgeons fingers, roll the cement into small spheres and thread over 18 gauge wire or #2 Ethibond; - counting the beads and adding methylene blue helps ensure that none of the beads will be left behind at removal; - a small drain is left adjacent to the beads and the wound is sealed w/ Opsite; - drain is left to gravity (not suction) to prevent drainage overflow; - references: - Antibiotic bead chains. - The antibiotic bead pouch technique. The management of severe compound fractures. - Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. - Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis. - Septopal beads and autogenous bone grafting for bone defects in patients with chronic osteomyelitis. - The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. - Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate? JF Keating, PA Blachut, PJ O'brien, RN Meek, and H. Broekhuyse. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303. - In vitro characteristics of tobramycin PMMA beads: compressive strength and leaching. DK Kirkpatrick et al. Orthopedics. Vol 8. 1130-1133. 1985. - Types of Cement Spacers Following Total Joint Replacement: - Palacos cement: - superior ATB elution characteristics for treating osteomyelitis; - higher porosity allows for improved elution characteristics but may make it less amenable to modern cementing techniques & THR; - when mixing the cement it is important not decrease the porosity of the cement by not using the vacuum pump; - temporary spacer: - add 2.4 to 3.6 grams of tobramycin and one to two grams of vancomycin per forty grams of cement) for temporary spacer; - Simplex-P bone cement - loaded w/ antibiotics (0.6 to 2.4 grams of tobramycin & 0.5 to 1.0 gram of vancomycin per forty grams of cement) - has superior handling characteristics; - amount of ATB that can be added to Simplex Cement (40 gm/pack); - cefazolin: 6.0 gm - tobramycin 9.6 gm - vancomycin 5.0 gm * based on allowed volume (24 cc ATB / 120 cc cement); - note: the antibiotics must be added to the cement in a powered form (which may or may not be available from the pharmacy); - references: - A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. - Characteristics of Individual Antibiotics: - gentamicin: - elution falls below the mean inhibitory concentration by 6-8 weeks; - references: - A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. - Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. - Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. - Audiometric thresholds in osteomyelitis patients treated with gentamicin-impregnated methylmethacrylate beads (Septopal). - Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis. - The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. - Reimplantation in infection: elution of genamicin from cement and beads. EA Salvati et al. CORR. Vol 207. 1986. p 83-93. - Total hip joint arthroplasty with gentamycin-impregnated cement. C Torholm et al. CORR. Vol 181. 1983. p 99-106. - The release of gentamicin from polymethylmethacrylate beads: An experimental and pharmacokinetic study. H Wahlig et al. JBJS. Vol 60-B. 1978. p 270. - vancomycin: - has much slower and more consitent elution characteristics than tobramycin; - tobramycin: - has rapid elution of antibiotics which diminishes quickly after 2 weeks; - of interest, some bacteria will be able to survive on tobramycin or vancomycin beads alone, but generally cannot survive when both antibiotics are added to the cement mixture; - the addition of 3.6 gm of powered tobramycin / 40 gm of cement should not raise the serum levels above 3 mg / dl; - references: - Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin. - The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. - note: the antibiotics must be added to the cement in a powered form (which may or may not be available from the pharmacy); - amount of antibiotics that can be added to cement, depends in part on the specific cement brand; - amount of ATB that can be added to Simplex Cement (40 gm/pack); - cefazolin: 6.0 gm - tobramycin 9.6 gm - vancomycin 5.0 gm * based on allowed volume (24 cc ATB / 120 cc cement); Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin. A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. Antibiotic bead chains. The antibiotic bead pouch technique. The management of severe compound fractures. Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. Audiometric thresholds in osteomyelitis patients treated with gentamicin-impregnated methylmethacrylate beads (Septopal). Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis. The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. Septopal beads and autogenous bone grafting for bone defects in patients with chronic osteomyelitis. The role of local antibiotic therapy in the management of compound fractures. The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate? JF Keating, PA Blachut, PJ O'brien, RN Meek, and H. Broekhuyse. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303. In vitro characteristics of tobramycin PMMA beads: compressive strength and leaching. DK Kirkpatrick et al. Orthopedics. Vol 8. 1130-1133. 1985.

Addition of Antibiotics to Cement:

- See: Wound Management: - Cement Bead Pouch: - after fracture stabilization has been completed, osseous defects may be filled with antibiotic-impregnated methylmethacrylate beads; - these beads provide local depot administration of antibiotic and maintain space for subsequent bone graft; - as noted by Keating et al 1996, bead pouches help reduce the infection rate in open tibia fractures from 16% to 4%; - add 2.4 gm of tobramycin per cement package, and fashion small beads attached to a O silk suture; - once cement no longer sticks to the surgeons fingers, roll the cement into small spheres and thread over 18 gauge wire or #2 Ethibond; - counting the beads and adding methylene blue helps ensure that none of the beads will be left behind at removal; - a small drain is left adjacent to the beads and the wound is sealed w/ Opsite; - drain is left to gravity (not suction) to prevent drainage overflow; - references: - Antibiotic bead chains. - The antibiotic bead pouch technique. The management of severe compound fractures. - Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. - Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis. - Septopal beads and autogenous bone grafting for bone defects in patients with chronic osteomyelitis. - The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. - Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate? JF Keating, PA Blachut, PJ O'brien, RN Meek, and H. Broekhuyse. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303. - In vitro characteristics of tobramycin PMMA beads: compressive strength and leaching. DK Kirkpatrick et al. Orthopedics. Vol 8. 1130-1133. 1985. - Types of Cement Spacers Following Total Joint Replacement: - Palacos cement: - superior ATB elution characteristics for treating osteomyelitis; - higher porosity allows for improved elution characteristics but may make it less amenable to modern cementing techniques & THR; - when mixing the cement it is important not decrease the porosity of the cement by not using the vacuum pump; - temporary spacer: - add 2.4 to 3.6 grams of tobramycin and one to two grams of vancomycin per forty grams of cement) for temporary spacer; - Simplex-P bone cement - loaded w/ antibiotics (0.6 to 2.4 grams of tobramycin & 0.5 to 1.0 gram of vancomycin per forty grams of cement) - has superior handling characteristics; - amount of ATB that can be added to Simplex Cement (40 gm/pack); - cefazolin: 6.0 gm - tobramycin 9.6 gm - vancomycin 5.0 gm * based on allowed volume (24 cc ATB / 120 cc cement); - note: the antibiotics must be added to the cement in a powered form (which may or may not be available from the pharmacy); - references: - A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. - Characteristics of Individual Antibiotics: - gentamicin: - elution falls below the mean inhibitory concentration by 6-8 weeks; - references: - A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. - Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. - Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. - Audiometric thresholds in osteomyelitis patients treated with gentamicin-impregnated methylmethacrylate beads (Septopal). - Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis. - The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. - Reimplantation in infection: elution of genamicin from cement and beads. EA Salvati et al. CORR. Vol 207. 1986. p 83-93. - Total hip joint arthroplasty with gentamycin-impregnated cement. C Torholm et al. CORR. Vol 181. 1983. p 99-106. - The release of gentamicin from polymethylmethacrylate beads: An experimental and pharmacokinetic study. H Wahlig et al. JBJS. Vol 60-B. 1978. p 270. - vancomycin: - has much slower and more consitent elution characteristics than tobramycin; - tobramycin: - has rapid elution of antibiotics which diminishes quickly after 2 weeks; - of interest, some bacteria will be able to survive on tobramycin or vancomycin beads alone, but generally cannot survive when both antibiotics are added to the cement mixture; - the addition of 3.6 gm of powered tobramycin / 40 gm of cement should not raise the serum levels above 3 mg / dl; - references: - Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin. - The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. - note: the antibiotics must be added to the cement in a powered form (which may or may not be available from the pharmacy); - amount of antibiotics that can be added to cement, depends in part on the specific cement brand; - amount of ATB that can be added to Simplex Cement (40 gm/pack); - cefazolin: 6.0 gm - tobramycin 9.6 gm - vancomycin 5.0 gm * based on allowed volume (24 cc ATB / 120 cc cement); Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin. A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. Antibiotic bead chains. The antibiotic bead pouch technique. The management of severe compound fractures. Long-term implantation of gentamicin-polymethylmethacrylate antibiotic beads. Audiometric thresholds in osteomyelitis patients treated with gentamicin-impregnated methylmethacrylate beads (Septopal). Gentamicin-impregnated polymethylmethacrylate beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis. The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads. Septopal beads and autogenous bone grafting for bone defects in patients with chronic osteomyelitis. The role of local antibiotic therapy in the management of compound fractures. The use of tobramycin-impregnated polymethylmethacrylate beads in the therapy of deep bone and joint infections. Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate? JF Keating, PA Blachut, PJ O'brien, RN Meek, and H. Broekhuyse. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303. In vitro characteristics of tobramycin PMMA beads: compressive strength and leaching. DK Kirkpatrick et al. Orthopedics. Vol 8. 1130-1133. 1985.
 
 
 
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