در بروز عفونت در شكستگي هاي باز تيبيا كدام اثر مهمتر است نوع شكستگي يا زمان جراحي؟

In Open Tibial Fracture which is more Important Surgery Time or Fracture Pattern?

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﺷﮑﺴﺘﮕﻲ ﺑﺎﺯ ﺗﻴﺒﻴﺎ ﺷﺎﻳﻌﺘﺮﻳﻦ ﺷﮑﺴﺘﮕﻲ ﺍﺳﺘﺨﻮﺍﻥﻫﺎﻱ ﺑﻠﻨﺪ ﺑﺪﻥ ﺍﺳﺖ ﻭ ﻳﮑﻲ ﺍﺯ ﺍﻭﺭﮊﺍﻧﺲﻫﺎﻱ ﺍﺭﺗﻮﭘﺪﻱ ﺍﺳﺖ ﻭ ﺩﺭﻣﺎﻥ ﺍﺳﺘﺎﻧﺪﺍﺭﺩ ﺗﻮﺻﻴﻪ ﺷﺪﻩ ﺁﻥ ﺩﺑﺮﻳﺪﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻭ ﺩﺭ ﺻﻮﺭﺕ ﻧﻴﺎﺯ ﻓﻴﮑﺴﺎﺳﻴﻮﻥ ﺩﺭ 6 ﺳﺎﻋﺖ ﺍﻭﻝ ﺁﺳﻴﺐ ﻣﻲﺑﺎﺷﺪ ﺗﺎ ﺧﻄﺮ ﻋﻔﻮﻧﺖ ﮐﺎﻫﺶ ﻳﺎﺑﺪ. ﺯﻣﺎﻥ ﺍﻧﺠﺎﻡ ﺩﺑﺮﻳﺪﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻣﻮﺭﺩ ﺗﻮﺍﻓﻖ ﻫﻤﮕﺎﻥ ﻧﻴﺴﺖ. ﻫﺪﻑ ﺍﺯ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻌﻴﻴﻦ ﺗﺄﺛﻴﺮ ﻓﺎﺻﻠﻪ ﺯﻣﺎﻥ ﺁﺳﻴﺐ ﺗﺎ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺩﺭ ﺍﻳﺠﺎﺩ ﻭ ﻳﺎ ﺟﻠﻮﮔﻴﺮﻱ ﺍﺯ ﻋﻔﻮﻧﺖ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺷﮑﺴﺘﮕﻲﻫﺎﻱ ﺑﺎﺯ ﺗﻴﺒﻴﺎ ﻣﻲﺑﺎﺷﺪ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: 92 ﺑﻴﻤﺎﺭ ﺑﺎ ﺷﮑﺴﺘﮕﻲ ﺑﺎﺯ ﺗﻴﺒﻴﺎ ﮐﺎﻧﺪﻳﺪ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺩﺭ ﺑﻴﻦ ﺳﺎﻝﻫﺎﻱ 1387-1392 ﺩﺭ ﻳﮏ ﻣﻄﺎﻟﻌﻪ ﮔﺬﺷﺘﻪﻧﮕﺮ ﺗﻮﺻﻴﻔﻲ ﻣﻘﻄﻌﻲ ﺗﺤﻠﻴﻠﻲ ﻭﺍﺭﺩ ﺷ ﺪﻧﺪ. ﺍﻃﻼﻋﺎﺕ ﺍﺯ ﭘﺮﻭﻧﺪﻩ ﺑﻴﻤﺎﺭﺍﻥ ﺧﺎﺭﺝ ﺷﺪ. ﺑﻴﻤﺎﺭﺍﻥ ﺑﺮﺣﺴﺐ ﻓﺎﺻﻠﻪ ﺯﻣﺎﻥ ﺍﻳﺠﺎﺩ ﺁﺳﻴﺐ ﺗﺎ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺑﻪ ﭼﻬﺎﺭ ﮔﺮﻭﻩ ﺗﻘﺴﻴﻢ ﺷﺪﻧﺪ. 6 -0 ﺳﺎﻋﺖ )ﮔﺮﻭﻩ 1(، 12 -6 ﺳﺎ ﻋﺖ )ﮔﺮﻭﻩ 2(، 24 -12 ﺳﺎﻋﺖ ﮔﺮﻭﻩ 3 ﻭ ﺑﺎﻻﻱ 24 ﺳﺎﻋﺖ ﮔﺮﻭﻩ 4 ﺷﺪﺕ ﺁﺳﻴﺐ ﺷﮑﺴﺘﮕﻲ ﺑﺮ ﺍﺳﺎﺱ ﻣﻌﻴﺎﺭﻫﺎﻱ ﮔﺎﺳﺘﻴﻠﻮ ﻃﺒﻘﻪﺑﻨﺪﻱ ﺷﺪ. ﺷﻴﻮﻉ ﻋﻔﻮﻧﺖ ﺑﺮﺍﻱ ﻫﺮ ﮔﺮﻭﻩ ﺍﻧﺪﺍﺯﻩﮔﻴﺮﻱ ﻭ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺁﺯﻣﻮﻥ ﺗﺴﺖ ﻓﻴﺸﺮ ﻭ ﺁﺯﻣﻮﻥ ﮐﺎﯼ ﺍﺳﮑﻮﺍﺭ ﺩﺭ ﮔﺮﻭﻩﻫﺎ ﻣﻘﺎﻳﺴﻪ ﺷﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﻫﻴﭽﮕﻮﻧﻪ ﺍﻓﺰﺍﻳﺶ ﺩﺭ ﺷﻴﻮﻉ ﻋﻔﻮﻧﺖ ﺑﺎ ﺍﻓﺰﺍﻳﺶ ﻓﺎﺻﻠﻪ ﺯﻣﺎﻥ ﺁﺳﻴﺐ ﺗﺎ ﺟﺮﺍﺣﻲ ﺩﻳﺪﻩ ﻧﺸﺪ. ﺍﺯ 7 ﺑﻴﻤﺎﺭﻱ ﮐﻪ ﺩﭼﺎﺭ ﻋﻔﻮﻧﺖ ﺷﺪﻩ ﺑﻮﺩﻧﺪ، 5 ﺑﻴﻤﺎﺭ ﺩﺭ ﻓﺎﺻﻠﻪ 6 -0 ﺳﺎﻋﺖ ﺍﻭﻝ ﺗﺤﺖ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻪ ﺑﻮﺩﻧﺪ ﻭ ﻳﮏ ﺑﻴﻤﺎﺭ ﺩﺭ ﻓﺎﺻﻠﻪ ﺯﻣﺎﻥ 12 -6 ﺳﺎﻋﺖ ﻭ ﺩﺭ ﻳﮏ ﺑﻴﻤﺎﺭ ﺩﻳﮕـﺮ ﺑﻴﺸﺘـﺮ ﺍﺯ 24 ﺳﺎﻋﺖ ﺍﺯ ﺁﺳﻴﺐ ﮔـﺬﺷﺘﻪ ﺑﻮﺩ ﮐﻪ ﺗﺤـﺖ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻗﺮﺍﺭﮔﺮﻓﺖ. ﻣﻴﺰﺍﻥ ﻋﻔﻮﻧﺖ ﺑﺎ ﺩﺭﺟﻪ ﺁﺳﻴﺐ ﺑﺮ ﺣﺴﺐ ﻃﺒﻘﻪﺑﻨﺪﻱ ﮔﺎﺳﺘﻴﻠﻮ ﺍﺭﺗﺒﺎﻁ ﺩﺍﺷﺖ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻣﻌﻨﯽﺩﺍﺭ ﺑﻮﺩﻥ ﺍﺭﺗﺒﺎﻁ ﺑﻴﻦ ﻣﻴﺰﺍﻥ ﻋﻔﻮﻧﺖ ﻭ ﺩﺭﺟﻪﺑﻨﺪﯼ ﮔﺎﺳﺘﻴﻠﻮ ﺑﺮ ﺍﺳﺎﺱ ﺁﺯﻣﻮﻥ ﻓﻴﺸﺮ )P<0.05( ﻭ ﻋﺪﻡ ﻭﺟﻮﺩ ﺍﺭﺗﺒﺎﻁ ﺑﻴﻦ ﻣﻴﺰﺍﻥ ﻋﻔﻮﻧﺖ ﻭ ﺯﻣﺎﻥ ﺍﻧﺠﺎﻡ ﺟﺮﺍﺣﯽ )0.09 =P( ﺑﻪ ﻧﻈﺮ ﻣﻲﺭﺳﺪ ﺷﻴﻮﻉ ﻋﻔﻮﻧﺖ ﺑﻌﺪ ﺍﺯ ﺷﮑﺴﺘﮕﻲ ﺑﺎﺯ ﺗﻴﺒﻴﺎ ﺑﻴﺶ ﺍﺯ ﺁﻧﮑﻪ ﺑﺎ ﻓﺎﺻﻠﻪ ﺯﻣﺎﻥ ﺁﺳﻴﺐ ﺗﺎ ﺍﻧﺠـﺎﻡ ﻋﻤﻞ ﺟﺮﺍﺣـﻲ ﺍﺭﺗﺒﺎﻁ ﺩﺍﺷﺘﻪ ﺑﺎﺷﺪ ﺑﺎ ﺩﺭﺟﻪ ﺁﺳﻴﺐ ﺑﺮﺣﺴﺐ ﻃﺒﻘﻪﺑﻨﺪﻱ ﮔﺎﺳﺘﻴﻠـﻮ ﺍﺭﺗﺒـﺎﻁ ﺩﺍﺭﺩ ﻭ ﺍﻳﻦ ﻧﺸﺎﻥ ﻣﻲﺩﻫﺪ ﮐﻪ ﻣﻲﺗﻮﺍﻥ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺷﮑﺴﺘﮕﻲ ﺑﺎﺯ ﺗﻴﺒﻴﺎ ﺭﺍ ﺗﺎ ﺍﻳﺠﺎﺩ ﺷﺮﺍﻳﻂ ﻣﻨﺎﺳﺐ ﺑﺮﺍﻱ ﺟﺮﺍﺣﻲ ﺑﻪ ﺗﺄﺧﻴﺮ ﺍﻧﺪﺍﺧﺖ.

Introduction & Objective: Tibial shaft open fractures are the most common long bone fractures and are prone to complications such as infection. Tibial open fracture is one of the orthopedic urgencies. Standard surgical technique for the management of this problem is fixation and surgical debridement within the first 6 hours. But appropriate time for the debridement is not agreed upon. We aimed to evaluate the role of delayed surgical management in prevalencies of infection in open tibial fractures. Materials & Methods: The 92 patients with open tibilal fractures who were candidate for surgical management in the orthopedic ward of the university hospital, from 2008 to 2013, enrolled in this cross sectional descriptive prospective study. Analysis was done by SPSS 16. Patient were divided into 4 groups according to the average period of time from the damage (tibial fracture) to the time of surgery (0-6, 6-12-, 12-24 and more than 24 hours). The severity of injury was classified based on Gastilo criteria. The number of patients with infection was determined and compared in each group by chi2 test and fisher exact test. Results: No increase in infection was seen in operation time delay. Infection had occurred in 7, but five of the underwent the operation during the first six hours after injury. One person was in 6-12 hours group and the management (operation) was done in one patient later than 24 hours after injury. There were direct correlation the between severity of injury, ime interval between gustillo type and infection. Conclusions: The prevalence of infection is related to severity of injury more than the of injury and surgical operation. So surgery can be delayed to a suitable situation