Postoperative management

10.1055/b-0034-87602

Postoperative management

Tadashi Tanaka, Toru Sato, Suthorn Bavonratanavech

1 Introduction 115
2 Analgesics 115
3 Antibiotic prophylaxis 115
4 Thromboembolism 116
4.1 Risk factors 116
4.2 Prophylaxis 116
4.3 Diagnosis 116
4.4 Treatment of DVT 116
5 Wound care and drains 117
5.1 Wounds 117
5.2 Drains 117
6 Positioning and support of the affected limb 117
7 Mobilization and weight bearing 118
8 Postoperative x-ray examination 118
9 Discharge and follow-up observation 118
10 Implant removal 118
11 Further reading 119

Introduction

To ensure a successful outcome in the operative treatment of fractures, a well-managed postoperative program is indispensable, as is a good preoperative plan, and a carefully executed operation.

Postoperative management should in principle aim at the prevention of fracture disease. Early mobilization helps to prevent joint contracture and disuse atrophy of the muscles. To achieve this aim, the stability imparted to the fracture following the minimally invasive plate osteosynthesis (MIPO) procedure must be adequate; otherwise the purpose of the fracture fixation is lost. These factors must be considered for successful postoperative management and are discussed in this chapter:

Analgesics
Antibiotic prophylaxis
Thromboembolism
Wound care and drains
Positioning and support of the affected limb
Mobilization and weight bearing
Postoperative x-ray examination
Discharge and follow-up observation
Implant removal

Analgesics

Adequate analgesia reduces postoperative pain and increases patient comfort. This encourages the patient to cooperate effectively in the postoperative rehabilitation program.

In general, analgesics should be administered well before pain becomes unbearable. Commonly used methods of analgesia include:

Local anesthetic infiltration around the surgical wounds
Epidural analgesia
Suppositories
Intravenous/intramuscular injections
Patient-controlled analgesia (PCA) pump
Oral analgesic agents

In MIPO, the extent of analgesia required is usually less and of shorter duration than open reduction and internal fixation because of the smaller wounds and redzced soft-tissue dissection.

Antibiotic prophylaxis

By its nature, MIPO limits soft-tissue exposure and dissection which in turn reduces the risks of wound infection. Yet, it is usually accepted that prophylactic antibiotics should be administered in implant surgery.

The following points should be considered when using prophylactic antibiotics:

It has been shown that Staphylococcus aureus is the most common infective agent in implant-associated bone infection.
The prophylactic antibiotic used should therefore be sensitive against Staphylococcus aureus, taking into account the resistance pattern of the organisms in the hospital. First- or second-generation cephalosporins are usually suitable.
The choice of antibiotic should also take into consideration its potential adverse effects on the patient as well as his/her history of drug allergy.
Antibiotics should be administered intravenously 30–60 minutes before the time of skin incision to obtain adequate inhibitory antibiotic levels in the surgical site. The usual practice is to administer the antibiotic at the time of induction of anesthesia. If a tourniquet is used, at least 10 minutes should be allowed between antibiotic administration and tourniquet inflation.
The antibiotic may be administered as a single preoperative dose or over the course of 24 hours. There is no advantage in prolonging the prophylaxis beyond 1 day.

The use of prophylactic antibiotics does not preclude the occurrence of wound infection. The surgeon must be aware of the symptoms and signs as well as the laboratory markers of wound infection and institute the appropriate treatment as soon as possible.

Thromboembolism

Major surgery in patients older than 60 years carries a high risk for venous thromboembolism including deep vein thrombosis (DVT) and pulmonary embolism. Venous thromboembolism is a significant cause of postoperative morbidity and mortality in orthopaedic traumatology. It is therefore incumbent on the part of the surgeon to be familiar with the risk factors, preventive measures, diagnostic tests, and treatment strategies for this potentially fatal complication.

Risk factors

Important risk factors include:

Advanced age
History of venous thromboembolism
Strong family history of thromboembolism, history of cancer, myocardial infarction, congestive heart failure
Chronic obstructive pulmonary disease, cerebrovascular accident, or paralysis
Prolonged bed rest or delayed mobilization
Obesity
Pregnancy
Estrogen use
Fractures of the pelvis, proximal femur, and around the knee
Multiple trauma