足踝部慢性骨髓炎的手术治疗策略
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摘要
目的:足踝部特殊的解剖结构使其在手术或创伤打击之后易发骨髓炎,本文介绍了足踝部慢性骨髓炎的治疗策略及治疗结果。方法:回顾性分析2010年1月到2015年12月于我科治疗的足踝部慢性骨髓炎患者的临床特点及治疗结果,纳入患者术后随访至少2年,有糖尿病或免疫缺陷者被排除在研究之外。骨髓炎的病因,原发部位,致病菌,是否累及临近关节及骨髓炎复发情况被纳入评估,所有患者术前均进行SPECT/CT检查,用以评估骨髓炎感染的范围以及是否累及临近关节。手术治疗策略包括彻底的病灶清除,去除死腔以及累及关节时进行关节融合等。结果:足踝部慢性骨髓炎最常见的病因是创伤后的开放骨折或脱位,占所有患者的70%。耐甲氧西林金黄色葡萄球菌和铜绿假单胞菌是最常见的致病病原体。在45%的患者中,骨髓炎侵犯邻近关节,所有累及关节患者均进行了关节融合术。平均住院天数为16.5天。20例患者中18例无复发。结论:足踝部慢性骨髓炎发生邻近关节侵犯时,在进行彻底的病灶清除和去除死腔后,进行关节融合可获得良好疗效。
Objective: The unique anatomical structure of the foot and ankle makes it easy to develop osteomyelitis after surgery or trauma. This paper introduced the treatment strategy and outcomes of chronic osteomyelitis involving the foot and ankle. Methods:The clinical characteristics and treatment outcomes of patients with chronic osteomyelitis involving foot and ankle were retrospectively analyzed. All the patients were treated in our department from January 2010 to December 2015. The patients were followed up for at least2 years, and those with diabetes or immunodeficiency were excluded from the study. The etiology, primary site, pathogenic bacteria,involvement of adjacent joints and site of recurrence were evaluated. All patients underwent SPECT/CT before surgery to assess the extent of osteomyelitis infection and whether adjacent joints were involved. Surgical treatment strategies included radical debridement,control of the dead space, and arthrodesis when the joint was involved. Results: The most common cause of chronic osteomyelitis in the foot and ankle was open fracture or dislocation after trauma, accounting for 70% of all patients. Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa were the most common pathogenic pathogens. In 45% of patients, osteomyelitis invaded adjacent joints, and arthrodesis was performed in all these patients. The average length of hospital stay was 16.5 days. Of the 20 patients, 18 had no recurrence. Conclusions: When the chronic osteomyelitis involving the foot and ankle occurred adjacent to the joint, the arthrodesis can be performed after radical debridement and control of the dead space.
Objective: The unique anatomical structure of the foot and ankle makes it easy to develop osteomyelitis after surgery or trauma. This paper introduced the treatment strategy and outcomes of chronic osteomyelitis involving the foot and ankle. Methods:The clinical characteristics and treatment outcomes of patients with chronic osteomyelitis involving foot and ankle were retrospectively analyzed. All the patients were treated in our department from January 2010 to December 2015. The patients were followed up for at least2 years, and those with diabetes or immunodeficiency were excluded from the study. The etiology, primary site, pathogenic bacteria,involvement of adjacent joints and site of recurrence were evaluated. All patients underwent SPECT/CT before surgery to assess the extent of osteomyelitis infection and whether adjacent joints were involved. Surgical treatment strategies included radical debridement,control of the dead space, and arthrodesis when the joint was involved. Results: The most common cause of chronic osteomyelitis in the foot and ankle was open fracture or dislocation after trauma, accounting for 70% of all patients. Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa were the most common pathogenic pathogens. In 45% of patients, osteomyelitis invaded adjacent joints, and arthrodesis was performed in all these patients. The average length of hospital stay was 16.5 days. Of the 20 patients, 18 had no recurrence. Conclusions: When the chronic osteomyelitis involving the foot and ankle occurred adjacent to the joint, the arthrodesis can be performed after radical debridement and control of the dead space.
引文
[1]Conterno LO,Turchi MD.Antibiotics for treating chronic osteomyelitis in adults[J].Cochrane Database Syst Rev,2013,(9):D4439
[2]Rao N,Ziran BH,Lipsky BA.Treating osteomyelitis:antibiotics and surgery[J].Plast Reconstr Surg,2011,127(Suppl 1):177S-187S
[3]Chou PH,Lin HH,Su YP,et al.Staged protocol for the treatment of chronic femoral shaft osteomyelitis with Ilizarov's technique followed by the use of intramedullary locked nail[J].J Chin Med Assoc,2017,80(6):376-382
[4]Jiang N,Ma YF,Jiang Y,et al.Clinical Characteristics and Treatment of Extremity Chronic Osteomyelitis in Southern China:ARetrospective Analysis of 394 Consecutive Patients[J].Medicine(Baltimore),2015,94(42):e1874
[5]Gulabi D,Erdem M,Cecen GS.Treatment of chronic osteomyelitis of the femur with combined technique[J].Eklem Hastalik Cerrahisi,2014,25(3):173-178
[6]Wiewiorski M,Barg A,Hoerterer H,et al.Risk factors for wound complications in patients after elective orthopedic foot and ankle surgery[J].Foot Ankle Int,2015,36(5):479-487
[7]Wukich DK,Mc Millen RL,Lowery NJ,et al.Surgical site infections after foot and ankle surgery:a comparison of patients with and without diabetes[J].Diabetes Care,2011,34(10):2211-2213
[8]Tantigate D,Jang E,Seetharaman M,et al.Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery[J].Foot Ankle Int,2017,38(3):283-288
[9]Donley BG,Philbin T,Tomford JW,et al.Foot and ankle infections after surgery[J].Clin Orthop Relat Res,2001,(391):162-170
[10]Lima AL,Oliveira PR,Carvalho VC,et al.Recommendations for the treatment of osteomyelitis[J].Braz J Infect Dis,2014,18(5):526-534
[11]喻胜鹏,傅景曙,李伟,等.Masquelet技术治疗长骨骨髓炎骨缺损的临床分析[J].第三军医大学学报,2014,36(15):1630-1634
[12]Miller EA,Friedrich J.Soft Tissue Coverage of the Hand and Upper Extremity:The Reconstructive Elevator[J].J Hand Surg Am,2016,41(7):782-792
[13]Godina M.Early microsurgical reconstruction of complex trauma of the extremities[J].Plast Reconstr Surg,1986,78(3):285-292
[14]马云飞,姜楠,王磊,等.Masquelet技术基础及临床应用研究进展[J].中华创伤骨科杂志,2015,17(10):879-883
[15]Wang X,Wang Z,Fu J,et al.Induced membrane technique for the treatment of chronic hematogenous tibia osteomyelitis[J].BMCMusculoskelet Disord,2017,18(1):33
[16]Hogan A,Heppert VG,Suda AJ.Osteomyelitis[J].Arch Orthop Trauma Surg,2013,133(9):1183-1196
[17]Fodor L,Ullmann Y,Soudry M,et al.Prophylactic external fixation and extensive bone debridement for chronic osteomyelitis[J].Acta Orthop Belg,2006,72(4):448-453
[18]Simpson AH,Deakin M,Latham JM.Chronic osteomyelitis.The effect of the extent of surgical resection on infection-free survival[J].JBone Joint Surg Br,2001,83(3):403-407
[19]Malizos KN,Gougoulias NE,Dailiana ZH,et al.Ankle and foot osteomyelitis:treatment protocol and clinical results[J].Injury,2010,41(3):285-293
[20]Jeong JJ,Lee HS,Choi YR,et al.Surgical treatment of non-diabetic chronic osteomyelitis involving the foot and ankle[J].Foot Ankle Int,2012,33(2):128-132
[21]Sealey RJ,Myerson MS,Molloy A,et al.Sagittal plane motion of the hindfoot following ankle arthrodesis:a prospective analysis[J].Foot Ankle Int,2009,30(3):187-196
[22]Dym H,Zeidan J.Microbiology of Acute and Chronic Osteomyelitis and Antibiotic Treatment[J].Dent Clin North Am,2017,61(2):271-282
[23]Grigoropoulou P,Eleftheriadou I,Jude EB,et al.Diabetic Foot Infections:an Update in Diagnosis and Management[J].Curr Diab Rep,2017,17(1):3
[24]Tuchscherr L,Kreis CA,Hoerr V,et al.Staphylococcus aureus develops increased resistance to antibiotics by forming dynamic small colony variants during chronic osteomyelitis[J].J Antimicrob Chemother,2016,71(2):438-448
[25]Kalinka J,Hachmeister M,Geraci J,et al.Staphylococcus aureus isolates from chronic osteomyelitis are characterized by high host cell invasion and intracellular adaptation,but still induce inflammation[J].Int J Med Microbiol,2014,304(8):1038-1049
[2]Rao N,Ziran BH,Lipsky BA.Treating osteomyelitis:antibiotics and surgery[J].Plast Reconstr Surg,2011,127(Suppl 1):177S-187S
[3]Chou PH,Lin HH,Su YP,et al.Staged protocol for the treatment of chronic femoral shaft osteomyelitis with Ilizarov's technique followed by the use of intramedullary locked nail[J].J Chin Med Assoc,2017,80(6):376-382
[4]Jiang N,Ma YF,Jiang Y,et al.Clinical Characteristics and Treatment of Extremity Chronic Osteomyelitis in Southern China:ARetrospective Analysis of 394 Consecutive Patients[J].Medicine(Baltimore),2015,94(42):e1874
[5]Gulabi D,Erdem M,Cecen GS.Treatment of chronic osteomyelitis of the femur with combined technique[J].Eklem Hastalik Cerrahisi,2014,25(3):173-178
[6]Wiewiorski M,Barg A,Hoerterer H,et al.Risk factors for wound complications in patients after elective orthopedic foot and ankle surgery[J].Foot Ankle Int,2015,36(5):479-487
[7]Wukich DK,Mc Millen RL,Lowery NJ,et al.Surgical site infections after foot and ankle surgery:a comparison of patients with and without diabetes[J].Diabetes Care,2011,34(10):2211-2213
[8]Tantigate D,Jang E,Seetharaman M,et al.Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery[J].Foot Ankle Int,2017,38(3):283-288
[9]Donley BG,Philbin T,Tomford JW,et al.Foot and ankle infections after surgery[J].Clin Orthop Relat Res,2001,(391):162-170
[10]Lima AL,Oliveira PR,Carvalho VC,et al.Recommendations for the treatment of osteomyelitis[J].Braz J Infect Dis,2014,18(5):526-534
[11]喻胜鹏,傅景曙,李伟,等.Masquelet技术治疗长骨骨髓炎骨缺损的临床分析[J].第三军医大学学报,2014,36(15):1630-1634
[12]Miller EA,Friedrich J.Soft Tissue Coverage of the Hand and Upper Extremity:The Reconstructive Elevator[J].J Hand Surg Am,2016,41(7):782-792
[13]Godina M.Early microsurgical reconstruction of complex trauma of the extremities[J].Plast Reconstr Surg,1986,78(3):285-292
[14]马云飞,姜楠,王磊,等.Masquelet技术基础及临床应用研究进展[J].中华创伤骨科杂志,2015,17(10):879-883
[15]Wang X,Wang Z,Fu J,et al.Induced membrane technique for the treatment of chronic hematogenous tibia osteomyelitis[J].BMCMusculoskelet Disord,2017,18(1):33
[16]Hogan A,Heppert VG,Suda AJ.Osteomyelitis[J].Arch Orthop Trauma Surg,2013,133(9):1183-1196
[17]Fodor L,Ullmann Y,Soudry M,et al.Prophylactic external fixation and extensive bone debridement for chronic osteomyelitis[J].Acta Orthop Belg,2006,72(4):448-453
[18]Simpson AH,Deakin M,Latham JM.Chronic osteomyelitis.The effect of the extent of surgical resection on infection-free survival[J].JBone Joint Surg Br,2001,83(3):403-407
[19]Malizos KN,Gougoulias NE,Dailiana ZH,et al.Ankle and foot osteomyelitis:treatment protocol and clinical results[J].Injury,2010,41(3):285-293
[20]Jeong JJ,Lee HS,Choi YR,et al.Surgical treatment of non-diabetic chronic osteomyelitis involving the foot and ankle[J].Foot Ankle Int,2012,33(2):128-132
[21]Sealey RJ,Myerson MS,Molloy A,et al.Sagittal plane motion of the hindfoot following ankle arthrodesis:a prospective analysis[J].Foot Ankle Int,2009,30(3):187-196
[22]Dym H,Zeidan J.Microbiology of Acute and Chronic Osteomyelitis and Antibiotic Treatment[J].Dent Clin North Am,2017,61(2):271-282
[23]Grigoropoulou P,Eleftheriadou I,Jude EB,et al.Diabetic Foot Infections:an Update in Diagnosis and Management[J].Curr Diab Rep,2017,17(1):3
[24]Tuchscherr L,Kreis CA,Hoerr V,et al.Staphylococcus aureus develops increased resistance to antibiotics by forming dynamic small colony variants during chronic osteomyelitis[J].J Antimicrob Chemother,2016,71(2):438-448
[25]Kalinka J,Hachmeister M,Geraci J,et al.Staphylococcus aureus isolates from chronic osteomyelitis are characterized by high host cell invasion and intracellular adaptation,but still induce inflammation[J].Int J Med Microbiol,2014,304(8):1038-1049