慢性骨髓炎的分期治疗策略

背景：慢性骨髓炎是骨科临床的疑难杂症之一,本文旨在探讨一种目前比较合理的治疗方式。目的：探讨运用灌洗负压引流和可吸收人工骨或者骨水泥混合抗生素分期治疗慢性骨髓炎的临床效果。方法：2008年3月至2012年3月采用一期清创灌洗负压引流,二期可吸收人工骨或者骨水泥混合抗生素植入治疗27例慢性骨髓炎患者,男21例,女6例;年龄20~77岁,平均38岁;骨髓炎发生部位：胫腓骨17例,股骨7例,跟骨3例。结果：27例患者均得到随访,随访时间6~51个月（平均27个月）,25例痊愈,2例复发。结论：一期清创、灌洗负压引流,二期可吸收人工骨或者骨水泥混合抗生素治疗慢性骨髓炎可以取得良好的临床疗效。     

抗生素骨水泥治疗创伤性胫骨骨髓炎的临床疗效分析

目的探讨抗生素骨水泥治疗创伤性胫骨骨髓炎的临床疗效。方法自2008-07-2013-01诊治23例创伤性胫骨慢性骨髓炎,所有患者均一期彻底清创及清除病灶、自制抗生素骨水泥置入病灶区、根据创面情况行一期闭合或VSD技术封闭创面,使用VSD者7~10 d后再次清创,视创面情况更换自制抗生素骨水泥链珠及VSD,或行创面游离植皮、组织瓣转移附加钢板内固定,同期行骨移植术。结果本组治疗后感染均得到控制,植皮成活,皮肤弹性可,无复发。5例一期缝合伤口者,4例伤口一期愈合,1例皮缘变黑坏死,经换药、康复新局部外用后愈合。13例采用皮瓣移植,5例行创面邮票植皮,创面均愈合良好,创面愈合时间平均31.6(14~167)d。23例术后均获得平均28.6(18~60)个月随访,骨折端均获得骨性愈合,骨折愈合时间平均9.2个月。结论一期病灶彻底清除、髓腔或者局部植入万古霉素骨水泥、应用VSD负压封闭引流技术,二期结合皮瓣移植或邮票植皮技术闭合创面结合使用全身敏感抗生素,在治疗创伤性骨髓炎方面可获得较好的临床效果。     

开窗减压万古霉素骨水泥链珠填塞治疗硬化性骨髓炎

目的探讨手术开窗减压万古霉素骨水泥链珠填塞治疗硬化性骨髓炎的疗效。方法回顾2004年5月至2010年6月于长治医学院附属和平医院诊治的硬化性骨髓炎患者16例,其中男6例,女10例;年龄14~46岁,平均年龄22.4岁;胫骨11例,股骨5例,均采用开窗减压万古霉素骨水泥链珠填塞抗感染,二期取出骨水泥链珠并行同种异体骨植入治疗。结果所有16例患者均得到随访,随访时间2~7年,平均随访3.4年;所有患者治疗后疼痛消失,化验检查正常,无病理性骨折发生。结论手术开窗减压万古霉素骨水泥链珠填塞治疗硬化性骨髓炎控制感染理想,二期植骨治疗骨髓炎,疗效满意。     

应用抗生素骨水泥治疗骨折术后髓内感染

目的探讨应用万古霉素骨水泥治疗骨折钢板内固定术后髓内感染的临床疗效。方法本组病例35例,男25例,女10例;年龄20~64岁,平均年龄38.2岁;高处坠落伤10例,交通事故伤16例,重物压砸伤9例。全部患者钢板取出,清创置入万古霉素骨水泥,6个月后待感染控制后,二期取出万古霉素骨水泥,自体髂骨植骨再次钢板内固定。结果本组患者术后全部得到随访,随访时间9~24个月,平均13.6个月。其中34例清创置入万古霉素骨水泥患者感染获得控制,疗程3~6个月,平均4.3个月。1例感染未控制,经再次清创置入万古霉素骨水泥,感染得到控制。结论采用彻底清创、置入万古霉素骨水泥法可有效控制感染,是治疗骨折内固定术后髓内感染的较好的方法。     

抗生素骨水泥珠链联合负压封闭引流技术治疗慢性骨髓炎伴软组织缺损

目的 探讨抗生素骨水泥珠链联合负压封闭引流(VSD)技术治疗慢性骨髓炎伴软组织缺损的临床疗效. 方法 2007年7月至2010年6月共收治42例四肢慢性骨髓炎患者,男35例,女7例;年龄25 ～ 62岁,平均37.2岁.对所有患者局部行彻底清创、抗生素骨水泥珠链植入并同时行VSD治疗.7～10d后,打开创面,取出抗生素骨水泥珠链,再次清创.若创面清洁、肉芽组织新鲜,则行游离植皮或皮瓣移植覆盖创面;若创面欠清洁,再次抗生素骨水泥珠链植入并同时行VSD治疗,择期行植皮或皮瓣移植覆盖创面.结果 42例患者术后获6 ～ 26个月(平均13个月)随访.37例患者应用1次VSD治疗,5例患者应用2次VSD治疗;29例患者创面植皮,创面愈合良好;13例患者创面行带血管蒂游离皮瓣移植,皮瓣均存活.10例患者皮瓣切口一期愈合良好,3例患者皮瓣皮缘局部变黑、坏死,经2～3周换药后愈合.所有患者骨折均顺利愈合,5例骨缺损患者植骨后改为接骨板螺钉内固定,局部无感染复发.植皮及皮瓣移植前创面均未培养出细菌.术后l、2、3周白细胞、血沉及C反应蛋白均在正常范围内. 结论 彻底清创、抗生素骨水泥珠链植入联合VSD技术是治疗慢性骨髓炎伴软组织缺损简单而有效的方法.     

抗生素骨水泥链珠结合骨搬移技术分期治疗下肢长骨慢性骨髓炎

目的 探讨应用抗生素骨水泥链珠结合骨搬移技术分期治疗下肢长骨慢性骨髓炎的临床疗效,寻找有效解决长骨慢性骨髓炎的治疗方案。方法 选自我院2012年1月至2016年1月行手术治疗的股骨及胫骨慢性骨髓炎患者32例,采用分期治疗,一期进行彻底清创、去除死骨、放置万古霉素骨水泥链株,安装环形外固定延长架,二期取出万古霉素抗生素链珠,进行截骨延长、骨搬移,定期拍片检查骨搬移情况,骨搬移结束后视断端对合情况决定是否植骨。结果 32例患者治疗结束后炎症完全控制,且均达到骨性愈合,其中12例在搬移结束后行自体骨移植,20例断端对合后骨性愈合,所有患者均恢复了日常生活。结论 抗生素链珠结合骨搬移技术分期治疗下肢长骨慢性骨髓炎临床疗效肯定,慢性骨组织炎症经局部使用抗生素链珠后感染被控制,而后行骨搬移技术进行缓慢骨搬移,最终达到骨性愈合,为临床上治疗较为棘手的慢性骨髓炎提供一种有效的方法。     

VSD联合替加环素持续灌洗引流治疗广泛耐药革兰氏阴性菌骨髓炎

目的探讨应用负压封闭引流技术(vacuum sealing drainage, VSD)持续替加环素灌洗引流治疗广泛耐药革兰氏阴性菌骨髓炎的临床疗效。方法 12例术后继发广泛耐药革兰氏阴性菌骨髓炎患者中,肺炎克雷伯菌感染8例,鲍曼不动杆菌感染4例。7例有内固定物的病例予以拆除原内固定,所有病例进行彻底清创后覆盖VSD,用替加环素持续灌洗引流配合全身抗感染治疗,根据药代动力学/药效学(pharmacokinetics/pharmacodynamics, PK/PD)理论指导抗菌药物使用。结果 12例患者均获得随访,随访时间10～22个月,中位时间14.5个月。从二次手术至感染控制时间1.5～4.7个月,中位时间2.7个月。临床痊愈11例,基本痊愈1例,从二次手术至治愈时间2～5.2个月,中位时间3.2个月。结论采用彻底清创、VSD联合替加环素持续灌洗引流、利用PK/PD理论指导抗菌药物使用,可有效控制骨科难治的广泛耐药菌感染。     

VSD联合骨移植替代材料植入治疗跟骨慢性骨髓炎疗效观察

目的探讨负压封闭引流（VSD）联合骨移植替代材料植入治疗跟骨慢性骨髓炎的临床疗效。方法应用VSD联合骨移植替代材料植人治疗跟骨慢性骨髓炎12例,经VSD负压封闭引流7～10d后,行清创、载抗生素骨移植替代材料植人术。结果12例术后均获平均8．9（6～12）个月随访,ESR、CRP、WBC于术后平均15．2（11-24）d恢复正常。12例全部治愈,随访期内无复发。结论VSD联合骨移植替代材料植人是治疗跟骨慢性骨髓炎的一种有效方法。     

抗生素骨水泥链珠治疗慢性骨髓炎的手术配合

对11例慢性骨髓炎患者实施髓腔清创、抗生素骨水泥链珠填塞手术.平均随访12.0个月,髓腔感染均得到控制.提出术前访视患者时增强其手术治疗信心、做好保护患肢的健康指导及措施;术中密切观察血压变化,及时提供各种冲洗液,制备骨水泥链珠,严格无菌操作是手术成功的重要保障.     

VSD结合Papineau技术治疗创伤后慢性骨髓炎

目的 探讨VSD结合Papineau技术治疗创伤骨折内固定术后感染所致慢性骨髓炎的临床疗效。方法 对本院2008年1月至2013年6月,收治的18例骨折内固定术后感染所致的骨外露、骨缺损患者,多次清创和负压封闭引流(Vacuum sealing drainage,VSD)治疗,待创面肉芽组织生长良好后采用Papineau技术开放肉芽创面植骨,Ⅱ期植皮或直接缝合闭合创面。结果 18例均获随访,随访时间11~21月,平均16月。18例感染控制骨折愈合,无感染复发病例。结论 VSD结合Papineau技术能有效控制感染,消灭骨死腔促进骨愈合,对骨折内固定术后感染所致的慢性骨髓炎及骨缺损具有重要的临床意义。     

自制抗生素骨水泥珠链治疗医源性慢性骨髓炎

目的：探讨抗生素骨水泥珠链植入结合外固定架固定治疗医源性慢性骨髓炎的疗效。方法：本组50例患者,先取出内固定物,清创后植入抗生素骨水泥珠链,Ⅰ期闭合伤口;行外固定架固定：Ⅱ期取出抗生素骨水泥珠链,取髂骨植骨。结果：随访11-40个月（21．51±4．52月）。46例伤口Ⅰ期愈合,植骨患者32例植骨全部愈合。结论：彻底清创、抗生素骨水泥珠链植入结合外固定架固定及Ⅱ期植骨是治疗感染性骨折不愈合简单而有效的方法。     

抗生素骨水泥珠链结合外固定架治疗感染性骨折不愈合

目的：探讨抗生素骨水泥珠链植入结合外固定架固定治疗感染性骨折不愈合的疗效。,方法：回顾分析22例感染性骨折不愈合患者,男20例,女2例;年龄21±74岁,平均（34．7±11．6）岁。骨折部位：股骨粗隆间3例、股骨干6例、股骨髁上2例、胫骨干9例、肱骨干2例。治疗过程分为3个步骤：先取出内固定物,清创后植入抗生素骨水泥珠链,Ⅰ期闭合伤口;1周后再次清创,更换抗生素骨水泥珠链,行外固定架固定;3个月后取出抗生素骨水泥珠链,取髂骨植骨。结果：随访15～28个月,平均（19．98±4．16）个月。1例胫骨干骨折和1例股骨粗隆问骨折患者分别于植骨术后2、3个月感染复发,其余20例患者感染控制良好。22例患者骨折全部愈合,愈合时间为植骨术后8-24周,平均（15．09±4．13）周。结论：彻底清创、抗生素骨水泥珠链植入结合外固定架固定及Ⅱ期植骨是治疗感染性骨折不愈合简单而有效的方法、     

Antibiotic-polymethylmethacrylate strut: an option for treating cervical pyogenic spondylitis. Case report

Antibiotic-polymethylmethacrylate (PMMA) cement and beads constitute an effective system of local drug delivery of antibiotic agents in patients with bone and soft-tissue infections. Debridement followed by implantation of antibiotic-PMMA beads and systemic administration of antibiotic agents has achieved a 100% success rate in treating chronic osteomyelitis; however, there have been no reports of an antibiotic-PMMA strut for treating spinal pyogenic spondylitis. In this case report we describe a 57-year-old woman with C5-6 pyogenic spondylitis, progressive kyphotic deformity, and neurological deficits. The patient underwent anterior C-5 and C-6 corpectomy and spinal reconstruction in which we used an antibiotic-PMMA strut. The strut was 14 mm in diameter and contained PMMA and vancomycin powder. The operation was technically successful, and no complication related to anesthesia or the surgical procedure occurred. At the 12-month follow-up examination, dynamic radiographs revealed cervical spine stabilization. The patient's neck pain subsided and she recovered neurologically with no residual infection. No antibiotic-PMMA strut dislodgment or failure was identified; however, 9.8% subsidence of the strut into the vertebrae was observed. The long-term outcome in this case requires further evaluation.     

负压封闭引流联合筋膜皮瓣转移分期手术治疗创伤后骨髓炎

目的:探讨应用负压封闭引流技术(VSD)及筋膜皮瓣转移分期手术治疗伴有皮肤缺损创伤后骨髓炎的疗效。方法:自2007年12月至2009年12月,应用负压VSD及筋膜皮瓣转移分期手术治疗创伤后骨髓炎14例,男9例,女5例;年龄20～63岁,平均36岁;所有患者均为创伤术后感染。受伤部位:胫骨9例,跟骨3例,股骨1例,尺桡骨1例。感染时间2～96周,平均32周。结果:所有患者获得随访,时间12～36个月,平均19.2个月。使用VSD清创1～3次,平均1.57次。13例患者创面伤口Ⅰ期愈合,1例有渗出,经引流换药,术后3周愈合。8例患者因骨缺损及骨折延迟愈合,Ⅱ期行自体植骨术,术后1年随访骨折均愈合,术后感染未复发。结论:负压封闭引流技术联合筋膜皮瓣转移治疗创伤术后骨髓炎能够发挥负压封闭引流技术和皮瓣转移技术的优点,缩短治疗时间,安全性及可靠性较好,是一种有效的治疗方法。     

Application of VSD technique in adults with chronic osteomyelitis of the extremities combined with soft tissue defects

To investigate the clinical application of vacuum sealing drainage (VSD) in chronic osteomyelitis of the extremities combined with soft tissue defects in adults. This study retrospectively included 32 adult patients with clearly diagnosed chronic osteomyelitis of the extremities combined with local soft tissue defects, and the trauma was covered by VSD after debridement, osteotomy, and vancomycin-laden bone cement filling of the occupancy, and the trauma was covered by selecting a suitable flap transfer repair according to the site and extent of the soft tissue defect after the trauma condition was suitable, and the secondary trauma was taken from the abdominal full-thickness skin free skin slice graft, according to whether the skin graft area was performed. The skin flap hematoma and infection rate, as well as the skin flap survival rate and implant fixation time were compared and analysed between the two groups. The primary outcome is the implant fixation time, and the secondary outcome is the skin fragment survival rate. In 32 patients, VSD was performed on the bone cement surface to cover the trauma, and 33.2 to 39.8 kPa continuous vacuum sealing drainage was set. The average VSD time duration before soft tissue coverage was 47.87 ± 23.14 days, and the average number of VSD use was 7.18 ± 3.23. The use of VSD before soft tissue coverage did not cause complications such as negative pressure could not be maintained, vacuum sealing drainage was not smooth, skin blistering, trauma. Among the 32 patients, 12 cases of soft tissue coverage were followed by trauma free skin grafting with packing + VSD, and 20 cases were fixed with packing alone, and the duration of continuous packing and fixation of free skin pieces in the VSD group was significantly less than that in the control group (P = .006). The survival rate was significantly higher than that of the control group (P = .019). VSD in adult patients with chronic osteomyelitis of the extremities combined with soft tissue defects can effectively improve the trauma condition, provide the possibility of second-stage soft tissue coverage, and significantly shorten the preparation time for soft tissue coverage. In addition, when soft tissue coverage trauma is performed, VSD combined with skin graft packing technique can significantly improve the survival rate of skin pieces, shorten the time of skin graft fixation.     

Treatment of chronic post-traumatic infections of the bone and soft tissue with gentamycin PMMA beads (PMMA = polymethylmethacrylate) (author's transl)

Temporary implantation of Gentamycin PMMA beads and chains provides a most effective local antibiotic therapy as supplementary and consecutive treatment after surgical procedures executed in bone and soft tissue infections. Gentamycin beads and chains are used as an alternative to irrigation-suction drainage. From 1977 to 1979 70 patients were treated for chronic post-traumatic osteomyelitis and infection of the soft tissue. The chronic bone infections subsided completely in 90% of the patients, but 8.3% re-infections were observed within 3 to 24 months after termination of treatment. In 18 patients with gunshot wounds 66.6% of the patients got primary healing and 33.4% secondary healing.     

Adult osteomyelitis: debridement versus debridement plus Osteoset T pellets

This long-term retrospective study investigated the value of debridement versus debridement and Osteoset T antibiotic-loaded calcium sulphate pellets in the treatment of adult chronic osteomyelitis. Sixty-five patients were included in the study. The mean follow-up was 75 months (range: 36 to 334). Forty cases were treated by debridement, and 25 by debridement and Osteoset T. The healing rates were 60% and 80%, respectively; however, the difference was not significant. In a subgroup of 39 patients with medullary osteomyelitis and a normal immune system (IA according to the Cierny-Mader classification of adult osteomyelitis), 22 patients were treated with debridement, 17 with debridement and Osteoset T. The healing rates were 59% and 94%, respectively (p < 0.05). Twenty-eight patients with Staphylococcus aureus osteomyelitis were also studied apart; 13 were treated with debridement and 15 with debridement and Osteoset T. The healing rates were 46% and 80%, respectively. The difference was not significant. The results obtained with debridement were less good than with debridement plus Osteoset T, but the difference was not significant, except in a single subgroup. Osteoset T obviates the need for removal, which is the rule after implantation of gentamycin beads. Bony ingrowth is however limited.     

应用VSD治疗跟骨骨折术后伤口不愈合

目的:探讨清创VSD封闭引流技术治疗跟骨骨折术后伤口不愈合的效果。方法:2008年6月至2011年12月,收治跟骨骨折术后伤口缺血坏死、伤口不愈合的患者11例,其中男10例,女1例;年龄21～55岁,平均39岁;病程7～9周。利用手术清创的同时联合负压封闭引流伤区灌注技术治疗,术后参考张铁良跟骨关节内骨折疗效标准评估疗效。结果:伤区经VSD封闭引流后自体植皮均顺利愈合。11例患者术后获得随访,时间6～18个月,平均11个月,伤口无迟发感染及慢性骨髓炎发生。依据张铁良跟骨关节内骨折疗效评价标准:优6例,良4例,可1例。结论:跟骨骨折术后伤口愈合不良联合VSD封闭引流治疗能获得满意的疗效。     

前臂及手部毁损性骨折治疗体会

【】目的:探讨前臂及手部毁损性骨折的早期修复及功能重建的手术方法及疗效。方法:对2010-2014年收治36例前臂及手部毁损性骨折进行急性修复及功能重建,根据毁损性骨折的分型₁,其中a2型12例,b2型10例,c2 型14例,所有创面采用脉冲冲洗器冲洗,骨折采用外固定支架、克氏针固定,一期修复神经、肌腱、血管,创面以VSD封闭。结果:术后随访10个月-24月,患肢功能都有不同程度的恢复,明显优于假肢,其中5例去除负压后创面直接缝合,伴骨骼、肌腱、神经外露者以皮瓣覆盖后治愈,浅表感染20例,经清创、换药、植皮后治愈,骨髓炎7例,经过去除死骨,换药及多次负压引流后治愈,骨折一期愈合18例,延迟愈合6例,骨缺损不愈合12例,经植骨内固定后愈合。结论：外固定支架、克氏针、脉冲冲洗器、VSD联合治疗开放性前臂及手部毁损性骨折,具有创伤小、清创彻底、减轻创伤后肿胀、降低感染率等优点,为功能恢复、骨折愈合及二期处理提供有利条件。