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。     

Surgical management of diabetic foot infections and osteomyelitis

Foot ulceration and subsequent infection are a major complication of diabetes mellitus. Without proper diagnosis and treatment, these infections often lead to amputation. A multidisciplinary team approach is essential to maximize outcomes in the attempt to limit amputation and decrease patient morbidity. Mild to moderate diabetic foot infections often respond favorably to local wound care, offloading, and antibiotic therapy. When conservative measures fail or when faced with limb- or life-threatening infection, surgical intervention, whether it be incision and drainage or possible amputation, is warranted. The authors review underlying pathophysiology of diabetic foot infections and an evidenced-based approach to surgical management, with additional emphasis on treatment of osteomyelitis.     

Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration

The accepted hallmarks of care for plantar forefoot ulceration are meticulous wound care, nutrition, management of infection, and non-weight bearing of the ulcerative area. Tendo-Achilles lengthening is crucial in healing these ulcerations when it is determined that the Achilles tendon is one of the main biomechanical stresses that led to the ulceration. The Silfverskiold test helps determine whether a percutaneous lengthening or gastrocnemius recession is called for. A gastrocnemius recession is the safer operation because it does not carry the postoperative risk of overlengthening or rupture, calcaneal gait, and subsequent plantar heel ulceration, but gastrocnemius recession carries a higher late recurrence rate of late plantar forefoot reulceration (16%). A more permanent result can be achieved with percutaneous tendo-Achilles lengthening, although one assumes the associated risk of overlengthening the tendo-Achilles, calcaneal gait, and the difficult-to-treat plantar calcaneal ulceration. It is crucial to address other biomechanical abnormalities that may have contributed to the specific plantar ulceration, such as hammer toe, prominent plantar metatarsal head, prominent sesamoids, and long metatarsal. In addition, the patient should be placed in proper footwear, which at the minimum includes orthoses but may include specialized accommodative shoe wear. Failure to include these adjunctive procedures to Achilles tendon lengthening may prevent healing or hasten ulcer recurrence. Future studies will be directed toward determining the roles of prophylactic Achilles tendon lengthening preventing equinovarus deformities, possible plantar foot ulceration, and Charcot collapse.     

Surgical treatment of long bones' chronic osteomyelitis

The experience in surgical treatment of 269 patients with long bone chronic osteomyelitis based on the principles of active surgical policy for purulent wounds is summarized. Some aspects of osteomyelitis surgical treatment are reconsidered and complemented. Variants of osteomyelitic focus surgical debridement dependent on severity the lesion as well as methods of plastic replacement of bones' and soft tissues' defects are demonstrated.     

Surgical treatment of hematogenous vertebral Aspergillus osteomyelitis

Three cases of Aspergillus fumigatas vertebral osteomyelitis failed courses of medical treatment. Each was subsequently treated with anterior vertebral debridement and posterior segmental spinal instrumentation. Despite poor nutritional and immune systems, resolution of the infection and subsequent anterior ankylosis occurred in each patient, with follow-up ranging from 1 to 3 years. If patients with aspergillus vertebral osteomyelitis do not respond to medical treatment, early surgical debridement and stabilization in combination with intravenous amphotericin B can lead to resolution and bony ankylosis.     

Surgical treatment of forefoot deformity with special reference to polyarthritis

Among 523 patients consecutively treated for forefoot pain and deformity, 64 had inflammatory arthritis. Most patients no longer had difficulties finding shoes that fit after the deformities were surgically corrected. Although about one half of the patients had some residual symptoms after treatment, 57 (89%) were satisfied with the operation. If the deformities are corrected early, joint resections can be avoided and toe function preserved.     

创伤性主动脉损伤的外科治疗策略

目的总结创伤所致主动脉损伤的外科治疗策略。方法纳入2009年1月至2018年1月北京安贞医院心血管外科治疗的34例创伤性主动脉损伤患者(交通肇事伤31例、坠落伤2例、物体砸伤1例)。男23例,女11例。患有高血压病10例,胸主动脉假性动脉瘤9例,胸主动脉离断6例,主动脉夹层共19例。开放手术5例,年龄(44.80±20.57)岁;2例A型主动脉夹层行Bentall+孙氏手术,1例B型夹层及2例胸主动脉假性动脉瘤行术中支架人工血管置入术。胸主动脉腔内修复术29例,年龄(45.93±11.01)岁。结果开放手术时间(403.20±30.30)min,患者住院(19.00±6.04)天;胸主动脉腔内修复术手术时间(105.72±27.76)min,患者住院(5.76±3.08)天。所有患者术后随访(45.09±23.10)个月,两组均无死亡,2例胸主动脉腔内修复术患者因封闭左锁骨下动脉未开通而出现左上肢乏力麻木。结论创伤性主动脉损伤应根据患者全身情况、损伤等级、损伤累及部位及解剖特点来选择不同的治疗方案。但远期预后仍有待确定。     

颈椎骨折手术入路的选择策略

目的 回顾性分析前路、后路及前后联合入路手术治疗颈椎骨折的临床效果,为临床颈椎骨折手术入路的选择提供依据. 方法对2004年1月至2008年1月采用前路、后路及前后联合入路手术治疗且获得随访的151例颈椎骨折患者进行回顾性分析.入院时ASIA脊髓损伤分级:A级51例,B级40例,C级28例,D级24例,E级8例.手术方式:前路手术87例,后路手术49例,前后联合入路15例.前路手术方式包括前路颈椎间盘切除或椎体次全切除减压、椎体间融合、前路钛钢板内固定,或齿状突空心螺钉复位固定.后路手术方式主要为椎板切除减压、骨折复位,侧块钢板或椎弓根螺钉内固定.前后联合入路一般先行后路减压,解除关节交锁、骨折复位、植骨内固定,再一期行前路椎间盘或次全椎体切除减压、植骨融合内固定术. 结果 151例患者术后获平均12.5个月(6个月～4年)随访.术后除2例患者外,其余患者伤口均一期愈合.所有骨折复位满意,颈椎排序及稳定性均获得良好恢复,植骨逐步融合.骨折愈合时间平均为2.6个月(2.0～4.5个月).所有患者神经功能均有不同程度恢复,最终随访时ASIA脊髓损伤分级:A级30例,B级24例,C级31例,D级40例,E级26例.其中前路手术和后路手术患者神经功能恢复较好. 结论前路、后路及前后联合入路手术治疗颈椎骨折均可获得较好的临床疗效,三种入路各有其适应证及优、缺点,脊髓受压方向、颈椎骨折的部位及外伤后残留的脊柱稳定性足选择手术入路的关键.     

Hallux amputation for diabetic osteomyelitis

Digital amputation for infection in the diabetic patient requires accurate assessment of wound healing potential as a function of clinical and noninvasive studies of cutaneous blood flow. The diabetic propensity for staphylococcal infection, microangiopathy, and delayed wound healing may be questionable in light of recent literature. X-rays, xeroradiographs, and bone scans are useful guides to osseous infection involvement. Amputation technical planning is mandatory. Proper assessment results in a dynamic functional amputation stump with little impact on gait.     

颅骨慢性骨髓炎的手术治疗

目的总结颅骨慢性骨髓炎的治疗方法及其疗效。方法 2004年1月-2009年2月,收治24例颅骨慢性骨髓炎患者。男16例,女8例;年龄18～56岁,平均45.6岁。病程3～11年,平均5.8年。病因:开颅术后感染3例,烧伤15例,电击伤6例。部位:额顶部10例,颞顶部8例,枕部6例。彻底清除感染坏死组织后软组织缺损范围为7 cm×6 cm～19 cm×12 cm,颅骨缺损范围为5 cm×4 cm～10 cm×7 cm。采用邻位头皮瓣(12例)、斜方肌肌皮瓣(6例)、游离股前外侧皮瓣(6例)修复,皮瓣切取范围为8 cm×7 cm～20 cm×13 cm。供区直接缝合或中厚皮片游离移植修复。结果术中病理检查均为颅骨化脓性骨髓炎伴死骨形成,1例发现局部鳞癌。术后2周1例出现皮瓣下感染,再次手术清除残留组织后愈合;其余皮瓣及皮片均成活好,切口Ⅰ期愈合。术后患者均获随访,随访时间10个月～4年,平均2年。皮瓣颜色、质地较好,骨髓炎无复发。1例局部鳞癌患者术后随访4年未复发。8例术后3～6个月出现头痛、头晕等颅骨缺损相关症状,二期行钛网颅骨重建。结论颅骨慢性骨髓炎应早期彻底清除感染病灶,选择适宜的皮瓣或肌皮瓣修复创面,可获满意效果。     

Surgical treatment of chronic osteomyelitis of the sternum

The efficacy of surgical rehabilitation of patients with chronic osteomyelitis of the sternum is shown. Surgical treatment was divided in most cases into two stages: removal of the involved areas of the sternum and adjoining ribs and fixed muscular or musculocutaneous plastics. The obtained results are reassuring and promote further development of surgery of this region.     

Surgical treatment of chronic osteomyelitis of the calcaneus

The authors examine the anatomophysiologic peculiarities of the calcaneus area which cause difficulties in the treatment of osteomyelitis of the calcaneus. The surgical treatment of 53 patients suffering from osteomyelitis of the calcaneus is analysed. Three types of surgical procedures are described; they consist in a radical resection of the calcaneus from the inside using the osteoplastic approach to the focus of the lesion, which allows to create the optimal conditions for reparative osteogenesis in the osseous cavity that has been formed. The follow-up results after 1 to 5 years were positive in 86.8% of the operated patients.     

Surgical treatment of hematogenic osteomyelitis of the spine

The article presents principles of the surgical treatment of hematogenic osteomyelitis of the vertebral column and its complications developed on the basis of studying and analysis of results of operative interventions performed in 145 patients. A system of operative procedures is proposed which showed high effectiveness in treatment of both purulent infections and complications of the disease, spinal disorders in particular.     

Surgical treatment of osteomyelitis defects of long bones

Results of treatment of 116 patients with gunshot osteomyelitis are analyzed. Positive and negative moments of different surgical methods (sequestrnecrectomy, Ilizarov's method, auto- and alloplasty) are discussed. Two-stage method of treatment of long bones gunshot osteomyelitis (with osteoplastic surgeries after elimination of inflammation and before severe scarring process into tissues) is developed.     

Surgical correction of the cavus forefoot

A cavus forefoot deformity can exist as a result of muscle imbalance, and, when identified, the patient shouldundergo appropriate neurological evaluation. The deformity can result in increased stresses on the metatarsal heads and push the hindfoot into a varus position. In more advanced cases, it can result in decreased motion of both the subtalar and ankle joints. Physical examination is of great importance in evaluating these patients and includes evaluation of the gait cycle, as well as the position of the heel and toes at rest. Evaluation of the muscle strength available is also important. The Coleman and Chestnut block test can be very helpful in determining hindfoot stiffness and the relationship of the forefoot cavus and the hindfoot varus. Surgical correction of the cavus forefoot often can be accomplished with a Jones procedure, sometimes with a closing wedge osteotomy of the first and possibly second and third metatarsals. This will sometimes be sufficient to allow the hindfoot to come out of varus.     

80岁以上结直肠癌65例的外科治疗

目的 探讨80岁以上老年患者结直肠癌的外科治疗策略. 方法 回顾性分析北京肿瘤医院1999-2006年外科手术治疗的80岁以上结直肠癌65例的临床资料.统计方法 采用单因素分析和Cox回归分析.结果 患者术后并发症发生率53.8%,术后吻合口漏发生率4%,手术死亡率1.5%.患者术后1年,3年,5年的生存率分别为79%,28%,16%.单因素分析和Cox回归分析结果 表明:肿瘤TNM分期和术前血色素降低及白细胞升高是影响患者预后的独立因素,而年龄,性别,肿瘤分化,术前CEA水平,血清蛋白水平,肿瘤大小不是影响患者预后的独立因素.结论 虽然80岁以上结直肠癌患者的手术风险较高,但经过完善的围手术期处理,可以获得较理想的治疗效果.