Türk Elizabeth E, Tsokos Michael, Delling G
Institute of Legal Medicine, University of Hamburg, Hamburg, Germany.
Arch Pathol Lab Med. 2003 Dec;127(12):1599-602. doi: 10.5858/2003-127-1599-AAOEAT.
Decubitus ulcers constitute a serious medical problem, often encountered in association with hospitalization or institutionalization in senior citizens' or nursing homes. Potentially life-threatening sepsis has been reported to originate not only from soft tissue infection, but also from osteomyelitis as a complication of involvement of bone tissue in decubitus ulcers.
To assess the histopathology of osseous structures involved in grade IV decubitus ulcers.
Autopsy-based histopathologic assessment of the presence and extent of osteomyelitis on os sacrum specimens from 28 deceased individuals with grade IV sacral decubitus ulcers using an undecalcified preparation following plastic embedding (staining with Goldner, Kossa modification, toluidine blue, and Giemsa).
The histologic findings were classified in 4 types of pathomorphologic changes: type 1, decubitus ulcer confined to soft tissue, no inflammation (n = 7); type 2, decubitus ulcer involving bone, no inflammation (n = 7); type 3, decubitus ulcer involving bone, inflammation of soft tissue, no osteomyelitis (n = 1); and type 4, decubitus ulcer involving bone, presence of osteomyelitis (n = 13). Type 4 changes are further described as follows: type 4a, chronic osteomyelitis alone (n = 6); and type 4b, chronic and acute osteomyelitic changes (n = 7). More than half of the cases (n = 15) showed no inflammatory reaction within the medullary cavity (types 1-3). In all cases with osteomyelitis, inflammation was exclusively confined to the superficial parts of the os sacrum. Chronic osteomyelitis was seen in all cases in which osteomyelitis was present. In addition, mild acute osteomyelitic changes were observed in 7 cases. Severe liquefying osteomyelitis affecting deeper layers of the os sacrum was not found. Sepsis was present in 2 cases; in one of these cases, the decubitus ulcer was considered a possible source of infection.
Our results provide evidence that in cases of grade IV decubitus ulcers, the macroscopic aspect and clinical imaging techniques may lead to an overestimation of the extent of osseous involvement. We suggest that the investigation of bone biopsies is not necessary in a considerable proportion of cases of grade IV decubitus ulcers in patients without sepsis, as the minor osseous alterations are of little consequence when establishing a therapeutic approach.
褥疮是一个严重的医学问题，在老年人或疗养院住院或机构化期间经常出现。据报道，潜在的危及生命的败血症不仅源于软组织感染，还源于褥疮中骨组织受累引发的骨髓炎并发症。
评估IV级褥疮中骨结构的组织病理学。
对28例IV级骶部褥疮死者的骶骨标本进行基于尸检的组织病理学评估，采用塑料包埋后不脱钙制片（用Goldner法、改良Kossa法、甲苯胺蓝和吉姆萨染色），以确定骨髓炎的存在及范围。
组织学发现分为4种病理形态学改变类型：1型，褥疮局限于软组织，无炎症（n = 7）；2型，褥疮累及骨，无炎症（n = 7）；3型，褥疮累及骨，软组织炎症，无骨髓炎（n = 1）；4型，褥疮累及骨，存在骨髓炎（n = 13）。4型改变进一步描述如下：4a型，单独的慢性骨髓炎（n = 6）；4b型，慢性和急性骨髓炎改变（n = 7）。超过半数病例（n = 15）髓腔内无炎症反应（1 - 3型）。在所有骨髓炎病例中，炎症仅局限于骶骨浅表部分。所有存在骨髓炎的病例均可见慢性骨髓炎。此外，7例观察到轻度急性骨髓炎改变。未发现累及骶骨深层的严重液化性骨髓炎。2例存在败血症；其中1例，褥疮被认为是可能的感染源。
我们的结果表明，在IV级褥疮病例中，宏观表现和临床影像技术可能导致对骨受累程度的高估。我们建议，在相当一部分无败血症的IV级褥疮患者中，进行骨活检的必要性不大，因为在制定治疗方案时，轻微的骨改变影响不大。
