Department of Orthopaedic Surgery & Musculoskeletal Trauma, Faculty of Medicine, School of Health Sciences, University of Thessalia, University Hospital of Larissa, Larissa, Greece.
Injury. 2010 Mar;41(3):285-93. doi: 10.1016/j.injury.2009.09.010.
A management protocol for ankle and foot osteomyelitis and the outcome in 84 patients treated in a unit with special interest in musculoskeletal infection, is presented.
Patients' mean age was 50.7+/-16.5 years and mean follow-up 31.5+/-18.2 months. Systemic antibiotics were administered initially empirically, and later according to cultures. Surgical treatment included surgical debridement and bead-pouch technique, minor amputation (ray or toe), below knee amputation, and joint fusion. "Second-look" procedures were performed after 48-7h. Vascularised grafts or Ilizarov's technique were used for bone defect reconstruction. Soft tissues were managed according the 'reconstructive ladder' concept.
Host-type (Cierny's classification) was A in 25, B in 53 and C in 6 patients. Seventy-six infections were chronic. Causes were: open trauma without fracture (45/84), open fractures (9/84), ORIF of closed fractures (25/84) and elective surgery (5/84). Patients underwent 3.0+/-1.5 (range 1-10) operative procedures and spent 14.8+/-12.2 (range 3-60) days in hospital. Two (host-C) patients died. Complications requiring reoperations occurred in 20/84 (2/25 host-A, 16/53 host-B, 2/6 host-C; significant difference between host-A versus host-B and -C patients, p<0.001). Infection recurrence occurred in 12 (none host-A; significant difference between host-A versus host-B and -C patients, p<0.001). Multiple organisms were isolated in 39/84. Ankle arthrodesis using external fixation was performed in 9 (fusion rate 8/9). The free vascularised fibula graft was used in 2 and distraction osteogenesis in 8 patients with a mean bone defect of 5.4 cm (range 3-13). Below knee amputations were performed in 5/84 (3/53 host-B, 2/6 host-C) and foot ray amputations in 8/84 (6/53 host-B, 2/6 host-C). Soft tissue coverage required: free muscle flap transfer in 6/84, reverse soleus flap in 1/84, local fasciocutaneous flaps in 7/84, split thickness skin grafts in 5/84, and vacuum assisted closure in 5/84 patients. Eighty-two surviving patients, including amputees, were able to mobilise independently and were satisfied with the result of treatment.
Host-B and -C patients had more complications and infection recurrences and occasionally required amputations. Reconstructive procedures were performed for limb salvage in patients with soft tissue and bone defects and restoration of a functional limb was achieved.
介绍了一种专门研究肌肉骨骼感染的单位治疗踝关节和足部骨髓炎的管理方案以及 84 例患者的治疗结果。
患者的平均年龄为 50.7±16.5 岁，平均随访 31.5±18.2 个月。最初根据经验给予全身抗生素治疗，然后根据培养结果进行治疗。手术治疗包括清创和珠袋技术、小截肢（射线或脚趾）、膝下截肢和关节融合。在 48-7h 后进行“第二次观察”手术。使用带血管的移植物或伊利扎罗夫技术进行骨缺损重建。软组织根据“重建阶梯”概念进行管理。
宿主类型（Cierny 分类）为 A 型 25 例，B 型 53 例，C 型 6 例。76 例感染为慢性。病因包括：无骨折的开放性创伤（45/84）、开放性骨折（9/84）、闭合性骨折的切开复位内固定（25/84）和择期手术（5/84）。患者接受了 3.0±1.5（范围 1-10）次手术，住院 14.8±12.2（范围 3-60）天。有 2 名（宿主-C）患者死亡。20/84 例（2/25 宿主-A、16/53 宿主-B、2/6 宿主-C）患者发生需要再次手术的并发症，差异有统计学意义（宿主-A 与宿主-B 和 -C 患者，p<0.001）。12 例（均为宿主-A）发生感染复发，差异有统计学意义（宿主-A 与宿主-B 和 -C 患者，p<0.001）。84 例中有 39 例分离出多种病原体。9 例（融合率 8/9）采用外固定器进行踝关节融合。2 例采用游离腓骨血管化移植，8 例采用骨延长术，平均骨缺损 5.4cm（范围 3-13）。5/84 例（3/53 宿主-B、2/6 宿主-C）行膝下截肢，8/84 例（6/53 宿主-B、2/6 宿主-C）行足跖骨截肢。需要软组织覆盖：6/84 例游离肌肉皮瓣转移，1/84 例反向比目鱼肌皮瓣，7/84 例局部筋膜皮瓣，5/84 例中厚皮片移植，5/84 例负压辅助闭合。82 例存活患者（包括截肢患者）能够独立活动，对治疗结果满意。
宿主-B 和 -C 型患者并发症和感染复发较多，偶尔需要截肢。对有软组织和骨缺损的患者进行重建手术，以保留肢体，并实现功能肢体的恢复。
