Fujii Miki, Terashi Hiroto, Yokono Koichi
Department of Plastic and Reconstructive Surgery, Kitaharima Medical Center, Ono, Japan.
Department of Plastic and Reconstructive Surgery, Kobe University Hospital, Kobe, Japan.
Wound Repair Regen. 2016 Mar;24(2):447-53. doi: 10.1111/wrr.12418. Epub 2016 Mar 1.
The aim of this study was to propose an appropriate surgical treatment for diabetic forefoot osteomyelitis (DFO) involving ischemia or moderate to severe soft tissue infection. The records of 28 patients with osteomyelitis from 2009 to 2015 were retrospectively studied. All patients had undergone surgery based on preoperative magnetic resonance imaging examinations and histopathological or culture analyses confirming the surgical bone margin. The appropriate surgical margin, crucial factors for early healing, and prognosis after complete resection of osteomyelitis were examined. After healing, patients were followed up to assess prognosis (range 32-1,910 days, median 546 days). The healing rate of nonischemic cases of DFO with negative surgical margins was 100% and that of ischemic cases was 84.6%; the ambulatory rates for both types of cases were 100%. No wound (and/or osteomyelitis) recurrence was observed. Nine new cases of DFO developed in six patients (21.4%; eight were due to vascular stenosis, and one was due to biomechanical changes in the foot. After complete resection of osteomyelitis, preoperative and postoperative C-reactive protein levels and the size of the ulcer were significant predictors of early healing (p < 0.05, 0.01, and 0.05, respectively). The appropriate surgical margin should be set in the area of bone marrow edema, based on magnetic resonance imaging examinations after revascularization. In cases with high preoperative or postoperative C-reactive protein levels, long-term antibiotic therapy is recommended, and surgery should be planned after the C-reactive protein levels decrease, except in emergencies.
本研究的目的是针对伴有缺血或中重度软组织感染的糖尿病足前骨髓炎（DFO）提出一种合适的手术治疗方法。回顾性研究了2009年至2015年28例骨髓炎患者的病历。所有患者均根据术前磁共振成像检查以及确认手术切缘的组织病理学或培养分析结果接受了手术。研究了合适的手术切缘、早期愈合的关键因素以及骨髓炎完全切除后的预后情况。愈合后，对患者进行随访以评估预后（范围为32 - 1910天，中位值为546天）。手术切缘阴性的非缺血性DFO病例的愈合率为100%，缺血性病例的愈合率为84.6%；两种病例的行走率均为100%。未观察到伤口（和/或骨髓炎）复发。6例患者出现9例新的DFO病例（21.4%；8例由于血管狭窄，1例由于足部生物力学改变）。骨髓炎完全切除后，术前和术后C反应蛋白水平以及溃疡大小是早期愈合的重要预测指标（分别为p < 0.05、0.01和0.05）。应根据血运重建后的磁共振成像检查结果，将合适的手术切缘设定在骨髓水肿区域。对于术前或术后C反应蛋白水平较高的病例，建议进行长期抗生素治疗，除紧急情况外，应在C反应蛋白水平下降后再计划手术。
