Orthopaedic and Traumatology Department, ASL TO3 Ospedale Civile E. Agnelli Pinerolo, Pinerolo, Italy.
Hand Surgery and Reconstructive Microsurgery Department, ASST (Azienda Socio Sanitaria Territoriale) Gaetano Pini CTO di Milano, Milano, Italy.
Microsurgery. 2024 Jan;44(1):e31139. doi: 10.1002/micr.31139. Epub 2023 Dec 27.
Chronic osteomyelitis is an invalidating disease, and its severity grows according to the infection's particular features. The Cierny-Maiden criteria classify it according to the anatomical aspects (I to IV) and also by physiological class (A host being in good immune condition and B hosts being locally (L) or systemically (S) compromised). The surgical approach to chronic osteomyelitis involves radical debridement and dead space reconstruction. Two-stage management with delayed reconstruction is the most common surgical management, while one-stage treatment with concomitant reconstruction is a more aggressive approach with less available literature. Which method gives the best results is unclear. The purpose of this study is to compare single and two-stage techniques.
The authors carried out a retrospective multicentric cohort study to compare two primary outcomes (bone union and infection healing) in one versus two-stage reconstructions with vascularized bone flaps in 23 cases of limb osteomyelitis (22 patients, 23 extremities). Thirteen subjects (56.5%) sustained a single-stage treatment consisting of a single surgery of radical debridement, concomitant soft tissue coverage, and bone reconstruction. Ten cases (43.5%) sustained a two-stage approach: radical debridement, simultaneous primary soft tissue closure, and antibiotic PMMA spacers implanted in 7 patients.
No statistical differences were observed between one- and two-stage approaches in bone union rate and infection recurrence risk. Even though bone union seems to be higher and faster in the two-stage than in the one-stage group, and all infection relapses occurred in the one-stage group, data did not statistically confirm these differences. Two of the six cases (33.3%) of bone nonunion occurred in compromised hosts (representing only 17.4% of our sample). The B-hosts bone union rate was 50.0%, while it reached 78.9% in A-hosts, but the difference was not statistically significant (p = .5392). Infection recurrence was higher in B-hosts than in A-hosts (p = .0086) and in Pseudomonas aeruginosa sustained infections (p = .0208), but in the latter case, the treatment strategy did not influence the outcome (p = .4000).
Bone union and infection healing rates are comparable between one and two-stage approaches. Pseudomonas aeruginosa infections have a higher risk of infection relapse, with similar effectiveness of one- and two-stage strategies. B-hosts have a higher infection recurrence rate without comparable data between the two approaches. Further studies with a larger sample size are required to confirm our results and define B-hosts' best strategy.
Level III of evidence, retrospective cohort study investigating the results of treatments.
慢性骨髓炎是一种使人丧失能力的疾病，其严重程度取决于感染的特殊特征。Cierny-Maiden 标准根据解剖方面（I-IV）和生理分类（A 宿主免疫状况良好，B 宿主局部（L）或全身（S）受损）对其进行分类。慢性骨髓炎的手术方法包括彻底清创和死腔重建。两阶段延迟重建是最常见的手术管理方法，而一期同时重建是一种更具侵袭性的方法，但文献报道较少。哪种方法效果最好尚不清楚。本研究旨在比较一期和两期治疗方法。
作者进行了一项回顾性多中心队列研究，比较了 23 例肢体骨髓炎（22 例患者，23 个肢体）中血管化骨瓣一期和两期重建的两种主要结局（骨愈合和感染愈合）。13 例（56.5%）接受一期治疗，包括一次彻底清创、同时软组织覆盖和骨重建。10 例（43.5%）接受两期治疗：在 7 例患者中进行彻底清创，同时行一期软组织闭合，植入抗生素 PMMA 间隔物。
一期和两期方法在骨愈合率和感染复发风险方面无统计学差异。尽管两期组的骨愈合似乎更快更高，而且所有感染复发都发生在一期组，但数据并未统计学上证实这些差异。6 例（33.3%）骨不连中有 2 例发生在功能障碍宿主（仅占我们样本的 17.4%）。B 宿主的骨愈合率为 50.0%，而 A 宿主为 78.9%，但差异无统计学意义（p=0.5392）。B 宿主感染复发率高于 A 宿主（p=0.0086）和铜绿假单胞菌持续感染（p=0.0208），但在后一种情况下，治疗策略对结果没有影响（p=0.4000）。
一期和两期方法的骨愈合率和感染愈合率相当。铜绿假单胞菌感染的感染复发风险较高，但一期和两期策略的效果相似。B 宿主的感染复发率较高，但两种方法之间没有可比数据。需要进一步进行更大样本量的研究来证实我们的结果，并确定 B 宿主的最佳策略。
III 级证据，回顾性队列研究调查治疗结果。
