Mader J T, Ortiz M, Calhoun J H
Division of Marine Medicine, University of Texas Medical Branch, Galveston, USA.
Clin Podiatr Med Surg. 1996 Oct;13(4):701-24.
Osteomyelitis can be classified by duration, pathogenesis, location, extent, and host status. Bone infections are currently classified by the Waldvogel or the Cierny-Mader classification. Because the Waldvogel classification is an etiologic system and the Cierny-Mader classification is descriptive, both classifications can be simultaneously used. The Cierny-Mader classification is based on the anatomy of the bone infection and the physiology of the host. Cierny-Mader staging allows stratification of long bone osteomyelitis and the development of comprehensive treatment guidelines for each stage. Current trends in long bone osteomyelitis therapy emphasize early diagnosis and aggressive treatment. Radiographs and bone cultures are the mainstays of diagnosis. Imaging with radionuclide scans, computerized tomography, and magnetic resonance imaging are used when the diagnosis of osteomyelitis is equivocal or to help guage the extent bone and soft tissue infection. Surgical treatment involves débridement of necrotic bone and tissue, obtaining appropriate cultures, managing dead space, and, when necessary, obtaining bone stability. Medical therapy includes improving any host deficiencies, initial antibiotic selection, and antibiotic modification based on culture results. Antibiotic delivery has expanded to include effective oral agents and local therapy with antibiotics mixed in polymethylmethacrylate. Cierny-Mader staging was developed to describe long bone osteomyelitis. This staging system has to be modified to describe diabetic foot osteomyelitis and vertebral osteomyelitis. Osteomyelitis in patients with diabetes mellitus involves the bones of the feet or ankles. The vascular and neurologic status of the patient must be carefully accessed. Patients may be managed with local débridement surgery or ablative surgery plus 2 to 4 weeks of antibiotic therapy depending on whether all of the osteomyelitis is surgically removed. If the patient does not wish surgery or is not a surgical candidate, suppressive antibiotic therapy can be used. Vertebral osteomyelitis is usually hematogenous in origin. The diagnosis is made by bone cultures, histology, and radiographs. Magnetic resonance imaging and technetium scans are useful in making the diagnosis and in gauging the extent of the bone and soft tissue infection. Therapy requires parenteral antibiotic therapy and may include early surgery and stabilization. The choice of an antibiotic therapy is guided by the bone biopsy or débridement culture results.
骨髓炎可根据病程、发病机制、部位、范围和宿主状态进行分类。目前骨感染采用Waldvogel分类法或Cierny-Mader分类法。由于Waldvogel分类法是一种病因学系统，而Cierny-Mader分类法是描述性的，两种分类法可同时使用。Cierny-Mader分类法基于骨感染的解剖结构和宿主的生理状况。Cierny-Mader分期可对长骨骨髓炎进行分层，并为每个阶段制定综合治疗指南。目前长骨骨髓炎治疗的趋势强调早期诊断和积极治疗。X线片和骨培养是诊断的主要手段。当骨髓炎的诊断不明确或为了帮助判断骨和软组织感染的范围时，可使用放射性核素扫描、计算机断层扫描和磁共振成像等影像学检查。手术治疗包括清除坏死骨和组织、获取适当的培养物、处理死腔，必要时实现骨稳定。药物治疗包括改善宿主的任何缺陷、初始抗生素选择以及根据培养结果调整抗生素。抗生素的给药方式已扩展到包括有效的口服制剂以及将抗生素混入聚甲基丙烯酸甲酯中的局部治疗。Cierny-Mader分期是为描述长骨骨髓炎而制定的。该分期系统必须进行修改以描述糖尿病足骨髓炎和脊椎骨髓炎。糖尿病患者的骨髓炎累及足部或踝部骨骼。必须仔细评估患者的血管和神经状况。根据骨髓炎是否全部通过手术切除，患者可接受局部清创手术或切除手术加2至4周的抗生素治疗。如果患者不希望进行手术或不适合手术，可采用抑制性抗生素治疗。脊椎骨髓炎通常血行感染。通过骨培养、组织学检查和X线片进行诊断。磁共振成像和锝扫描有助于诊断并判断骨和软组织感染的范围。治疗需要胃肠外抗生素治疗，可能包括早期手术和固定。抗生素治疗的选择以骨活检或清创培养结果为指导。
