慢性骨髓炎.ppt

慢性骨髓炎的外科治疗 流行病学 发病特点----创伤后慢性骨髓炎成为病人的主体，急性血源性骨髓炎转变为慢性者越来越少----但是没有大规模的流行病学资料 细菌种类的变化 治疗方法和治疗效果的变化 临床分类 Cierny-Mader Classification system MAY CLASSIFICATION GENERAL PRINCIPLES OF TREATING POSTTRAUMATIC OSTEOMYELITIS First there must be adequate debridement of all infected and necrotic soft and osseous tissues. Second antibiotics are used at the time of fracture to prevent infection, and when infection is established, to control infection. The third principle is stabilization of the fracture The fourth principle is ablation of dead space The final principle is soft tissue coverage and bone reconstruction. 清创术 Debridement 术前检查了解病灶范围 死骨的范围----MRI放射性同位素 ----目前尚无一种很好的方法在术前清晰的判定死骨的范围----术中判定---- Paprika sign 、术中多普勒 清创的内容 窦道、炎性肉芽组织、脓汁、异物 *瘢痕组织（if tissue is of insufficient vascularity and can not contribute to wound healing, it must be considered an impediment to success and should be removed during the course of debridement ) *死骨 对骨的血运的保护，清除死骨的同时不要产生新的死骨 *死骨清除必须彻底 （Simpson 2001 APRIL JBJS-B ） 最好应用高速磨钻 *对于感染性骨不连采用段截的方法较好 抗生素的应用 抗生素的选择依据细菌培养的结果 ----经窦道采集的标本结果不准确，应以术中采集的深层标本为准 如细菌培养为阴性，则可选用妥布霉素和万古霉素联合应用，试验治疗 抗生素剂量要大，如有条件进行血药浓度监测来指导治疗 给药方式：静脉给药4-6周，口服给药4-6周 静脉给药1周，口服给药6周 （JBJS-B 1999 november) The Cierny-Mader staging system provides an antibiotic treatment guideline. For Stage 1 osteomyelitis, a 4-week course of antibiotics dated from initiation of therapy or after last major debridement surgery is used. Stage 2 osteomyelitis usually can be arrested when treated with a 2-week course of antibiotics after superficial debridement and local or microvascular soft tissue coverage. Stages 3 and 4 osteomyelitis are treated with 4 weeks of parenteral antimicrobial therapy dated from the last major debridement surgery. In some institutions, the patient is treated with 2 weeks of parenteral antibiotics followed by 4 weeks of oral antibiotic therapy. Without adequate debride