慢性骨髓炎（ChronicOsteomyelitis）

慢性骨髓炎（ChronicOsteomyelitis）

书上说：你一个苹果，我一个苹果，我们交换一下，还是一人一个苹果；你一个思想，我一个思想，我们交换一下，却能产生两个想法。

外科技术的发展和抗生素的合理使用，在外伤后导致的慢性骨髓炎病例总数并没有显著减少，这或许和交通事故及城市建设都有关系。但和19世纪早期，开放性骨折患者的较高死亡率相比，我们毋庸置疑，感觉到了医学的进步给人类带来的收益。在基层，我们遇到一些这样的病例，如何规范化治疗是我们需要遵循的。今天为大家总结一篇慢性骨髓炎的文章，希望大家能在其中能学到一些有用的知识。

Bone setter

髓炎常见致病菌为金黄色葡萄球菌，当然也有分枝杆菌和真菌感染等其他微生物引起。急性骨髓炎和血源性骨髓炎：两者常互换使用，特点：无死骨形成。慢性骨髓炎：提示存在骨坏死的骨内感染。但是慢性骨髓炎多为创伤性感染所致，也可由急性转为慢性。因此创伤后的、外源性的及慢性的是经常互换使用。

开放性骨折的Gustilo分型中Ⅰ、Ⅱ型的感染可能性为2%，Ⅲ型中感染的可能性为10%-50%

Ⅲ型损伤的感染率和如下有关

①骨折端缺少覆盖

②创面污染严重

③不恰当的冲洗

④骨折端的不稳定

Although it is known that a vascular insult predisposes person to the development of chronic osteomyelitis, this progression should not be viewed solely as an inverse correlation between blood flow and risk of infection. In any acute inflammatory process, the balance between host and microbe is determined in large part by the efficacy of the immune response to the infectious challenge. Patients suffering from a disorder of polymorphonuclear leukocytes, for example, have been shown to be at an increased risk for the development and progression of osteomyelitis. In one series of 42 children with chronic granulomatous disease, the authors identified 13 patients who had osteomyelitis.134 Other immunocompromised individuals such as organ transplant recipients,73,154 patients with end-stage renal disease, and those receiving chemotherapy18 also seem to be at an increased risk. Although human immunodeficiency virus infection has not been identified as an independent risk factor in developing osteomyelitis,92 skeletal infection in this population is clearly associated with a more severe clinical course with elevated morbidity and mortality.

血源性骨髓炎

在感染早期，微生物渗透长管状骨的终动脉并繁殖，从而引起炎

症反应。炎症细胞涌入骨管内，导致骨内压升高，出现明显的疼痛，并继而演变成慢性骨髓炎，因为这时候可以出现死骨形成。如今抗生素的使用使得这些过程难以进展。

慢性骨髓炎

发病机制第一步：病原微生物的入侵，穿过宿主的外层防御皮肤和粘膜（开放性骨折就是这一过程）。同时细菌需要粘附，并释放蛋白受体，和宿主胶原蛋白结合。死骨上会有大量的细菌附着，因此感染约严重，死骨越多，形成恶性进展。

鼻腔和肛门处存在大量的金黄色葡萄球菌

S. aureus and S. epidermidis are elements of normal skin flora, with S. aureus in greater numbers in the nares and anal mucosa and S. epidermidis more

prevalent on the skin.

Cierny-Mader索尼曼德分期分类系统

①受累骨的解剖范围

②宿主的免疫活性（分为A、B、C 3级）

骨髓炎的四种解剖分类

Ⅰ、髓型Ⅱ、浅表型Ⅲ、局限型Ⅳ、弥漫型

初步检查

病史

检查

培养

平片

实验室检查

进一步影像学检查

核医学

CT/MRI

Osteomyelitis of the femur showing characteristic radiolucent lesions with cortical erosion and periosteal reaction. A, Coronal T1-weighted magnetic resonance imaging (MRI) with fat saturation showing low signal intensity in femoral diaphysis.B, Coronal T1-weighted MRI with fat saturation postcontrast showing enhancement of femoral diaphysis

with nonenhancing abscess.

Modifiable risk factors for surgical site infection

感染风险

邻近感染灶

围手术期贫血

HIV

尿路感染

耐甲氧西林

肥胖

吸烟

口腔问题

类风湿性关节炎

治疗决策