Tratamiento de la osteomielitis asociada a úlceras alrededor de la pelvis.

• Autores: Guido Carabelli, Virginia María Cafruni, Jorge Barla, Danilo Taype, Carlos Federico Sancineto
• Localización: Revista de la Asociación Argentina de Ortopedia y Traumatología, ISSN 1852-7434, Vol. 83, Nº. 4, 2018, págs. 248-255
• Idioma: español
• Títulos paralelos:
  • Treatment of pressure ulcer-related pelvic osteomyelitis
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  • español

    Introducción: El tratamiento de la osteomielitis crónica asociada a úlceras alrededor de la pelvis es complejo y multidisciplinario. Un tratamiento antibiótico, dirigido a más de un microorganismo, sumado a la cirugía permitiría disminuir la recurrencia de la infección. El objetivo de este estudio fue analizar los resultados en pacientes con osteomielitis crónica asociada a úlceras por presión, con gran defecto de cobertura alrededor de la pelvis, tratados con desbridamiento del lecho y un colgajo para el defecto de cobertura.Materiales y Métodos: Se realizó un estudio descriptivo, retrospectivo, basado en los datos de las historias clínicas de pacientes que requirieron cobertura quirúrgica de úlceras por presión, entre octubre de 2010 y febrero de 2017. Los pacientes fueron tratados con un procedimiento en dos tiempos quirúrgicos: desbridamiento y luego colgajo de cobertura del defecto remanente.Resultados: Se trataron 27 úlceras (9 sacras, 13 isquiáticas y 5 trocantéricas) en 15 pacientes (edad promedio 44. 9 años [rango 22-81]). Tres úlceras desarrollaron un solo germen, en el resto, los cultivos fueron polimicrobianos. Se administraron antibióticos intravenosos durante un mínimo de 4-6 semanas. Los valores iniciales de eritrosedimentación y proteína C reactiva ultrasensible fueron 72 mm/h y 55 mg/l, respectivamente, y disminuyeron a 49 mm/h y 20 mg/l, respectivamente, a los 3 meses.Conclusiones: Nuestro protocolo acorta los tiempos de tratamiento, ya que no se espera a terminar la antibioticoterapia para realizar el colgajo. Consideramos que la cobertura inmediata del defecto de partes blandas permite controlar el acceso de nuevos microorganismos a la región afectada. Así hemos obtenido buenos resultados con una baja tasa de recidiva comparada con la de otras series.

  • English

    Introduction:Chronic osteomyelitis treatment related to pressure sores around the pelvis is complex and multidisciplinary.The combination of antibiotics, usually aimed at more than one microorganism, in addition to a surgical treatment would reduce the recurrence of infection.The goal of our work was to analyze the results in patients with chronic osteomyelitis associated  to pressure sores around the pelvis,being treated with debridement and then with a flap to cover the soft tissue defect. MethodA descriptive, retrospective study was carried out based on data obtained from review of medical records of those patients requiring surgical coverage of pressure sores, between October 2010 until February 2017, being surgically treated 15 patients with 27 pressure sores around the pelvis.Patients were treated as Protocol performing a procedure in two surgical times, the first being the debridement and the second, the flap to fill the remaining soft tissue defect.The patients were discharge from hospital with an intravenous antibiotic treatment for an approximate period of 4-6 weeks for chronic osteomyelitis underlying clinical evolutionary controls and laboratory of erythrocyte sedimentation rate and C-reactive protein ultrasensitive. Results: 15 patients were treated, being 2 of them female. The average age was 44, 9 years (22-81).We treated 27 pressure sores, which can be divided into:-9 sacral pressure sores were treated by cutaneous flaps from the superior gluteal perforator pedicle or lumbar bipedicle perforator flap, depending on the size of the ulcers. One ulcer suffered a recurrency being treated with an advance of the same flap.-13 ischial ulcers were treated with different options, being used in 4 cases a inferior gluteus miocutaneous pedicle flap in V-Y shape. One of this suffered a new pressure sore.6 cases were treated with a muscle flap, being one of them the treatment of recurrence of a previously failed flap.Finally a patient presenting an ischial and trochanteric homolateral ulcer, was treated with a fascia lata miocutaneous flap to cover both soft tissue defects.-5 trochanteric pressure sores were treated with a fascia lata miocutaneous flap, not presenting  a recurrency.From 27 ulcers, only three of them developed a single germ, the remains ulcers developed more than one germ.The patients were treated with  intravenous antibiotic for a minimum period of 4 to 6 weeks.The initial values for the erythrocyte sedimentation rate and protein C reactive ultrasensitive were 72 mm/h and 55 mg/L respectively, after 3 months of flap surgery, values decrease 49 mm/h and 20 mg/L respectively. Discusion.Many methods have been described in the history of the management of pressure sores.The range of recurrence in the past 50 years, after a flap in this type of ulcers is between 3% and 82%.Larson et al. had a recurrence of 16.8% in 101 patients. Grassetti et al. in 143 patients with a follow-up of 2 years had a recurrence of 22.4%. Our patients were treated as Protocol in two surgical times in addition to intravenous antibiotic treatment. We treated 27 pressure sores with good results and a recurrence rate of 7.4%, comparable to the international literature. ConclusionOur Protocol reduces treatment, since it is not expected to complete the antibiotics before the flap performance. We consider that the soft tissues defects coverage as soon as possible decreases access of new microorganisms to the affected region, being an indispensable part of the effective treatment of pelvic osteomyelitis and local infection control. We obtained good results with low recurrence rate compared to other series.