I. Characteristics of osteochondritis and osteomyelitis
1.The five characteristics of osteoconnection
①Long course of disease: starting from 12 weeks after surgery, after at least 6 months of continuous observation, there is no progress in fracture healing. Those with obvious bone defects or signs of loose displacement of internal fixation are not subject to this time limit; Su Jiachan, Department of Traumatology and Orthopedics, Shanghai Changhai Hospital
②Activity impairment; there are clinical symptoms, pain or functional limitation or abnormal activity at the fracture site.
③Imaging evidence: X-ray film shows persistence of fracture gap, atrophy, sclerosis or defect of fracture break end and closure of bone marrow cavity; as well as the finding of partial loosening and slipping of internal fixation.
④ Deformity and muscle atrophy Unconnected fractures may have angulation, shortening and rotational deformity. Due to the long-term inability to use the limb, joint contracture deformity and muscle atrophy can occur.
④Conservative ineffective: After regular postoperative rehabilitation instructions, i.e., taking auxiliary external fixation, such as splint, cast or brace fixation, and limiting functional activities, such as crutch support, still ineffective.
2, the characteristics of osteomyelitis
①Hazardous: Osteomyelitis is hazardous and may be life-threatening if not treated in a timely manner.
②Easy to relapse: Osteomyelitis is difficult to treat and easy to relapse due to poor blood circulation in local bone and soft tissue.
③Long course of disease: the persistence of pathogenic bacteria, bacterial toxins long-term damage to the body, so that the course of chronic osteomyelitis is very long.
④Poor prognosis: the inflammatory site shows hypo-responsiveness, dead bone appears, and sinus tracts are formed. Recurrent infection with hypothermia is a distinctive feature of chronic osteomyelitis.
B. Etiology of osteoconjugation and osteomyelitis
1. Causes of osteochondrosis
(1) Patient factors: Older people and those who have suffered from bone metabolic diseases and osteoporosis may cause delayed fracture healing or bone discontinuity.
Local factors: open fractures, serious contamination of the fracture site, post-operative infection and surgical failure may cause bone discontinuity; comminuted fractures, heavy soft tissue damage may also cause bone discontinuity; insufficient blood supply to the fracture site, resulting in poor nutrition and slow healing.
(3) Surgical factors: surgery is inherently traumatic and can cause invasion and damage to the soft tissues around the fracture; excessive stripping of the periosteum during surgery can affect the blood supply to the fracture end; improper selection of internal fixation or inadequate internal fixation can cause displacement of the fracture end and fracture of the internal fixation, resulting in bone nonunion; damage to the nerves during surgery, rough repositioning during surgery, and removal of too many fragments of bone, inadequate cleaning of the fracture end and The damage to the nerve during surgery, rough repositioning during surgery, and removal of too many fragmented bone pieces, inadequate cleaning and poor alignment of the fracture end may cause delayed bone healing or bone nonunion.
④Postoperative factors: premature removal of plaster fixation, premature exercise or weight-bearing without doctor’s guidance after surgery may cause displacement of the fracture end or fracture of the internal fixation material or loosening of the screws, which may not play a stabilizing role and form a pseudo-joint, resulting in bone discontinuity; as well as the use of some drugs that are unfavorable to fracture healing, which may also cause bone discontinuity.
⑤ Infection: Not paying attention to the protection of the surgical wound can lead to infection. Infection can lead to necrosis of the fracture end and soft tissues, and also prolong local congestion, necrosis and resorption of the fracture end will be more obvious, the time for vascular regeneration and rebuilding blood circulation will be prolonged, and the process of bone scab formation and transformation will be disturbed, resulting in delayed or stagnant fracture healing and leading to bone discontinuity.
2.The etiology of osteomyelitis
Three conditions are required for the development of osteomyelitis.
①Bacterial virulence: fungi, parasites, mycobacteria, mycoplasma, gram-negative or gram-positive bacteria can cause osteomyelitis.
②Physiological state of the host: The state of the bacteria in the wound is not the first factor causing the infection. Many surgical wounds are infected with bacteria, but few of them develop bone infections. The local environment of the wound influences the occurrence of infection, and these environments are influenced by systemic and local factors, such as the local bone and soft tissue blood supply.
(iii) Stability of the anatomical structure: The stability of healthy bones can prevent the development of osteomyelitis. Loss of stability often results in a sustained inflammatory response in the bone and surrounding soft tissues. The inflammatory response to an unstable fracture can lead to an increase in the area of local destruction, and may also eventually contribute to infection.
Heart problems of patients with osteonecrosis and osteomyelitis
1. Bone discontinuity
(1) Abnormal activity of the fracture end: If the fracture end has abnormal activity during the activity check after 6 months or more, it can be diagnosed as bone discontinuity.
②Pain: pain is produced when the bone end is moved or when trying to do weight-bearing.
③Deformity and muscle atrophy: Unconnected fractures may have angular, shortening and rotational deformities. Joint contracture deformity and muscle atrophy can occur due to long-term inability to use the limb.
⑤ Loss of weight-bearing function: loss of weight-bearing function of unconnected bones after a backbone fracture, but some femoral neck fractures have claudication.
(6) Reduced bone conduction sounds: Bone nonunion or delayed connection, weaker bone conduction sounds than the healthy side
2.Osteomyelitis
If patients with osteomyelitis are not treated in a timely manner, the following complications often occur, causing great physical and mental pain to patients.
① deformity: due to inflammatory stimulation of the epiphysis, the affected limb becomes longer due to overgrowth; or the destruction of the epiphyseal plate affects the development, resulting in shortened limbs and, as a result, inversion or valgus deformity of the joint; due to soft tissue scar contracture, it can also cause flexion deformity.
② Joint ankylosis: Due to the spread of infection into the joint, the cartilage surface of the joint is destroyed, making the joint fibrous or bony ankylosis. ③Carcinoma: The skin of the sinus tract opening can be combined with carcinoma commonly as squamous epithelial carcinoma due to constant stimulation.
④Anemia: chronic septic osteomyelitis with prolonged course and long-term recurrent acute attacks will produce chronic wasting damage to the whole body, causing anemia and hypoproteinemia.
⑤ Systemic amyloidosis, manifested by the deposition of amyloid material on the intercellular space and vascular basement membrane of the organs of the body.
Surgical treatment of osteochondritis and osteomyelitis
1.Surgical treatment of osteochondritis
Surgical treatment is currently the most important method for the treatment of osteoarthrosis, more than 90% of the osteoarthrosis can be treated surgically, and 80% of the cases have a good prognosis, mainly including lesion removal, reasonable internal fixation, fracture end compression, compression external fixation, bone grafting and the combined application of each method.
①Internal fixation
The application of compression plate fixation can make close contact with the fracture end, increase the longitudinal compression, eliminate the stress on the fracture end, facilitate the growth and creep of capillaries, and promote healing. The compression plate can be fixed without external fixation, thus the joint and muscle movement is early, while the application of common plate requires a period of cast braking.
②External fixation
Bone external fixator for treatment of long diaphyseal discontinuity is an important progress in the treatment of bone discontinuity in recent years, this method is less invasive and mainly applicable to the treatment of tibial diaphyseal discontinuity and bone defect. Its advantages are mainly as follows.
Uniform distribution of compressive stress at the fracture end; stable elastic fixation and adjustable fixation stiffness, small stress masking effect;
No interference with the blood supply to the fracture end, which facilitates deformity correction;
It enables early weight-bearing and functional exercise of the limb, produces intermittent stress stimulation of the fracture, and makes the fracture easy to heal. The disadvantage is that the postoperative management is more complicated and pinhole infection is more common, and serious infection will force the extraction of the pin and terminate the treatment.
(iii) Bone grafting
Bone grafting is now widely used to treat delayed healing and bone nonunion, bone defects. Bone grafts support the formation of new bone through osteogenesis, osteoconduction and osteoinduction. Currently, autogenous cancellous and cortical bone grafting is still the best bone grafting material, mostly taken from the proximal iliac bone or tibia. Artificial bone grafting is a chemically produced substance that is grafted onto the bone defect in place of the bone graft. Artificial bone does not induce osteogenesis, and its bone growth mechanism is a crawling replacement process. At present, domestic research on artificial bone is mostly carried out as a carrier of bone morphogenetic protein, which has been used in clinical practice.
2.Surgical treatment of osteomyelitis
Most acute purulent osteomyelitis is caused by Staphylococcus aureus. It should first be treated with antibiotics effective against the bacterium, and the antibiotics should be adjusted promptly if the efficacy is not obvious in 3 days. If the systemic symptoms do not decrease after the use of antibiotics but the pain increases, bone drilling or bone opening should be performed to achieve drainage and decompression.
Chronic osteomyelitis can lead to necrosis of the bone tissue lesion, scarring of the surrounding tissue, and lack of local blood flow, so that antibiotics cannot reach the lesion. Therefore, either oral or intravenous antibiotics are not very effective in chronic osteomyelitis. Chronic osteomyelitis with recurrent episodes and long-term sinus tracts that do not heal require surgical treatment. The principles of treatment are complete removal of granulation tissue, removal of dead bone, closure of the dead space and improvement of local blood flow. The surgical approach should be patient specific and commonly used methods include: simple lesion removal and dead bone removal, disc surgery, bone grafting, local grafting with tip or free grafting. Local use of antibiotics is also effective.
V. Preventive measures for osteochondritis and osteomyelitis
1.Preventive measures for osteochondrosis
The treatment of osteonecrosis is quite difficult and the patient suffers more. If the doctor can fully understand and effectively deal with the medical factors of fracture non-union, the rate of fracture non-union can be greatly reduced. Therefore, attention must be paid to the prevention of bone nonunion throughout fracture treatment. The following points must be noted in fracture treatment: avoid formation of interfracture ends; during fracture fixation, attention should be paid to moving non-braking joints; early repositioning; perfect fixation and sufficient time; non-surgical repositioning method as much as possible; enhanced nutrition; and attention to medication to avoid infection.
During fracture treatment, attention should be paid to the effects of age, gender, malnutrition, alcoholism, smoking, diabetes, atherosclerosis, neurological diseases, multiple trauma, radiation therapy, and drugs (such as hormones, anticoagulants, cytotoxic drugs, and non-steroidal anti-inflammatory drugs) on fracture healing, which should be controlled in appropriate amounts to avoid the occurrence of non-healing fractures.
2.Preventive measures for osteomyelitis
① Prevention of general infectious diseases: Boils, furuncles, sores, carbuncles and upper respiratory tract infections are the most common infectious diseases, which can lead to hematogenous osteomyelitis if secondary infections occur, so prevention of general infectious diseases is important to prevent the occurrence of osteomyelitis.
② Prevention of traumatic infection: traumatic infection, including infection after tissue injury and infection after bone injury, is also a common cause of osteomyelitis. Therefore, it is important to strengthen labor safety management and prevent accidents such as skin abrasions.
③ timely detection and treatment of infection: regardless of the cause of infection, its severity, the size of the scope of impact, and systemic and local conditions have a close relationship, and with the discovery of the early and late, timely treatment or not, also has a great relationship. Therefore, early detection and timely treatment of infectious diseases should have a positive effect on the prevention of osteomyelitis.
④ For the management of open fractures, the first step is to prevent infection. Generally, internal fixation is not used, but hemostasis, debridement, osteotomy and splint fixation are performed first to reduce the chance of infection.
VI. Postoperative exercise methods for osteoconjugation and osteomyelitis
1.Postoperative exercise methods for osteoconnection
Early functional exercise is beneficial to fracture healing, but it should be combined with clinical reality and regular review. Select a reasonable functional exercise program according to the X-ray film results and the strength of internal fixation. In the early stage, the main exercise is muscle contraction and joint movement, and weight-bearing activities will be carried out gradually after the basic healing of the fracture.
However, incorrect postoperative functional exercises need to be avoided. There are two common mistakes: (1) early rehabilitation, such as the doctor’s optimistic estimation of the strength of the internal fixation, too fast estimation of the speed of bone healing, premature release of external fixation, and blindly wrong and premature functional exercises. The main reason for this is that the patient did not receive formal training on rehabilitation from the medical staff during hospitalization, or the physician did not emphasize the importance of regular review of the patient after discharge and did not provide clear instructions before discharge.
2.Postoperative exercise methods of osteomyelitis
After surgery, attention should be paid to the pain and swelling of the affected limb. Those who are fixed with splints or casts and in continuous traction should elevate the affected limb and reduce activities, and should pay attention to the color, temperature and sensory changes of the affected limb. After the inflammation is controlled, joint activities should be performed under the guidance and assistance of the doctor to prevent joint ankylosis and muscle wasting atrophy and to restore motor function. Take care not to exercise strenuously after discharge and adhere to treatment to prevent recurrence.
Four main features of surgical treatment for osteochondritis and osteomyelitis
First, whether the original fixation has been loosened, broken or pulled out, in this case, it must be replaced. If the intramedullary nail is used, even if there is no loosening, the patient’s age, activity and time of use should be taken into account to make a comprehensive assessment. For example, a bone that has been fixed with an intramedullary nail for 5 years may be fine at the time of the doctor’s visit, but soon the nail may break. At this point, a simple bone graft would be very dangerous.
Second, analyze whether the bone discontinuity is caused by improper selection of fixation, if this is the main reason, of course, it must be replaced.
Third, if the previously applied external fixation stent is used, it is necessary to see if there is any relaxation, rejection, and infection in the nail tract, and if these factors are excluded, it is possible to continue to apply it and simply treat the broken bone. If the internal fixation is to be replaced, then, after unloading the stent, stop for more than 2 weeks, and the nail eye becomes dry and closed, then do the surgery.
Fourth, patients with infected internal fixation originally used, i.e., infected bone discontinuity, generally need to be replaced with an external fixation stent with the nail tract away from the infected site to facilitate the management of the infection while ensuring the relative stability of the bone break end.
Fifth, the middle femoral stem bone discontinuity, if not pediatric, the original application of the plate, whether or not fracture, should be replaced with intramedullary nail.
Sixth, a very popular opinion is that the original intramedullary nail is too thin, so it causes bone nonunion. Stabilization is achieved by inserting a thicker intramedullary nail, and bone grafting is possible with the expansion of the nail. This sounds grand, but it is actually a paper argument. We reject this ridiculous idea. Reason: There are thick and thin intramedullary nails, but nowadays the intramedullary nails are with locking, 1-2 cross nails at each end locking, there is no instability. Expanded marrow implant is pure nonsense, first of all, the amount is too small, the second is bone foam, easy to lose, and thirdly, how do you ensure that this poor bone foam is placed exactly at the broken end of the bone, if it loses itself to the distal end of the medullary cavity, is it not useless. Our experience confirms that if there is no loosening of the nail when dealing with bone discontinuity, even though it is relatively thin, there is absolutely no need to replace it and simply deal with the broken end of the bone. If the broken end does move, is unstable, etc., a common screw can be tapped in the broken end transversely close to the medullary nail to act as a block, the technical term is Poller’s nail. The problem is solved.
Seventh, if the skin is all scarred, the condition is not good, but do not need to do flap coverage, you can use intramedullary nail or external fixation, generally do not use the steel plate, because the plate occupies the space, may not close the skin. If the decision to cover the flap is made at the same time, then the fixation should be based on mechanical stability.
Eighth, in general, intramedullary nailing is preferred for cadres of femur and tibia, while plates are predominant in other parts. Nowadays, the emergence of LISS plates and other locking nail plates and the application of minimally invasive techniques, patients with bone discontinuity may more often just need bone grafting, internal fixation is quite solid ah.
① bone graft material: nano artificial bone application prospect is very bright, it has the ideal bone repair material should have a variety of characteristics, repair effect is comparable or close to the autologous bone, sufficient sources, both no immune rejection, but also to avoid taking the pain and complications caused by autologous bone to patients, easy to use, patients are happy to accept, and the price is close to other existing artificial bone, or even cheaper (free at this stage). Currently, Nanoartificial Bone is developing various types of bone blocks (artificial vertebral plates) or injectable materials suitable for different parts of the body, as well as a composite recombinant bone growth factor (BMP-2 bone forming protein-2). The technology has been patented in the U.S. and China, and its research results have caused a great stir internationally. With the development of China’s economy and the improvement of people’s living standards, people’s awareness of bone diseases is deepening, and the demand for bone grafting materials will increase a lot, and nano-artificial bone will bring huge social benefits while relieving patients’ pain. At present, experts from the Department of Materials of Tsinghua University are redoubling their efforts to continuously improve nano-artificial bone for the benefit of mankind.
②Comprehensive treatment: The basic pathological changes of osteonecrosis of long bones include resorption and sclerosis of bone ends, osteoporosis and atrophy of bone and soft tissue, accompanied by joint stiffness. Therefore, the surgical treatment of osteonecrosis should be approached from various aspects, including reconstruction of bone structure; removal of sclerotic bone, opening the bone marrow cavity; repair of bone defects, increasing the support capacity of the damaged bone itself and the holding power of internal fixation; providing good biological induction and firm and stable mechanical conditions for bone healing; on the basis of obtaining secure fixation of osteonecrosis, doing adhesion release or surgical release of stiff joints to restore the limbs and joints as soon as possible. The function of the limbs and joints can be restored as soon as possible.
③ Functional exercise: functional exercise is an important factor to promote fracture healing, often maintain the normal function of muscles, maintain a certain amount of joint activity, can effectively prevent bone quality osteoporosis, increase blood circulation, is conducive to the formation of bone scabs, the same can also delay or reduce the degenerative changes of the joint.
The first stage (l-2 weeks after injury)
For the period of inflammation receding. The purpose of functional exercise is to promote blood circulation, make the swelling subside as soon as possible, and prevent muscle atrophy and joint adhesion. The main form of functional exercise in this period is to make the affected muscles stretch and contract. Patients with upper limb fractures can make fist clenching and shoulder lifting activities, making the whole upper limb muscles exert force when clenching fist and then relaxing it. Patients with lower extremity fractures can contract the quadriceps muscles to make the whole lower extremity muscles exert and then relax, but not necessarily flex the knee joint. Patients with ankle fractures can do some toe dorsiflexion.
The second stage (3-4 weeks after injury)
It is the period of bone scab formation. The swelling of the affected limb subsides, the local pain gradually disappears, the soft tissue injury is gradually repaired, the fracture end is partially connected with fibers and gradually forms bone scabs, and the fracture site becomes more stable. In addition to continuing the muscle stretching and contraction activities of the affected limb, patients with upper limb fracture can gradually move the joints near the fracture under the guidance of the doctor; besides making fist clenching and moving the shoulder joint, they can also do some active joint extension and flexion activities, such as moving the wrist joint and elbow joint, and the extension and flexion, abduction and adduction of the whole upper limb, starting with simple movements and gradually increasing, with gentle and slow movements, as the As the fracture heals, the number of activities can be increased appropriately. Patients with lower extremity fractures can perform leg lifting and hip extension and flexion activities, and can combine upper and lower extremities to climb and stand, and gradually start light weight-bearing activities. After the 4th week, patients with femur fracture of lower extremity can support the bed with both hands, do hip lifting, hip extension and knee flexion. After 4-6 weeks, the patient can get up and move around with the help of crutches, but cannot bear weight.
The third stage (5-7 weeks after injury)
This is the period of bone scab maturation. At this time, the soft tissues of the affected area have returned to normal, the muscles are strong, there is enough bone scab, and generally close to clinical healing, except for a certain aspect of joint activities that is not conducive to fracture healing still need to be restricted, other activities can be carried out, and the number and range of activities can be expanded.
Stage 4 (7-10 weeks after injury)
This is the clinical healing period. The main form of functional exercise is to strengthen the active movement of the joints of the affected limb, so that the joints can quickly resume normal activities. Patients with upper limb fracture can do some light work within their ability. Patients with lower extremity fractures can go up and down slopes and stairs, and do some weight-bearing activities under the protection of crutches or canes.
Duration of fracture immobilization: 3-4 weeks for children and 6-8 weeks for adults for the upper extremity; 8-10 weeks for the lower extremity.