Documente Academic
Documente Profesional
Documente Cultură
GR.T.POPA IAI
FACULTATEA DE MEDICIN
REZUMAT
TEZ DE DOCTORAT
OSTEOMIELITA HEMATOGEN
CONDUCTOR TIINIFIC
PROF. DR. GHEORGHE FLOARE
DOCTORAND
DR. DANIELA- LILIANA DAMIR
Iai, 2011
Osteomielita hematogen
CUPRINS
CAPITOLUL 1. Osteomielita hematogen....................................................... 4
CAPITOLUL 2. Osteomielita hematogen. Studiul clinico-statistic .............. 7
2.1. Motivaia alegerii temei de cercetare..................................................... 7
2.2. Obiective ............................................................................................... 8
2.3. Rezultate clinico-statistice..................................................................... 9
2.4. Aspecte histopatologice n osteomielita hematogen .......................... 36
2.5. Discuii - aspecte de etic i deontologie medical, bioetic............... 44
2.6. Analiza rezultatelor a 9 cazuri de osteomielit subacut hematogen. 49
CAPITOLUL 3. Consideraii biomecanice cu privire la folosirea
substituenilor osoi in tratamentul osteomielitelor ................ 60
3.1. Evaluarea biomecanic, histologic i histo-morfometric n studiul
substituenilor osoi.................................................................................... 60
3.2. Elemente de biomecanica coapsei, cu calcularea forelor maxime ce
acioneaz asupra femurului, n timpul mersului normal ................ 64
3.2.1. Elemente de cinematic.............................................. 64
3.2.2. Elemente de dinamic ................................................ 65
3.3. Elemente de remodelare osoas cu aprofundarea noiunilor
legate de mecanotransducie ................................................... 69
3.4. Analiza n element finit a strii de tensiuni de deformaii
specifice i deplasri care apar la nivelul femurului ............... 69
3.4.1. Analiza n element finit a strii de tensiuni
de deformaii specifice i deplasri care apar
la nivelul femurului normal ...................................... 76
3.4.2. Analiza n element finit a strii de tensiuni
de deformaii specifice i deplasri care apar
la nivelul femurului infectat...................................... 77
3.4.3. Analiza n element finit a strii de tensiuni
de deformaii specifice i deplasri care apar
la nivelul femurului tratat cu substitut osos.............. 78
3.5. Comparaie ntre starea de tensiuni pentru
cele trei cazuri enunate anterior ....................................... 79
DISCUII.................................................................................................. 81
CONCLUZII............................................................................................. 83
BIBLIOGRAFIE ...................................................................................... 88
Osteomielita hematogen
CAPITOLUL I
OSTEOMIELITA HEMATOGEN. ASPECTE GENERALE
Osteomielita hematogen
Osteomielita hematogen
Osteomielita hematogen
CAPITOLUL II
OSTEOMIELITA HEMATOGEN. STUDIU CLINICOSTATISCTIC
Osteomielita hematogen
1.1. OBIECTIVE
Studiul i propune realizarea unei analize retrospective reprezentative a
cazuisticii clinicilor: Clinica de Ortopedie- Traumatologie Spitalul Clinic de
Recuperare Iai i Clinica de Chirurgie Infantil a Spitalului de Copii Sf. Maria Iai
n perioada 1994-2010, privind cazurile de osteomielit hematogen.
Apariia unor forme noi de osteomielit hematogen datorit modificrii
sensibilitii la antibiotice, ne-au determinat s aprofundm studiul acestei afeciuni n
dorina de a realiza un diagnostic precoce i un tratament ct mai corespunztor.
De asemenea apariia unor tehnici chirurgicale noi precum i a unor
substitueni osoi de nou generaie, a fcut necesar reactualizarea datelor referitoare
Osteomielita hematogen
Osteomielita hematogen
10
Aduli,43.07%
Copii,56.93%
Osteomielita hematogen
Osteomielita hematogen
dect n rndul copiilor la acetia regsindu-se doar la 9.9% din cazuri. Exist o
corelaie semnificativ ntre vrsta pacienilor i diagnosticul de osteomielit cronic.
OSH
40.1%
OC
28.8%
5-6 ani
7-8 ani
9-12 ani
13-17 ani
42.8%
OAH
OSH
OC
OAH
31.1%
28.3%
5.3%
14.5%
9.2%
2-4 ani
5-6 ani
7-8 ani
9-12 ani
LOTUL A
13-17 ani
21-30 ani
31-40 ani
41-50 ani
Peste 61 ani
31.3%
18.3%
8.7%
OC
51-60 ani
13.0% 13.9%
14.8%
9.9%
53.9%
OSH
61.8%
18-20 ani
21-30 ani
31-40 ani
41-50 ani
LOTUL B
51-60 ani
Peste 61 ani
11.3%
OAH
28.3%
Copii
34.8%
OC
Aduli
OSH
OAH
12
Osteomielita hematogen
Osteomielita hematogen
60
varsta [ani]
50
46.7
40
Sexul pacientilor
30
20
Feminin,
40.07%
10.3
10
Mean
MeanSE
MeanSD
0
copii
adulti
Masculin,
59.93%
Lot de studiu
Masculin
Feminin
Feminin
40
Masculin
30
22.9
20
44.16%
55.84%
16.0
Osteomielit cronic
10
27.10%
Osteomielit subacut
hematogen
0
-10
OAH
OSH
OC
Mean
MeanSE
MeanSD
72.90%
42.17%
Osteomelita acuta
hematogena
57.83%
Fforma clinica
0%
20%
40%
60%
80%
100%
13
14
Osteomielita hematogen
Osteomielita hematogen
Mediul de
provenienta
Rural
62.6%
Urban
Rural
65
60
55
50.1
50
43.2
45
Rural
varsta
40
Urban
35
30
30.4%
Lot B (adulti)
25
69.6%
20
15
10
10.5
9.7
Lot A (copii)
5
0
F
lot A: copii
Mean
MeanSE
MeanSD
lot: adulti
15
-10%
42.8%
57.2%
10%
30%
50%
70%
90%
110%
Osteomielita hematogen
pacieni este semnificativ mai mare frecvena cazurilor din mediul rural (73.5%
respectiv 67.5%). Pentru pacienii cu osteomielit subacut hematogen nu se constat
o diferena semnificativ ntre numrul cazurilor din mediul urban fa de cele din
mediul rural.
Rural
Urban
80%
70%
60%
50%
40%
30%
20%
10%
0%
73.49%
67.53%
49.53%
50.47%
32.47%
26.51%
Rural
Urban
Osteomelita acuta
hematogena
Osteomielit subacut
hematogen
Osteomielit cronic
73.49%
26.51%
50.47%
49.53%
67.53%
32.47%
Epifiz
39.7%
Epifiz
Diafiz/metafiza
Osteomielita hematogen
Diafiz/metafiza
Epifiz
80.37%
93.98%
80.52%
19.48%
19.63%
6.02%
Osteomelita acuta
hematogena
Osteomielit subacut
hematogen
Osteomielit cronic
93.98%
6.02%
19.63%
80.37%
80.52%
19.48%
Diafiz/metafiza
Epifiz
Diafiz/metafiza
53.75%
Epifiz
46.25%
Masculin
70.09%
29.91%
Feminin
0%
20%
40%
60%
80%
100%
Osteomielita hematogen
Osteomielita hematogen
Categ. Box & Whisker Plot: varsta
F(1,265) = 22, p = 0.00000; Kruskal-Wallis-H(1,267) = 25, p = 0.00000
60
50
40
30.8
varsta [ani]
30
18.5
20
10
Diafiz/metafiza
Diafiza/metafiza
Epifiza
Mean
MeanSE
MeanSD
localizare
Epifiz
18.3%
Lot B
-10
81.7%
Lot A
44.1%
10%
30%
50%
70%
90%
110%
Oaselungi,
67.42%
19
20
Oasescurte,
32.58%
Osteomielita hematogen
Localizare la nivelul scheletului
35%
30%
25.84%
loc. schelet
29.96%
25%
20%
17.23%
15%
10%
5.99%
5%
0.37%
0%
Femur
loc. schelet
6.37%
4.87%
3.75%
5.62%
25.84%
Tibie
Cub/radiu
s
Hum
Oase lungi
29.96%
5.99%
Col.v
5.62%
Pelvis
Peroneu Calcaneu
Oase scurte
3.75%
4.87%
0.37%
17.23%
Craniu Sf.
ORL
6.37%
Osteomelita acuta
hematogena
Osteomielit cronic
Osteomielita hematogen
Lot B (adulti)
Oase lungi
Oase scurte
38.26%
61.74%
Osteomielit subacut
hematogen
Lot A (copii)
28.29%
71.71%
48.28%
Oase scurte
37.93%
-10%
13.79%
10%
30%
50%
70%
90%
110%
Oase lungi
41.11%
39.44%
-10%
10%
30%
50%
70%
90%
110%
22
Osteomielita hematogen
Osteomielita hematogen
100
80
120
60
100
40
80
20
60
40
oase lungi
20
adulti
oase scurte
copii
LOCALIZARE
lot
Oase lungi
oase lungi
F
oase scurte
LOCALIZARE
sex
Oase scurte
50
67.50%
Feminin
-10%
40
32.71%
67.29%
10%
30%
varsta [ani]
Masculin
32.50%
50%
70%
90%
110%
30.1
30
23.9
20
10
0
oase lungi
oase scurte
Mean
MeanSE
MeanSD
23
24
LOCALIZARE OH
Osteomielita hematogen
Osteomielita hematogen
Osteomelita acuta
hematogena
Osteomielit subacut
hematogen
Osteomielit cronic
0%
40%
60%
cubitus/radius
40
31.25%
humerus
28.75%
45%
26.25%
tibie
0%
20%
15.94%
39.13%
44.93%
femur
40%
6.25%
varsta [ani]
62.50%
60%
80%
100%
30
23.4
25.1
24.5
22.1
20
10
0
femur
tibie
humerus
cubitus/radius
Mean
MeanSE
MeanSD
OASE LUNGI
Osteomielita hematogen
Osteomielita hematogen
Osteomelita acuta
hematogena
Osteomielit cronic
Osteomielit subacut
hematogen
120%
100%
100%
100%
80%
80%
60%
53.85%
54.35%
40%
30.43%
20%
23.08%
20%
0%
20%
0%
23.08%
15.22%
0%
0%
Calcaneu
0%
Col.v
Pelvis
Peroneu
Osteomelita acuta
hematogena
15.22%
20%
23.08%
0%
0%
Osteomielit subacut
hematogen
54.35%
0%
53.85%
100%
0%
Osteomielit cronic
30.43%
80%
23.08%
0%
100%
varsta [ani]
50
45.6
44.7
40
30
26.0
22.8
20
16.0
10
0
-10
Col.v
peroneu
pelvis
Mean
MeanSE
MeanSD
ASPECT RADIOLOGIC
Rezultatul radiologic a evideniat aspecte diferite n funcie de formele
clinice ale osteomielitei hematogene.
n osteomielita cronic radiologia a evideniat n 54.55% din cazuri abces
Brodie, n 16.8% din cazuri osteoperiostit i n 14.29% din cazuri osteoliz
metafizar. Pentru aceast form clinic cu o frecven mai sczut se regsesc
abcesul subperiostic (9.09%) i sechestrul osos (2.41%). n Osteomielita acut
hematogen rezultatele examenului radiologic a evideniat o frecven mare a
cazurilor cu osteoliz metafizar (59.04%) i abces subperiostic (24.1%). Osteomielita
subacut hematogen prezint radiologic n 68.2% din cazuri abces Brodie.
Aspectul radiologic al leziunilor de osteomielit acut este variabil n funcie
de forma clinic i perioada de evoluie. Radiografia efectuat la nceputul unei
osteomielite nu semnaleaz nici o modificare n structura osului. n schimb
radiografiile efectuate dup 15 zile de la debut arat nceputul unei remanieri osoase.
Apariia sechestrelor determin modificri semnificative ale aspectului radiologic.
Acestea apar sub forma unor puncte nchise mai mult sau mai puin neregulate,
nconjurate de o linie clar a crei grosime crete progresiv.
Imaginea radiologic caracteristic pentru osteomielita subacut hematogen,
descris n literatura clasic este aceea de afectare epifizar caracterizat prin lacun
bine circumscris care nu respect totdeauna corticala.
Localizarea metafizar corespunde unui aspect radiologic tipic de
osteomielit. Aceast leziune poate traversa cartilajul de cretere
Aspectele radiologice clasice se menin n linii mari i n prezent cu unele
modificri impuse de apariia unor noi forme de osteomielit cronic.
Analiza corelaional demonstreaz diferenele semnificative ce apar ntre
formele clinice de osteomielit hematogen i aspectele evideniate radiologic, aspect
demonstrat de valoare statisticii Chi-ptrat (2=113.06, p<<0.05, 95%CI) i de valoare
mare a coeficientului de corelaie neparametric (r=0.86, p<<0.05, 95%CI).
Radiologic cele mai importante aspecte evideniate au fost osteoliza
metafizar In cazul osteomielite acute hematogene (59.04% din cazurile de OHA). n
cazul osteomielitei subacute hematogene i a celei cronice radiografia a evideniat
ntr-o proporie foarte mare abcesul Brodie (68.2% - n osteomielit subacut
hematogen i 54.5% - n cazul osteomielitei cronice).
28
Osteomielita hematogen
Forma clinica vs.
rezultat radiologic
Osteomelita acuta
hematogena
80%
70%
Osteomielit subacut
hematogen
Osteomielit cronic
68.22%
59.04%
60%
54.55%
50%
40%
24.10%
30%
20%
10%
0%
16.88%
14.46%
11.21%
14.29%
13.08%
Osteoliza
metaf
9.09%
Abces
subperiostic
7.48%
Osteoperios
tita
5.19%
2.41%
Abces
Brodie
Sechestru
osos
2.41%
Osteomelita acuta
hematogena
59.04%
24.10%
14.46%
0%
Osteomielit subacut
hematogen
13.08%
11.21%
7.48%
68.22%
0%
Osteomielit cronic
14.29%
9.09%
16.88%
54.55%
5.19%
Osteomielita hematogen
32.47%
29%
Trat.chirg simplu
19%
44.16%
Lot B (aduli)
Lot A (copii)
9.35%
35.51%
Osteomielit subacut
hematogen
86.75%
13.25%
0.00%
Osteomelita acuta
hematogena
0%
20%
40%
60%
80%
100%
120%
53.04%
28.95%
26.96%
20.00%
9%
Osteomielit cronic
55.14%
62.50%
39%
1%
23.38%
Lot A (copii)
59%
Lot B (aduli)
8.55%
Tratament
Medicamentos
(ANTIBIOT)
62.50%
Trat.chirg simplu
53.04%
Plombarea Cavit cu
mat.
28.95%
8.55%
20.00%
26.96%
Osteomielita hematogen
Osteomielita hematogen
Osteomelita acuta
hematogena
Osteomielit subacut
hematogen
Osteomielit cronic
89%
76.64%
79%
69%
59%
49%
38.55%
39%
29%
19%
29.87%
21.69%
15.66%
20.78%
9%
1%
21.69%
20.78%
19.48%
9.09%
5.61%
11.21%
2.80%
1.87%
0.93%
RX
ECO
RX+ECO
CT
RMN
Scitigrafie
Biopsie
Osteomelita acuta
hematogena
38.55%
15.66%
21.69%
2.41%
0.00%
21.69%
0%
Osteomielit subacut
hematogen
11.21%
76.64%
5.61%
0.93%
0.93%
1.87%
2.80%
Osteomielit cronic
20.78%
0%
19.48%
9.09%
29.87%
20.78%
0%
Fig.36. Aspect radiologic de osteomielit subacut la nivelul 1/3 inferioare tibie dreapt (fa)
Lot B (aduli)
Lot A (copii)
54.61%
49%
39%
29%
19%
23.48%
21.74%
21.71%
9%
1%
Lot B (aduli)
Lot A (copii)
RX
21.71%
23.48%
18.26%
6.09%
10.43%
9.21%
ECO
54.61%
10.43%
RX+ECO
9.21%
21.74%
1.97%
CT
1.97%
6.09%
Fig. 37. Aspect radiologic de osteomielit subacut tibie, 1/3 inferioar complicat cu artrit
septic la nivelul glezn dreapt. (profil)
19.13%
1.32%
1.97%
RMN
1.97%
18.26%
9.21%
Scitigrafie
9.21%
19.13%
0.87%
Biopsie
1.32%
0.87%
Osteomielita hematogen
Osteomielita hematogen
Forma clinica vs.
etiopatogenie
60%
Osteomelita acuta
hematogena
60.24%
Osteomielit subacut
hematogen
Osteomielit cronic
58.88% 57.14%
50%
40%
30%
14.46% 14.02%
20%
10.84% 10.28%
7.23%
10%
9.09%
0%
6.02%
6.54%
5.19%
5.19%
2.60%
0%
10.39%
1.20%
0%
0%
0%
0%
0%
0%
10%
Lot B (aduli)
Lot A (copii)
60.00%
57.89%
50%
40%
30%
20%
10%
0%
13.82%
11.30%
9.87%
4.35%
1.74%
7.83%
1.97%
1.97%
3.48%
0.66%
4.61% 3.95%
0%
0.87%
4.35%
3.29%
0%
6.09%
1.32%
0.66%
10%
Fig. 39. Aspect radiologic osteomielit cronic la nivelul metafizei distale a femurului stng
(plombarea cavitii restante cu granule de gentamicin) vedere profil
ETIOPATOGENIE
Distribuia cazurilor de osteomielit hematogen n funcie de
etiopatogenie
Frecvena rezultatelor etiopatogenice n funcie de formele clinice ale
osteomielitelor hematogene sunt prezentate n studiul urmtor i evideniaz o serie de
diferene ce apar n funcie de formele OH.
33
34
Osteomielita hematogen
Osteomielita hematogen
literatur se prezint faptul c 85% din mbolnviri apar pn la 16 ani (un vrf de
frecven sub 2 ani i al doilea ntre 8 si 12 ani). n lotul de studiu s-a remarcat
frecvena ridicat a osteomielitei subacute hematogene i a osteomielitei acute cu o
frecven mai sczut pentru osteomielita cronic.
2. Analiza vrstei n funcie de forma clinic a diagnosticului din lotul de studiu
demonstreaz prezena diferenelor semnificative, astfel n cazul osteomielitei cronice
vrsta prezint valori semnificativ mai mari, cele mai mici valori ale vrstei
regsindu-se la pacienii cu osteomielit subacut hematogen.
3. n cazul osteomielit cronice hematogene ponderea sexului masculin este
comparabil cu cea a sexului femin, ns diferene semnificative apar pentru
osteomielit subacut hematogen situaie n care cel mai frecvent este ntlnit sexul
masculin. Referitor la vrsta medie a pacienilor de sex feminin se constat c aceasta
nu difer semnificativ de vrsta pacienilor de sex masculin, remarcndu-se doar o
valoare uor crescut a vrstei pacienilor de sex masculin.
4. Distribuia cazurilor n funcie de lotul de studiu i mediul de provenien al
pacienilor cu osteomielit hematogen evideniaz o frecven mai mare a cazurilor
n mediul rural comparativ cu mediul urban la aduli, n timp ce la copii nu apar
diferene semnificative frecvena cazurilor n mediul urban fiind comparabil cu cel
rural.
5. n cazul osteomielitei acute hematogene localizarea la nivelul epifizei este
foarte rar ntlnit, aceast localizare se regsete mai frecvent n osteomielita
subacut hematogen. Osteomielita cronic i cea acut se ntlnesc cel mai frecvent
la nivelul diafizei sau metafizei.
6. Analiza distribuiei cazurilor n funcie de localizare i sexul pacienilor
evideniaz prezena localizrii pe diafiz sau metafiz mai frecvent la sexul feminin,
n timp ce la pacienii de sex masculin aceast localizare este regsit ntr-o pondere
mai mic a cazurilor.
7. Studiul localizrii la nivelul scheletului a evideniat frecvena mare a
cazurilor cu localizare la nivelul tibiei i a femurului din cadrul oaselor lungi, iar din
categoria oaselor scurte ce mai frecvent localizare a fost ntlnit la nivelul coloanei
vertebrale. S-a remarcat de asemenea prezena foarte rar la nivelul calcaneului.
8. Referitor la distribuia la nivelul oaselor lungi comparativ cu oasele scurte se
remarc urmtoarele: la nivelul oaselor lungi se regsesc cel mai frecvent formele
subacute n timp ce la nivelul oaselor scurte se regsesc formele cronice.
9. Rezultatele analizei localizare vs. form clinic ne indic ponderea mare a
cazurilor cu osteomielit acut hematogen localizat la nivelul humerusului sau
cubitus/radius n timp ce la nivelul tibiei cel mai frecvent a fost ntlnit forma de
osteomielit hematogen subacut iar la nivelul femurului forma acut a avut o
pondere asemntoare.
10. Referindu-ne la oasele scurte ale scheletului am constatat c cel mai frecvent
osteomielita subacut hematogen este localizat la nivelul calcaneului. Trebuie avut
n vedere ns numrul mic de cazuri cu aceast localizare (1 caz). Osteomielita
subacut hematogen este regsit de asemenea frecvent la nivelul pelvisului i al
coloanei vertebrale.
35
36
Osteomielita hematogen
Osteomielita hematogen
Fig.45. Osteit leziuni osteitice cronice cu lamele osoase i esut conjunctiv tnr
Col. hematoxilina eozina, x 100
Cronicizare infeciei duce la formarea de esut conjunctivo-vascular de
neoformaie bogat celularizat, avnd numeroase fibroblaste, capilare de neoformaie,
care umple defectele osoase determinate de procesul inflamator. Evoluia leziunilor
este spre maturarea esutului conjunctiv intramedular cu fibroz.
Osteomielita hematogen
Osteomielita hematogen
39
40
Osteomielita hematogen
Osteomielita hematogen
41
Osteomielita hematogen
Osteomielita hematogen
43
Fig.56. Osteomielit cronic- esut fibros moderat inflamat situat n jurul unor lamele
osoase cu leziuni necrotice- Coloratie Van Gieson x 100)2.5. Discuii- aspecte de etic i deontologie medical privind
osteomielita hematogen
Aspectele de etic i deontologie medical care pot fi luate n discuie n
cazul osteomielitei hematogene sunt n general aceleai ca n cazul oricrei alte
afeciuni medicale ce implic stabilirea unei relaii medic-pacient, relaie din care
deriv dou noiuni extrem de importante pentru practica medical: consimmntul
informat i confidenialitatea.
Complexitatea valorilor implicate, statutul medicului n societate i
implicarea pacientului n procesul decizional pot determina apariia unor multiple
controverse, dileme, interogaii, toate acestea conferind relaiei medic pacient o
ncrctur moral deosebit.
La baza relaiei medic-pacient st noiunea de respect a persoanei cu cele
dou faete ale sale: respectul ca i comportament i respectul ca i atitudine. Un alt
44
Osteomielita hematogen
Osteomielita hematogen
45
46
Osteomielita hematogen
Osteomielita hematogen
practica medical: Un doctor va pstra secretul absolut asupra a tot ceea ce cunoate
despre pacient datorit ncrederii ce i s-a acordat.
Referitor la acest aspect legea drepturilor pacientului din Romnia stipuleaz:
Toate informaiile privind starea pacientului, rezultatele investigaiilor, diagnosticul,
prognosticul, tratamentul, datele personale sunt confideniale chiar i dup decesul
acestuia [189].
Totui confidenialitatea nu este absolut. Dei respectul confidenialitii i
autonomia pacientului reprezint fundamentul relaiei medic-pacient, exist situaii
cnd acestea sunt neglijate din anumite considerente morale. Situaiile ce implic o
restricionare a confidenialitii sunt cele care implic un risc public, o potenial
vtmare pentru ceilali sau necesit resurse speciale, care nu pot fi alocate.
Legea romneasc a drepturilor pacientului prevede situaii care sunt
exceptate de la regula confidenialitii excepii- cazurile n care pacientul reprezint
pericol pentru sine sau pentru sntatea public. Astfel c dreptul pacientului la
confidenialitate este contrabalansat de beneficiul pentru comunitate. n prezent,
potrivit unui acord ntre medici, legiutori i specilitii n bioetic, binele individual al
unui pacient este amendat n favoarea binelui comunitii, ceea ce permite o nclcare
a confidenialitii, cu meniunea ca aceasta s stea la baza preveniei unui ru
semnificativ.
Putem concluziona c n medicin confidenialitatea este un principiu de baz
dar trebuie individualizat de la caz la caz.
Chirurgia este una dintre specialitile care se confrunt cel mai des cu
anumite principii de etic, n special consimmntul, n baza cruia este realizat
intervenia chirurgical. Diferenele care apar la aduli fa de copii sunt cele date de
faptul c minorii sub 18 ani nu pot decide singuri, fiind necesar acordul prinilor,
tutorilor sau autoritilor tutelare, de la caz la caz. Exist situaii, vrsta peste 16 ani,
n care se comunic i copilului necesitatea unei intervenii chirurgicale i n ce va
consta ea, dar decizia final revine tot prinilor.
n cazuistica analizat n cele dou Clinici de Ortopedie din totalul de 267
cazuri analizate, 111 au fost supuse interveniei chirurgicale. Dintre acestea 54 cazuri
au fost aduli i 57 copii. La 67 dintre cazuri a fost tratament chirurgical simplu i doar
44 cazuri au beneficiat de tratament chirurgical cu plombarea cavitii restante cu
substitueni osoi.
La toate cazurile supuse unei intervenii chirurgicale a existat n prealabil
acordul pacientului sub forma consimmntului informat, cu precizarea c nu n toate
cazurile acesta s-a fcut pe formulare speciale de consimmnt (n special la cazurile
din prima perioad a statisticii analizate), el fiind regsit pe foaia de observaie clinic,
anterior protocolului operator.
La cazurile internate n Clinica de Pediatrie s-a respectat protocolul obineri
consimmntului de la prini.
Doar 19 cazuri (11aduli i 8 copii) au necesitat biopsie n vederea stabilirii
unui diagnostic cert i la toate s-a luat n prealabil acordul pacientului la aceast
intervenie.
47
48
Osteomielita hematogen
Osteomielita hematogen
49
50
Osteomielita hematogen
Osteomielita hematogen
51
52
Osteomielita hematogen
Osteomielita hematogen
53
54
Osteomielita hematogen
arat extinderea procesului patologic n esuturile moi din jur, punnd sub semnul
ntrebrii existena unei tumori cu celule gigante.
Diagnosticul a fost de: Osteomielit pseudotumoral 1/3 medie coaps
dreapt.
Se intervine chirurgical prin incizia periostului care pune n eviden semnele
de infecie (osul este alb, sclerotic fr semne de invazie tumoral). Ulterior se
practic lavaj i drenaj aspirativ cu Cefalexin- Gentamicin i plombare cavitii
restante cu Ceraform n vederea unei reconstrucii osoase ct mai rapide. A necesitat
imobilizarea gipsat a membrului. Examenul anatomo-patologic i culturile de esuturi
au pus n eviden stafilococul sensibil la meticilin.
Ulterior s-a continuat antibioterapia cu Pefloxacin, recuperarea fiind bun
dup 3 luni de tratament, pacientul prezentnd o atrofie moderat a musculaturii
coapsei drepte i uoar redoare de genunchi. Evoluia spre cronicizarea afeciunii.
7. Pacienta O.D., n vrst de 47 ani se adreseaz specialistului ortoped
pentru dureri la nivelul coapsei drepte i genunchiului drept de aproximativ o lun,
astenie, scdere n greutate. Iniial durerile cedau n repaus, progresiv ele devenind
permanente. La internare examenul clinic pune n eviden la inspecie uoar
deformare n regiunea inferioar coaps dreapt, fr modificarea aspectului
tegumentelor n acea zon, durere la palpare, impoten funcional moderat a
membrului inferior drept.
Diagnosticul la internare: Osteomielit subacut metafiz distal femur
drept.
Examenul radiologic precizeaz: opacitate neomogen alternnd cu osteoliz
metafiz inferioar femur drept. Suspiciunea unei formaiuni tumorale impune biopsia
chirurgical. Care pune n eviden aspectul de condrom metafiz distal femur dreptmalignizare.
8. Pacientul H.P. n vrst de 47 ani acuz de cteva sptmni dureri la
nivelul coapsei stngi, cu iradiere n genunchi, ce fac dificil sprijinul pe membrul
inferior stng i mersul. Starea general puin influenat, afebril, astenie marcat.
Radiografia pune n eviden aspectul se imagine litic osoas la nivelul
metafizei distale femur drept, cu reacie periostic, hiperostoz cortical, prezena
sechestrului osos.
Diagnosticul este: Osteomielit cronic metafiz distal femur stng,
fistulizat.
Se intervine chirurgical practicndu-se: asanarea focarului de osteomielit,
fistulectomie, trepanoevidare, sechestrectomie, chiuretaj, lavaj. Ulterior se realizeaz
plombarea defectului osos cu granule de PMMA- gentamicin.
Evoluia ulterioar relativ bun.
55
Osteomielita hematogen
Osteomielita hematogen
Osteomielita hematogen
Osteomielita hematogen
i ntr-un caz s-a efectuat computer tomografie; nici un caz nu a fost investigat RMN
i nici testat HIV.
Complicaiile cele mai frecvente au fost de tipul artrozei i un caz de fractur
pe os patolgic; nu au fost nregistrate tulburri de cretere n cazul pacientului de 17
ani, nici anterior diagnosticrii nici ulterior instituirii tratamentului.
Tratamentul a respectat trepiedul chirurgie- antibioterapie- imobilizare (4
cazuri). Dei n literatura de specialitate nu toi autorii sunt de acord cu aceast ordine,
chirurgia fiind rezervat cazurilor ce nu rspund la tratament medicamentos, cazurile
rezolvate n clinic au beneficiat toate de intervenie chirurgical de la nceput.
Intervenia chirurgical a vizat incizie, chiuretaj, lavaj, drenaj instilatoraspirativ cu Cefalexin- Gentamicin. S-a mai utilizat Pefloxacin i Augmentin.
Un caz complicat cu fractur a beneficiat de reducerea acesteia i
introducerea de tije Ender i un caz a necesitat plombarea cavitii restante cu material
de substituie osoas (CERAFORM).
Concluzii:
1.Osteomielita subacut hematogen la adult rmne n continuare dificil de
diagnosticat, n ciuda metodelor moderne de imagistic datorit aspectelor care pot
evoca o formaiune tumoral osoas.
2. Aspectele radiologice la adult nu difer esenial fa de copil.
3. Posibilitatea existenei unei confuzii cu o tumor osoas benign sau
malign presupune realizarea unui diagnostic diferenial ceea ce impune efectuarea
biopsiei chirurgicale nu doar n scop diagnostic ci i terapeutic (excizie- chiuretaj).
4. Apariia acestei forme relativ noi, se datoreaz utilizrii pe scar larg a
antibioterapiei, introducerea n practica uzual a vaccinrilor cu implicaii imediate n
ceea ce privete rezistena organismului gazd (care scade) i a germenilor patogeni (a
cror rezisten la antibioterapie crete).
5. Spre deosebire de formele de osteomielit subacut aprute la copii sau
adolesceni, cele ale adultului prezint anumite particulariti, datorit conexiunilor
realizate ntre sistemul vascular metafizar i cel epifizar prin dispariia cartilajului de
conjugare:
- inciden mai sczut (doar 10% din totalul osteomielitelor), stafilococul
negsind condiii prielnice de dezvoltare;
- apariia relativ frecvent a artritelor din seria complicaiilor;
- raritatea decolrilor periostale ntinse i a sechestrelor masive (periostul
fiind fibrozat i aderent la corticala osoas).
6. Tomografia computerizat i mai ales RMN-ul permit o mai bun
vizualizare a extinderii leziunilor la prile moi, precum i analiza unor localizri
atipice sau profunde. Scintigrafia arat o hiperfixaie care nu se regsete la tumori.
7. Tratamentul a fost n principiu chirurgical (excizie- chiuretaj- plombaj
eventual) asociat cu antibioterapia adaptat fiecrui caz n parte.
59
Osteomielita hematogen
CAPITOLUL III
CONSIDERAII BIOMECANICE CU PRIVIRE LA
FOLOSIREA SUBSTITUIENILOR OSOI N
TRATAMENTUL OSTEOMIELITELOR
n acest capitol se va face o evaluare a strii de tensiuni care apare le nivelul
unui femur afectat de osteomielit i a distribuiei eforturilor unitare atunci cnd, n
urma unei intervenii chirurgicale care presupune ndeprtarea esutului infectat, se
introduce substitut osos. Comparaia dintre cele dou cazuri demonstreaz un
beneficiu biomecanic deosebit de important al substitutului osos asupra osului ce se
afla n proximitatea zonei infectate.
3.1. Evaluarea biomecanic, histologic i histo-morfometric n studiul
substituenilor osoi;
Evaluarea biomecanic a rezistenei mecanice a osului permite studiul
comportamentului osului la ncrcare prin intermediul curbei de ncrcare- deformare
avnd rol important n vindecarea osoas. Pentru realizarea acestui studiu este necesar
calculul unor parametri cum ar fi: rezistena mecanic a osului, ncrcarea maxim
care conduce la fractur i energia necesar pentru producerea fracturii [215].
1.
Rezistena mecanic a osului este dat de raportul ncrcare (for) /
deformare (distan).
2.
Energia necesar producerii fracturii reprezint aria de sub curba de
ncrcare deformare pn n momentul producerii fracturii.
Aceti parametri au valori diferite n funcie de tipul, direcia i modul de ncrcare.
Pentru a aprecia comportamentul vscoelastic al osului se efectueaz o serie de teste
biomecanice. Acestea se realizeaz n funcie de:
3.
direcia de testare: a. Prin ncovoiere, b. Prin torsiune, c. Prin compresie;
4.
dup tipul de ncrcare: a. De distrucie, b. De oboseal;
5.
dup modul de ncrcare: a. Controlul forei (ncrcrii), b. Controlul
deplasrii.
Examenul histologic i histomorfometric se refer la rspunsul celular de la
interfaa cu materialul de studiu i vine n completarea evalurii biomecanice. n
studiul esutului osos i al vindecrii osoase se utilizeaz mai frecvent ca metode de
preparare, fixare i colorare urmtoarele tehnici: coloraia intravital, histologia
clasic, examinarea histologic calitativ, examinarea histologic cantitativ
(histomorfometric).
Coloraia intravital presupune injectarea colorantului n animalul de studiu
succedat de fixarea colorantului, fie de componenta organic fie de cea mineral a
esutului osos. Preparatele recoltate de la animalul de studiu pot fi studiate fie
nedecalcifiate, fie decalcifiate n prealabil dup care se analizeaz n microscopia
optic cu lumin ultraviolet. Se analizeaz frontul de mineralizare reprezentat de
60
Osteomielita hematogen
Osteomielita hematogen
linia de fixare a colorantului de esutul osos nou format. Se pot obine mai multe
fronturi de mineralizare, prin introducerea de colorani intravitali la intervale de timp
diferite, putndu-se calcula astfel rata de formare osoas. Ca i colorani intravitali se
utilizeaz mai frecvent pentru preparatele decalcifiate tetraciclia, calceina i xilenolul
orange, iar pentru preparatele decalcifiate cel mai adesea acetatul de plumb.
Examinarea histologic calitativ a probelor de esut osos are drept scop evidenierea:
- locului de apariie i a caracterelor morfologice ale esutului osos nou format
(esut osteoid);
a zonelor de formare (osteoblaste) i resorbie osoas (osteoclaste);
- a zonei de interfa dintre esutul osos mineralizat i cel nemineralizat (continu
sau discontinu);
- a zonei de interfa dintre esutul osos i implantul (metalic sau ceramic) prin
prezena sau absena esutului fibros colagen) sau a celui inflamator (celule
macrofage polinucleate); [86].
- rspunsul materialului implantat (inerie, biocompatibilitate, biorezorbabilitate).
Examinarea histologic cantitativ (histomorfometric) const n msurarea
mai multor parametri cum ar fi: a.creterea osoas n aria defectului,
b. creterea osoas n volumul porului,
c. gradul de acoperire cu os al implantului,
d. grosimea stratului de esut osos de apoziie al implantului.
Cele dou metode care stau la baza tehnicilor de histomorfometrie osoas
sunt: metoda numrrii punctelor(point counting analysis) i metoda interseciei
liniare (linear intercept analysis). Parametrii urmrii prin utilizarea tehnicilor de
histomorfometrie sunt:
1. creterea osoas n interiorul implantului (bone in-growth),
2. acoperirea osoas a implantului (bone on-growth),
3. rata de apoziie osoas (rata de cretere osoas),
4. rata de resorbie a implantului [215].
Creterea osoas n interiorul implantului este utilizat pentru studiul
efectului pe care l are diametrul porilor asupra osteointegrrii implantului i
reprezint de fapt o evaluare a osteoconductivitii acestuia.
Acoperirea osoas a implantului msoar interfaa dintre implant i esutul
gazd. Rata de apoziie osoas se poate aplica att la creterea osoas n interiorul
implantului (pentru implantele poroase), ct i la cea de acoperire osoas a acestuia
pentru implantele bloc sau granulare. Rata de resorbie a implantului se aplic pentru
evaluarea implantelor biorezorbabile. Modelul ideal de implant trebuie s asigure o
cretere osoas rapid on-growth urmat de rezorbia rapid a implantului i apoziia
osoas simultan astfel nct s nu se formeze spaii ntre implant i osul nou format
[215]. Gradul de prezervare a esutului recoltat i grosimea probelor studiate sunt
criterii eseniale de care depinde valoarea examenului histomorfometric, prezervarea
tisular presupunnd aceeai osmolaritate i acelai ph pentru soluiile utilizate.
n cazuistica celor dou clinici de chirurgie, analizat n capitolul de
statistic, distribuia cazurilor a fost urmtoarea: 267 de cazuri de osteomielit
hematogen. Distribuia cazurilor copii:
din 152 cazuri: OAH 43 cazuri, OSH 94 cazuri, OC 15 cazuri
Distribuia cazurilor aduli:
din 115 cazuri aduli: OAH (OSTEOMELITA ACUTA HEMATOGENA) 40
cazuri, OSH (OSTEOMIELITA SUBACUTA HEMATOGENA) 13 cazuri, OC
(OSTEOMIELITA CRONICA) 62 cazuri.
.
Fig.60. Fronturi de mineralizare
(os nou) n coloraie intravital
cu xilenol-orange.[215]
)
61
62
Osteomielita hematogen
Osteomielita hematogen
63
Osteomielita hematogen
Osteomielita hematogen
Fig. 65. Variaia unghiurilor de flexie extensie, abducie aducie i rotaie internextern pe parcursul a trei cicluri de mers.
3.2.2. Elemente de dinamic
Pentru nceput se evalueaz forele ce acioneaz asupra femurului drept n
timpul mersului, lund n consideraie punctele de inserie ale muchilor [2] i,
implicit, direciile de aciune ale forelor.
65
Rx Ax A sin 30o
(2)
66
Osteomielita hematogen
Ry Ay G Gc
(3)
A cos 30o G Gg
Rx R sin 21o
(4)
Ry R cos 21o
(5)
R Rx2 Ry2
(6)
Osteomielita hematogen
AS
bmers
a
(9)
S
Gcorp
R
GCorp
(10)
unde s este fora de reaciune adimensional, iar r este fora rezultant adimensional
de la nivelul capului femural.
Fig.68. Balana lui Pauwels
(7)
67
68
Osteomielita hematogen
Osteomielita hematogen
70
Osteomielita hematogen
Osteomielita hematogen
Osteomielita hematogen
Osteomielita hematogen
volume sunt n contact este foarte important ca la contactul dintre dou structuri (pe
suprafeele de contact) nodurile s se suprapun perfect. Tipul de element folosit
pentru aceast discretizare este brick. Se observ faptul c s-a ales o densitate de
mesh-are mare, ceea ce duce, implicit la micorarea elementelor de volum, dar i o
analiz n element finit mai precis.
Cu acest ultim pas s-a ncheiat sinteza geometric a structurii, finalizarea
demonstrnd faptul c a fost realizat o sintez geometric foarte apropiat de cea
real.
calculat fora medie. Valorile forei medii, ale deformaiei, ale grosimii medii i ale
suprafeei medii au fost introduse n relaia (1) rezultnd, n final un ir de valori ale
modulului de elasticitate. S-a trasat curba a modulului de elasticitate n funcie de fora
aplicat pentru fiecare material n parte (figura 80), deoarece valoarea modulului de
elasticitate al substitutului osos are influen asupra osului cu care vine n contact, la o
anumit for aplicat.
F h
E
S h
(1)
E [MPa]
65
60
55
50
45
40
35
30
25
20
0
500
1000
1500
2000
2500
F [N]
E k F rezult k
h
.
S h
h
c
c . Panta curbei modulului de elasticitate k devine k
, iar modulul de
S
h
elasticitate poate fi scris ca:
c
F
h
(2)
73
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Osteomielita hematogen
Osteomielita hematogen
e) Sinteza reazemelor
Reazemele (locul de sprijin) se consider a fi pe suprafaa condililor
femurali, i reprezint fore de reaciune ale forelor musculare care acioneaz pe
femur (figura 81, figura 82).
3.4.1. Analiza n element finit a strii de tensiuni de deformaii specifice i
deplasri care apar la nivelul femurului normal
Odat parcurse toate etapele premergtoare analizei cu element finit, se d
comanda analyse, rezultatul distribuiei de tensiuni putnd fi vizualizat n figura 84.
76
Osteomielita hematogen
Osteomielita hematogen
78
Osteomielita hematogen
Osteomielita hematogen
Fig.88. Distribuia de tensiuni pentru un femur tratat cu substitute osos (n stnga este
reprezentat un detaliu)
Procedndu-se, ca i n cazul anterior, la o secionare a femurului pentru zona
cu substitut osos, se poate observa c osul adiacent substitutului este ncrcat,
rezultnd, astfel, tensiuni mai mari la nivelul acestuia i mai mici pe substitut (figura
89).
3.5. Comparaie ntre starea de tensiuni pentru cele trei cazuri enunate
anterior
Se iau n discuie cele trei cazuri analizate anterior.
n figura 90, sunt ilustrate detaliile din figurile 84, 85 i 88 (detalii care
cuprind zona n care se afl infecia osoas) i mesh-ul femurului infectat, pentru a se
putea face o coresponden corect ntre distribuia de tensiuni a fiecrui caz analizat
i poziionarea volumului infectat (ulterior a zonei cu substitut osos).
79
80
a.
b.
c.
2.
a.
b.
c.
3.
Osteomielita hematogen
Osteomielita hematogen
Induce la nivelul osului adiacent infeciei tensiuni mai mici dect n cazul
osului sntos;
Tensiunea mai mic, presupune existena unor deformaii mai mici ale osului
adiacent infeciei, o circulaie ineficient a fluidului prin canalicule i, n
consecin, o remodelare osoas ineficient, cu reducerea rezistenei
mecanice a osului;
ncrcarea ineficient a osului adiacent infeciei osoase poate duce la fractura
femurului n zona infectat, tiut fiind faptul c solicitrile complexe care
apar la nivelul unui os lung duc la apariia unor tensiuni mari, mai ales in
zona diafizei osului;
Distribuia de tensiuni pentru un femur tratat cu substitut osos:
Induce la nivelul osului adiacent substitutului tensiuni cu aceleai valori ca i
n cazul femurului normal, dar cu o arie de aciune mai mare;
Existena unei tensiuni fiziologice, presupune o remodelare corect a osului
n zona considerat;
Substitutul osos are n componen hidroxiapatit, ceea ce ofer o baz pentru
reconstrucie osoas i n regiunea care a fost infectat;
Din cele enunate anterior, se poate trage concluzia c nlocuirea deficitului
osos consecutiv unei osteomielite subacute sau cronice cu material de
substituie este benefic, mai ales din punctul de vedere al comportrii
biomecanice a osului.
82
Osteomielita hematogen
83
Osteomielita hematogen
Osteomielita hematogen
Osteomielita hematogen
85
86
Osteomielita hematogen
Osteomielita hematogen
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
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osteomyelitis, J.Pediatr.Orthop., 1993, 13:766-8.;
Abaev Iuk, Shved IA., Kletskii SK- Subacute and primary- chronic osteomyelitis in children. Vestn Kir. Im Grek.
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Abaev Iuk- Fetal osteomyelitis. Vestn Khir Im Grek.2008; 167 (4): 56-60;
Adams Baum C., Kalifa G.- Osteitis and osteomyelitis:a too quickly forgotten diagnosis in children-Ann Pediatr
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