Evaluating the efficacy of combined flap coverage, antibiotic-loaded bone cement and negative pressure irrigation in traumatic osteomyelitis management

Abstract

We recently read with great interest by Cong et al.¹ about evaluating the efficacy of combined flap coverage, antibiotic-loaded bone cement and negative-pressure irrigation in traumatic osteomyelitis management. The article effectively highlighted a synergistic strategy that integrated skin flap coverage, antibiotic bone cement and negative-pressure irrigation for the treatment of traumatic osteomyelitis. This multifaceted approach not only tackled the bone infection but also addressed the associated soft tissue defects, providing a holistic solution to this intricate medical issue. However, there are some shortcomings from our perspective.

First, the article did not detail the outcomes of bacterial cultures and drug sensitivity tests for patients with traumatic osteomyelitis in both groups. This information was crucial for understanding the treatment strategy. The selection and application of sensitive antibiotics were pivotal in the successful management of osteomyelitis. Drawing from our clinical experience, employing bone cement impregnated with antibiotics sensitive to the causative bacteria (Gram positive or Gram negative) could enhance therapeutic efficacy. And the authors mentioned that antibiotics were mixed with bone cement at a 1:5 ratio, tailored to the patient's specific condition. Given that the dosage–response relationship varies among different antibiotics, it is essential to customize the mixing ratios of sensitive antibiotics with bone cement rather than adhering to a one-size-fits-all ratio.²

Second, the pre-treatment soft tissue defect areas were 11.5 ± 1.5 (cm²) and 11.4 ± 1.4 (cm²) in the control and observation groups, respectively. To address such extensive soft tissue defects, it was important for readers to know whether the authors utilized a pedicled or a free flap.³ However, the article lacked specifics regarding the method and type of flap harvesting, as well as the location of the donor sites. This information was crucial for understanding the repair protocol. The remaining area of the wound after one month of treatment left readers feeling puzzled. The authors reported that the soft tissue defect areas one month post-treatment were 9.3 ± 1.0 (cm²) and 7.4 ± 1.0 (cm²) in the control and observation groups, respectively. It was perplexing why there remained a significant soft tissue defect area after skin flap repair. In our surgical practice, we typically employed skin flap transfer to cover all soft tissue defects to ensure the treatment objectives were met. Additionally, the article did not enumerate the body parts affected by traumatic osteomyelitis. The location of lesions (the superior, middle or inferior segment of the limbs) could influence treatment outcomes.

Third, there were a subset of patients in both groups who did not respond effectively to the treatment, showing signs such as inadequate wound healing, partial necrosis of the skin flap, noticeable exudate and localized inflammation with symptoms like redness, swelling, heat, pain and the presence of an unclosed sinus tract. Because we have encountered these same issues in our clinical practice, we are particularly interested in learning how the authors proceeded with the management of these patients. If the authors could provide additional details on the treatment methods used for these cases within the article, it would offer us substantial guidance and insight.

In conclusion, addressing the aforementioned issues would certainly elevate the overall quality of the article and increase its appeal to a wider readership.

The authors declare no conflicts of interest.