- Rhomberg M.
- Frischhut B.
- Ninkovic M.
- Schwabegger A.H.
- Ninkovic M.
2. Materials and methods
2.1 Treatment protocol
- (1)Detection. In order to estimate the spread of an abscess as closely as possible, contrast-enhanced computed tomography (CT) should be performed. If osteomyelitis is suspected, magnetic resonance imaging (MRI) should be performed to estimate the spread of osteomyelitis in detail.
- (2)Design. First, the spread of the infection is estimated in detail from the imaging findings (Fig. 2A and B). Based on this, the arrangement of the dual-lumen tube (Salem Sump Tube™, Cardinal, unknown) and the position of insertion of the bone marrow needle (Tohoku University bone marrow puncture needle; Senko Medical Instrument Manufacturing Co., Tokyo, Japan) are determined.
- (3)Defense of the tissue. In surgery, all procedures should be performed in a protective manner to prevent further invasion of the tissue (Fig. 2C). The tissue that is clearly not biologically active is removed, and the bone marrow needles and dual-lumen tubes are placed to be as minimally invasive as possible, based on preoperative examination. To avoid obstruction during treatment, we inserted a dual-lumen tube with the largest possible diameter, depending on the size of the dead space. At this point, if there is a fracture, internal fixation should be performed to obtain enough fixation according to the principles of fracture treatment. Performing osteosynthesis during the first operation stabilizes the bone and protects the surrounding tissue.
- (4)Do thoroughly. For 14 days after surgery, gentamicin (60 mg/50 cc) is continuously administered at a low flow rates (2 mL/h) by a syringe pump through the bone marrow puncture needles and dual-lumen tubes. Of course, there are parts (in the blood and outside the surgical field) where antibiotics do not reach sufficiently with CLAP; therefore, systemic administration of antibiotics based on drug sensitivity is often necessary. If there are remaining signs of infection or wound healing problems, Steps 1–4 are repeated thoroughly until Step 5 is reached.
- (5)Disappearance of signs of infection. The goals of CLAP are wound closure and improvement of clinical findings, such as redness, tenderness, spontaneous pain, exudate, and fever (Fig. 2D). We prioritized clinical findings and C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), which are markers of inflammation that are generally considered to be proportional to the degree of infection [], were used only as a reference finding. We comprehensively evaluated wound healing, clinical symptoms, and CRP/ESR, and considered the termination of antibiotic administration.
2.2 Surgical procedure
2.2.1 Intra-soft-tissue antibiotic perfusion
2.2.2 Intramedullary antibiotic perfusion
2.2.3 Dead space management
2.3 Postoperative management
|Case||Sex||Age (years)||Country of birth||Underlying conditions||Positive culture||Site of infection||Treatment period (days)||Maximum gentamicin blood concentration (μg/dL)||Additional surgery||Sequelae|
|1||Male||47||Japan||None||Femoral abscess, lower leg abscess||Liver, lungs, femur, lower leg||61||1.9||Iliac bone graft||–|
|2||Female||47||Philippines||Diabetes mellitus||Blood, stool, talar, tibia||Sepsis, femur, tibia, fibula, talar, ankle joint||43||1.6||–||Ankle osteoarthritis|
|3||Female||72||Japan||Diabetes mellitus, obstructive arteriosclerosis, chronic renal failure||Blood, lower leg abscess||Septic shock, superior mesenteric artery, lower leg||43||0.8||Wound closure||–|
|4||Female||46||Japan||SLE||Blood, buttocks abscess||Septic shock (cardiopulmonary arrest), buttocks abscess||30||1.9||Wound closure||Higher brain dysfunction|
3.1 Case presentation
3.1.1 Case 1
|Postoperative days (week)||−1||0||1||2||3||8||12||36||48||120|
|Events during treatment||Transfer to our hospital||first operation||end of CLAP||discharge from hospital Change to oral antibiotics||end of oral antibiotics||before bone grafting||final follow up|
3.1.2 Case 4
Declaration of competing interest
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