Comparative analysis of the efficacy of drip drainage surgery and bone cement placement surgery in the treatment of haematogenous osteomyelitis of the extremities

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Method: Information on 129 Hematogenic osteomyelitis (HO) patients, 67 treated with bone cement placement surgery and 62 with drip drainage surgery, was collected from January 2015 to January 2023. Baseline data, osteomyelitis classification, and clinical regression were compared between the two groups, with a mean follow-up of 2 years. Result: Bone cement placement surgery had a higher infection control rate than drip drainage surgery (94% vs. 82.3%, P <0.001), and the EuroQol five-dimensional questionnaire (EQ-5D-3L)effect value was higher (0.763±0.29 vs. 0.717±0.42, P = 0.192). The efficacy of drip drainage surgery for Acute Hematogenic Osteomyelitis (AHO) was greatly improved, and the overall infection control rate was increased from 82.3% to 93.1%, which was even slightly higher than that of bone cement placement surgery ( P = 0.452); bone cement placement surgery had a higher rate of infection control in chronic patients (94.5% vs. 72.7%, P = 0.004) and was more effective in treating metaphyseal focal osteomyelitis (97.5% vs. 71.4%, P = 0.002). The use of calcium sulfate calcium phosphate complex (CS/CP) was superior to polymethylmethacrylate (PMMA) (100% vs. 88.69%, P <0.001). Conclusion: Bone cement placement surgery is recommended for the treatment of HO; drip drainage surgery is only indicated for AHO with long marrow cavity lesions; and CS/CP bone cement is preferred to PMMA, which requires a second removal to achieve good results because failure to remove it predisposes to recurrence of osteomyelitis. calcium sulfate/calcium phosphate bone cement polymethylmethacrylate hematogenous osteomyelitis irrigation Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Background HO is caused by hematogenous spread away from the site of the lesion and is usually a monobacterial infection, with Staphylococcus aureus being the most common [ 1 – 3 ]. Treatment for methicillin-resistant Staphylococcus aureus (MRSA) patients is more challenging [ 4 ]. It is more common in the elderly and children, with the extremities accounting for 70% of cases [ 5 – 6 ]. The most common single sites of infection are the tibia, femur, and phalanges in that order [ 7 ]. The United States 2021 guidelines for the diagnosis and management of acute HO in pediatrics recommend blood culture and bone biopsy as the diagnostic criteria, with bone biopsy having a higher diagnostic yield [ 8 ], and HO treatment consists of antibiotics and surgery [ 9 ]. However, there are numerous surgical treatment options, and currently, there is still a lack of unified standards for the selection of surgical indications and methods [ 10 ]. Drip drainage surgery originated in the 1960s [ 11 ]. It was developed and applied by Willenegger for chronic hematogenic osteomyelitis (CHO) with good results. Bone fragments are aspirated continuously by flowing an antibiotic solution into the infected area of the bone [ 12 ]. However, this method also has complications such as drug resistance, anaerobic infections, and catheter blockage [ 13 ]. In 2010, Bar-On et al. reported the successful treatment of four CHO with medullary expansion combined with PMMA piggyback antibiotics. This was the first time that a non-absorbable topical antibiotic release system was proposed to be used in pediatric osteomyelitis [ 14 ]. Later, Masquelet proposed a two-step surgical technique (one-stage debridement followed by application of antibiotic-impregnated PMMA, but PMMA suffers from deficiencies such as non-absorbability, the tendency to leave voids after antibiotic elution leading to infection, heat production, and drug resistance [ 15 ]. Antonio Andreacchio et al. 2019 reported the first report of absorbable topical antibiotic-releasing system application in pediatric HO by successfully treating 12 pediatric CHO patients with calcium sulfate (CS) carrying antibiotics [ 16 ], and the drug-carrying CS had fewer clearances and lower recurrence rates [ 17 ]. Absorbable CS and CS/CP bone cement placement surgery has achieved good therapeutic results in recent years, which deserves further in-depth study to choose a more appropriate surgical procedure [ 7 , 18 – 19 ]. There is a lack of controlled studies on drip drainage surgery and antibiotic bone cement placement surgery, the two main surgical methods for the treatment of HO, and further clarification of their respective indications for the treatment of HO is needed. In this study, we used a retrospective study to analyse the efficacy of the two treatments in a controlled manner, in the hope of providing further evidence for the treatment of HO. 2. Patients and Methods 2.1.Patient inclusion This study was basically conducted in accordance with the STROBE Statement.Surgery was recommended for patients with persistent pain and fever despite empirical antibiotic application, worsening radiological bone lesions, or evidence of septicity [ 20 , 21 ]. The use of drip drainage surgery or antibiotic-loaded bone cement depends on the experience of the operator, and the surgeon needs to be informed about the procedure, risks, and cost of the surgery. This study was approved by the Ethical Review Committee of Tangdu Hospital, Air Force Military Medical University(The ethical number is K202203-8). Consistent with the Declaration of Helsinki of the World Medical Association.Informed consent was obtained from the patients for the use of relevant body pictures. Inclusion criteria included: (1) definite local and systemic symptoms (fever, local pain); (2) subperiosteal abscess or effusion visible on computed radiography (CR), computed tomography (CT), or magnetic resonance imaging (MRI); (3) laboratory tests that are significantly elevated; (4) positive blood culture or bacterial culture of tissue or pus; (5) undergoing surgery, and the name of the surgery contains drip drainage surgery row or bone cement placement surgery. Exclusion criteria were (1) patients with traumatic osteomyelitis, (2) patients with diabetic foot osteomyelitis, (3) missing clinical data and incomplete medical records, (4) those who did not undergo surgery but only received other forms of treatment, and (5) patients with non-extremity lesions. 2.2 Assessment of efficacy The criteria were based on the standard of the chronic osteomyelitis curative effect established by “Huang Jiasi Surgery” in 2008. Patients can be classified as “cured” or “not cured”. Cured: systemic and local symptoms and signs disappeared, inflammatory indexes were completely normal, sinus tracts and wounds were completely healed, X-ray scanning showed uniform bone density, no dead bone or cavities were seen at the original lesion, and the patient was not re-admitted to the hospital due to recurrence. Unhealed: the patient's systemic and local symptoms and signs did not change significantly or even worsened; the inflammatory indexes were abnormal; and the X-ray examination showed unstable lesions, dead bones, or cavities. The patient was readmitted to the hospital for a recurrence. Functional evaluation: apply for registration of the EQ-5D-3L rating scale (registration number 59411) on the official website of the European Society for Quality of Life, obtain the results of the five dimensions of walking, mobility, self-care, pain, and anxiety through telephone follow-up, and obtain the effect value through conversion as the second criterion. 2.3 Statistical analyses Statistical analyses were performed using SPSS version 27.0. Continuous data were expressed as mean and standard deviation with an independent sample t-test. Categorical variables were expressed as percentages, and the chi-square test was used. The correlation of categorical variables was reflected by correlation coefficients and significance p-values using the Spearman's correlation test, with a P -value of less than 0.05 representing statistical significance. 2.4 Bone cement placement surgery Surgery is performed in a standardised sequence, including bone opening, collection of pus samples, adequate enlargement of the medullary cavity, and excision of locally infected tissue [ 22 ]. (Fig. 1 A). Fill the bone defect with a specific proportion of antibiotic-mixed bone cement (2–4 g/40 g) and shape it into granules, as shown in Fig. 1 B [ 23 ]. Finally, suture the wound. 2.5 Drip drainage surgery After debridement, a 3L nutrient bag is selected for antibiotic fluid (concentration of 2.6 g/L) irrigation and flushing; usually, 1 in-tube is placed proximal to the limb and 2 out-tubes are placed distal to the limb [ 24 ] (Fig. 2 , A); and finally, the wound is closed with sutures, and the duration of the drip is usually about 7 days. 3. Results 3.1 Baseline characteristics Bone cement placement surgery group: mean age was 35 ± 20 years, including 45 (67.2%) male and 22 (32.8%) female cases; the diseased site was mainly femur in 23 (34.3%) cases, tibia in 17 (25.4%) cases, and foot bone in 19 (28.4%) cases; bacterial cultures were positive for bacterial cultures in 44 cases. Mainly methicillin-sensitive staphylococcus aureus (MSSA) in 23 (34.3%) cases and culture negative in 23 (34.3%) cases.The mean age of the Drip drainage surgery group was 33 ± 21 years and included 45 males (72.6%) and 17 females ( 27.4%). The site of disease was mainly femur in 23 (37.1%) cases, tibia in 21 (33.9%) cases, and foot bone in 15 (20.3%) cases; bacterial culture was mainly MSSA, in 27 (43.5%) cases, and culture negative in 15 (24.2%) cases. Differences in various indicators such as days of hospitalisation and number of preoperative dressing changes (some patients underwent debridement) were not statistically significant ( P > 0.05) (Table 1 ). Table 1 Baseline characteristics of 129 Patients with HO. Characteristic Bone cement group Instillation drainage group P -value Male/female, n (%) 45(67.2)/22(32.8) 45(72.6)/17(27.4) 0.503 Age of onset (years) 35 ± 20 33 ± 21 0.660 Smoking/Nonsmoking, n (%) 11(17.7)/51(82.3) 17(25.4)/50(74.6) 0.294 Region of osteomyelitis, n (%) 0.867 Tibia 17(25.4) 20(33.9) Femur 23(34.3) 20(33.9) Foot bones 19(28.4) 12(20.3) Pelvis 5(7.5) 5(8.5) Humerus 2(3) 1(1.7) Miscellaneous 1(1.5) 1(1.7) Pathogen, n (%) 0.764 MSSA 23(34.3) 27(43.5) MRSA 3 (4.5) 3(4.8) Escherichia coli 3 (4.5) 3(4.8) Other 15(22.4) 14(22.6) N 23(34.3) 15(24.2) Hospitalization days 30 ± 15 33 ± 22 0.354 Preoperative dressing changes 5(3–8) 4.5(2–6) 0.863 *, P < 0.05. 3.2 Patient outcome The bone cement placement surgery group had a lower recurrence rate (0% vs. 12.3%, P = 0.003), in addition to a higher infection control rate and higher EQ-5D-3L effect value than the Drip drainage surgery group, which had a higher number of debridements ( P < 0.001), with 1 additional debridement in 20 patients (31.7%) and 2 and 3 debridements in 5 patients (11.1%). In the Drip drainage surgery group, the number of debridements was higher ( P < 0.001), with 1 additional debridement in 20 patients (31.7%) and 2 and 3 debridements in 5 patients (11.1%), whereas in the Bone cement placement surgery group, only 6 patients (11.3%) underwent 1 additional debridement, and 1 patient (1.9%) underwent 3 debridements, and the number of drainage tubes used was less ( P < 0.001), and the rate of negative-pressure suction use was lower ( P < 0.001) (Table 2 ).A total of 68 drain drainage surgery procedures were performed on 62 patients with 14 (20.6%) drain blockages. Detailed information on the EQ-5D-3L data is provided in the supplementary material. Table 2 Outcome of postoperative follow-up of patients with bone cement exclusion and drip drainage. Bone cement group Instillation drainage group P -value Healed / Unhealed, n (%) 63(94)/4༈6༉ 51(82.3)/11༈17.7༉ 0.001* Recurrence, n (%) 0(0) 8(12.3) 0.003* Amputation, n (%) 4(6) 3(4.9) 0.78 EQ-5D-3L 0.763 ± 0.29 0.717 ± 0.42 0.192 Number of dressing changes 6(4–9) 12(5–21) 0.001* Negative pressure suction 16(23.9)/51(76.1) 49(79)/13(21) 0.001* Additional Debridements, n (%) 0.004* 0 46(86.8) 36(57.1) 1 6(11.3) 20(31.7) 2 0(0) 5(7.9) 3 1(1.9) 2(3.2) *, P < 0.05. 3.3 Subgroup analysis Bone cement materials The infection control rate was 100% (31/31) in the resorbable cement group and 88.69% (32/36) in the non-resorbable cement group, with a significant difference in efficacy ( P < 0.001) (Table 3 ). In the non-resorbable group, 22 patients had their bone cement removed and underwent second stage bone grafting, and no patient had recurrence, while 4 (28.6%) of 14 patients in the cement-unremoved group had their limbs amputated (Table 4 ). Table 3 Efficacy of different bone cement materials in the treatment of hematogenous osteomyelitis. PMMA CS/CP P -value Healed / Unhealed, n (%) 32(88.9)/4(11.1) 31 (100)/0 0.001* EQ-5D-3L effect value 0.712 ± 0.361 0.823 ± 0.18 0.684 Removed twice, n (%) 22(61.1)/14(39.9) 0(100) 0.001* *, P < 0.05. Table 4 Outcomes after removal / non-removal of PMMA bone cement Remove bone cement Yes(22) No(14) P -value Healed / Unhealed, n (%) 22(100)/0 10(71.4)/4(28.6) 0.008* *, P < 0.05. Analysis of acute and chronic subgroups AHO is defined as an infection lasting less than 4 weeks, according to the recommendations of the Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) multidisciplinary teams. Many patients relapse over time due to the presence of bone isolation and biofilm production [ 25 – 26 ]. Drip drainage surgery in the treatment of acute osteomyelitis resulted in a greater improvement in infection control rate to 93.1%, which was comparable to the Bone cement Placement surgery group infection control rate was comparable ( P = 0.872), due to the categorical variable, osteomyelitis acute and chronic with the site of lesion was subjected to Spearman's correlation analysis, and the results showed that there was no significant correlation between acute and chronic onset of disease and the site of disease in the two groups of patients ( P > 0.05), as shown in Table- 5. Table 5 Additional debridement times of two surgical method. Typing Bone cement group Instillation drainage group Correlation Spearman- P P -value Healed / Unhealed, n (%) Acute 11(91.7)/1(8.3) 27(93.1)/2(6.9) 0.122 0.452 0.872 Chronic 52(94.5)/3(4.5) 24(72.7)/9(27.3) 0.129 0.229 0.004 * *, P < 0.05. Site of HO According to the site of osteomyelitis, the patients were classified into long bone osteomyelitis, metaphyseal/focal osteomyelitis, and patients with simultaneous involvement. The results showed that the treatment of metaphyseal/focal osteomyelitis with bone cement placement surgery was better than that of drip drainage surgery ( P = 0.002), and the infection control rate decreased in drip drainage surgery (from 82.3–71.4%). The infection control rate of Drip drainage surgery decreased (from 82.3–71.4%); there was no significant difference in the infection control rate between osteomyelitis of long bone cadres and osteomyelitis with simultaneous involvement ( P ≤ 0.05), and similarly, in the two groups of patients with metaphyseal involvement, there was no significant correlation between acute and chronic classification and site typing ( P = 0.168), as shown in Table 6 . There were 5 patients with drip drainage surgery followed by bone cement placement surgery, and the infection was controlled in all of them, among which there were 3 cases with simultaneous involvement of the cadre and the epiphysis. Table 6 Analysis of the location of osteomyelitis involvement and the cure rate of two procedures. Typing Bone cement group Instillation drainage group Correlation Spearman- P P -value Healed / Unhealed, n (%) Epiphyseal/local invasion 39(97.5)/1(2.5) 15(71.4)/6(28.6) -0.178 0.168 0.002 * Marrow cavity 14(87.5)/2(12.5) 30(85.7)/5(14.3) -0.411 0.003 * 0.863 Concurrently involved 10(90.9)/1(9.1) 6(100)/0(0) -0.290 0.246 0.446 *, P < 0.05. 4. Discussion 4.1 Comparison of efficacy The results of this study proved that bone cement placement surgery has the advantages of a high infection control rate, and that HO is not easy to recur compared to drip drainage surgery. The fewer times of debridement, less use of drainage tubes, and negative pressure suction also mean less burden on the patients. And bone cement has the advantages of filling the dead space, providing mechanical support, and providing slow-release antibiotics for sterilisation [ 13 ]. Drip drainage surgery has an inaccurate antibiotic flush, extravasation of the flush fluid, catheter clogging requiring early extubation, and sometimes it is difficult to meet the therapeutic needs [ 27 ]. However, it reduces soft tissue damage and intraoperative exposure, promotes necrotic tissue lysis or drainage, and removes necrosis and exudate before and after surgical debridement or when surgical debridement is not possible [ 24 ]. Relevant literature has reported that bone cement placement surgery reduces the chance of postoperative secondary infection, shortens hospital stay, and is more effective than closed irrigation and drainage [ 28 ]. Using the EQ-5D-3L score, which is an assessment scheme suitable for Chinese residents [ 29 ], the results showed that overall, the bone cement placement surgery group had a higher percentage of patients with moderate impairment in mobility and pain than the drip drainage surgery group, so even though the infection control rate was higher, the final EQ-5D-3L effect value The difference was not significant. The limitations of this study are that it did not compare the technical differences between the different hospitals and did not count the evaluation of the two procedures by the medical staff at large. 4.2 Differences in bone cement materials correlate with prognosis PMMA has become a popular material for local delivery of antibiotics in recent decades, releasing therapeutic agents with a large surface area, maintaining high concentrations of drugs in situ, and reducing acute hypersensitivity reactions [ 30 ]. The results of this study show that the CS/CP infection control rate is higher than that of PMMA and does not require secondary removal, which reduces patient burden. PMMA tends to leave gaps after prolonged placement [ 31 ] and generates heat during reaction, which limits the use of heat-stable antibiotics only [ 32 , 33 ] and the antibiotic release rate decreases with time [ 18 , 34 ]. A number of factors make their efficacy inferior to that of resorbable bone cements [ 35 ]. Clinicians prefer CS/CP, which is degradable, osteoinductive, and has a relatively constant rate of antibiotic release above therapeutic levels over time [ 36 – 37 ]. Moreover, antibiotic release above the local minimum inhibitory concentration (MIC) is more capable of penetrating biofilms. The release of antibiotics above the local MIC is more likely to penetrate the biofilm. CS can react with the surrounding tissues to promote bone growth factors such as β-TGF, PDGF, and BMP release at higher than normal levels and thus promote osteogenesis [ 38 ].CS also creates a favourable microenvironment for vascularization and corticalization, while PMMA does not promote bone regeneration and needs to be removed a second time[ 16 , 36 , 39 ]. In a patient who underwent PMMA bone cement placement surgery, using a shaped bone cement wrapped around a Kirschner pin to treat right femoral HO, imaging showed no change in the contour of the bone cement six months postoperatively, and it was present as a foreign body in the bone tissue (Fig. 3 ). The resorbable bone cement resorption process is shown in Fig. 1 , and our preliminary study also demonstrated the excellent efficacy of the new CS/CP mixture. [ 40 ]. 4.3 Subgroup analysis In this study, drip drainage surgery was recommended for the treatment of AHO. In acute patients, the local lesions were not yet severe, and flushing with antibiotic solution removed bacteria, necrotic tissue, and pus from the bone, reduced medullary canal pressure, and curtailed the progression of the disease at an early stage. The drawbacks of drip drainage tubes that are prone to clogging, the limited effect of local flushing, and the susceptibility of prolonged intubation to cross-infections make them unsuitable for CHO [ 41 ]. In our experience, the infection in patients with AHO is mainly pus, and there is no dead bone formation, so the flushing effect is significant and avoids the continued formation of abscess and dead bone; and local antibiotic solutions at concentrations higher than the MIC or above do not easily induce drug resistance, whereas the problems of severe local dead bone formation, medullary closure, and sinusoids in CHO result in the inability of antibiotic solutions to circulate effectively, which can easily lead to drainage tube blockage (10 patients). The efficacy of bone cement placement surgery has been stable, with infection control rates consistently above 90% in both AHO and CHO. The infection control rate of drip drainage surgery for treatment of limited lesions decreased to 71.4%, as shown in Table 6 , which was significantly lower than the infection control rate when treating long marrow cavities (85.7%). Therefore, drip drainage surgery is more recommended for HO patients with long marrow cavities. Long marrow cavities can create conditions for the flow of antibiotic solutions, improve local nutritional status and granulation tissue production, and are more conducive to lowering intramedullary pressure [ 39 , 42 ]. Epiphyseal, focal, or irregular bone lesions are not as effective as in the long marrow cavity due to their morphologic characteristics that prevent adequate irrigation of the infected area with antibiotic solution. The problem of clogging of the drip drainage surgery tubes can also be overcome by the use of a double-lumen vacuum system and intermittent titration of streptokinase [ 43 ]. Drip drainage surgery Infection was controlled in all five patients in combination with bone cement placement surgery, and the literature has reported that treatment with a combination of flap coverage, negative pressure wound therapy, and antibiotic-impregnated bone cement resulted in a higher healing rate (91.3%, P < 0.01), shorter hospital stays, fewer dressing changes, accelerated wound healing, and reduced costs ( P < 0.001) [ 44 ]. As shown in Fig. 4 , the child had right femoral osteomyelitis, which was treated using a combined procedure, with an open window in the distal bone of the right femur (Fig. 4 A), placement of a drip drainage system (Fig. 4 B), and a postoperative gross view (Fig. 4 C), as the patient had both a focal metaphyseal lesion as well as a medullary cavity lesion, which was visible in the extent of the lesion on CT and MRI (Fig. 4 D, E, and F) but could not be detected by CR (Fig. 4 G), and the orthotopic postoperative CR showed drainage canal with cemented bone shadow (Fig. 4 H). The extubated patient was reviewed 1 month postoperatively, and no recurrence of osteomyelitis was seen (Fig. 4 I).Correlation analysis showed a correlation between the urgency of onset and the site of disease ( P = 0.003), and it could not be concluded that there was no difference in the efficacy of the two surgical procedures for the treatment of marrow cavity lesions. The recommended procedures for each type of osteomyelitis are shown in Table 7 . 5. Conclusion Bone cement placement surgery is more effective than drip drainage surgery in the treatment of hematogenous osteomyelitis. We found for the first time that drip drainage surgery is only indicated for acute hemogenous osteomyelitis of the long bone marrow cavity and that bone cement placement surgery should be used in acute metaphyseal, focal, or chronic patients, with a combination of the two treatments if necessary. Bone cement material determines prognosis, with polymethylmethacrylate being inferior to calcium sulphate-calcium phosphate complexes ( P < 0.001) and requiring secondary removal. A combination of the two treatments can be used if necessary, and this combined procedure needs to be studied in larger samples to further confirm efficacy. Abbreviations HO:Hematogenic osteomyelitis;EQ-5D-3L:EuroQol five-dimensional questionnaire; AHO:Acute Hematogenic Osteomyelitis; PMMA:polymethylmethacrylate; CS/CP:calcium sulfate calcium phosphate complex; MRSA:methicillin-resistant Staphylococcus aureus; CHO: chronic hematogenic osteomyelitis; CS:calcium sulfate; CT:computed tomography; MSSA:methicillin-sensitive staphylococcus aureus; PIDS:Pediatric Infectious Diseases Society; IDSA:Infectious Diseases Society of America; MIC: minimum inhibitory concentration. Declarations Acknowledgements We thank Dr.Yunfei Zhang for proof reading of the manuscript. Funding This work was supported by the project Antibiotic-loaded Thiophos Mixture for Focal Infected Bone Defects at Tangdu Hospital, Air Force Military Medical University (XJSXYW2021007) and membrane induction combined with RIA intramedullary irrigation and aspiration of bone technique for the treatment of infected bone defects (XJSXYW-2023004). Availability of data and materials All relevant data and studies are provided in supplemental. Ethics approval and consent to participate This study was reviewed by the Medical Ethics Committee of Tangdu Hospital of the Fourth Military Medical University.Informed consent has been obtained from the patients concerned. Consent for publication Not applicable. Conflict of interest statement All authors have no financial disclosures to declare and no conflicts of interest to report. 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Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic- impregnated cement rods. J Pediatr Orthop. 2010 Jul-Aug;30(5):508-13. Ferguson JY, Dudareva M, Riley ND, Stubbs D, Atkins BL, McNally MA. The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases.Bone Joint J. 2014 Jun;96-B(6):829-36. Wu L, Wen B, Xu Z, Lin K. Research progress on negative pressure wound therapy with instillation in the treatment of orthopaedic wounds. Int Wound J.2022 Oct;19(6):1449-1455. Masters EA, Ricciardi BF, Bentley KLM, Moriarty TF, Schwarz EM, Muthukrishnan G. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nat Rev Microbiol. 2022 Jul;20(7):385-400. Subramanyam KN, Mundargi AV, Prabhu MV, Gopakumar KU, Gowda DSA, Reddy DR.Surgical management of chronic osteomyelitis: Organisms, recurrence and treatment outcome. Chin J Traumatol. 2023 Jul;26(4):228-235. Lang ZG, Zhang X, Guo Q, Liang YX, Yuan F. Clinical observations of vancomycin-loaded calcium phosphate cement in the 1-stage treatment of chronic osteomyelitis: a randomized trial. Ann Palliat Med. 2021 Jun;10(6):6706-6714. Sun PQ, Ma Y, Zhang YC, Cheng MG. Application of antibiotic impregnated beads on the patients with tibial chronic osteomyelitis. Pak J Pharm Sci. 2018 Nov;31(6(Special)):2783-2786. Zhuo L, Xu L, Ye J, Sun S, Zhang Y, Burstrom K, Chen J. Time Trade-Off Value Set for EQ-5D-3L Based on a Nationally Representative Chinese Population Survey.Value Health. 2018 Nov;21(11):1330-1337. Wassif RK, Elkayal M, Shamma RN, Elkheshen SA. Recent advances in the local antibiotics delivery systems for management of osteomyelitis. Drug Deliv. 2021 Dec;28(1):2392-2414. Robiller FC, Stumpe KD, Kossmann T, Weisshaupt D, Bruder E, von Schulthess GK. Chronic osteomyelitis of the femur: value of PET imaging. Eur Radiol. 2000;10(5):855-8. van Vugt TAG, Arts JJ, Geurts JAP. Antibiotic-Loaded Polymethylmethacrylate Beads and Spacers in Treatment of Orthopedic Infections and the Role of Biofilm Formation. Front Microbiol. 2019 Jul 25;10:1626. Jiamton C, Apivatgaroon A, Aunaramwat S, Chawalitrujiwong B, Chuaychoosakoon C, Suwannaphisit S, Jirawison C, Iamsumang C, Kongmalai P, Sukvanich P, Nakorn PN, Ongbumrungphan W, Rattanasumrit P, Tharakulphan S, Thongtanworapat T, Thammarakcharoen F, Srion A, Suwanprateeb J, Chernchujit B. Efficacy and Safety of Antibiotic Impregnated Microporous Nanohydroxyapatite Beads for Chronic Osteomyelitis Treatment: A Multicenter, Open-Label, Prospective Cohort Study.Antibiotics (Basel). 2023 Jun 15;12(6):1049. Tao R, Wu JQ, Luo JW, Hong L, Zhou CH, Cheng GY, Qin CH. Antibiotic-impregnated calcium sulfate for the treatment of pediatric hematogenous osteomyelitis. BMC Pediatr. 2022 Dec 23;22(1):732. Thahir A, Lim JA, West C, Krkovic M. The Use of Calcium Sulphate Beads in the Management of Osteomyelitis of Femur and Tibia: A Systematic Review. Arch Bone Jt Surg. 2022 Apr;10(4):320-327. Pääkkönen M, Peltola H. Antibiotic treatment for acute haematogenous osteomyelitis of childhood: moving towards shorter courses and oral administration. Int J Antimicrob Agents. 2011 Oct;38(4):273-80. Thabit AK, Fatani DF, Bamakhrama MS, Barnawi OA, Basudan LO, Alhejaili SF. Antibiotic penetration into bone and joints: An updated review. Int J Infect Dis. 2019 Apr;81:128-136. Qin CH, Zhang HA, Chee YH, Pitarini A, Adem Ali A. Comparison of the use of antibiotic-loaded calcium sulphate and wound irrigation-suction in the treatment of lower limb chronic osteomyelitis. Injury. 2019 Feb;50(2):508-514. Yasheng T, Mijiti A, Yushan M, Liu Z, Liu Y, Yusufu A. Ozonated water lavage and physiological saline irrigation combined with vacuum-sealed drainage in the treatment of 18 cases of chronic osteomyelitis. J Int Med Res. 2021 Mar;49(3):300060521999530. Zhao Z, Wang G, Zhang Y, Luo W, Liu S, Liu Y, Zhou Y, Zhang Y. The effect of calcium sulfate/calcium phosphate composite for the treatment of chronic osteomyelitis compared with calcium sulfate. Ann Palliat Med. 2020 Jul;9(4):1821-1833. Healthcare Engineering JO. Retracted: MRI Manifestations and Diagnostic Value of Chronic Osteomyelitis. J Healthc Eng. 2023 Oct 11;2023:9806362. Hung NN. Cortical bone fenestrations with continuous antibiotic irrigation to mediate hematogenous tibial osteomyelitis in children. J Pediatr Orthop B. 2010 Nov;19(6):497-506. Caesar BC, Morgan-Jones RL, Warren RE, Wade RH, Roberts PJ, Richardson JB. Closed double-lumen suction irrigation in the management of chronic diaphyseal osteomyelitis: long-term follow-up. J Bone Joint Surg Br. 2009 Sep;91(9):1243-8. Cong B, Chen M. Evaluating the efficacy of combined flap coverage, antibiotic-loaded bone cement and negative pressure irrigation in traumatic osteomyelitis management. Int Wound J. 2024 Jan;21(1):e14650. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterials1.docx Supplementarymaterials2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4509030","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318288986,"identity":"678831c9-6832-418b-8c20-39e0a42305ae","order_by":0,"name":"Hu Wang","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hu","middleName":"","lastName":"Wang","suffix":""},{"id":318288987,"identity":"7cc3753a-703a-4506-b8c7-2beebc8b6b12","order_by":1,"name":"Shuaikun Lu","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shuaikun","middleName":"","lastName":"Lu","suffix":""},{"id":318288988,"identity":"8472a7f2-b309-484e-8bb1-feee58d8b770","order_by":2,"name":"Wen Luo","email":"","orcid":"","institution":"Xijing Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Luo","suffix":""},{"id":318288989,"identity":"ece31d71-9192-4693-8bb1-fd2ef935cbfa","order_by":3,"name":"Congxiao Fu","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Congxiao","middleName":"","lastName":"Fu","suffix":""},{"id":318288990,"identity":"c6d3fb0b-d145-40a3-aac0-33ab3f629fd7","order_by":4,"name":"Hao Gao","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Gao","suffix":""},{"id":318288991,"identity":"17fd9219-f982-4164-bbe9-740abe59f6ce","order_by":5,"name":"Guoliang Wang","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guoliang","middleName":"","lastName":"Wang","suffix":""},{"id":318288992,"identity":"1ebb8d9b-f434-43bf-812e-6e6e1eec45af","order_by":6,"name":"Zhenfeng Zhu","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhenfeng","middleName":"","lastName":"Zhu","suffix":""},{"id":318288993,"identity":"3cb19e97-2601-456c-b15a-3b5efbdeec32","order_by":7,"name":"Wei Liu","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Liu","suffix":""},{"id":318288994,"identity":"2671cc60-1d56-49cc-bf12-f654e15917e4","order_by":8,"name":"Chuan Liu","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chuan","middleName":"","lastName":"Liu","suffix":""},{"id":318288995,"identity":"5f2d7812-3986-42ca-9f11-a3c7b534a3e2","order_by":9,"name":"Jun Ren","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Ren","suffix":""},{"id":318288996,"identity":"42218549-f646-48a4-a8fb-b3eca8e4f3db","order_by":10,"name":"Xiang Liu","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Liu","suffix":""},{"id":318288997,"identity":"8d61a655-3367-41fa-b16f-e0c5b918014e","order_by":11,"name":"Yong Zhang","email":"","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Zhang","suffix":""},{"id":318288998,"identity":"a691abd5-5a15-406a-b54a-5e42108b3bd6","order_by":12,"name":"Yunfei Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnklEQVRIiWNgGAWjYFCCHBBhw8PP30CkBh6IljQZyRkHSNNy2MagIYFILfbsuQcfF1Sc5zFgOMD44WMOMbbwvEs2nnHmNo85cwOz5MxtxGiRyDGT5m27zWPZcICNmZd4Lf/O8RgcSCBJS8MBUrScAfqF51gyj+SMg83E+YW9HRhiPDV29vz8zQc/fCRGCxJgbCBN/SgYBaNgFIwC3AAAa+kwmZQwO+8AAAAASUVORK5CYII=","orcid":"","institution":"Tang Du Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yunfei","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-05-31 12:41:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4509030/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4509030/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60428760,"identity":"d25bffe9-6d4e-448f-90de-41f44a46c963","added_by":"auto","created_at":"2024-07-16 15:58:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":86011,"visible":true,"origin":"","legend":"\u003cp\u003eAbsorbable bone cement placement surgery for focal AHO of the proximal tibia. A and B are the bone opening and filling of bone cement particles, respectively. C: preoperative, as shown by the arrows; the upper end of the tibia can be seen as a patchy inhomogeneous high-density shadow; and another class of rounded low-density shadows; and the infection is considered; D: 1 day after placement surgery, the bone cement particles can be seen filling the placeholder, and the border with the bone tissue is clear; E：2 months after surgery, the bone cement particles can be seen, but the border with the bone tissue is blurred. F: 4 months after surgery, the scope of the bone cement is slightly reduced; G: 9 months after surgery, the scope of the cement can be seen to be significantly reduced and blurred；H：1 year after surgery, there are only a few remaining high-density shadows, and the bone cement is basically absorbed.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/e84f106fdcf082f738c38a73.jpg"},{"id":60427335,"identity":"481b185d-0c6b-4ffc-b2cd-6d16eed05577","added_by":"auto","created_at":"2024-07-16 15:50:58","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35325,"visible":true,"origin":"","legend":"\u003cp\u003eDrip drainage surgery for the treatment of femoral marrow cavity AHO. A: Example of Drip drainage surgery; B: Preoperative CR showed uneven thickening of bone cortex in the right femur, suggesting infection; C: Postoperative CR one week after the operation showed localised bone defects, with the upper defect being the entrance canal opening window and the lower defect being the exit canal opening window; D: Three months after the operation, the open window of the bone was repaired, the thickened bone cortex returned to normal, and the local bone at the window of entry canal opening was repaired.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/365b5ea04f7fff80db6ccd7e.jpg"},{"id":60427332,"identity":"3e6d179b-c428-4727-aedb-b4aadb74a023","added_by":"auto","created_at":"2024-07-16 15:50:57","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":80458,"visible":true,"origin":"","legend":"\u003cp\u003eNon-absorbable PMMA bone cement placement surgery for CHO in the femoral marrow cavity. A: Kirschner's needle encapsulated with PMMA bone cement for absentia placement; B: Preoperatively, a mass of low-density shadow in the right femoral marrow cavity was seen, as shown by the arrow, and the infection was considered; C:1 week after the surgery, the bone cement contour was clear; D: six months after the surgery, the bone cement contour did not show any obvious change. The local infection was controlled.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/5526d3e57803cf3f9c965474.jpg"},{"id":60428762,"identity":"45b76955-6f8a-4bf9-9790-93c925f3ab3d","added_by":"auto","created_at":"2024-07-16 15:58:58","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":69565,"visible":true,"origin":"","legend":"\u003cp\u003eDrip drainage surgery combined with bone cement placement surgery for the treatment of acute femoral medullary cavity and metaphyseal infections. The patient, a 9-year-old male, presented with pain and discomfort in the proximal medial side of the right knee joint without obvious cause. Conservative treatment was ineffective, and drip drainage surgery was performed. A: local fenestration of the distal tibia; B: filling the distal medullary cavity with bone cement and retaining the drip drainage system; C: In the postoperative gross view, as indicated by the arrow, place 1 insertion tube and 2 exit tubes; D: Preoperative CT showed a clear, quasi-circular-shaped infection lesion in the distal medial condyle of the right femur. E: Preoperative MRI revealed a low signal patchy shadow at the distal end of the right femur, suspected of medullary cavity lesions; F:Supplement the MRI of the entire femur, revealing scattered irregular high and low signal shadows scattered within the femoral bone marrow cavity; G: Preoperative CR showed no significant abnormalities in the distal femur; H: Postoperative CR coronal view shows bone cement shadow and drip drainage duct. The red arrow above indicates the entry site, the bottom indicates the exit site, and the yellow arrow indicates the bone cement shadow; I: 2 months postoperative CR with clear cement-filled margins.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/269af930525bd469af66ae72.jpg"},{"id":70312874,"identity":"bdbecaf6-6ce0-4853-8d8f-9b78324db552","added_by":"auto","created_at":"2024-12-02 04:47:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1022508,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/842e3da8-abc0-47d7-8e77-e69c5b831990.pdf"},{"id":60427338,"identity":"c9c24f5a-8653-46db-add4-aa5a2fb673de","added_by":"auto","created_at":"2024-07-16 15:50:58","extension":"docx","order_by":13,"title":"","display":"","copyAsset":false,"role":"supplement","size":49537,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/84dc212f656fcb6c7aaaf779.docx"},{"id":60427337,"identity":"4172fbe4-b459-4ef5-9255-434beb17947d","added_by":"auto","created_at":"2024-07-16 15:50:58","extension":"docx","order_by":14,"title":"","display":"","copyAsset":false,"role":"supplement","size":22500,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4509030/v1/8d717013387cdc3870a20b0b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative analysis of the efficacy of drip drainage surgery and bone cement placement surgery in the treatment of haematogenous osteomyelitis of the extremities","fulltext":[{"header":"1. Background","content":"\u003cp\u003eHO is caused by hematogenous spread away from the site of the lesion and is usually a monobacterial infection, with Staphylococcus aureus being the most common [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Treatment for methicillin-resistant Staphylococcus aureus (MRSA) patients is more challenging [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is more common in the elderly and children, with the extremities accounting for 70% of cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most common single sites of infection are the tibia, femur, and phalanges in that order [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The United States 2021 guidelines for the diagnosis and management of acute HO in pediatrics recommend blood culture and bone biopsy as the diagnostic criteria, with bone biopsy having a higher diagnostic yield [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and HO treatment consists of antibiotics and surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, there are numerous surgical treatment options, and currently, there is still a lack of unified standards for the selection of surgical indications and methods [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDrip drainage surgery originated in the 1960s [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It was developed and applied by Willenegger for chronic hematogenic osteomyelitis (CHO) with good results. Bone fragments are aspirated continuously by flowing an antibiotic solution into the infected area of the bone [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, this method also has complications such as drug resistance, anaerobic infections, and catheter blockage [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2010, Bar-On et al. reported the successful treatment of four CHO with medullary expansion combined with PMMA piggyback antibiotics. This was the first time that a non-absorbable topical antibiotic release system was proposed to be used in pediatric osteomyelitis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Later, Masquelet proposed a two-step surgical technique (one-stage debridement followed by application of antibiotic-impregnated PMMA, but PMMA suffers from deficiencies such as non-absorbability, the tendency to leave voids after antibiotic elution leading to infection, heat production, and drug resistance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Antonio Andreacchio et al. 2019 reported the first report of absorbable topical antibiotic-releasing system application in pediatric HO by successfully treating 12 pediatric CHO patients with calcium sulfate (CS) carrying antibiotics [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and the drug-carrying CS had fewer clearances and lower recurrence rates [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Absorbable CS and CS/CP bone cement placement surgery has achieved good therapeutic results in recent years, which deserves further in-depth study to choose a more appropriate surgical procedure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a lack of controlled studies on drip drainage surgery and antibiotic bone cement placement surgery, the two main surgical methods for the treatment of HO, and further clarification of their respective indications for the treatment of HO is needed. In this study, we used a retrospective study to analyse the efficacy of the two treatments in a controlled manner, in the hope of providing further evidence for the treatment of HO.\u003c/p\u003e"},{"header":"2. Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1.Patient inclusion\u003c/h2\u003e \u003cp\u003eThis study was basically conducted in accordance with the STROBE Statement.Surgery was recommended for patients with persistent pain and fever despite empirical antibiotic application, worsening radiological bone lesions, or evidence of septicity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The use of drip drainage surgery or antibiotic-loaded bone cement depends on the experience of the operator, and the surgeon needs to be informed about the procedure, risks, and cost of the surgery. This study was approved by the Ethical Review Committee of Tangdu Hospital, Air Force Military Medical University(The ethical number is K202203-8). Consistent with the Declaration of Helsinki of the World Medical Association.Informed consent was obtained from the patients for the use of relevant body pictures.\u003c/p\u003e \u003cp\u003eInclusion criteria included: (1) definite local and systemic symptoms (fever, local pain); (2) subperiosteal abscess or effusion visible on computed radiography (CR), computed tomography (CT), or magnetic resonance imaging (MRI); (3) laboratory tests that are significantly elevated; (4) positive blood culture or bacterial culture of tissue or pus; (5) undergoing surgery, and the name of the surgery contains drip drainage surgery row or bone cement placement surgery.\u003c/p\u003e \u003cp\u003eExclusion criteria were (1) patients with traumatic osteomyelitis, (2) patients with diabetic foot osteomyelitis, (3) missing clinical data and incomplete medical records, (4) those who did not undergo surgery but only received other forms of treatment, and (5) patients with non-extremity lesions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Assessment of efficacy\u003c/h2\u003e \u003cp\u003eThe criteria were based on the standard of the chronic osteomyelitis curative effect established by \u0026ldquo;Huang Jiasi Surgery\u0026rdquo; in 2008. Patients can be classified as \u0026ldquo;cured\u0026rdquo; or \u0026ldquo;not cured\u0026rdquo;.\u003c/p\u003e \u003cp\u003eCured: systemic and local symptoms and signs disappeared, inflammatory indexes were completely normal, sinus tracts and wounds were completely healed, X-ray scanning showed uniform bone density, no dead bone or cavities were seen at the original lesion, and the patient was not re-admitted to the hospital due to recurrence.\u003c/p\u003e \u003cp\u003eUnhealed: the patient's systemic and local symptoms and signs did not change significantly or even worsened; the inflammatory indexes were abnormal; and the X-ray examination showed unstable lesions, dead bones, or cavities. The patient was readmitted to the hospital for a recurrence.\u003c/p\u003e \u003cp\u003eFunctional evaluation: apply for registration of the EQ-5D-3L rating scale (registration number 59411) on the official website of the European Society for Quality of Life, obtain the results of the five dimensions of walking, mobility, self-care, pain, and anxiety through telephone follow-up, and obtain the effect value through conversion as the second criterion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analyses\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 27.0. Continuous data were expressed as mean and standard deviation with an independent sample t-test. Categorical variables were expressed as percentages, and the chi-square test was used. The correlation of categorical variables was reflected by correlation coefficients and significance p-values using the Spearman's correlation test, with a \u003cem\u003eP\u003c/em\u003e-value of less than 0.05 representing statistical significance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Bone cement placement surgery\u003c/h2\u003e \u003cp\u003eSurgery is performed in a standardised sequence, including bone opening, collection of pus samples, adequate enlargement of the medullary cavity, and excision of locally infected tissue [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Fill the bone defect with a specific proportion of antibiotic-mixed bone cement (2\u0026ndash;4 g/40 g) and shape it into granules, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Finally, suture the wound.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Drip drainage surgery\u003c/h2\u003e \u003cp\u003eAfter debridement, a 3L nutrient bag is selected for antibiotic fluid (concentration of 2.6 g/L) irrigation and flushing; usually, 1 in-tube is placed proximal to the limb and 2 out-tubes are placed distal to the limb [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, A); and finally, the wound is closed with sutures, and the duration of the drip is usually about 7 days.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Baseline characteristics\u003c/h2\u003e \u003cp\u003eBone cement placement surgery group: mean age was 35\u0026thinsp;\u0026plusmn;\u0026thinsp;20 years, including 45 (67.2%) male and 22 (32.8%) female cases; the diseased site was mainly femur in 23 (34.3%) cases, tibia in 17 (25.4%) cases, and foot bone in 19 (28.4%) cases; bacterial cultures were positive for bacterial cultures in 44 cases. Mainly methicillin-sensitive staphylococcus aureus (MSSA) in 23 (34.3%) cases and culture negative in 23 (34.3%) cases.The mean age of the Drip drainage surgery group was 33\u0026thinsp;\u0026plusmn;\u0026thinsp;21 years and included 45 males (72.6%) and 17 females ( 27.4%). The site of disease was mainly femur in 23 (37.1%) cases, tibia in 21 (33.9%) cases, and foot bone in 15 (20.3%) cases; bacterial culture was mainly MSSA, in 27 (43.5%) cases, and culture negative in 15 (24.2%) cases. Differences in various indicators such as days of hospitalisation and number of preoperative dressing changes (some patients underwent debridement) were not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of 129 Patients with HO.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBone cement group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstillation drainage group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale/female, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45(67.2)/22(32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(72.6)/17(27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of onset (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026thinsp;\u0026plusmn;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u0026thinsp;\u0026plusmn;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking/Nonsmoking, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(17.7)/51(82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(25.4)/50(74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion of osteomyelitis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTibia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoot bones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHumerus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiscellaneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathogen, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.764\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEscherichia coli\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative dressing changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(3\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5(2\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Patient outcome\u003c/h2\u003e \u003cp\u003eThe bone cement placement surgery group had a lower recurrence rate (0% vs. 12.3%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), in addition to a higher infection control rate and higher EQ-5D-3L effect value than the Drip drainage surgery group, which had a higher number of debridements (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with 1 additional debridement in 20 patients (31.7%) and 2 and 3 debridements in 5 patients (11.1%). In the Drip drainage surgery group, the number of debridements was higher (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with 1 additional debridement in 20 patients (31.7%) and 2 and 3 debridements in 5 patients (11.1%), whereas in the Bone cement placement surgery group, only 6 patients (11.3%) underwent 1 additional debridement, and 1 patient (1.9%) underwent 3 debridements, and the number of drainage tubes used was less (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the rate of negative-pressure suction use was lower (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).A total of 68 drain drainage surgery procedures were performed on 62 patients with 14 (20.6%) drain blockages. Detailed information on the EQ-5D-3L data is provided in the supplementary material.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome of postoperative follow-up of patients with bone cement exclusion and drip drainage.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBone cement group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstillation drainage group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealed / Unhealed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63(94)/4༈6༉\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(82.3)/11༈17.7༉\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmputation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-3L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.763\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.717\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of dressing changes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(4\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(5\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative pressure suction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(23.9)/51(76.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49(79)/13(21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional Debridements, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46(86.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Subgroup analysis\u003c/h2\u003e \u003cp\u003eBone cement materials\u003c/p\u003e \u003cp\u003eThe infection control rate was 100% (31/31) in the resorbable cement group and 88.69% (32/36) in the non-resorbable cement group, with a significant difference in efficacy (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the non-resorbable group, 22 patients had their bone cement removed and underwent second stage bone grafting, and no patient had recurrence, while 4 (28.6%) of 14 patients in the cement-unremoved group had their limbs amputated (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEfficacy of different bone cement materials in the treatment of hematogenous osteomyelitis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePMMA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCS/CP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealed / Unhealed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(88.9)/4(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (100)/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-3L effect value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.712\u0026thinsp;\u0026plusmn;\u0026thinsp;0.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.823\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemoved twice, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22(61.1)/14(39.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes after removal / non-removal of PMMA bone cement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemove bone cement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes(22)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo(14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealed / Unhealed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(100)/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10(71.4)/4(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnalysis of acute and chronic subgroups\u003c/p\u003e\u003cp\u003eAHO is defined as an infection lasting less than 4 weeks, according to the recommendations of the Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) multidisciplinary teams. Many patients relapse over time due to the presence of bone isolation and biofilm production [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Drip drainage surgery in the treatment of acute osteomyelitis resulted in a greater improvement in infection control rate to 93.1%, which was comparable to the Bone cement Placement surgery group infection control rate was comparable (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.872), due to the categorical variable, osteomyelitis acute and chronic with the site of lesion was subjected to Spearman's correlation analysis, and the results showed that there was no significant correlation between acute and chronic onset of disease and the site of disease in the two groups of patients (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table- 5.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdditional debridement times of two surgical method.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTyping\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBone cement group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstillation drainage group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpearman-\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealed / Unhealed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11(91.7)/1(8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27(93.1)/2(6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.872\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52(94.5)/3(4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24(72.7)/9(27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eSite of HO\u003c/p\u003e \u003cp\u003eAccording to the site of osteomyelitis, the patients were classified into long bone osteomyelitis, metaphyseal/focal osteomyelitis, and patients with simultaneous involvement. The results showed that the treatment of metaphyseal/focal osteomyelitis with bone cement placement surgery was better than that of drip drainage surgery (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), and the infection control rate decreased in drip drainage surgery (from 82.3\u0026ndash;71.4%). The infection control rate of Drip drainage surgery decreased (from 82.3\u0026ndash;71.4%); there was no significant difference in the infection control rate between osteomyelitis of long bone cadres and osteomyelitis with simultaneous involvement (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.05), and similarly, in the two groups of patients with metaphyseal involvement, there was no significant correlation between acute and chronic classification and site typing ( \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.168), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. There were 5 patients with drip drainage surgery followed by bone cement placement surgery, and the infection was controlled in all of them, among which there were 3 cases with simultaneous involvement of the cadre and the epiphysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of the location of osteomyelitis involvement and the cure rate of two procedures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTyping\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBone cement group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstillation drainage group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpearman-\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealed / Unhealed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpiphyseal/local invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39(97.5)/1(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(71.4)/6(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.002 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarrow cavity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14(87.5)/2(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(85.7)/5(14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003 *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcurrently involved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(90.9)/1(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(100)/0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Comparison of efficacy\u003c/h2\u003e \u003cp\u003eThe results of this study proved that bone cement placement surgery has the advantages of a high infection control rate, and that HO is not easy to recur compared to drip drainage surgery. The fewer times of debridement, less use of drainage tubes, and negative pressure suction also mean less burden on the patients. And bone cement has the advantages of filling the dead space, providing mechanical support, and providing slow-release antibiotics for sterilisation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Drip drainage surgery has an inaccurate antibiotic flush, extravasation of the flush fluid, catheter clogging requiring early extubation, and sometimes it is difficult to meet the therapeutic needs [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, it reduces soft tissue damage and intraoperative exposure, promotes necrotic tissue lysis or drainage, and removes necrosis and exudate before and after surgical debridement or when surgical debridement is not possible [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Relevant literature has reported that bone cement placement surgery reduces the chance of postoperative secondary infection, shortens hospital stay, and is more effective than closed irrigation and drainage [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Using the EQ-5D-3L score, which is an assessment scheme suitable for Chinese residents [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], the results showed that overall, the bone cement placement surgery group had a higher percentage of patients with moderate impairment in mobility and pain than the drip drainage surgery group, so even though the infection control rate was higher, the final EQ-5D-3L effect value The difference was not significant. The limitations of this study are that it did not compare the technical differences between the different hospitals and did not count the evaluation of the two procedures by the medical staff at large.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Differences in bone cement materials correlate with prognosis\u003c/h2\u003e \u003cp\u003ePMMA has become a popular material for local delivery of antibiotics in recent decades, releasing therapeutic agents with a large surface area, maintaining high concentrations of drugs in situ, and reducing acute hypersensitivity reactions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The results of this study show that the CS/CP infection control rate is higher than that of PMMA and does not require secondary removal, which reduces patient burden. PMMA tends to leave gaps after prolonged placement [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and generates heat during reaction, which limits the use of heat-stable antibiotics only [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and the antibiotic release rate decreases with time [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A number of factors make their efficacy inferior to that of resorbable bone cements [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Clinicians prefer CS/CP, which is degradable, osteoinductive, and has a relatively constant rate of antibiotic release above therapeutic levels over time [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Moreover, antibiotic release above the local minimum inhibitory concentration (MIC) is more capable of penetrating biofilms.\u003c/p\u003e \u003cp\u003eThe release of antibiotics above the local MIC is more likely to penetrate the biofilm. CS can react with the surrounding tissues to promote bone growth factors such as β-TGF, PDGF, and BMP release at higher than normal levels and thus promote osteogenesis [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].CS also creates a favourable microenvironment for vascularization and corticalization, while PMMA does not promote bone regeneration and needs to be removed a second time[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In a patient who underwent PMMA bone cement placement surgery, using a shaped bone cement wrapped around a Kirschner pin to treat right femoral HO, imaging showed no change in the contour of the bone cement six months postoperatively, and it was present as a foreign body in the bone tissue (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The resorbable bone cement resorption process is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and our preliminary study also demonstrated the excellent efficacy of the new CS/CP mixture. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Subgroup analysis\u003c/h2\u003e \u003cp\u003eIn this study, drip drainage surgery was recommended for the treatment of AHO. In acute patients, the local lesions were not yet severe, and flushing with antibiotic solution removed bacteria, necrotic tissue, and pus from the bone, reduced medullary canal pressure, and curtailed the progression of the disease at an early stage. The drawbacks of drip drainage tubes that are prone to clogging, the limited effect of local flushing, and the susceptibility of prolonged intubation to cross-infections make them unsuitable for CHO [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In our experience, the infection in patients with AHO is mainly pus, and there is no dead bone formation, so the flushing effect is significant and avoids the continued formation of abscess and dead bone; and local antibiotic solutions at concentrations higher than the MIC or above do not easily induce drug resistance, whereas the problems of severe local dead bone formation, medullary closure, and sinusoids in CHO result in the inability of antibiotic solutions to circulate effectively, which can easily lead to drainage tube blockage (10 patients). The efficacy of bone cement placement surgery has been stable, with infection control rates consistently above 90% in both AHO and CHO.\u003c/p\u003e \u003cp\u003eThe infection control rate of drip drainage surgery for treatment of limited lesions decreased to 71.4%, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, which was significantly lower than the infection control rate when treating long marrow cavities (85.7%). Therefore, drip drainage surgery is more recommended for HO patients with long marrow cavities. Long marrow cavities can create conditions for the flow of antibiotic solutions, improve local nutritional status and granulation tissue production, and are more conducive to lowering intramedullary pressure [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Epiphyseal, focal, or irregular bone lesions are not as effective as in the long marrow cavity due to their morphologic characteristics that prevent adequate irrigation of the infected area with antibiotic solution. The problem of clogging of the drip drainage surgery tubes can also be overcome by the use of a double-lumen vacuum system and intermittent titration of streptokinase [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Drip drainage surgery Infection was controlled in all five patients in combination with bone cement placement surgery, and the literature has reported that treatment with a combination of flap coverage, negative pressure wound therapy, and antibiotic-impregnated bone cement resulted in a higher healing rate (91.3%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), shorter hospital stays, fewer dressing changes, accelerated wound healing, and reduced costs (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the child had right femoral osteomyelitis, which was treated using a combined procedure, with an open window in the distal bone of the right femur (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA), placement of a drip drainage system (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB), and a postoperative gross view (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC), as the patient had both a focal metaphyseal lesion as well as a medullary cavity lesion, which was visible in the extent of the lesion on CT and MRI (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD, E, and F) but could not be detected by CR (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eG), and the orthotopic postoperative CR showed drainage canal with cemented bone shadow (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eH). The extubated patient was reviewed 1 month postoperatively, and no recurrence of osteomyelitis was seen (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eI).Correlation analysis showed a correlation between the urgency of onset and the site of disease (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), and it could not be concluded that there was no difference in the efficacy of the two surgical procedures for the treatment of marrow cavity lesions. The recommended procedures for each type of osteomyelitis are shown in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eBone cement placement surgery is more effective than drip drainage surgery in the treatment of hematogenous osteomyelitis. We found for the first time that drip drainage surgery is only indicated for acute hemogenous osteomyelitis of the long bone marrow cavity and that bone cement placement surgery should be used in acute metaphyseal, focal, or chronic patients, with a combination of the two treatments if necessary. Bone cement material determines prognosis, with polymethylmethacrylate being inferior to calcium sulphate-calcium phosphate complexes (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and requiring secondary removal. A combination of the two treatments can be used if necessary, and this combined procedure needs to be studied in larger samples to further confirm efficacy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHO:Hematogenic osteomyelitis;EQ-5D-3L:EuroQol five-dimensional questionnaire; AHO:Acute Hematogenic Osteomyelitis; PMMA:polymethylmethacrylate; CS/CP:calcium sulfate calcium phosphate complex; MRSA:methicillin-resistant Staphylococcus aureus; CHO: chronic hematogenic osteomyelitis; CS:calcium sulfate; CT:computed tomography; MSSA:methicillin-sensitive staphylococcus aureus; PIDS:Pediatric Infectious Diseases Society; IDSA:Infectious Diseases Society of America; MIC: minimum inhibitory concentration.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Dr.Yunfei Zhang for proof reading of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the project Antibiotic-loaded Thiophos Mixture for Focal Infected Bone Defects at Tangdu Hospital, Air Force Military Medical University (XJSXYW2021007) and membrane induction combined with RIA intramedullary irrigation and aspiration of bone technique for the treatment of infected bone defects (XJSXYW-2023004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data and studies are provided in supplemental.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed by the Medical Ethics Committee of Tangdu Hospital of the Fourth Military Medical University.Informed consent has been obtained from the patients concerned.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no financial disclosures to declare and no conflicts of interest to report.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHu Wang collected data and wrote the article, Shuaikun Lu analysed the data, Wen Luo conducted the literature search and summarised the data to assist with data analysis, Congxiao Fu collected the imaging data, Hao Gao created the tables, Guoliang Wang collected the baseline data, Zhenfeng Zhu collected the surgical information, Wei Liu collected the medical history, Chuan Liu collected the biochemical test data, Jun Ren took the intraoperative and postoperative pictures, Xiang Liu translated the article, Yong Zhang and Yunfei Zhang revised the article and provided relevant guidance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLew DP, Waldvogel FA. 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Int Wound J. 2024 Jan;21(1):e14650.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"calcium sulfate/calcium phosphate bone cement, polymethylmethacrylate, hematogenous osteomyelitis, irrigation","lastPublishedDoi":"10.21203/rs.3.rs-4509030/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4509030/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe classical surgical treatment for hematogenous osteomyelitis is debridement and drip drainage surgery, and in recent years, antibiotic bone cement placement surgery has gradually gained widespread use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eInformation on 129 Hematogenic osteomyelitis (HO) patients, 67 treated with bone cement placement surgery and 62 with drip drainage surgery, was collected from January 2015 to January 2023. Baseline data, osteomyelitis classification, and clinical regression were compared between the two groups, with a mean follow-up of 2 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult: \u003c/strong\u003eBone cement placement surgery had a higher infection control rate than drip drainage surgery (94% vs. 82.3%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and the EuroQol five-dimensional questionnaire (EQ-5D-3L)effect value was higher (0.763±0.29 vs. 0.717±0.42, \u003cem\u003eP\u003c/em\u003e = 0.192). The efficacy of drip drainage surgery for Acute Hematogenic Osteomyelitis (AHO) was greatly improved, and the overall infection control rate was increased from 82.3% to 93.1%, which was even slightly higher than that of bone cement placement surgery (\u003cem\u003eP\u003c/em\u003e = 0.452); bone cement placement surgery had a higher rate of infection control in chronic patients (94.5% vs. 72.7%,\u003cem\u003e P\u003c/em\u003e = 0.004) and was more effective in treating metaphyseal focal osteomyelitis (97.5% vs. 71.4%, \u003cem\u003eP \u003c/em\u003e= 0.002). The use of calcium sulfate calcium phosphate complex (CS/CP) was superior to polymethylmethacrylate (PMMA) (100% vs. 88.69%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eBone cement placement surgery is recommended for the treatment of HO; drip drainage surgery is only indicated for AHO with long marrow cavity lesions; and CS/CP bone cement is preferred to PMMA, which requires a second removal to achieve good results because failure to remove it predisposes to recurrence of osteomyelitis.\u003c/p\u003e","manuscriptTitle":"Comparative analysis of the efficacy of drip drainage surgery and bone cement placement surgery in the treatment of haematogenous osteomyelitis of the extremities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 15:50:53","doi":"10.21203/rs.3.rs-4509030/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cfbf5235-20c0-4d6d-9def-8eacf92c6f65","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T04:39:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-16 15:50:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4509030","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4509030","identity":"rs-4509030","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}