A new and effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur - carbon fiber rod bone cement combined with calcium sulfate loaded with antibiotics

A new and effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur - carbon fiber rod bone cement combined with calcium sulfate loaded with antibiotics | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A new and effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur - carbon fiber rod bone cement combined with calcium sulfate loaded with antibiotics Hao Guo, Cheng Ren, Chaofeng Wang, Yibo Xu, Deyin Liu, Congming Zhang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6906791/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Nov, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Infection after intramedullary nail fixation of intertrochanteric fractures is relatively rare at present. This article aims to explore and compare the therapeutic effects of combined treatment with antibiotic bone cement carbon fiber rods loaded with antibiotic calcium sulfate and the traditional Masquelet technique in the treatment of chronic osteomyelitis after intramedullary nail fixation of intertrochanteric fractures. Methods: A retrospective analysis was conducted on a total of 88 patients with chronic osteomyelitis after intramedullary nail internal fixation of intertrochanteric fractures in our hospital from September 2018 to September 2024. The patients were divided into two groups by random number expression method, with 44 people in each group. The control group was treated with the Masquelet technique. After debridement, the first stage was treated with antibiotic bone cement rods, and the second stage was bone grafting. The experimental group was treated with the antibiotic calcium sulfate in the second stage on the basis of the first stage of the control group. The inflammatory indicators, therapeutic effects and pain conditions of the patients at 6 weeks after the operation were recorded. Corresponding evaluations were conducted for the two groups respectively to comprehensively assess and compare the therapeutic effects of the two surgical methods. Results: The wound healing time and bone healing time of the patients in the experimental group were shorter than those in the control group, and the total effective rate was higher than that in the control group. There was no significant difference in the operation time between the two groups. The levels of postoperative inflammatory indicators in both groups were significantly reduced compared with those before treatment, and the levels in the experimental group were significantly lower than those in the control group. The pain scores of the two groups of patients showed a decreasing trend 2 weeks, 1 month after treatment and 3 months after follow-up, and the pain scores of the experimental group were all lower than those of the control group. Conclusion: The combined treatment of postoperative infection with antibiotic bone cement carbon fiber rods loaded with antibiotic calcium sulfate in the proximal femur can effectively reduce inflammatory responses and pain. While eliminating infection, it also has the effect of osteogenic formation. The postoperative recurrence rate is greatly reduced, and it has good clinical efficacy. Calcium sulfate Chronic osteomyelitis Bone cement Carbon fiber rod Vancomycin Proximal femoral fracture Figures Figure 1 Figure 2 Background With the aging of the population, the incidence of intertrochanteric fractures of the femur has been increasing year by year. According to statistics, the total number of hip fracture patients in 204 countries around the world in 2019 was 14.2 million [1]. Currently, it remains one of the most common fracture types among the elderly [2]. Under such a huge increase in the patient base, postoperative complications have also attracted much attention. Among them, the incidence of chronic osteomyelitis can be as high as 16% [3]. Due to its long disease course, complex treatment process, high treatment cost, high recurrence rate and disability risk, and unsatisfactory postoperative effect, it is called "the second cancer" [4] and is recognized as one of the difficult problems in the management of postoperative complications of fractures [5]. At present, relevant scholars have respectively applied antibiotic bone cement and calcium sulfate in the treatment of chronic osteomyelitis [6][7]. The Masquelet membrane induction technique is one of the common treatment methods for chronic osteomyelitis. It promotes osteogenic reconstruction by inducing a protective isolation mechanism of connective tissue membrane formed by the bone cement occupying the bone defect area in the surrounding soft tissue [8]. Calcium sulfate is a biodegradable carrier for the sustained-release system of antibacterial drugs. It carries sensitive antibiotics that can be slowly released at the site of infection. For chronic osteomyelitis after internal fixation of intertrochanteric fractures of the femur, the infection site is deep and the operation is difficult. Currently, there is no effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur. This study retrospectively analyzed and compared the therapeutic effects of Masquelet membrane induction technique and antibiotic bone cement rods combined with antibiotic-loaded calcium sulfate. To explore the clinical efficacy of antibiotic bone cement rods combined with calcium sulfate loaded with antibiotics, and to provide guiding treatment for future clinical practice. Objects and Methods 1.1 Objects A total of 88 patients with infection-related chronic osteomyelitis after intramedullary nail internal fixation of intertrochanteric fractures of the femur admitted to Honghui Hospital Affiliated to Medical College of Xi 'an Jiaotong University from March 2018 to March 2024 were selected as the research subjects. Inclusion criteria: 1. Meeting the diagnostic criteria for chronic osteomyelitis of the International Association for the study of Internal Fixation (Assocication for the study of Internal Fixation, AO/ASIF) in 2017: Sinus ducts, fistulas or wound dehiscence (with exposed bone or exposed internal fixators) that directly communicate with bone tissue or implants, pus was found around the internal fixator during the operation, the bacterial culture of the suspected infected tissue was positive during the operation, and the special staining of histopathology confirmed the presence of pathogenic microorganisms in the suspected infected tissue during the operation. 2. Those over 18 years old; 3. Those with complete postoperative follow-up data. Exclusion criteria: Patients with hematogenous osteomyelitis, those with other acute or chronic infectious diseases, those with malignant tumor diseases, those with hematopoietic dysfunction and autoimmune diseases, and those with severe cardiovascular and cerebrovascular diseases, etc. 1.2 General data A total of 49 males and 39 females were included in this experiment. The age ranged from 48 to 71 years old, with an average of 55.6 years old. The course of osteomyelitis was 4 to 9 months. All of them were closed intertrochanteric fractures of the femur, and intramedullary screws were used for internal fixation after fractures. Among the 81 patients with skin and soft tissue sinus tract formation, 78 cases showed positive bacterial culture of wound secretions, including 71 cases of single bacterial infection and 6 cases of mixed bacterial infection. There were 11 cases of methicillin-resistant Staphylococcus aureus, 17 cases of Staphylococcus aureus, 18 cases of Pseudomonas aeruginosa, 11 cases of Enterobacter cloacae, 12 cases of Escherichia coli, 8 cases of Acinetobacter baumannii and 5 cases of Staphylococcus epidermidis. According to different surgical methods, they were divided into the control group and the experimental group. According to the Cinery-Mader classification of chronic osteomyelitis [9] : Control group: 21 cases of CM type III (localized type), 23 cases of CM type IV (diffuse type); Experimental group: 20 cases of CM type Ⅲ (localized type) and 24 cases of CM type Ⅳ (diffuse type). Sensitive antibiotics should be selected for those with detected bacteria during the operation. For those with negative preoperative bacterial culture, vancomycin and gentamicin were used in combination during the operation. Meanwhile, necrotic bone, infected tissue and secretions from the lesion were taken during the operation for metagenomic factor detection and drug sensitivity test, so as to compare and verify with those with positive preoperative bacterial culture. And for patients with negative preoperative bacterial culture results, precise detection was conducted to guide the application of sensitive antibiotics. This study has been approved by the Medical Ethics Committee of Honghui Hospital Affiliated to Xi 'an Jiaotong University School of Medicine (202306007), and all patients gave informed consent and signed the informed consent form. 1.3 Method 1.3.1 Preoperative management: The selection of intraoperative sensitive antibiotics is determined based on the results of bacterial culture drug sensitivity, and no antibiotic treatment is given before the operation. Complete X-ray films, CT (soft tissue window), and MRI to determine the infection site and debridement range. 1.3.2 Control Group: Incision was made layer by layer along the lateral side of the thigh. The sinus tract and deep infected necrotic tissues were resected until the intramedullary nails were exposed. The internal fixation device was completely removed. Samples of necrotic bone, soft tissue, and purulent secretions were collected respectively for metagenomic next generation sequencing (mNGS). A local groove was made at the locking site of the distal femur. An intramedullary nail guide needle was inserted from the entrance of the original intramedullary nail of the greater trochanter of the femur. Intraoperative X-ray revealed that both the groove site and the position of the guide needle exceeded the length of the original intramedullary nail. A medullary expander larger than the diameter of the main nail was used to remove the intramedullary biofilm and inflammatory tissue to achieve the purpose of expanded debridement [10]. A scraper and a grinding drill were used to remove the biofilm and inflammatory tissue in the anti-rotation nail. During the operation, the integrity of the medial femoral wall was preserved to avoid causing defects in the cortical bone of the medial wall. The pulse pressure irrigation gun uses a large amount of normal saline to flush the medullary cavity, anti-screw canal and wound surface. Then, taking the femoral anti-rotation intramedullary nail as the model, a carbon fiber rod of appropriate length was taken and wrapped around it with bone cement mixed with vancomycin and gentamicin to form the shapes of the main nail and the anti-rotation nail (as shown in Figure 1), placed for drainage, and the wound was closed. Bone grafting treatment should be considered as appropriate after the inflammatory indicators decrease after 6 weeks. 1.3.3 Experimental Group: On the basis of the first-stage treatment of the control group, the second-stage operation was performed two weeks after the operation. Bone cement rods were removed along the original wound, and calcium sulfate artificial bone mixed with sensitive antibiotics was shaped and filled to the bone defect of the medullary cavity. Indwelling drainage was carried out, and the wound was closed. 1.3.4 Postoperative management: The intraoperative mNGS results were compared with the bacterial culture of sinus exudate substances. In case of inconsistency between the intraoperative and preoperative results, the intraoperative sampling results were taken as the standard [11]. According to the results of the drug sensitivity test, sensitive antibiotic drugs were used for standardized treatment in sufficient dosage and duration. Inflammatory indicators were reexamined and the follow-up was conducted once a month within the first 3 months after the operation, once every 3 months after 3 months, and once every 6 months after 1 year. 1.4 Therapeutic Effect Evaluation 1.4.1 Postoperative recovery: The operation time, wound healing time, bone healing time and total effective rate of the control group and the experimental group were statistically analyzed. According to the relevant standards in "Practical Orthopedics" [12], the clinical efficacy is classified as marked effect, effective and ineffective. The total effective rate = marked effect + effective rate. The infection recurrence rate of the two groups 6 weeks after treatment was statistically analyzed. Recurrence could be diagnosed when the lesion site showed the same symptoms as chronic osteomyelitis related to bone infection again after the operation, such as continuous increase in body temperature and inflammatory indicators, inflammatory reactions such as redness, swelling, heat and pain at the primary disease site, non-healing of the wound or formation of sinus tract discharge of pus [13]. 1.4.2 Inflammatory index levels: Observe the white blood cells, C-reactive protein, erythrocyte sedimentation rate, procalcitonin, and serum amyloid A (SAA) of the patients before the operation and 6 weeks after the operation [14], and dynamically observe the postoperative therapeutic effect of the patients. 1.4.3 Pain assessment in patients with preoperative and postoperative visual analog pain score (visual the an a - logue scale) using VAS score of patients before and after treatment for 2 weeks, 1 month, 3 months assess pain, total score 10 points, the higher the more intense pain said [15]. 1.5 Statistical Analysis Data analysis was conducted using IBM SPSS 27.0 statistical software. Count data were expressed as [n(%)] and analyzed using the Chi-square test. Rank data were compared using the rank sum test. Normally distributed measurement data were expressed as（ ±s）and analyzed using independent sample t-tests for inter-group comparisons, paired t-tests for intra-group comparisons, and analysis of variance for repeated measures data. P < 0.05 was considered statistically significant. Results 2.1 General information of the two groups of patients There were no statistically significant differences in the preoperative general information such as gender, age, injured side, disease duration, and Cinery-Mader classification between the two groups of patients (P > 0.05, Table 1), and they were comparable. 2.2 Postoperative recovery data of the two groups The wound healing time and bone healing time of the patients in the experimental group were shorter than those in the control group (P < 0.05), there was no significant difference in the operation time between the two groups, as shown in Table 2. The total effective rate of the experimental group was higher than that of the control group (P < 0.05), as shown in Table 3. 2.3 Levels of inflammatory indicators in the two groups At 6 weeks after the operation, the levels of peripheral blood white blood cells(WBC), C-reactive protein(CRP), erythrocyte sedimentation rate(ESR), procalcitonin(PCT), and serum amyloid A (SAA) in both groups were significantly decreased compared with those before treatment ( P < 0.05), proving that both treatment methods were effective. However, all inflammatory indicators in the experimental group were lower than those in the control group. The differences were statistically significant ( P < 0.05), as shown in Table 4. It can be seen that the therapeutic effect of the experimental group was better than that of the control group. 2.4 PFNA displacement The maximum PFNA displacement occurred at the tip of the spiral blade, as shown in Figure 8. In the experimental group, PFNA displacement increased with increase in osteoporosis, up to 0.46 cm. In the control group, the maximum displacement of PFNA was also at the tip of the spiral blade; however, in the analysis involving 12 degrees of osteoporosis, the displacement was smaller than that of the experimental group. The displacement change rate was less than 3.5% in the first 7 groups, and significantly increased in the last 5 groups to a maximum of 5.13%, as shown in Figure 9. 2.4 Postoperative pain situation The pain scores of the two groups of patients showed a decreasing trend 2 weeks, 1 month after treatment and 3 months after follow-up. (F = 205.378, 342.284; both P < 0.001), and the pain scores of experimental group were all lower than those of control group ( P < 0.05), as shown in Table 5. 2.5 Typical cases are shown in Figure 2. Discussion Healthy bone tissue has extremely strong resistance to infection. However, when the body has necrosis, severe infection, foreign bodies and peripheral vascular diseases, this balance of bone tissue will tilt towards being prone to infection. Pathogenic bacteria can reach bones through the bloodstream and also directly invade through infections of adjacent soft tissues (such as diabetic foot ulcers). Inflammatory responses can cause a further increase in the pressure within the local bone marrow, leading to blood stasis and thrombosis. If not treated promptly and effectively, this pressure can break through the cortical bone and reduce the blood supply to the periosteum, resulting in necrotic bone [16]. Incomplete removal of the infection focus is an important reason for the recurrence of chronic osteomyelitis. Mature bacterial biofilms can resist the bactericidal effect of the host immune system and antibiotics. Only by thoroughly removing the diseased tissues with biofilms, such as implants, dead bones, scars and granulation tissue, can the risk of infection recurrence be reduced. Therefore, eliminating the infected lesion is regarded as a key step for the successful treatment of chronic osteomyelitis [17][18]. The treatment of chronic osteomyelitis of the proximal femur mainly includes the removal of the original internal fixation device, complete elimination of the lesion and the application of sensitive antibiotics against bacteria. In the use of antibiotics, two modes are usually adopted: systemic application and local application. For systemic application, it is recommended to use antibiotics for 6 weeks [19]. For local application of antibiotics, carriers are needed. In previous clinical treatments, antibiotic bone cement was implanted at the site of bone infection to maintain a high concentration of antibiotics in the local surrounding tissues, which could achieve the purpose of eliminating infected bacteria. Moreover, the lower dosage used could avoid the concentration of intravenous drugs exceeding the toxic level, was less likely to develop drug resistance, and could produce biofilms [20]. In the later stage of bone grafting for bone defect treatment, This is the currently more common Masquelet technique.However, this method also has certain drawbacks. There are certain constraints in the selection of antibacterial drugs. Antibacterial drugs that are water-soluble, heat-resistant and stable need to be chosen, which leads to a lower-level inflammatory response at the infection site and subsequently the occurrence of drug resistance [21]. Moreover, relevant studies indicate that the effective effect of antibiotic bone cement is relatively low. Studies have shown that approximately 90% of the antibiotic effects cannot be released [22]. At present, a new type of biomaterials - medical calcium sulfate - has begun to be gradually applied in clinical practice. Calcium sulfate is a degradable material with good histocompatibility. The local application of antibiotic concentration can be 100 to 200 times more effective than systemic application of antibiotics. It can maintain a relatively high antibiotic concentration locally and the treatment time can last up to one month. It has the advantages of accurate positioning, high local concentration, few side effects and long treatment time [23]. Moreover, its degradability can form a high-calcium and slightly acidic environment after degradation, thereby promoting the formation of new bone tissue. It has an osteogenic effect. After filling the lesion, it does not need to be removed through reoperation and has an auxiliary effect on bone repair. Moreover, calcium sulfate filling at the defect site of the bone segment can not only provide effective support, but also prevent the proliferation of soft tissue at the defect site, which is not conducive to bone healing. However, while calcium sulfate degrades, aseptic exudation may also occur, leading to the possibility of delayed wound healing and recurrence of infection [25]. A single treatment plan is difficult to solve the problems caused by bone infection [26], and there is still a chance of retaining harmful bacteria after bone cement filling [27]. This experiment combines the advantages of the two materials to explore the clinical value of the combined treatment of antibiotic bone cement carbon fiber rods and antibiotic-loaded calcium sulfate for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur.It was found in the study that the total effective rate of the experimental group 6 weeks after treatment was higher than that of the control group. The wound healing time and wound suture removal time of the experimental group were shorter than those of the control group. The levels of inflammatory factors at 2 weeks and 6 weeks after the operation were also lower than those of the experimental group. The pain scores at 2 weeks, 1 month and 3 months after the operation were also significantly lower than those of the experimental group. It is indicated that the combined treatment of antibiotic bone cement carbon fiber rods and calcium sulfate loaded with antibiotics can effectively control the infection symptoms of patients, promote the postoperative recovery of patients, and has a good therapeutic effect.In the traditional Masquelet technique, the antibiotic bone cement filled at the bone defect site has the problem of low mechanical strength. There are certain requirements for the ratio of antibiotics to bone cement, and the maximum should not exceed 1: 10 [28]. Ji Zhengang and Yu Xin [29][30] wrapped the steel plate with bone cement to improve the strength of the filled bone cement and the stability of the bone defect for this kind of insufficient stability. However, it has a great interference for the imaging examination of the lesion segment after the operation. The imaging of metals in magnetic resonance can easily affect the magnetic resonance imaging of residual or new infections. It has a significant impact on whether the infectious lesion is completely cleared. In this study, combined with the innovative clinical application of bone cement wrapped carbon fiber rods for filling bone defects, the lengths and thicknesses of the carbon fiber rods are diverse to meet the filling requirements in the proximal femoral medullard cavity. On the one hand, it is relatively low economically; on the other hand, it is also relatively easy to obtain the materials. The most important thing is that in the postoperative follow-up MRI imaging, it will not affect the therapeutic effect of lesion removal. At present, the detection of bacteria causing bone infections mainly relies on bacterial culture 31. However, this method requires a long laboratory testing time and has a low positive rate. It is often difficult to apply sensitive antibiotics quickly, thus delaying the course of the disease and the timing of treatment. mNGS technology is a relatively new molecular biology detection technique. It can simultaneously detect multiple pathogenic microorganisms by using genomic research strategies. It has the advantages of fast detection speed, high specificity and sensitivity, and wide identification range 32 33 34. In this experiment, the bacterial culture protocol was applied to patients with sinus tract secretions on the skin surface before the operation. During the operation, samples were taken from necrotic bone, soft tissue, and purulent secretions respectively, and the mNGS technique and intraoperative tissue bacterial culture were applied. We found that among the 88 patients, the preoperative bacterial culture of 10 patients was negative. During the operation, all effective positive results were detected by mNGS technology. However, the intraoperative bacterial culture results of 5 patients were still negative. The intraoperative mNGS test results of all samples were obtained within 48 hours, while the bacterial culture results were on average about 5-7 days, which was relatively consistent with the experimental data of Hao Linjie [35]. The mNGS technology can conduct rapid and accurate detection of bacteria, providing great clinical significance and value for treatment. For patients with intramedullary infection, debridement is different from that for infection at other sites. A complete removal of the medullary cavity lesion is required with the use of a medullary expansion device. For patients with intramedullary infection, RIA (reamamer -irrigator-aspirator) is currently recommended for medullary cavity debridement[36]. It can thoroughly remove necrotic bone tissue while also performing sufficient drainage and having the function of flushing. It can also prevent fat embolism and thermal necrosis of normal bone tissue in the medullary cavity caused by excessive pressure and temperature in the medullary cavity[37]. Compared with the more common medullary expansion device combined with distal fenestration drainage, it has better therapeutic effects and practicality. However, due to its high price, it was not applied in this experiment. The future is worth promoting. There are still some deficiencies in this study. Firstly, the sample size of this experiment is relatively small, the follow-up time is relatively short, and the data is prone to bias. Secondly, surgical bias caused by different physicians is inevitable. The infection sites of the experimental sample data selected in this article did not involve the joint cavities. Conclusion The combination of antibiotic bone cement carbon fiber rods and antibiotic calcium sulfate technology in the treatment of patients with chronic osteomyelitis related to bone infection after proximal femoral PFNA surgery can effectively reduce the inflammatory response and pain, eliminate the infection while achieving osteogenic effects, and significantly reduce the postoperative recurrence rate, showing good clinical efficacy. Abbreviations PFNA: proximal femoral nail anti-rotation, mNGS: metagenomic next generation sequencing，WBC: white blood cells, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, PCT: procalcitonin, SAA: serum amyloid A, VAS:visual an a-logue scale Declarations Ethics approval and consent to participate: Ethical clearance was obtained through the Ethics Review Committee of Hong-Hui Hospital, Xi’an Jiaotong University and the informed consent was obtained from individual or guardian participants. Data collected from participants were kept confidential and were accessible only to the researchers. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication: Not applicable. Availability of date and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files. Competing interests: The authors declare that they have no competing interests. Authors’ contribution: All authors conceived of the study, took active part in all aspects of the study and read and approved the final manuscript. TM was the lead author of the original report. HG was the main contributor in the process of up-dating and revising the contents of the original report and in preparing this manuscript. Authors’ information: Affiliation: Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Xi’an, China Hao Guo, Resident physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Cheng Ren, Attending physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Yibo Xu, Attending physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Chaofeng Wang, Associated chief physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Ten Ma, Professor, Chief physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Dawei Zhou, Resident physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] De-yin Liu, Associated chief physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Cong-ming Zhang, Associated chief physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Dong-yang Li, Resident physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Chang-jun He, Resident physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] Kun Zhang, Chief physician of the Severe & Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected] . 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Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections. J Bone Jt Infect . 2017;2(1):38-51. Published 2017 Jan 1. doi:10.7150/jbji.17234 Anagnostakos K, Fürst O, Kelm J. Antibiotic-impregnated PMMA hip spacers: Current status. Acta Orthop . 2006;77(4):628-637. doi:10.1080/17453670610012719 Ji Zhengang, Zhou Dapeng, Han Tianyu, et al. Efficacy of Masquelet membrane induction technique for traumatic long bone defects[J]. Chinese Journal of Trauma, 2019, 35(02): 128-135. doi:10.3760/cma.j.issn.1001-8050.2019.02.006. Xin Yu, Shuo Jia, Hongri Wu, et al. Application of antibiotic cement-coated locking plates in induced membrane technique for treating post-traumatic tibial osteomyelitis. Chinese Journal of Trauma, 2017, 33(6): 539-543. doi: 10.3760/cma.j.issn.1001-8050.2017.06.012 Glaudemans AWJM, Jutte PC, Cataldo MA, et al. Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging . 2019;46(4):957-970. doi:10.1007/s00259-019-4262-x Tarabichi M, Shohat N, Goswami K, Parvizi J. Can next generation sequencing play a role in detecting pathogens in synovial fluid?. Bone Joint J . 2018;100-B(2):127-133. doi:10.1302/0301-620X.100B2.BJJ-2017-0531.R2 Wang J, Han Y, Feng J. Metagenomic next-generation sequencing for mixed pulmonary infection diagnosis. BMC Pulm Med. 2019 Dec 19;19(1):252. doi: 10.1186/s12890-019-1022-4. Köser CU, Bryant JM, Becq J, et al. Whole-genome sequencing for rapid susceptibility testing of M. tuberculosis. N Engl J Med. 2013 Jul 18;369(3):290-2. doi: 10.1056/NEJMc1215305. Hao Linjie, Zhang Yumin, Wen Pengfei, et al. Application of metagenomic next-generation sequencing in pathogen detection of periprosthetic joint infection [J]. Chinese Journal of Joint Surgery(ElectronicEdition),2021,15(02):185-191. doi:10.3877/cma.j.issn.1674-134X.2021.02.009 Zalavras CG, Sirkin M. Treatment of long bone intramedullary infection using the RIA for removal of infected tissue: indications, method and clinical results. Injury. 2010 Nov;41 Suppl 2:S43-7. doi: 10.1016/S0020-1383(10)70008-5. Dehghan N，Schemitsch EH．Extended applications of the reamer-irrigator-aspirator (RIA) system［J］.Injury,2017,48 (Suppl 1:) S47－S51. doi: 10.1016 /j.injury.2017.04.025． Tables Table 1 Comparion of the baseline date between the groups of patient Groups Age（year， ±s） Gender （case） Injured side（case） Disease duration（month） Cinery-Mader classification（case） male female left right CM-III CM-IV Control group（44） Experimental group（44） 51.17±4.45 25 19 19 25 5.17±1.45 21 23 52.39±3.98 24 20 18 26 4.86±2.13 20 24 Test statistics 1.001 0.173 0.012 0.668 0.720 P 0.320 0.682 0.921 0.423 0.392 Table 2 Postoperative recovery data of the two groups Recovery data Experimental group（44） Control group（44） t p Operation time（hours） 3.1±1.70 3.5±1.01 1.188 0.238 Wound healing time（days） 9.15±1.42 12.32±4.14 4.942 <0.001 Bone healing time（days） 1.34±0.21 1.72±0.78 2.895 0.005 Table 3 The total effective rate. Curative effect Experimental group（44） Control group（44） Test statistics p case efficiency case efficiency Excellent 29 65.9% 20 45.5% 6.150 0.013 Valid 11 25% 11 25% Invalid 4 9.1% 13 29.5% Table 4 Levels of inflammatory indicators in the two groups Index prior a 6 weeks after p difference value b prior c 6 weeks after p difference value d a vs c b vs d WBC 11.51±2.44 6.52±1.86 <0.001 5.07±2.83 12.17±2.14 9.87±1.57 <0.001 2.67±1.83 0.116 <0.001 CRP 69.55±43.64 4.44±2.85 <0.001 65.11±43.36 67.34±41.78 11.79±3.54 <0.001 56.56±40.79 0.890 0.005 ESR 61.93±18.27 9.67±5.51 <0.001 52.62±20.77 59.89±17.19 14.17±4.51 <0.001 45.48±16.99 0.485 0.018 PCT 0.58±0.61 0.04±0.02 <0.001 0.52±0.12 0.57±0.54 0.11±0.07 <0.001 0.46±0.13 0.638 0.031 SAA 49.73±4.52 4.97±2.68 <0.001 44.70±5.15 51.14±3.68 13.71±1.09 <0.001 37.16±3.83 0.182 <0.001 Table5 Postoperative pain situation (Note: a. Compared with before treatment, P < 0.05; b. Compared with 2 weeks after treatment, P < 0.05; C. Compared with one month after treatment, P < 0.05.) Index Experimental group Control group t p prior treatment 7.21±1.78 7.15±1.69 0.186 0.853 Two weeks after 4.17±0.89 a 5.24±1.94 a 3.201 0.002 One month after 2.75±0.67 ab 3.41±1.53 ab 2.575 0.012 Three month after 1.37±0.24 abc 1.89±0.74 abc 4.400 <0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Nov, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 06 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviewers invited by journal 02 Sep, 2025 Editor assigned by journal 17 Jun, 2025 Submission checks completed at journal 17 Jun, 2025 First submitted to journal 16 Jun, 2025 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. 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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-6906791","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511116554,"identity":"cb61865b-7b98-43e0-b224-072ecfa8fc12","order_by":0,"name":"Hao Guo","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Guo","suffix":""},{"id":511116555,"identity":"172f551f-0752-4f95-81d5-a15342f4e0ee","order_by":1,"name":"Cheng Ren","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Cheng","middleName":"","lastName":"Ren","suffix":""},{"id":511116556,"identity":"1acd0231-3723-4061-ab81-5dd64ccf64d1","order_by":2,"name":"Chaofeng Wang","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Chaofeng","middleName":"","lastName":"Wang","suffix":""},{"id":511116557,"identity":"dc2bafab-7fc5-4cd0-8e10-d9579ca576cc","order_by":3,"name":"Yibo Xu","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Yibo","middleName":"","lastName":"Xu","suffix":""},{"id":511116558,"identity":"2b022bef-8c12-49f7-a0c8-099379dfc5db","order_by":4,"name":"Deyin Liu","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Deyin","middleName":"","lastName":"Liu","suffix":""},{"id":511116559,"identity":"e904e06c-532b-4df2-8dce-b23cd3d323bd","order_by":5,"name":"Congming Zhang","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Congming","middleName":"","lastName":"Zhang","suffix":""},{"id":511116563,"identity":"208f9388-9fe5-4bf1-a5cc-1219f40ee5a1","order_by":6,"name":"Dawei Zhou","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Dawei","middleName":"","lastName":"Zhou","suffix":""},{"id":511116565,"identity":"ca41e2ce-1e8c-41aa-a87c-e2acd62d0f21","order_by":7,"name":"Dongyang Li","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Dongyang","middleName":"","lastName":"Li","suffix":""},{"id":511116566,"identity":"4349e1d3-827a-4344-b503-e4cc2e876bb9","order_by":8,"name":"Changjun He","email":"","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Changjun","middleName":"","lastName":"He","suffix":""},{"id":511116567,"identity":"a425f5e1-3a6e-4d8b-af8f-e2e45be35bae","order_by":9,"name":"Teng Ma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYJCCAx8qauRI0sH4cMaZY8YkaWE25m1jTmwgWr28e/MxaR42tvS+4wmMHz7mEKHF8MyxNMk5PDK5M888YJacuY0YLTNyzCTeSLDlbriRwMbMS7QWHgPmdAOitchL5Bgb8iQwJxCvxYDnWOLDGQeOGc4887CZOL/ItzcfOPDxX4083/Hkgx8+EmXLARjrALFRIw9XdyCBOB2jYBSMglEw8gAAB2k6Co+q5vkAAAAASUVORK5CYII=","orcid":"","institution":"Honghui Hospital, Xi ’ an Jiaotong 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15:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6906791/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6906791/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-06381-z","type":"published","date":"2025-11-07T15:57:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90903133,"identity":"f9664999-6a1c-43fa-9c4c-97360756ca1f","added_by":"auto","created_at":"2025-09-09 12:47:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":394949,"visible":true,"origin":"","legend":"\u003cp\u003eDebridement and preparation of carbon fiber rod bone cement (a: Schematic diagram of medullary cavity dilation; b: Metagenomic next-generation sequencing samples; c: Select the length of the carbon fiber rod; d: Producing carbon fiber bar bone cement\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6906791/v1/69b9d848cb73c1fc9d7bc95a.png"},{"id":90903134,"identity":"8a34bafe-b142-4da3-8a71-8616d14e405a","added_by":"auto","created_at":"2025-09-09 12:47:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":100945,"visible":true,"origin":"","legend":"\u003cp\u003eTypical cases (a: Preoperative status of chronic osteomyelitis; b: After the primary debridement with carbon fiber rod bone cement filling; c: After secondary calcium sulfate filling; d: The follow-up examination three months after discharge showed that calcium sulfate was gradually absorbed and new bone was formed.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6906791/v1/7921dc279cc304567a4c2c41.png"},{"id":95564280,"identity":"cfa73b83-fc43-4f62-b8ec-14164b67129b","added_by":"auto","created_at":"2025-11-10 16:09:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1355563,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6906791/v1/7d7e202d-7a0c-4273-93be-adf3751267a6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A new and effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur - carbon fiber rod bone cement combined with calcium sulfate loaded with antibiotics","fulltext":[{"header":"Background","content":"\u003cp\u003eWith the aging of the population, the incidence of intertrochanteric fractures of the femur has been increasing year by year. According to statistics, the total number of hip fracture patients in 204 countries around the world in 2019 was 14.2 million [1]. Currently, it remains one of the most common fracture types among the elderly [2]. Under such a huge increase in the patient base, postoperative complications have also attracted much attention. Among them, the incidence of chronic osteomyelitis can be as high as 16% [3]. Due to its long disease course, complex treatment process, high treatment cost, high recurrence rate and disability risk, and unsatisfactory postoperative effect, it is called \"the second cancer\" [4] and is recognized as one of the difficult problems in the management of postoperative complications of fractures [5].\u003c/p\u003e\n\u003cp\u003eAt present, relevant scholars have respectively applied antibiotic bone cement and calcium sulfate in the treatment of chronic osteomyelitis [6][7]. The Masquelet membrane induction technique is one of the common treatment methods for chronic osteomyelitis. It promotes osteogenic reconstruction by inducing a protective isolation mechanism of connective tissue membrane formed by the bone cement occupying the bone defect area in the surrounding soft tissue [8]. Calcium sulfate is a biodegradable carrier for the sustained-release system of antibacterial drugs. It carries sensitive antibiotics that can be slowly released at the site of infection. For chronic osteomyelitis after internal fixation of intertrochanteric fractures of the femur, the infection site is deep and the operation is difficult. Currently, there is no effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur. This study retrospectively analyzed and compared the therapeutic effects of Masquelet membrane induction technique and antibiotic bone cement rods combined with antibiotic-loaded calcium sulfate. To explore the clinical efficacy of antibiotic bone cement rods combined with calcium sulfate loaded with antibiotics, and to provide guiding treatment for future clinical practice.\u003c/p\u003e"},{"header":"Objects and Methods","content":"\u003cp\u003e1.1 Objects\u003c/p\u003e\n\u003cp\u003eA total of 88 patients with infection-related chronic osteomyelitis after intramedullary nail internal fixation of intertrochanteric fractures of the femur admitted to Honghui Hospital Affiliated to Medical College of Xi 'an Jiaotong University from March 2018 to March 2024 were selected as the research subjects. Inclusion criteria: 1. Meeting the diagnostic criteria for chronic osteomyelitis of the International Association for the study of Internal Fixation (Assocication for the study of Internal Fixation, AO/ASIF) in 2017: Sinus ducts, fistulas or wound dehiscence (with exposed bone or exposed internal fixators) that directly communicate with bone tissue or implants, pus was found around the internal fixator during the operation, the bacterial culture of the suspected infected tissue was positive during the operation, and the special staining of histopathology confirmed the presence of pathogenic microorganisms in the suspected infected tissue during the operation. 2. Those over 18 years old; 3. Those with complete postoperative follow-up data. Exclusion criteria: Patients with hematogenous osteomyelitis, those with other acute or chronic infectious diseases, those with malignant tumor diseases, those with hematopoietic dysfunction and autoimmune diseases, and those with severe cardiovascular and cerebrovascular diseases, etc.\u003c/p\u003e\n\u003cp\u003e1.2 General data\u003c/p\u003e\n\u003cp\u003eA total of 49 males and 39 females were included in this experiment. The age ranged from 48 to 71 years old, with an average of 55.6 years old. The course of osteomyelitis was 4 to 9 months. All of them were closed intertrochanteric fractures of the femur, and intramedullary screws were used for internal fixation after fractures. Among the 81 patients with skin and soft tissue sinus tract formation, 78 cases showed positive bacterial culture of wound secretions, including 71 cases of single bacterial infection and 6 cases of mixed bacterial infection. There were 11 cases of methicillin-resistant Staphylococcus aureus, 17 cases of Staphylococcus aureus, 18 cases of Pseudomonas aeruginosa, 11 cases of Enterobacter cloacae, 12 cases of Escherichia coli, 8 cases of Acinetobacter baumannii and 5 cases of Staphylococcus epidermidis. According to different surgical methods, they were divided into the control group and the experimental group. According to the Cinery-Mader classification of chronic osteomyelitis [9] : Control group: 21 cases of CM type III (localized type), 23 cases of CM type IV (diffuse type); Experimental group: 20 cases of CM type\u0026nbsp;Ⅲ\u0026nbsp;(localized type) and 24 cases of CM type\u0026nbsp;Ⅳ\u0026nbsp;(diffuse type).\u003c/p\u003e\n\u003cp\u003eSensitive antibiotics should be selected for those with detected bacteria during the operation. For those with negative preoperative bacterial culture, vancomycin and gentamicin were used in combination during the operation. Meanwhile, necrotic bone, infected tissue and secretions from the lesion were taken during the operation for metagenomic factor detection and drug sensitivity test, so as to compare and verify with those with positive preoperative bacterial culture. And for patients with negative preoperative bacterial culture results, precise detection was conducted to guide the application of sensitive antibiotics.\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Medical Ethics Committee of Honghui Hospital Affiliated to Xi 'an Jiaotong University School of Medicine (202306007), and all patients gave informed consent and signed the informed consent form.\u003c/p\u003e\n\u003cp\u003e1.3 Method\u003c/p\u003e\n\u003cp\u003e1.3.1 Preoperative management: The selection of intraoperative sensitive antibiotics is determined based on the results of bacterial culture drug sensitivity, and no antibiotic treatment is given before the operation. Complete X-ray films, CT (soft tissue window), and MRI to determine the infection site and debridement range.\u003c/p\u003e\n\u003cp\u003e1.3.2 Control Group: Incision was made layer by layer along the lateral side of the thigh. The sinus tract and deep infected necrotic tissues were resected until the intramedullary nails were exposed. The internal fixation device was completely removed. Samples of necrotic bone, soft tissue, and purulent secretions were collected respectively for metagenomic next generation sequencing (mNGS). A local groove was made at the locking site of the distal femur. An intramedullary nail guide needle was inserted from the entrance of the original intramedullary nail of the greater trochanter of the femur. Intraoperative X-ray revealed that both the groove site and the position of the guide needle exceeded the length of the original intramedullary nail. A medullary expander larger than the diameter of the main nail was used to remove the intramedullary biofilm and inflammatory tissue to achieve the purpose of expanded debridement [10]. A scraper and a grinding drill were used to remove the biofilm and inflammatory tissue in the anti-rotation nail. During the operation, the integrity of the medial femoral wall was preserved to avoid causing defects in the cortical bone of the medial wall. The pulse pressure irrigation gun uses a large amount of normal saline to flush the medullary cavity, anti-screw canal and wound surface. Then, taking the femoral anti-rotation intramedullary nail as the model, a carbon fiber rod of appropriate length was taken and wrapped around it with bone cement mixed with vancomycin and gentamicin to form the shapes of the main nail and the anti-rotation nail (as shown in Figure 1), placed for drainage, and the wound was closed. Bone grafting treatment should be considered as appropriate after the inflammatory indicators decrease after 6 weeks.\u003c/p\u003e\n\u003cp\u003e1.3.3 Experimental Group: On the basis of the first-stage treatment of the control group, the second-stage operation was performed two weeks after the operation. Bone cement rods were removed along the original wound, and calcium sulfate artificial bone mixed with sensitive antibiotics was shaped and filled to the bone defect of the medullary cavity. Indwelling drainage was carried out, and the wound was closed.\u003c/p\u003e\n\u003cp\u003e1.3.4 Postoperative management: The intraoperative mNGS results were compared with the bacterial culture of sinus exudate substances. In case of inconsistency between the intraoperative and preoperative results, the intraoperative sampling results were taken as the standard [11]. According to the results of the drug sensitivity test, sensitive antibiotic drugs were used for standardized treatment in sufficient dosage and duration. Inflammatory indicators were reexamined and the follow-up was conducted once a month within the first 3 months after the operation, once every 3 months after 3 months, and once every 6 months after 1 year.\u003c/p\u003e\n\u003cp\u003e1.4\u0026nbsp;Therapeutic Effect Evaluation\u003c/p\u003e\n\u003cp\u003e1.4.1 Postoperative recovery: The operation time, wound healing time, bone healing time and total effective rate of the control group and the experimental group were statistically analyzed. According to the relevant standards in \"Practical Orthopedics\" [12], the clinical efficacy is classified as marked effect, effective and ineffective. The total effective rate = marked effect + effective rate. The infection recurrence rate of the two groups 6 weeks after treatment was statistically analyzed. Recurrence could be diagnosed when the lesion site showed the same symptoms as chronic osteomyelitis related to bone infection again after the operation, such as continuous increase in body temperature and inflammatory indicators, inflammatory reactions such as redness, swelling, heat and pain at the primary disease site, non-healing of the wound or formation of sinus tract discharge of pus [13].\u003c/p\u003e\n\u003cp\u003e1.4.2 Inflammatory index levels: Observe the white blood cells, C-reactive protein, erythrocyte sedimentation rate, procalcitonin, and serum amyloid A (SAA) of the patients before the operation and 6 weeks after the operation [14], and dynamically observe the postoperative therapeutic effect of the patients.\u003c/p\u003e\n\u003cp\u003e1.4.3 Pain assessment in patients with preoperative and postoperative visual analog pain score (visual the an a - logue scale) using VAS score of patients before and after treatment for 2 weeks, 1 month, 3 months assess pain, total score 10 points, the higher the more intense pain said [15].\u003c/p\u003e\n\u003cp\u003e1.5\u0026nbsp;Statistical Analysis\u003c/p\u003e\n\u003cp\u003eData analysis was conducted using IBM SPSS 27.0 statistical software. Count data were expressed as [n(%)] and analyzed using the Chi-square test. Rank data were compared using the rank sum test. Normally distributed measurement data were expressed as（\u003cimg width=\"11\" height=\"22\" src=\"data:image/png;base64,R0lGODlhCwAWAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABQALAA0AhAAAACMfICQfTCQfdCRLdCRLmSRzvFAfIFBLmXYfIHZzmXa8vHa83na8/5tLIJtLdJtzdJve/71zIL1zTL3emb3e/73//96ZTN6ZdN7///+8dP/emf//vP//3gECAwECAwU9YCCOZACcaKqu7NpNQZEB2mGcWKMJ0YbMKU5i8bC4HIJGSyJjbQ4Do6oDoRyUqklDaOAoZhcB43QJECqnEAA7\" alt=\"image\"\u003e±s）and analyzed using independent sample t-tests for inter-group comparisons, paired t-tests for intra-group comparisons, and analysis of variance for repeated measures data. \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e2.1\u0026nbsp;General information of the two groups of patients\u003c/p\u003e\n\u003cp\u003eThere were no statistically significant differences in the preoperative general information such as gender, age, injured side, disease duration, and Cinery-Mader classification between the two groups of patients (P \u0026gt; 0.05, Table 1), and they were comparable.\u003c/p\u003e\n\u003cp\u003e2.2\u0026nbsp;Postoperative recovery data of the two groups\u003c/p\u003e\n\u003cp\u003eThe wound healing time and bone healing time of the patients in the experimental group were shorter than those in the control group (P \u0026lt; 0.05), there was no significant difference in the operation time between the two groups, as shown in Table 2. The total effective rate of the experimental group was higher than that of the control group (P \u0026lt; 0.05), as shown in Table 3.\u003c/p\u003e\n\u003cp\u003e2.3\u0026nbsp;Levels of inflammatory indicators in the two groups\u003c/p\u003e\n\u003cp\u003eAt 6 weeks after the operation, the levels of peripheral blood white blood cells(WBC), C-reactive protein(CRP), erythrocyte sedimentation rate(ESR), procalcitonin(PCT), and serum amyloid A (SAA) in both groups were significantly decreased compared with those before treatment (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), proving that both treatment methods were effective. However, all inflammatory indicators in the experimental group were lower than those in the control group. The differences were statistically significant (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), as shown in Table\u0026nbsp;4. It can be seen that the therapeutic effect of the experimental group was better than that of the control group.\u003c/p\u003e\n\u003cp\u003e2.4 PFNA displacement\u003c/p\u003e\n\u003cp\u003eThe maximum PFNA displacement occurred at the tip of the spiral blade, as shown in Figure 8. In the experimental group, PFNA displacement increased with increase in osteoporosis, up to 0.46 cm. In the control group, the maximum displacement of PFNA was also at the tip of the spiral blade; however, in the analysis involving 12 degrees of osteoporosis, the displacement was smaller than that of the experimental group. The displacement change rate was less than 3.5% in the first 7 groups, and significantly increased in the last 5 groups to a maximum of 5.13%, as shown in Figure 9.\u003c/p\u003e\n\u003cp\u003e2.4\u0026nbsp;Postoperative pain situation\u003c/p\u003e\n\u003cp\u003eThe pain scores of the two groups of patients showed a decreasing trend 2 weeks, 1 month after treatment and 3 months after follow-up.\u0026nbsp;(F = 205.378, 342.284; both \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), and the pain scores of experimental group\u0026nbsp;were all lower than those of control group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), as shown in Table\u0026nbsp;5.\u003c/p\u003e\n\u003cp\u003e2.5 Typical cases are shown in Figure 2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHealthy bone tissue has extremely strong resistance to infection. However, when the body has necrosis, severe infection, foreign bodies and peripheral vascular diseases, this balance of bone tissue will tilt towards being prone to infection. Pathogenic bacteria can reach bones through the bloodstream and also directly invade through infections of adjacent soft tissues (such as diabetic foot ulcers). Inflammatory responses can cause a further increase in the pressure within the local bone marrow, leading to blood stasis and thrombosis. If not treated promptly and effectively, this pressure can break through the cortical bone and reduce the blood supply to the periosteum, resulting in necrotic bone [16]. Incomplete removal of the infection focus is an important reason for the recurrence of chronic osteomyelitis. Mature bacterial biofilms can resist the bactericidal effect of the host immune system and antibiotics. Only by thoroughly removing the diseased tissues with biofilms, such as implants, dead bones, scars and granulation tissue, can the risk of infection recurrence be reduced. Therefore, eliminating the infected lesion is regarded as a key step for the successful treatment of chronic osteomyelitis [17][18].\u003c/p\u003e\n\u003cp\u003eThe treatment of chronic osteomyelitis of the proximal femur mainly includes the removal of the original internal fixation device, complete elimination of the lesion and the application of sensitive antibiotics against bacteria. In the use of antibiotics, two modes are usually adopted: systemic application and local application. For systemic application, it is recommended to use antibiotics for 6 weeks [19]. For local application of antibiotics, carriers are needed. In previous clinical treatments, antibiotic bone cement was implanted at the site of bone infection to maintain a high concentration of antibiotics in the local surrounding tissues, which could achieve the purpose of eliminating infected bacteria. Moreover, the lower dosage used could avoid the concentration of intravenous drugs exceeding the toxic level, was less likely to develop drug resistance, and could produce biofilms [20]. In the later stage of bone grafting for bone defect treatment, This is the currently more common Masquelet technique.However, this method also has certain drawbacks. There are certain constraints in the selection of antibacterial drugs. Antibacterial drugs that are water-soluble, heat-resistant and stable need to be chosen, which leads to a lower-level inflammatory response at the infection site and subsequently the occurrence of drug resistance [21]. Moreover, relevant studies indicate that the effective effect of antibiotic bone cement is relatively low. Studies have shown that approximately 90% of the antibiotic effects cannot be released [22].\u003c/p\u003e\n\u003cp\u003eAt present, a new type of biomaterials - medical calcium sulfate - has begun to be gradually applied in clinical practice. Calcium sulfate is a degradable material with good histocompatibility. The local application of antibiotic concentration can be 100 to 200 times more effective than systemic application of antibiotics. It can maintain a relatively high antibiotic concentration locally and the treatment time can last up to one month. It has the advantages of accurate positioning, high local concentration, few side effects and long treatment time [23]. Moreover, its degradability can form a high-calcium and slightly acidic environment after degradation, thereby promoting the formation of new bone tissue. It has an osteogenic effect. After filling the lesion, it does not need to be removed through reoperation and has an auxiliary effect on bone repair. Moreover, calcium sulfate filling at the defect site of the bone segment can not only provide effective support, but also prevent the proliferation of soft tissue at the defect site, which is not conducive to bone healing. However, while calcium sulfate degrades, aseptic exudation may also occur, leading to the possibility of delayed wound healing and recurrence of infection [25].\u003c/p\u003e\n\u003cp\u003eA single treatment plan is difficult to solve the problems caused by bone infection [26], and there is still a chance of retaining harmful bacteria after bone cement filling [27]. This experiment combines the advantages of the two materials to explore the clinical value of the combined treatment of antibiotic bone cement carbon fiber rods and antibiotic-loaded calcium sulfate for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur.It was found in the study that the total effective rate of the experimental group 6 weeks after treatment was higher than that of the control group. The wound healing time and wound suture removal time of the experimental group were shorter than those of the control group. The levels of inflammatory factors at 2 weeks and 6 weeks after the operation were also lower than those of the experimental group. The pain scores at 2 weeks, 1 month and 3 months after the operation were also significantly lower than those of the experimental group. It is indicated that the combined treatment of antibiotic bone cement carbon fiber rods and calcium sulfate loaded with antibiotics can effectively control the infection symptoms of patients, promote the postoperative recovery of patients, and has a good therapeutic effect.In the traditional Masquelet technique, the antibiotic bone cement filled at the bone defect site has the problem of low mechanical strength. There are certain requirements for the ratio of antibiotics to bone cement, and the maximum should not exceed 1: 10\u0026nbsp;[28].\u0026nbsp;Ji Zhengang\u0026nbsp;and\u0026nbsp;Yu Xin [29][30] wrapped the steel plate with bone cement to improve the strength of the filled bone cement and the stability of the bone defect for this kind of insufficient stability. However, it has a great interference for the imaging examination of the lesion segment after the operation. The imaging of metals in magnetic resonance can easily affect the magnetic resonance imaging of residual or new infections. It has a significant impact on whether the infectious lesion is completely cleared. In this study, combined with the innovative clinical application of bone cement wrapped carbon fiber rods for filling bone defects, the lengths and thicknesses of the carbon fiber rods are diverse to meet the filling requirements in the proximal femoral medullard cavity. On the one hand, it is relatively low economically; on the other hand, it is also relatively easy to obtain the materials. The most important thing is that in the postoperative follow-up MRI imaging, it will not affect the therapeutic effect of lesion removal.\u003c/p\u003e\n\u003cp\u003eAt present, the detection of bacteria causing bone infections mainly relies on bacterial culture 31. However, this method requires a long laboratory testing time and has a low positive rate. It is often difficult to apply sensitive antibiotics quickly, thus delaying the course of the disease and the timing of treatment. mNGS technology is a relatively new molecular biology detection technique. It can simultaneously detect multiple pathogenic microorganisms by using genomic research strategies. It has the advantages of fast detection speed, high specificity and sensitivity, and wide identification range 32 33 34. In this experiment, the bacterial culture protocol was applied to patients with sinus tract secretions on the skin surface before the operation. During the operation, samples were taken from necrotic bone, soft tissue, and purulent secretions respectively, and the mNGS technique and intraoperative tissue bacterial culture were applied. We found that among the 88 patients, the preoperative bacterial culture of 10 patients was negative. During the operation, all effective positive results were detected by mNGS technology. However, the intraoperative bacterial culture results of 5 patients were still negative. The intraoperative mNGS test results of all samples were obtained within 48 hours, while the bacterial culture results were on average about 5-7 days, which was relatively consistent with the experimental data of Hao Linjie\u0026nbsp;[35]. The mNGS technology can conduct rapid and accurate detection of bacteria, providing great clinical significance and value for treatment.\u003c/p\u003e\n\u003cp\u003eFor patients with intramedullary infection, debridement is different from that for infection at other sites. A complete removal of the medullary cavity lesion is required with the use of a medullary expansion device. For patients with intramedullary infection, RIA (reamamer -irrigator-aspirator) is currently recommended for medullary cavity debridement[36]. It can thoroughly remove necrotic bone tissue while also performing sufficient drainage and having the function of flushing. It can also prevent fat embolism and thermal necrosis of normal bone tissue in the medullary cavity caused by excessive pressure and temperature in the medullary cavity[37]. Compared with the more common medullary expansion device combined with distal fenestration drainage, it has better therapeutic effects and practicality. However, due to its high price, it was not applied in this experiment. The future is worth promoting.\u003c/p\u003e\n\u003cp\u003eThere are still some deficiencies in this study. Firstly, the sample size of this experiment is relatively small, the follow-up time is relatively short, and the data is prone to bias. Secondly, surgical bias caused by different physicians is inevitable. The infection sites of the experimental sample data selected in this article did not involve the joint cavities.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe combination of antibiotic bone cement carbon fiber rods and antibiotic calcium sulfate technology in the treatment of patients with chronic osteomyelitis related to bone infection after proximal femoral PFNA surgery can effectively reduce the inflammatory response and pain, eliminate the infection while achieving osteogenic effects, and significantly reduce the postoperative recurrence rate, showing good clinical efficacy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePFNA: proximal femoral nail anti-rotation, mNGS: metagenomic next generation sequencing，WBC: white blood cells, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, PCT: procalcitonin, SAA: serum amyloid A, VAS:visual an a-logue scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Ethical clearance was obtained through the Ethics Review Committee of Hong-Hui Hospital, Xi’an Jiaotong University and the informed consent was obtained from individual or guardian participants. Data collected from participants were kept confidential and were accessible only to the researchers. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of date and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eAuthors’ contribution: All authors conceived of the study, took active part in all aspects of the study and read and approved the final manuscript. TM was the lead author of the original report. HG was the main contributor in the process of up-dating and revising the contents of the original report and in preparing this manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors’ information:\u003c/p\u003e\n\u003cp\u003eAffiliation: \u003c/p\u003e\n\u003cp\u003eSevere \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Xi’an, China\u003c/p\u003e\n\u003cp\u003eHao Guo, Resident physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e\n\u003cp\u003eCheng Ren, Attending physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e\n\u003cp\u003eYibo Xu, Attending physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e\n\u003cp\u003eChaofeng Wang, Associated chief physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e\n\u003cp\u003eTen Ma, Professor, Chief physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e\n\u003cp\u003eDawei Zhou, Resident physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e\n\u003cp\u003eDe-yin Liu, Associated chief physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email:[email protected]\u003c/p\u003e\n\u003cp\u003eCong-ming Zhang, Associated chief physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email:[email protected]\u003c/p\u003e\n\u003cp\u003eDong-yang Li, Resident physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email:[email protected]\u003c/p\u003e\n\u003cp\u003eChang-jun He, Resident physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email:[email protected]\u003c/p\u003e\n\u003cp\u003eKun Zhang, Chief physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email:[email protected].\u003c/p\u003e\n\u003cp\u003eDongchen Li, Resident physician of the Severe \u0026amp; Poly-trauma Division, Orthopedic Trauma Department, Hong-Hui Hospital, Xi’an Jiaotong University, Email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGBD 2019 Fracture Collaborators. 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Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections. \u003cem\u003eJ Bone Jt Infect\u003c/em\u003e. 2017;2(1):38-51. Published 2017 Jan 1. doi:10.7150/jbji.17234\u003c/li\u003e\n \u003cli\u003eAnagnostakos K, F\u0026uuml;rst O, Kelm J. Antibiotic-impregnated PMMA hip spacers: Current status. \u003cem\u003eActa Orthop\u003c/em\u003e. 2006;77(4):628-637. doi:10.1080/17453670610012719\u003c/li\u003e\n \u003cli\u003eJi Zhengang, Zhou Dapeng, Han Tianyu, et al. Efficacy of Masquelet membrane induction technique for traumatic long bone defects[J]. Chinese Journal of Trauma, 2019, 35(02): 128-135. doi:10.3760/cma.j.issn.1001-8050.2019.02.006.\u003c/li\u003e\n \u003cli\u003eXin Yu, Shuo Jia, Hongri Wu, et al. Application of antibiotic cement-coated locking plates in induced membrane technique for treating post-traumatic tibial osteomyelitis. 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Whole-genome sequencing for rapid susceptibility testing of M. tuberculosis. N Engl J Med. 2013 Jul 18;369(3):290-2. doi: 10.1056/NEJMc1215305.\u003c/li\u003e\n \u003cli\u003eHao Linjie, Zhang Yumin, Wen Pengfei, et al. Application of metagenomic next-generation sequencing in pathogen detection of periprosthetic joint infection [J]. Chinese Journal of Joint Surgery(ElectronicEdition),2021,15(02):185-191. doi:10.3877/cma.j.issn.1674-134X.2021.02.009\u003c/li\u003e\n \u003cli\u003eZalavras CG, Sirkin M. Treatment of long bone intramedullary infection using the RIA for removal of infected tissue: indications, method and clinical results. Injury. 2010 Nov;41 Suppl 2:S43-7. doi: 10.1016/S0020-1383(10)70008-5.\u003c/li\u003e\n \u003cli\u003eDehghan N，Schemitsch EH．Extended applications of the reamer-irrigator-aspirator (RIA) system［J］.Injury,2017,48 (Suppl 1:) S47－S51. doi: 10.1016 /j.injury.2017.04.025．\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u0026nbsp; Comparion of the baseline date between the groups of patient\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eGroups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eAge（year，\u003cimg width=\"11\" height=\"22\" src=\"data:image/png;base64,R0lGODlhCwAWAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABQALAA0AhAAAACMfICQfTCQfdCRLdCRLmSRzvFAfIFBLmXYfIHZzmXa8vHa83na8/5tLIJtLdJtzdJve/71zIL1zTL3emb3e/73//96ZTN6ZdN7///+8dP/emf//vP//3gECAwECAwU9YCCOZACcaKqu7NpNQZEB2mGcWKMJ0YbMKU5i8bC4HIJGSyJjbQ4Do6oDoRyUqklDaOAoZhcB43QJECqnEAA7\" alt=\"image\"\u003e\u0026plusmn;s）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003e（case）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eInjured side（case）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eDisease duration（month）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eCinery-Mader classification（case）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eCM-III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eCM-IV\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eControl group（44）\u003c/p\u003e\n \u003cp\u003eExperimental group（44）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e51.17\u0026plusmn;4.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e5.17\u0026plusmn;1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e52.39\u0026plusmn;3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e4.86\u0026plusmn;2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eTest statistics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.921\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.423\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.392\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u0026nbsp; Postoperative recovery data of the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"692\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eRecovery data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003eExperimental group（44）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eControl group（44）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eOperation time（hours）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e3.1\u0026plusmn;1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e3.5\u0026plusmn;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eWound healing time（days）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e9.15\u0026plusmn;1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e12.32\u0026plusmn;4.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eBone healing time（days）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e1.34\u0026plusmn;0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e1.72\u0026plusmn;0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e2.895\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 3\u003c/strong\u003e\u0026nbsp; The total effective rate.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eCurative effect\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eExperimental group（44）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 137px;\"\u003e\n \u003cp\u003eControl group（44）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eTest statistics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003ecase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eefficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003ecase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eefficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eExcellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e65.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e45.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e6.150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eValid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eInvalid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e29.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eLevels of inflammatory indicators in the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"803\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eIndex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eprior\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6 weeks after \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003edifference value\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eprior\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e6 weeks after\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003edifference value\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003ea vs c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eb vs d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eWBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e11.51\u0026plusmn;2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e6.52\u0026plusmn;1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e5.07\u0026plusmn;2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e12.17\u0026plusmn;2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e9.87\u0026plusmn;1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e2.67\u0026plusmn;1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e69.55\u0026plusmn;43.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4.44\u0026plusmn;2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e65.11\u0026plusmn;43.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e67.34\u0026plusmn;41.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e11.79\u0026plusmn;3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e56.56\u0026plusmn;40.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eESR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e61.93\u0026plusmn;18.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e9.67\u0026plusmn;5.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e52.62\u0026plusmn;20.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e59.89\u0026plusmn;17.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e14.17\u0026plusmn;4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e45.48\u0026plusmn;16.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003ePCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.58\u0026plusmn;0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e0.04\u0026plusmn;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.52\u0026plusmn;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.57\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.11\u0026plusmn;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e0.46\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eSAA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e49.73\u0026plusmn;4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4.97\u0026plusmn;2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e44.70\u0026plusmn;5.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e51.14\u0026plusmn;3.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e13.71\u0026plusmn;1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e37.16\u0026plusmn;3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003eTable5\u003c/strong\u003e\u0026nbsp; Postoperative pain situation (Note: a. Compared with before treatment, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05; b. Compared with 2 weeks after treatment, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05; C. Compared with one month after treatment, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05.)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eIndex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eExperimental group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eprior treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e7.21\u0026plusmn;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e7.15\u0026plusmn;1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eTwo weeks after\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e4.17\u0026plusmn;0.89\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e5.24\u0026plusmn;1.94\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e3.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eOne month after\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e2.75\u0026plusmn;0.67\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e3.41\u0026plusmn;1.53\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e2.575\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eThree month after\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e1.37\u0026plusmn;0.24\u003csup\u003eabc\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e1.89\u0026plusmn;0.74\u003csup\u003eabc\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e4.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Calcium sulfate, Chronic osteomyelitis, Bone cement, Carbon fiber rod, Vancomycin, Proximal femoral fracture","lastPublishedDoi":"10.21203/rs.3.rs-6906791/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6906791/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Infection after intramedullary nail fixation of intertrochanteric fractures is relatively rare at present. This article aims to explore and compare the therapeutic effects of combined treatment with antibiotic bone cement carbon fiber rods loaded with antibiotic calcium sulfate and the traditional Masquelet technique in the treatment of chronic osteomyelitis after intramedullary nail fixation of intertrochanteric fractures.\u003c/p\u003e\n\u003cp\u003eMethods: A retrospective analysis was conducted on a total of 88 patients with chronic osteomyelitis after intramedullary nail internal fixation of intertrochanteric fractures in our hospital from September 2018 to September 2024. The patients were divided into two groups by random number expression method, with 44 people in each group. The control group was treated with the Masquelet technique. After debridement, the first stage was treated with antibiotic bone cement rods, and the second stage was bone grafting. The experimental group was treated with the antibiotic calcium sulfate in the second stage on the basis of the first stage of the control group. The inflammatory indicators, therapeutic effects and pain conditions of the patients at 6 weeks after the operation were recorded. Corresponding evaluations were conducted for the two groups respectively to comprehensively assess and compare the therapeutic effects of the two surgical methods.\u003c/p\u003e\n\u003cp\u003eResults: The wound healing time and bone healing time of the patients in the experimental group were shorter than those in the control group, and the total effective rate was higher than that in the control group. There was no significant difference in the operation time between the two groups. The levels of postoperative inflammatory indicators in both groups were significantly reduced compared with those before treatment, and the levels in the experimental group were significantly lower than those in the control group. The pain scores of the two groups of patients showed a decreasing trend 2 weeks, 1 month after treatment and 3 months after follow-up, and the pain scores of the experimental group were all lower than those of the control group.\u003c/p\u003e\n\u003cp\u003eConclusion: The combined treatment of postoperative infection with antibiotic bone cement carbon fiber rods loaded with antibiotic calcium sulfate in the proximal femur can effectively reduce inflammatory responses and pain. While eliminating infection, it also has the effect of osteogenic formation. The postoperative recurrence rate is greatly reduced, and it has good clinical efficacy.\u003c/p\u003e","manuscriptTitle":"A new and effective treatment plan for chronic osteomyelitis after intramedullary nail surgery for intertrochanteric fractures of the femur - carbon fiber rod bone cement combined with calcium sulfate loaded with antibiotics","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 12:47:22","doi":"10.21203/rs.3.rs-6906791/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-06T09:09:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T07:18:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T20:05:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59005276593111447595312714677088776671","date":"2025-09-02T12:07:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34100129756571608155330295919755634283","date":"2025-09-02T11:24:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-02T11:05:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-17T10:07:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-17T07:59:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-06-16T14:54:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b18af652-dd51-4e70-a4f5-3b623bdf3a0a","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:07:22+00:00","versionOfRecord":{"articleIdentity":"rs-6906791","link":"https://doi.org/10.1186/s13018-025-06381-z","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-11-07 15:57:45","publishedOnDateReadable":"November 7th, 2025"},"versionCreatedAt":"2025-09-09 12:47:22","video":"","vorDoi":"10.1186/s13018-025-06381-z","vorDoiUrl":"https://doi.org/10.1186/s13018-025-06381-z","workflowStages":[]},"version":"v1","identity":"rs-6906791","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6906791","identity":"rs-6906791","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}