Antibiotic-Loaded Bone Cement Combined with Negative Pressure Wound Therapy for Treating Sacrococcygeal Wound Following Sacral Chordoma Resection: A Case Report

Chordoma is a rare, malignant primary bone tumor that is thought to arise from notochord remnants.¹ Chordomas account for less than 5% of all primary bone neoplasms, and the most common location of chordomas is the sacrum (approximately 50–60%).²Sacrococcygeal chordoma starts insidiously and grows slowly. The early symptoms of sacral chordoma are hidden, and the clinical manifestations are not obvious. Sacral or lower back pain is the most common symptom. The nonspecific symptoms in patients with sacrococcygeal chordoma may lead to late diagnosis and, consequently, poor prognosis.³ As a result, the tumor can reach a considerable volume before treatment.⁴

Chordoma is poorly sensitive to chemotherapy and conventional radiotherapy. Surgical resection is the most effective treatment for sacrococcygeal tumors, using either a posterior approach or a combined posterior and anterior approach.⁵ The myocutaneous flaps are traditionally used to repair tissue defects. Given the location and large size of sacrococcygeal chordomas, the extensive cavity and soft tissue defects after a radical surgical resection can lead to complications such as sacrococcygeal skin necrosis, infection, cerebrospinal fluid (CSF) leakage, and delayed healing or nonhealing. A nonhealing sacrococcygeal wound after chordoma resection presents a major challenge to surgeons.⁶ Management of the nonhealing wound is complex, and improved methods of repair and reconstruction are necessary.

This case report describes the combination use of antibiotic-loaded bone cement (ALBC), gluteus maximus muscle flap, and modified negative pressure wound therapy (NPWT) in the management of a sacrococcygeal nonhealing wound following sacral chordoma resection in a 67-year-old female.
 

A 67-year-old female was admitted to the author’s hospital with a nonhealing sacrococcygeal wound on December 31, 2021. The patient had no history of familial genetic conditions or of food or drug allergies. She had undergone chordoma resection 22 years previously in a local hospital and received 8 courses of radiotherapy postoperatively. Owing to tumor recurrence, the patient underwent radical sacral chordoma resection surgery in another hospital 45 days before admission to the author’s hospital in December 2021. During that operation, the sacral tumor, the involved sacral canal, and a portion of the ilium were removed, and 3D printed internal fixation and Neuro-Patch (Aesculap; Center Valley, PA) (hereafter synthetic dura substitute) were implanted. The patient also reported that she had been suffering from headaches following the last operation. Wound disruption occurred when sutures were removed 21 days postoperatively. The surrounding area was red and swollen (Figure 1A). A radiograph revealed the absence of sacral and coccygeal vertebrae and high-density internal fixation in the sacrococcygeal region (Figure 1B).

After the patient was admitted to the author’s hospital, a treatment plan to repair the sacrococcygeal wound was created by the author after a discussion with colleagues in their departments. A series of perioperative treatments, including antibiotics and nutrition support, were planned. The wound secretion was collected, and bacteria culture and pathogen identification were performed. The culture result was positive for drug-resistant Staphylococcus epidermidis, and vancomycin was selected for antibiotic treatment.

Surgery was performed in 2 stages. In the first stage, debridement was done by cutting the skin along the original incision with the patient under general anesthesia. Meticulous surgical technique was used to remove necrotic tissues and expose the internal fixation and synthetic dura substitute (Figures 2A, 2B). Hemostasis was monitored. The wound was washed using copious normal saline. A small amount of fluid exudation was noted around the implanted synthetic dura substitute, which was suspected to be CSF leakage. After debridement, 40 g bone cement mixed with 4 g vancomycin was prepared to cover the internal fixation and fill the cavity while carefully protecting the synthetic dura substitute (Figure 2C). After application of the ALBC, an NPWT system was applied, with a planned 7-day duration (Figure 2D). A piece of polyurethane foam was cut to fit the shape of the wound and was fixed on the surface of the bone cement. A flushing tube was placed in the deep cavity of the wound (Figure 2D), and a transparent, semipermeable film was used to cover the foam to create a vacuum environment by connecting the drain tube to a negative pressure bottle. Daily, 3000 mL normal saline was used to irrigate the wound through the flushing tube to drain exudate and necrotic tissue via the NPWT system.

In the second stage, the NPWT foam and bone cement inserted during the first stage were removed. Fresh granulation tissue formation was observed around the internal fixation device (Figure 3A). The wound was washed with copious normal saline. A gluteus maximus muscle flap was used to fill the cavity after debridement and cover the synthetic dura substitute used to treat CSF leakage (Figure 3B). The gluteus maximus muscle flap was created and placed as follows: the incision was continued toward the left buttock to expose the left gluteus maximus muscle, after which the muscle was turned over to fill the defect after first detaching the distal portion of the muscle from the left trochanter. New ALBC was made to cover the internal fixation (Figure 3B). Before the wound was closed, a modified NPWT system including flushing and drainage tubes was placed to promote wound healing (Figure 3C). One deep drainage tube was placed around the synthetic dura substitute for CSF drainage, and another was placed on the surface of the bone cement. The flushing tube was placed in the deep cavity of the wound, then the wound was closed. A new piece of polyurethane foam was cut to size and laid onto the wound. All 3 tubes were passed through the foam dressing to avoid air leakage. The semipermeable film was then pasted over the foam and tubes to create a vacuum environment. Two sealed tubes and the 2 drainage tubes were connected to the negative pressure bottle set at 150 mm Hg to pull the fluid into the foam and container. Daily, 1000 mL normal saline was used to irrigate the wound through the flushing tube.

Antibiotic treatment and nutritional support were continued postoperatively. One week postoperatively, the NPWT system was removed along with the flushing tube and the subcutaneous drainage tube. After that, approximately 300 mL CSF was observed flowing out of the deep drainage tube every day. To reduce the volume of CSF drainage, the following nutritional support and posture control measures were implemented: human serum albumin was used to ensure a normal plasma albumin level (≥35 g/L), the patient was required to maintain a prone position, and the drainage bottle was positioned 20 cm above the head.

Three weeks postoperatively, the sutures were removed and favorable wound healing was observed (Figure 4A). The CSF drainage volume was less than 20 mL per day by 6 weeks postoperatively, at which time the drain tube was removed in the outpatient dressing room. At the 6-month follow-up visit, the patient reported she had not experienced headache postoperatively and that her recovery was satisfactory (Figure 4B).

Written informed consent was obtained from the patient for publication of this case report and accompanying images. All procedures performed in studies involving human participants were in accordance with the ethical standards of the author’s hospital and with the Declaration of Helsinki (as revised in 2013).

Chordoma is a slow-growing malignant tumor originating from the chordal tissue. By the time a patient is admitted to the hospital, often the tumor has grown quite large and the sacrococcygeal bone has been damaged by tumors.⁷ Neither radiotherapy nor chemotherapy is effective in managing chordoma. Radical resection of the tumor is the first choice for managing this condition.⁸ However, there are common problems and complications after radical resection of chordoma. The extensive cavity, soft tissue defects, and internal fixation can lead to sacrococcygeal skin necrosis, infection, CSF leakage, and delayed healing or nonhealing.^9,10 It is difficult to repair and reconstruct a nonhealing sacrococcygeal wound.

In the present case report, the combination use of ALBC, gluteus maximus muscle flap, and NPWT resolved the problems associated with radical resection of chordoma. First, ALBC was used to control infection and promote the growth of granulation tissues in the wound. Antibiotic-loaded bone cement has been used clinically for infection prevention and treatment as a stable carrier of antibiotics. It can aid in maintaining long-term, high concentrations of antibiotics in the local wound.¹¹ In addition to controlling infection, the induced membrane formed by ALBC may play a role in promoting wound healing by improving local wound vascularization.¹² Second, a gluteus maximus muscle flap was applied to fill the tissue defect cavity and cover the implanted synthetic dura substitute, because such flaps have a rich blood supply, large tissue volume, and high transplantation survival rate.¹³ The muscle flap can promote wound repair by improving the blood supply to surrounding tissues, and it can absorb some exudate, including CSF. Cerebrospinal fluid leakage can be effectively addressed using a muscle flap and a reasonable drainage volume. Third, modified NPWT was used to accelerate wound healing by augmenting local blood flow, promoting granulation tissue formation, and reducing bacterial contamination, edema, and exudate.¹⁴ Moreover, NPWT appears to allow for the retention of instrumentation after surgical site infection, and it is safe in the presence of exposed dura.¹⁴

Traditional NPWT involves a polyurethane foam dressing, a transparent semipermeable film, and a drain tube connected to a vacuum bottle or a computer-controlled negative pressure pump. This system creates a vacuum environment by applying continuous negative pressure to the surgical wound to remove the fluid between the tissue spaces and reduce edema.¹⁵ The modified NPWT system used in the present case added a wound closure flushing function to the traditional system. The modified NPWT system including the closed flushing and drainage tubes might promote improved wound healing and infection control.

This case report has limitations. The number of cases of sacrococcygeal chordoma is relatively small. More cases are needed to evaluate the treatment effects. A long-term follow-up of the patient is also needed to evaluate clinical effects.

The combination use of ALBC, gluteus maximus muscle flap, and modified NPWT can effectively repair sacrococcygeal wound resulting from chordoma resection. Compared with traditional myocutaneous flap treatment, the procedure described herein has the advantages of infection control, decreased intraoperative bleeding, and fewer postoperative complications.

Acknowledgments: The author appreciates all attending physicians working in the hospital for providing their full support for this study, and would also like to express their gratitude to Can Zhang, RN.

Affiliation: Department of Burns & Plastic Surgery, Zibo Central Hospital, Shandong Province, China.

Address all correspondence to: Yanwei Sun, MD; Department of Burns & Plastic Surgery, Zibo Central Hospital, 54# Gong Qing Tuan Xi Road, Zibo 255036, Shandong Province, China; syanwei005@163.com

Potential conflicts of interest: The author has no conflicts of interest to disclose.

Funding: None.

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