Letter to the Editor Response: Femoral Vein Cannulation in the Treatment of Osteomyelitis

Dear Editor,

We read with great interest your recent article “Femoral Vein Cannulation in the Treatment of Osteomyelitis,” which appeared in the June issue of Wounds.¹ You used a combined approach to treat osteomyelitis underlying Wagner Grade 2 ulcers, with intravenous vancomycin for 6 weeks, followed by hyperbaric oxygen (HBO) treatment, in 8 patients with diabetes and achieved healing in 75% of the cases.¹ Hyperbaric oxygen is used to treat diabetic foot, chronic refractory osteomyelitis, and many other diseases as an adjuvant therapy.^2-5 We respectfully thank the authors for this contribution.

Osteomyelitis is an infection of the bone tissue caused by different etiologies, and it is clinically classified as acute and chronic refractory.² There was no information about onset time of the ulcers. So we were not able to determine clinical type of the osteomyelitis. We think this article addresses femoral vein cannulation in the treatment of Wagner Grade 3 diabetic foot ulcers and does not represent all kind of osteomyelitis.

Coulson and colleagues¹ have classified wounds as Wagner Grade 2, but a deep ulcer with abscess or osteomyelitis is classified as Grade 3 in Wagner Ulcer Classification System.²

Total blood count, C-reactive protein, and erythrocyte sedimentation rate should be done before treatment and during follow-up.² Results of laboratory analyses were not mentioned in the article.¹

Treatment protocol includes surgical debridement, deep tissue biopsy, culture-guided antibiogram and antibiotherapy, proper wound care, treating comorbidities, and adjunctive HBO treatment.² Biopsy was not taken except in 2 cases. Causal microbiological agents, surgical debridement, and culture-guided antibiotherapy were not mentioned.¹ The smoking habits of the patients was not mentioned in the study. Smoking diminishes the efficacy of the HBO therapy and patients should quit smoking during HBO therapy.⁵

In conclusion, the findings obtained from the current study will lead to further studies examining the efficacy of HBO in the treatment of the osteomyelitis.

Sincerely,
Erdinc Ercan, MD¹ and Hamza Yildiz, MD<sup>2

1</sup>Department of Hyperbaric Medicine,
Eskisehir Military Hospital 26020 Eskisehir, Turkey
²Department of Dermatology,
Eskisehir Military Hospital

Dear Dr. Ercan and Dr. Yildiz,

I want to thank Dr. Ercan and Dr. Yildiz for their kind remarks and insights into osteomyelitis; coming from an international authority makes them especially valuable. There was much data that could have been included, including wound dimensions, nutritional state of the patients, vancomycin levels, bone oxygen levels, and the patients’ immune status, in addition to the omissions listed [in their letter to the editor].

Two particular aspects of this group of patients gave me trouble: the Cierny-Mader grade of the osteomyelitis in relation to HBO treatment, and, of course, the correct Wagner classification. The reported patients did not have any purulence or extensive abscess formation, and in most cases the osteomyelitis was not in continuity with the ulcer. This is what led me to describe these ulcers as Wagner Grade 2; then it becomes a question of semantics, if there is any osteomyelitis in the general area, does that automatically make them Grade 3? Maybe there should be a Wagner Grade 2.5 to describe these cases.

I would urge Dr. Ercan and Dr. Yildiz to consider devising a better classification of diabetic foot ulcers to help make this situation more rational. The way it is now seems to permit too much subjective interpretation.

Yours sincerely,
Alan Coulson, MD

From Hamlet PPM, LLC,
Sandhills Surgical,
Hamlet, NC