Intraosseous Approach to Treat Osteomyelitis and to Monitor Oxygen Levels During Hyperbaric Treatment

In a recent Letter to The Editor published in WOUNDS, Dr. Ercan and Dr. Yidiz¹ raised a number of important points in the treatment of osteomyelitis. In “Femoral Vein Cannulation in the Treatment of Osteomyelitis,” my coauthors and I² had previously made the case for a femoral approach to deliver long-term vancomycin to avoid the complication of pneumothorax. But on further consideration, why have we not gone directly to the target? Insertion of an intraosseous cannula³ would permit aspiration of marrow and assist in getting cultures of the pathogen especially in Cierny-Mader Stage 1 osteomyelitis. This could then be followed by the injection of a vancomycin gel to attain high local levels of antibiotic; using intravenous vancomycin is often difficult to attain recommended levels (troughs of 15–20 µg/mL). Furthermore, if a small dose of radio-opaque marker were added to the gel, we could see exactly how much to inject to fill the marrow space and to determine if the veins in Volkmann’s canals and in the Haversian canals were being filled appropriately.⁴

In addition, miniature polarographic electrodes could be introduced through the intraosseous cannula to enable us to get direct measurement of local oxygen levels within the bone. Currently, we are reduced to measuring transcutaneous oxygen measurements, which yield valuable information about skin oxygen pressures, but probably have little or no direct bearing on bone oxygen levels. This is especially important during hyperbaric oxygen treatment now that we know the prevailing oxygen pressure in marrow may be less than 32 mm Hg.⁵ This in turn may indicate the need for greater depths during the hyperbaric treatment of osteomyelitis.

One can also envisage a whole new world of minimally invasive endo-osseous surgery, with serial endoscopic directed biopsies to monitor response to treatment and possibly improved imaging of the bone to supplement the 3-phase bone scan.

Alan Coulson, MD
First Choice Medical
Rockingham, NC 28379
alancoulson41@yahoo.com