Response to ‘Promoting diabetic foot wound healing through antibiotic bone cement: Focus on ROCK1 protein expression’

Thank you very much for your letter. It is an honour to have the opportunity to exchange views and methods with you, aiming for better treatment outcomes for patients with diabetic foot ulcers. Below is my response to your letter: Response to first question: The core method for controlling surgical infection is drainage, and in this article, the primary use of antibiotic bone cement in treating diabetic foot infections is to fill cavities, ensure adequate drainage, cover the wound and reduce unnecessary dressing changes. Patients with diabetic foot often require early emergency debridement surgery, and there is a time gap between specimen culture and pathogen identification. Therefore, it is difficult to obtain the culture's antimicrobial spectrum before surgery. Staphylococcus is one of the most common genera listed in Table 3 of this article, and we empirically choose vancomycin antibiotics. Later, we also apply other sensitive antibiotics based on wound culture results, such as adding gentamicin to the bone cement, which is effective against Gram-negative bacteria. In summary, we believe that controlling the infection in diabetic foot wounds primarily depends on thoroughness of the debridement surgery and whether the bone cement effectively fills the cavities and ensures adequate drainage. Whether the bone cement contains antibiotics or which antibiotic it contains has a minor impact on treating open wounds. However, this still needs to be fully proven by extensive multicentre clinical studies in the future. Response to second question: The primary role of bone cement covering diabetic foot wounds is surgical drainage; it is just one part of the entire treatment process for diabetic foot ulcers. It is particularly suitable for patients who cannot undergo PTA or bypass surgery for lower limb revascularization, with its main role being to control infection while forming an induction membrane locally and improving the wound's microenvironment.1 Using single-cell sequencing, we found significantly increased expression of ROCK1 within this induction membrane. As described in this article, ROCK1 plays a role in improving wound repair, providing a favourable local environment for quickly performing secondary flap or skin graft transplantation to close the wound. For patients with significant ischaemic symptoms such as ischaemic rest pain in the lower limbs and ABI < 0.4 or TcPO2 < 30 mmHg, if the patient's overall condition allows, our team will also perform lower limb revascularization. For diabetic foot wounds, we adopt an integrated surgical treatment for comprehensive management. Our team includes wound repair surgeons and professional vascular intervention physicians who can routinely perform techniques such as PTA, free flap transplantation and transverse bone transport. As introduced in Figure 1 of this article, the use of antibiotic bone cement combined with free flap transplantation significantly improves local blood circulation.2 Here, I would also like to ask for your advice on the methods you typically use for lower limb revascularization in diabetic foot patients. As part of academic exchange, we are eager to learn and draw from your experiences to improve diabetic foot treatment outcomes.