Chronic Refractory Osteomyelitis and Hyperbaric Oxygen Therapy (HBOT)

Chronic osteomyelitis is the prototypical hyperbaric oxygen (HBO) problem wound, demanding meticulous attention to all details and coordinating a comprehensive care plan that includes: wound care, infectious disease, surgery, and rehabilitation. The hyperbaric care of these complicated patients requires commitment, communication and time.

What is Chronic Refractory Osteomyelitis? Chronic Refractory Osteomyelitis (CRO) is an ischemic as well as an infectious disease. The dense fibrous tissue produced by the body to isolate the infected area results in tissue pO2 levels below the 30-40 mmHg required for collagen synthesis by fibroblasts, bone synthesis by osteoblasts, and a normal leukocyte response. Once the pO2 falls below 30 mmHg, leukocytes are unable to phagocytize bacteria, and ischemia impedes the introduction of high dose antibiotics into the infected area.1, 3

What is the effect of HBO on CRO? Chronic Refractory Osteomyelitis is characterized by recurrent flare-ups resulting in pain, drainage or other signs of acute inflammation. Hyperbaric oxygen is not a substitute for surgery or proper antibiotics, but has been demonstrated to be of adjunctive value in those cases which have failed to respond to conventional treatment. The mechanism of action of HBO in the treatment of CRO includes raising tissue pO2 levels above 30 mmHg, thereby causing increased osteogenesis and or neovascularization to fill the dead space with vascular or structurally sound bony tissue. This improved vascularity facilitates entry of leukocytes, antibodies, and antibiotics to the infected area. HBO is also proven to enhance osteoclastic activity to remove bony debris. Unless an anaerobic organism is involved, there is no direct bacteriocidal effect.  The action of HBO does not lie solely in potentiating the action of antibiotics, as hyperbaric oxygen has been noted to produce good clinical results even when antibiotics are not being used concomitantly. Researchers have proven that leukocyte killing of infectious organisms increases at pO2 beyond 30 mmHg and peaking at about 150 mmHg, which can only be obtained through the use of hyperbaric oxygen.1, 2, 3 

Which patients will benefit from HBOT? Patients suitable for HBOT include those with refractory osteomyelitis who have failed to respond to appropriate organism specific antibiotic therapy or who have failed to respond to at least one surgical procedure intended to eradicate the disease or have had a recurrence.  Considerable evidence from human studies shows that when used as an adjunctive treatment, HBOT is associated with remission in approximately 85% of refractory cases. 2

References:

1)    Esterhai J, Pisarello J, Brighton C, et al: Adjunctive hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis. The Journal of Trauma 1987; 27 (7): 763-768.

2)    Goldman RJ: Hyperbaric oxygen therapy for wound healing and limb salvage: a systematic review. PM & R: The Journal of Injury, Function, and Rehabilitation 2009; 1(5): 471‐479.

 3)    Lazzarini L, Mader JT, Calhoun JH: Osteomyelitis in long bones. Journal of Bone and Foot Surgery 2004; 86-A (10) 2305-2318.