Hyperbaric Treatment of Chronic Refractory Osteomyelitis

Hanley ME, Hendriksen S, Cooper JS. Hyperbaric Treatment of Chronic Refractory Osteomyelitis. 2022 Sep 12. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28613536.

Excerpt

Osteomyelitis is infection of the bone or marrow caused by bacteria or mycobacteria. It is difficult to treat due to the relative paucity of blood vessels in bone and the fact that many antimicrobials do not penetrate bone well. Refractory osteomyelitis is a chronic osteomyelitis that does not respond or that returns after appropriate treatment. Patients presenting with osteomyelitis to the spine, skull, or sternum have a high risk for morbidity and mortality from this infection. The standard treatment for chronic and refractory osteomyelitis include surgical debridement and culture directed antibiotics. Hyperbaric oxygen treatments can be considered an American Heart Association (AHA) Class II recommendation for the treatment of chronic, refractory osteomyelitis. In patients with Wagner grade 3 or 4 diabetic foot ulcers (DFU) with osteomyelitis, adjunctive hyperbaric oxygen therapy is an AHA Class I intervention. Recent studies have postulated that up to 20% of patients presenting to Wound Care Centers for treatment of Wagner 3 Diabetic foot ulcers already have Osteomyelitis. Infection in bone is one of the causes of a nonhealing wound, and should be suspected and tested for sooner rather than later when a patient presents with a chronic, nonhealing wound.

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Hyperbaric oxygen for refractory osteomyelitis

Hart BB. Hyperbaric oxygen for refractory osteomyelitis. Undersea Hyperb Med. 2021 Third Quarter;48(3):297-321. PMID: 34390634.

Abstract

Refractory osteomyelitis is defined as a chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to accepted management techniques [1]. To date, no randomized clinical trials examining the effects of hyperbaric oxygen (HBO2) therapy on refractory osteomyelitis exist, and the number of new osteomyelitis clinical trials conducted over the past decade has been limited. However, based on a comprehensive review of the scientific literature, the addition of HBO2 therapy to routine surgical and antibiotic treatment of previously refractory osteomyelitis appears to be both safe and ultimately improves infection resolution rates. In most cases, the best clinical results are obtained when HBO2 treatment is administered in conjunction with culture-directed antibiotics and initiated soon after clinically indicated surgical debridement. Where extensive surgical debridement or removal of fixation hardware is relatively contraindicated (e.g., cranial, spinal, sternal, or pediatric osteomyelitis), a trial of culture-directed antibiotics and HBO2 therapy prior to undertaking more than limited surgical interventions provides a reasonable prospect for osteomyelitis cure. HBO2 therapy is ordinarily delivered on a once daily basis, five-seven days per week, for 90-120 minutes using 2.0-3.0 atmospheres absolute (ATA) pressure. Where prompt clinical improvement is seen, the existing regimen of antibiotics and HBO2 therapy should be continued for approximately four to six weeks. Typically, 20-40 HBO2 sessions are required to achieve sustained therapeutic benefit. In contrast, if prompt clinical response is not noted or osteomyelitis recurs after this initial treatment period, then continuation of the current antibiotic and HBO2 treatment regimen is unlikely to be effective. Instead, clinical management strategies should be reassessed and additional surgical debridement and/or modification of antibiotic therapy considered. Subsequent reinstitution of HBO2 therapy will again help maximize the overall chances for treatment success in these persistently refractory patients.

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Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery

Yu WK, Chen YW, Shie HG, Lien TC, Kao HK, Wang JH. Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery. J Cardiothorac Surg. 2011 Oct 17;6:141. doi: 10.1186/1749-8090-6-141. PMID: 22004802; PMCID: PMC3215992.

Abstract

Purpose: A retrospective study to evaluate the effect of hyperbaric oxygen (HBO2) therapy on sternal infection and osteomyelitis following median sternotomy

Conclusions: In addition to primary treatment with debridement and antibiotic use, HBO2 therapy may be used as an adjunctive and safe treatment to improve clinical outcomes in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery.

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Hyperbaric oxygen therapy with topical negative pressure: an alternative treatment for the refractory sternal wound infection

Sun IF, Lee SS, Chiu CC, Lin SD, Lai CS. Hyperbaric oxygen therapy with topical negative pressure: an alternative treatment for the refractory sternal wound infection. J Card Surg. 2008 Nov-Dec;23(6):677-80. doi: 10.1111/j.1540-8191.2008.00689.x. Epub 2008 Sep 10. PMID: 18793223.

Abstract

Sternal osteomyelitis is a potentially lethal complication after cardiac surgery. It may be the cause of postoperative morbidity and mortality. We present a case of deep sternal wound infection after sternotomy. The patient received three treatments of surgical debridement, irrigation, topical negative pressure (TNP) dressing, and hyperbaric oxygen (HBO) therapy. Forty-five HBO therapy sessions were administered. After nine weeks, the sternal wound was healed and completely epithelialized. This conservative therapy can be an alternative and inexpensive method for the difficult sternal wound infection patient.

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Effectiveness of Hyperbaric Oxygen Therapy for the Management of Chronic Osteomyelitis: A Systematic Review of the Literature

Savvidou OD, Kaspiris A, Bolia IK, Chloros GD, Goumenos SD, Papagelopoulos PJ, Tsiodras S. Effectiveness of Hyperbaric Oxygen Therapy for the Management of Chronic Osteomyelitis: A Systematic Review of the Literature. Orthopedics. 2018 Jul 1;41(4):193-199. doi: 10.3928/01477447-20180628-02. PMID: 30035798.

Abstract

Hyperbaric oxygen has been used as an adjunctive measure in the treatment of chronic osteomyelitis. The aim of this systematic literature review was to analyze the outcome and the complications of hyperbaric oxygen for chronic osteomyelitis. Forty-five of 96 studies reporting the use of hyper-baric oxygen for 460 patients with chronic osteomyelitis met the inclusion criteria and were analyzed qualitatively. All patients previously received antibiotics and surgical debridement. Mixed bacterial flora was detected in most of the studies. Staphylococcus aureus was the isolated pathogen in 12 (60%) of the 20 cohort and in 4 (20%) of the 20 case studies. Adjuvant hyperbaric oxygen was effective in 16 (80%) of the 20 cohort and 19 (95%) of the 20 case studies. Overall, 308 (73.5%) of 419 patients with complete data had a successful outcome and no reported relapse. Available evidence supports a potentially beneficial role of adjunctive hyperbaric oxygen, especially in refractory cases of chronic osteomyelitis. [Orthopedics. 2018; 41(4):193-199.].

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Results of Chronic Osteomyelitis of the Femur Treated with Hyperbaric Oxygen: A Preliminary Report

 Chen CE, Ko JY, Fu TH, Wang CJ. Results of chronic osteomyelitis of the femur treated with hyperbaric oxygen: a preliminary report. Chang Gung Med J. 2004 Feb;27(2):91-7. PMID: 15095953. 

Abstract

Background: Although only a few studies have shown the effectiveness, hyperbaric oxygen (HBO) therapy has been used as an adjunct in the management of chronic osteomyelitis in many hospitals in Taiwan. This retrospective study investigated the clinical results of HBO therapy for chronic refractory osteomyelitis of the femur.

Results: Complete eradication of infection with no recurrence of infection was noted in 12 of the 13 patients. One patient failed to respond to the treatment. The success rate of the treatment regimen was 92%. There were no HBO therapy related complications.

Conclusion: Hyperbaric oxygen therapy is an effective and safe adjunctive therapy for the management of chronic refractory osteomyelitis of the femur provided that patients had received adequate surgical debridement and appropriate antibiotic treatment.