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Refractory Osteomyelitis


Cases accepted for adjunctive hyperbaric oxygen must be judged to be refractory to adequate surgical and specific parenteral antibiotic treatment. While hyperbaric oxygen should improve results in acute osteomyelitis, it is considered too expensive except in critical sites such as skull, vertebra, hand, elbow, or other life-or-function threatening acute cases which have not responded at once to surgery and antibiotics. Judgment in declaring a given case refractory or critical must be jointly made by the surgeon and hyperbaric medicine specialists.


Following initial anecdotal case reports of successful use of adjunctive hyperbaric oxygen in very difficult cases during the 1960's, controlled animal studies clearly demonstrated benefit using hyperbaric oxygen. Studies to determine mechanism of action include demonstration of hypoxia in infected bone with elevation to normal or above normal bone pO2 when animals  breathe oxygen in the hyperbaric chamber. Periodic elevation of bone pO2 from hyperbaric levels to normal or above promotes fibroblastic division and collagen production and capillary angiogenesis as structural support is provided for budding capillaries. Hypoxic polymorphonuclear leukocytes' killing of S. aureus is returned to normal when bone oxygen tension is raised.

Hyperbaric oxygen must be used as an adjunct to debridement, wound care, specific bone culture dictated parenteral and antibiotic administration. Besides the benefit of HBO in enhancement of success of these measures because of the mechanisms described above, there is evidence that hyperbaric oxygen may enhance osteogenesis. The growing awareness of the importance of anaerobic bacteria involved in chronic ostemyelitis is another obvious indication for hyperbaric oxygen.

Cost Impact

When used within the above qualifications (and discontinuted, as soon as it appears success will not be possible), hyperbaric oxygen is not only clinically effective but quite cost effective. Sixty to eighty-five percent of cases which had failed to respond after years of costly repeated surgery and antibiotic care have been arrested successfully after intensive surgical-antibiotic approach using adjunctive hyperbaric oxygen. In other cases, especially about the skull or extensive osteomyelitis, HBO has proved lifesaving. Peer review is required after 60 treatments.

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