Refractory Chronic Osteomyelitis

Osteomyelitis is an infection of bone or bone marrow, usually caused by pyogenic bacteria or mycobacteria. 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.

To date, no randomized clinical trials examining the effects of HBOT on refractory osteomyelitis exist. However, the substantial majority of available animal data, human case series and non-randomized prospective trials suggest that the addition of HBOT to routine surgical and antibiotic management in previously refractory osteomyelitis is safe and improves the ultimate rate of infection resolution. Consequently, HBOT should be considered an American Heart Association (AHA) Class II recommendation in the management of refractory osteomyelitis. More specifically, in uncomplicated extremity osteomyelitis or cases where significant patient morbidity or mortality is not likely to occur, HBO2 therapy can be considered an AHA Class IIb treatment. For patients with more severe Cierny-Mader Class 3B or 4B disease, adjunctive HBOT should be considered an AHA Class IIa intervention. Additional consideration must also be given to patients with osteomyelitis involving the spine, skull, sternum or other bony structures associated with a risk for high morbidity or mortality. In these patients, HBO2 therapy may be considered an AHA Class IIa intervention prior to undergoing extensive surgical debridement. Finally, for osteomyelitis in the subset of patients with associated Wagner Grade 3 or 4 diabetic ulcers, adjunctive HBO2 should be regarded as an AHA Class I intervention.

In most cases, the best clinical results are obtained when HBO2 therapy is administered in conjunction with culture-directed antibiotics and scheduled to begin soon after thorough surgical debridement. HBOT is ordinarily delivered on a daily basis for 90–120 minutes using 2.0-3.0 atmospheres of absolute pressure (ATA). Recommendation of a specific treatment pressure is not supported by data. Where clinical improvement is seen, the present regimen of antibiotic and HBO2 therapy should be continued for approximately four to six weeks.

Typically, 20-40 postoperative HBOT sessions will be required to achieve sustained therapeutic benefit. In cases where extensive surgical debridement or removal of fixation hardware may be relatively contraindicated (e.g. cranial, spinal, sternal or pediatric osteomyelitis), a trial of limited debridement, culture-directed antibiotics and HBOT prior to more radical surgical intervention provides a reasonable chance for osteomyelitis cure. Again, a course of four to six weeks of combined HBOT and antibiotic therapy should be sufficient to achieve the desired clinical results. In contrast, if prompt clinical response is not noted or osteomyelitis recurs after this initial treatment period, then continuation of the existing antibiotic and HBOT treatment regimen is unlikely to be effective. Instead, clinical management strategies should be reassessed and additional surgical debridement and/or modification of antibiotic therapy implemented without delay. Subsequently, re-institution of HBO2 therapy will help maximize the overall chances for treatment success.

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