Chronic Refractory Osteomyelitis Research Articles

Outcome of Chronic Foot Osteomyelitis Treated With Hyperbaric Oxygen: An Observational Study.

Chronic refractory osteomyelitis of the foot stands as a formidable challenge in medical care, associated with significant morbidity and escalating healthcare costs. Traditional therapeutic approaches, including surgical debridement and systemic antibiotics, often fall short, leaving patients and clinicians in search of more efficacious interventions. Hyperbaric oxygen therapy (HBOT), an innovative therapeutic modality, has recently emerged as a promising adjunct therapy, offering a beacon of hope in this therapeutic conundrum. In this groundbreaking observational study, we meticulously analyzed the experiences of 80 patients suffering from chronic refractory osteomyelitis of the foot. Following surgical debridement and tailored antibiotic therapy, each patient was treated with HBOT at 2.5 atmospheres absolute for 120 min, 5 days a week, spanning an average of 50 days. Our primary endpoints focused on complete eradication of infection, recurrence metrics, and any adverse effects linked to HBOT. Astonishingly, 68 of the 80 patients (85%) achieved a total infection clearance, maintaining this status through a mean follow-up period of 36 months, all without a single report of HBOT-induced complications. Our compelling findings advocate that HBOT, synergized with standard surgical and antibiotic regimens, can revolutionize the treatment landscape for chronic refractory osteomyelitis of the foot. Given these promising preliminary results, there's an imperative need for extensive research to delineate the long-term advantages and to fine-tune HBOT protocols, potentially paving the way for a new therapeutic gold standard.

Current status and development direction of hyperbaric medicine in Korea

Background: The indications of hyperbaric oxygen therapy (HBOT) covered by the health insurance in Korea increased to 16 in 2019, which includes acute central retinal artery obstruction within 24 hours of vision loss; anemia due to excessive bleeding, since blood transfusion is impractical; chronic refractory osteomyelitis (Wagner grade ≥3); and intracranial abscess.Current Concepts: HBOT affects the treatment in the primary and secondary mechanisms. According to the Boyle’s law, the primary mechanism is important in treating decompression sickness and intravascular air embolism by decreasing the volume of air bubbles when pressure increases, whereas the secondary mechanism involves hyperoxygenation of the primary mechanism and various effects, such as vasoconstriction, angiogenesis, immune function enhancement, reperfusion injury prevention, antimicrobial action, and gas washout effect, occur. In the past 5 years, domestic HBOT has made significant progress. However, there are many non-therapeutic lowpressure HBOT facilities that are limited by insurance coverage issues, quality equipment management, and medical personnel in HBOT facilities.Discussion and Conclusion: To solve the problem, the introduction of the definition of therapeutic hyperbaric pressure and certification system of HBOT facilities must be initiated. Moreover, the system should be improved so that insurance can be applied for a more indication of HBOT.

Clinical Effectiveness of Hyperbaric Oxygen Therapy for Various Wound Conditions: A Systematic Review and Meta-Analysis

The objective of this review was to evaluate the clinical effectiveness of Hyperbaric Oxygen Therapy for various wound conditions in reducing the amputation of diabetic foot ulcer, healing of various wounds, mortality, neurophysiological condition, reduction in ulcers (wound area) and other complications in adults 18 years and over. Introduction: Inclusion criteria: This review included studies conducted among adults with acute traumatic ischemia, carbon monoxide poisoning, central retinal artery occlusion (CRAO), diabetic foot ulcers (DFU), Chronic refractory osteomyelitis, compromised skin graft or flaps (enhancement of healing in selected wounds), crush injuries, cyanide poisoning, decompression sickness, delayed radiation injury, including osteoradionecrosis, soft tissue radiation necrosis, and radiation cystitis, thermal burns, gas or air embolism, gas gangrene (for example, clostridial myositis and myonecrosis) and necrotizing soft-tissue infections. Methods: Databases to be searched include PubMed, Google scholar and Cochrane Following the search, titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria for the review. The full text of selected citations was assessed in detail against the inclusion criteria, and studies selected for retrieval was assessed by two independent reviewers for methodological validity using JBI critical appraisal tools. Results: The results of the meta-analysis comparing with HBOT compared with standard of wound carewas presented in a forest plot by subgroup analysis and those studies were statistically pooled studies and outcomes were measured. Conclusion: HBOT is a safe procedure for disease treatment and improves different aspects of quality of life in patients. HBOT is a non-invasive, safe treatment while used for different applications. HBOT application reduces the rate of major and minor amputations, and improves the rate of wound healing in nonhealing diabetic ulcers and other diseases. There was statistically significant reduction in amputation and improvement in wound healing and neurophysiological condition.

Hyperbaric oxygen adjuvant therapy in severe mangled extremities

BackgroundMangled Extremity Severity Score (MESS) was first described more than 30 years ago by attempting to predict the need for empiric amputation. In severe traumatic crush and blast injuries, achieving satisfactory limb salvage may be difficult. Notably, a MESS of 7 or higher is consistently predictive of amputation. Additionally, Hyperbaric Oxygen Therapy (HBOT) has been described for many purposes, and related studies have reported HBOT showed benefits in wound healing properties. ObjectiveThe study aimed to evaluate the results of a prospective series of a new modality of adjuvant HBOT for severe mangled extremities. MethodA total of 18 patients were evaluated for clinical and radiographic review. Current standard treatments followed by adjuvant HBOT were administered, and the mean follow-up period was 22 months. Time to wound closure, the number of surgeries and adjuvant HBOT treatment were analyzed for patient clinical evaluation. Complications and limb amputation rates were also recorded. ResultMost clinical findings on follow-up were good to excellent after adjunctive HBOT. Minimal soft tissue infection was recorded, and limb salvage was successful in most cases. Only 1 patient (5.56 %) needed limb amputation because of a dying limb with chronic refractory osteomyelitis. ConclusionHBOT is an excellent adjunctive option in severely mangled extremities. Nevertheless, the main treatments are eliminating infection and managing surgery, and are promising in the recovery of severe extremity injuries. Although the MESS was evaluated at 7 or higher, limb salvage procedures followed by HBOT should be considered.

Seizure frequency in more than 180,000 treatment sessions with hyperbaric oxygen therapy - a single centre 20-year analysis.

Hyperbaric oxygen therapy (HBOT) involves the risk of central nervous system oxygen toxicity (CNS-OT), including seizures in patients breathing oxygen at pressures ≥ 2 atmospheres absolute. This study aimed to determine the seizure frequency and assess the clinical benefit of a 5-minute air-break (5´-AIRBK). Twenty-year (1999-2018) retrospective analysis of all consecutive treatments with HBOT. Medical records were reviewed to determine patient demographics, comorbidities, HBOT indications, and seizure characteristics and timing. Seizure frequency was compared before and after incorporating a 5´-AIRBK in the treatment protocol. Chi-square testing was performed using SPSS (version 24.0); P < 0.05 was accepted as statistically significant. We evaluated 188,335 HBOT sessions (74,255 before versus 114,080 after introducing a 5´-AIRBK). A total of 43 seizures were observed: 29 before and 14 after the 5´-AIRBK introduction (3.9 versus 1.2 per 10,000 treatments; P < 0.0001). Seizures occurred after a median of 57 (range 15-85) minutes following compression and after a median of 21 HBOT sessions (1-126). Patients experiencing seizures were undergoing treatment for: diabetic ulcer (n = 11); acute traumatic peripheral ischaemia (ATPI) (n = 6); non-diabetic ulcer (n = 5); sudden sensorineural hearing loss (n = 5); chronic refractory osteomyelitis (n = 5); radionecrosis (n = 3); necrotising fasciitis (NF) (n = 2); and haemorrhagic cystitis after allogeneic bone marrow transplantation (n = 1). ATPI and NF had a considerably higher relative frequency of seizures compared to other indications. A statistically significant lower seizure frequency was achieved with a 5´-AIRBK. Assessing and defining the appropriate patient/treatment profile can be useful to minimise the risk of CNS-OT.

Hyperbaric Oxygen Therapy and Utilization in Infectious Disease

This review explores the multiple infectious processes in which the Undersea and Hyperbaric Medicine Society recommends hyperbaric oxygen as an adjunct to standard treatment to determine the benefit of including hyperbaric oxygen in standard treatment protocols. While the utilization of hyperbaric oxygen (HBO) has been shown to improve outcomes, there is limited research comparing it to other therapies. There are numerous case reports and retrospective analyses of the use of HBO as adjunctive treatment, but randomized control trials are glaringly absent from recent literature. The Undersea and Hyperbaric Medicine Society recommends the utilization of HBO as an adjunct to standard treatment for necrotizing fasciitis, clostridial myonecrosis, chronic refractory osteomyelitis, malignant otitis externa, intracranial abscesses, and diabetic foot ulcers. After review of recent literature, the utilization of HBO has been shown to improve patient outcomes in the previously mentioned infectious processes when added to standard antimicrobial and surgical treatment.

Hyperbaric Oxygen Therapy: Exploring the Clinical Evidence.

To provide information about hyperbaric oxygen therapy (HBOT), its mechanisms, indications and safe applications based on clinical evidence. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to:1. Recall the physiology of wound healing and the mechanisms of action of HBOT.2. Identify current applications of HBOT based on clinical evidence as well as its risks and contraindications. Treating chronic wounds and infections are challenging medical problems worldwide. Hyperbaric oxygen therapy (HBOT), the administration of 100% oxygen at pressures greater than 1.4 atmosphere absolute in a series of treatments, can be used as an adjunctive therapy in many wound care settings because it improves oxygenation and neovascularization and decreases inflammation in chronic wounds. A growing number of studies support the benefits of HBOT for enhancing wound healing and decreasing the likelihood of negative events such as amputation. However, many practitioners are unfamiliar with HBOT. This article provides a general introduction to HBOT, reviews the physiology and mechanisms of behind HBOT, discusses all the indications for HBOT, and explores in-depth the clinical evidence for HBOT in the treatment of arterial insufficiencies, diabetic ulcers, delayed radiation injury, and chronic refractory osteomyelitis.

Hyperbaric Oxygen Treatment Outcome for Different Indications from a Single Center

Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature. We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications. Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved. This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

Does hyperbaric oxygen therapy have the potential to improve salivary gland function in irradiated head and neck cancer patients?

Following radiotherapy, many patients with osteoradionecrosis suffer from xerostomia, thereby decreasing their quality of life. Patients can develop problems with speech, eating, increased dental caries, dysphagia, fractured dentition, chronic refractory osteomyelitis and osteoradionecrosis. Symptoms associated with salivary gland dysfunction can be severe enough that patients terminate the course of their radiotherapy prematurely due to the decrease in their quality of life. Currently, the only treatments available to patients are palliative. A definitive treatment has yet to be discovered. Head and neck cancers, which comprise 5% of overall cancer treatments, rank 8th most expensive to treat in the United States today. Hyperbaric oxygen is being considered for the therapy of radiated salivary glands because it has been shown to stimulate capillary angiogenesis and fibroplasia in radiation treated tissues. It has been hypothesized that salivary acinar cells undergo apoptosis following radiation therapy. The purpose of this paper is to discuss the mechanisms of salivary gland injury and evaluate whether hyperbaric oxygen therapy improves salivary gland function in patients who develop xerostomia and osteoradionecrosis following head and neck radiation.

Chronic refractory osteomyelitis as a part of synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome: a diagnostic challenge

Chronic refractory osteomyelitis as a part of synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome: a diagnostic challenge

Hyperbaric Oxygen Therapy for Chronic Refractory Osteomyelitis of the Sternum

This report describes a 32-year-old woman with chronic refractory osteomyelitis of the sternum after multiple surgical procedures including a sternotomy with underlying colonic interposition that was successfully managed with hyperbaric oxygen therapy. The clinical course is reviewed, and the complexities of this diagnosis are then discussed, including a brief review of the mechanisms of management with hyperbaric oxygen therapy.

Chronic Refractory Osteomyelitis of the Mandible and Maxilla Related to Dental Implant Placement

A 68-year-old diabetic woman with chronic refractory osteomyelitis involving the mandible and maxilla following dental implant placement is presented. The inflammatory lesion showed actinomycotic findings histopathologically and refractory responses to several surgical and medical treatments for over 2 years. A periapical lesion on an adjacent tooth was overlooked as a possible source of infection. The lesion was cured after complete surgical debridement in combination with long-term antibiotic therapy.

Adjuvant Hyperbaric Oxygen Therapy in the Treatment of Hemodialysis Patients with Chronic Osteomyelitis

Hemodialysis dependence is an independent risk factor for hematogenous complication, including distant metastatic infection and osteomyelitis. Chronic osteomyelitis is a serious disease that fails to respond to aggressive medical and surgical treatment. Hyperbaric oxygen therapy has been proved to enhance bone and soft tissue healing in many studies. This article presents the preliminary result of hyperbaric oxygen therapy in hemodialysis-dependent patients with chronic osteomyelitis. Ten hemodialysis dependent patients who were diagnosed with chronic diffuse osteomyelitis were treated prospectively with adjunctive hyperbaric oxygen therapy, in addition to aggressive surgical debridement and antibiotic treatment. The hyperbaric oxygen therapy averaged 20 daily sessions. Successful treatment was achieved in eight patients (80%). The mean length of treatment was 21 days. The preliminary results are comparable with other series. Hyperbaric oxygen is effective as an adjunct to aggressive medical and surgical treatment in chronic refractory osteomyelitis among hemodialysis-dependent patients.

Treatment of Massive Tibial Bone Loss Due to Chronic Draining Osteomyelitis: Fibula Transport Using the Ilizarov Frame

This article affirms the value of the application of the Ilizarov frame for gradual transport of the ipsilateral fibula to replace massive tibial bone loss following chronic refractory osteomyelitis.

Bisphosphonate-induced avascular osteonecrosis of the jaws: a clinical report of 11 cases

Bisphosphonates are compounds used in the treatment of various metabolic and malignant bone diseases. In the last 2 years there has been a significant increase in referrals to the Department of Oral and Maxillofacial Surgery of patients with exposed necrotic jaw bone, diagnosed elsewhere as chronic refractory osteomyelitis of jaws, mostly after several teeth extractions. The only clinical feature in common for all the patients was the use of bisphosphonates in the treatment of bone diseases. A retrospective study was performed of 11 patients with necrotic bone lesions of the jaws of various extents referred to this Department from July 2003 to November 2004. The management of the patients included cessation of bisphosphonate therapy for 2–8 months and various surgical restorative procedures thereafter. Four patients (36%) presented with maxillary bone involvement, 6 (55%) had mandibular bone necrosis and 1 (9%) presented with necrosis at 3 quadrants. All patients had received bisphosphonate therapy for 6 months to 5 years. Biopsies from the necrotic lesions revealed no metastatic disease. One patient who was removed from bisphosphonate therapy for 8 months recovered completely, one other who was not removed from bisphosphonate therapy relapsed and for all the others, with cessation of bisphosphonate therapy for 2–6 months, the results were inconsistent. A new complication of bisphosphonate therapy administration, i.e. osteonecrosis of jaws, seems to be developing. The improved results after cessation of the medication should make clinicians reconsider the merits of the rampant use of bisphosphonates, while further investigation is needed to completely elucidate this complication.

ADJUNCTIVE HYPERBARIC OXYGEN THERAPY IN THE TREATMENT KLEBSIELLA OSTEOMYELITIS OF FEMUR (A CASE REPORT)

&amp;lt;p&amp;gt;Klebsilla pneumoniae is the very rarely cause of osteomyelitis in adults, most commonly in the immunocompromised patients with extra-sceletal infections. Successful therapy of chronic refractory osteomyelitis included different orthopaedic methods of treatment, the long time antibiotics therapy and more and more freaquently treatment with adjuvant hyperbaric oxygenation. We report an uncommon case of patient with chronic postraumatic osteomyelitis cased by dissemination of Klebsilla pneumoniae from urinary tract to place of osteosinthesis of femur. Treatment of this case of chronic refractory Klebsilla osteomyelitis finished successfuly after treatment with hyperbaric oxygenation two years from start of desease.&amp;amp;nbsp;&amp;lt;/p&amp;gt;

Hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis: a preliminary report.

Hyperbaric oxygen (HBO) has been proven to enhance bone and soft tissue healing in ischemic tissue in vitro and in vivo studies. Although only a few reports have been proven using controlled studies, this treatment modality remains encouraging for chronic refractory osteomyelitis. In this retrospective study, we reported the clinical results of HBO therapy for chronic refractory osteomyelitis. From January through August 2000, 14 patients with chronic refractory osteomyelitis of the tibias treated with HBO were available for follow-up examination. According to the Cierny-Mader classification, all patients were classified as type III or IV osteomyelitis. Adequate debridement and parenteral antibiotic treatment in conjunction with HBO therapy at 2.5 atmospheres absolute for 120 minutes, and 5 days per week regimen was used in all patients. The patients were followed-up for an average of 15 months after completion of HBO therapy. The most common infecting microorganism was Staphylococcus aureus. Mixed infections were usually found in patients with open fractures. The average number of operations before HBO therapy was 5.4 including soft tissue reconstruction in 11 patients. The average number of HBO treatments was 33.6 times. There were no HBO related complications. No recurrence of infection was noted in 11 patients, which resulted in a success rate of 79%. Hyperbaric oxygen therapy is effective and safe for chronic refractory osteomyelitis provided that patients had received appropriate medical and surgical management.

Barotrauma during hyperbaric therapy: Can we predict patients who are predisposed based on diagnosis?

Study objectives: Hyperbaric oxygen therapy (HBOT) has been used for many years for multiple disease processes. One of the most frequently encountered adverse effects of this treatment is otic barotrauma resulting from atmospheric pressure changes. We determine whether patients with specific disease processes are at increased risk for barotrauma during HBOT. Methods: Historical and clinical data were obtained from January 2000 to December 2003 by a computerized tracking system. The hyperbaric facility is based at a suburban hospital with an emergency medicine residency program. HBOTs are on an emergency and nonemergency basis. Statistical analysis based on treatment indication was performed. Requirement of myringotomy tubes (tubes) was considered "significant" otic barotrauma. Excluded were 13 patients who received tubes before HBOT. Statistical tests used were 95% confidence intervals (CIs) and Fisher exact test as indicated. Results: Two hundred sixty-five patients were screened, 62% were male patients, and median age was 59 years (data available from 95% of patients); 252 patients met inclusion criteria. Forty-one (16%) patients overall (95% CI 2% to 30%) required tube placement. Tubes were not required in patients with air embolism, CO poisoning, gas gangrene, decompression sickness, or arterial insufficiency. Five percent of patients with necrotizing soft tissue infection (<i>P</i>=.33), 11% of patients with failed/threatened graft (<i>P</i>=.28), 17% of patients with chronic refractory osteomyelitis (<i>P</i>=.80), 22% of patients with problem wounds (<i>P</i>=.4), 22% of patients with soft tissue radionecrosis or osteoradionecrosis (<i>P</i>=.07), and 50% of patients with crush injury (<i>P</i>=.03) required tubes. With subset analysis based on radionecrosis or osteoradionecrosis affecting head and neck (57 patients), 28% of patients required tubes (<i>P</i>=.013). Eighteen percent (22/120) of patients treated at 2.0 atmospheres absolute (ATA) compared with 14% (19/132; <i>P</i>=.49) of patients in the greater than 2.0 ATA group required tubes. Conclusion: A moderate number of patients overall required tubes. Those patients with head and neck radiation and crush injury were at a significantly increased risk for otic barotrauma. No correlation about depth of treatment was demonstrated.

Hyperbaric oxygen therapy and chronic refractory osteomyelitis

The use of hyperbaric oxygen (HBO) therapy in chronic refractory osteomyelitis (CRO) has been documented in the literature as far back as 1964. 1 The literature, however, does not provide a great body of evidence for or against its efficacy in this disease. This article will discuss the research that has been done along with the history, uses, side effects and mechanisms of action of HBO.

Hyperbaric oxygen therapy in osteomyelitis.

Chronic refixtory osteomyehas is caused frequently by pyogenic bacteria either by direct inoculation or via the blood stream. These micro-orgamsms can survive in certain pauents for several yean, encapsulated in bone-sequesters, abscesses and hypovascbed scars [ 11. It has been suggested by several authors that the oxygen content of the assue is cruaal and to a great extent the limiting fktor in the healing of hctures and recovery from osteomyelitis. It has been shown that variaaons in oxygen supply can change the type of tissue in those areas and causes a change to csteous cissue whereas hypoxia results in camlage formation [2]. The reduction ofbarometric pressure to 375 mmHg leading to a reduction of the ambient 0, partial pressure from 159 mmHg to 79 mmHg resulted in a marked reducaon offixture heahng in rats [3]. Further, a reduction of syntheus of the collagenous matrix as well as of minecabation induced by hypoxia was shown [4]. By measuring the uptake of radioactive calcium and the breaking strength of fractured femurs in rats, stimulation offixture heahg was found m comparison to a n o r m o b c population (51. Similar results were shown by means of autoradiography, in which animals receiving hyperbaric oxygen (HBO) showed an acceleration in all phases of fracture repair [6]. Increasing the administered amount of oxygen by extending the hyperbaric treatment from 2 to 6 per day at 2 atm led to a reduction of breaking strength of the'fi-actures m . In addiaon to convencional methods such as intensive anubiotic therapy, surgical curettage, and drainage and removal of foreign material, HBO can beneficially d u e n c e the course ofpenistent sinuses in chronic osteomyelitis. By increasing the inspired oxygen partial pressure, tissue oxygen content can be increased in both infected and uninfected bone [8]. Using a rabbit model of SlaphylouKncs a u m osteomyehtu, eradxauon of bone infection by use of HBO alone was demonstrated [9]. In a consecutive study hypoxia in infected bone was found with a mean Ib, 2.7 kPa compared with 5.9 kPa in normal tissue; a level of 13.3 kPa was achievable at 2 atm BO in osteomyelitic bone. Additionally, the killing potency of leucocytes in regard to S. auras was impaired at low P0,s and improved in hyperoxic bone [lo]. During the fiat European consensus conference on hyperbaric medicine the following conclusions and therapy recommendations were published [l l] : infected bone is hypoxic; HBO can elevate pb, in infected bone is proportional to vascularity; hypoxia impairs leucocyte bacterial k d h g hypoxia impairs fibroblastic collagen production to support angiogenesis, in controlled studies in animal models, HBO alone can eradicate S. aurw in infected bone; aminoglycoside transport across the bacterial wall is oxygendependent; hyperbaric oxygenation enhances antibiotic efficacy in a hypoxic environment [ 121. For the treatment of chronic therapyretiactory osteomyelitis three entities were dfferentiated: chronic refractory osteomyehtis of the jaws; chronic refractory osteomyelitis in other locations; acute osteomyelitis of the skull, sternum and/or vertebrae.