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What is
Osteomyelitis (Refractory)?
Refractory osteomyelitis is a persistent bone infection that fails to respond to conventional treatments, including antibiotics and surgical interventions. This chronic condition can lead to significant morbidity, potentially resulting in loss of function, amputation, or systemic complications if left untreated.
Common Sources of
Osteomyelitis (Refractory)
Include:
Key characteristics of refractory osteomyelitis include:
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Persistent pain and inflammation in the affected bone
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Recurrent drainage or sinus tract formation
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Bone destruction visible on imaging studies
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Failure to respond to standard antibiotic therapy
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Presence of necrotic bone (sequestrum)
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Impaired wound healing in surrounding soft tissues
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Potential for pathological fractures
Osteomyelitis can be categorized based on various factors:
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Duration: Acute (< 2 weeks), subacute (2 weeks to 3 months), chronic (> 3 months)
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Mechanism: Hematogenous, contiguous spread, direct inoculation
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Anatomical location: Long bones, vertebrae, pelvis, etc.
Factors that contribute to the development of refractory osteomyelitis include:
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Presence of foreign bodies or implants
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Poor vascularization of the affected area
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Antibiotic resistance of causative organisms
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Host factors (e.g., diabetes, immunosuppression, peripheral vascular disease)
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Presence of biofilms
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Inadequate initial surgical debridement
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Chronic soft tissue defects
Early recognition and aggressive management of refractory osteomyelitis are crucial for preserving bone function and preventing complications.
How HBOT Helps with
Osteomyelitis (Refractory)
Hyperbaric Oxygen Therapy (HBOT) has emerged as a valuable adjunctive treatment for refractory osteomyelitis. Here’s how HBOT helps:
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Enhanced Tissue Oxygenation: HBOT dramatically increases oxygen levels in bone and surrounding tissues, supporting healing and reducing hypoxia-induced damage.
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Improved Antibiotic Efficacy: HBOT can potentiate the effects of certain antibiotics, particularly aminoglycosides and vancomycin, enhancing their penetration into poorly vascularized areas.
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Stimulation of Angiogenesis: HBOT promotes the formation of new blood vessels, improving long-term blood supply to affected bone and surrounding tissues.
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Enhanced Osteoclast and Osteoblast Activity: Increased oxygen levels stimulate bone remodeling processes, crucial for healing infected bone.
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Improved Leukocyte Function: HBOT enhances the oxygen-dependent killing capacity of white blood cells, aiding in infection control.
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Biofilm Disruption: The hyperbaric environment may help disrupt bacterial biofilms, making bacteria more susceptible to antibiotics and host defenses.
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Reduction of Inflammation and Edema: HBOT’s anti-inflammatory effects can help reduce swelling and pain associated with chronic osteomyelitis.
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Promotion of Collagen Synthesis: Increased oxygen levels stimulate fibroblast activity and collagen production, supporting soft tissue healing around the infected bone.
What Happens in Our Bodies During HBOT for
Osteomyelitis (Refractory)
During HBOT treatment for refractory osteomyelitis, several physiological processes occur:
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Hyperoxia Induction: Blood oxygen levels increase dramatically, with oxygen dissolved directly in the plasma, reaching levels up to 20 times normal.
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Bone Tissue Oxygenation: The increased oxygen levels in the blood allow oxygen to penetrate deeper into bone tissues, reaching areas that may have been deprived due to infection or compromised blood supply.
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Vasoconstriction and Edema Reduction: HBOT causes vasoconstriction in normal tissues, which can help reduce edema without compromising oxygen delivery to infected areas.
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Enhanced Phagocytosis: The hyperbaric environment enhances the ability of white blood cells to engulf and destroy bacteria within the bone.
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Antibiotic Synergy: HBOT can enhance the uptake and efficacy of certain antibiotics, particularly in hypoxic bone tissues.
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Modulation of Inflammatory Mediators: HBOT affects the production and activity of various cytokines and inflammatory mediators, helping to optimize the healing environment in and around the infected bone.
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Stimulation of Osteogenesis: Increased oxygen levels stimulate the activity of osteoblasts and osteoclasts, promoting bone remodeling and repair.
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Neovascularization: The alternating hyperoxic and relative hypoxic states during and after HBOT stimulate the release of growth factors that promote new blood vessel formation in the affected bone.
Protocol
HBOT treatment for refractory osteomyelitis typically involves pressurizing the chamber to 2.0-2.5 atmospheres absolute (ATA) for about 90-120 minutes, with treatments repeated daily or several times a week. The exact protocol may vary based on the patient’s condition and response to treatment, often requiring 20-40 sessions or more.
It’s important to note that while HBOT can be a valuable adjunctive therapy for refractory osteomyelitis, it should be used in conjunction with standard treatments, including appropriate antibiotic therapy, surgical debridement when indicated, and management of underlying conditions that may impair healing. The effectiveness of HBOT may be most pronounced when used as part of a comprehensive, multidisciplinary approach to treating this challenging condition.
References
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Mader, J. T., Adams, K. R., & Sutton, T. E. (1987). Infectious diseases: pathophysiology and mechanisms of hyperbaric oxygen. Journal of Hyperbaric Medicine, 2(3), 133-140.
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Chen, C. E., Ko, J. Y., Fu, T. H., & Wang, C. J. (2004). Results of chronic osteomyelitis of the femur treated with hyperbaric oxygen: a preliminary report. Chang Gung Medical Journal, 27(2), 91-97.
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Esterhai Jr, J. L., Pisarello, J., Brighton, C. T., Heppenstall, R. B., Gellman, H., & Goldstein, G. (1987). Adjunctive hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis. Journal of Trauma and Acute Care Surgery, 27(7), 763-768.
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Mendel, V., Reichert, B., Simanowski, H. J., & Scholz, H. C. (1999). Therapy with hyperbaric oxygen and cefazolin for experimental osteomyelitis due to Staphylococcus aureus in rats. Undersea & Hyperbaric Medicine, 26(3), 169-174.
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Mader, J. T., Adams, K. R., Wallace, W. R., & Calhoun, J. H. (1990). Hyperbaric oxygen as adjunctive therapy for osteomyelitis. Infectious Disease Clinics of North America, 4(3), 433-440.
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Goldman, R. J. (2009). Hyperbaric oxygen therapy for wound healing and limb salvage: a systematic review. PM&R, 1(5), 471-489.
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Fang, R. C., & Galiano, R. D. (2009). Adjunctive therapies in the treatment of osteomyelitis. Seminars in Plastic Surgery, 23(2), 141-147.
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Mathieu, D., Marroni, A., & Kot, J. (2017). Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving and Hyperbaric Medicine, 47(1), 24-32.