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Hyperbaric Oxygen Therapy In Osteoradionecrosis

Medical information reviewed by: ANDREI BOGDAN, MD, Orthopedics-traumatology doctor

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Discover the hyperbaric medicine center opened in our clinic. Centrokinetic has the top-performing hyperbaric chamber in Bucharest, with multiple medical and anti-aging uses. The Baroks chamber has 5 seats, and operates at a constant pressure of 2.5 atmospheres, being fully automated and having protocols for each condition, and can be used individually for each patient. 

Hyperbaric oxygen therapy - benefits

Patients who use the clinic's hyperbaric therapy services benefit from:

  • The only medically accredited hyperbaric therapy chamber in Bucharest, which operates at 2.5 atmospheres (those for aesthetic use go to 1 atmosphere and have no medical benefits).
  • A safe medical procedure, without irradiation, without pain, without other side effects. 
  • The specialized medical team consists of recovery doctors, orthopedists, rheumatologists, neurologists, and neurosurgeons, meaning a multidisciplinary team specialized in all diseases that can be treated with hyperbaric therapy. 
  • Premium conditions at a fair price. Our clinic is recognized for the conditions offered and for the care of each patient. But we do not need to pay exorbitant prices to have access to quality medical services. At Centrokinetic you can find an affordable and fair price. But note that we do not have a contract with the National Health Insurance House (we do not offer state reimbursed services)

Centrokinetic is keeping contact with prestigious clinics and universities in Belgium, the Netherlands, France, and Greece to constantly update treatments to provide patients with the best medical solutions.

What is osteoradionecrosis?

Osteoradionecrosis (ORN) is a common consequence of radiation provided to cancer patients. Currently, hyperbaric oxygen therapy (HBOT) has a major role in improving wound healing in patients with ORN. There is no strong scientific evidence to confirm the benefits of HBOT for ORN treatment as an adjunct treatment. This study aimed to determine the benefits of additional HBOT treatment in ORN. A retrospective study was conducted at Srinagarind Hospital, along with the Khon Kaen Faculty of Medicine, Thailand, on data collected between 2011 and 2017. 

Patients diagnosed with ORN, who received additional HBOT before surgery, were taken as a study sample. Complete wound healing was the outcome. There were 84 patients with ORN with a mean age of 58.78 years; 54.76% were men, and 45.24% were women. In conclusion, HBOT improved wound healing in patients with stage 1 and 2 ORN. Also, patients in stage 2 significantly required the highest number of HBOT treatments compared to other stages of ORN, to aid in healing. Stage 3 patients, who were treated with bone debridement combined with HBOT, required fewer treatments.

Introduction

Osteoradionecrosis (ORN) is a common consequence of radiation in cancer patients. The most commonly affected bone is the mandible. Patients with this malignancy generally receive conventional therapy, including surgery, chemotherapy, and radiation therapy. Various forms of ionizing radiation have been used to treat cancer. Also, ionizing radiation almost certainly harms soft and hard tissues. As a result, the affected soft tissues were damaged and this caused progressive endarteritis and fibrosis. These lead to ischemia of the affected tissues. Similarly, these side effects occurred in the bone, destroying local vascular systems and cellular components. 

Also, the histological findings of the affected bone showed low osteocytes and osteoblasts. Moreover, the periosteum is also affected and fibrosis can occur quickly which leads to decreased bone regeneration. These changes occur progressively and can eventually lead to bone necrosis. Consequently, patients with ORN often have poor treatment outcomes and high morbidity. Many malignant patients have suffered from ORN after a full course of cancer treatment.

There are several treatment modalities to improve wound healing in patients with ORN. Both conservative and modern treatments are used to improve the healing process of ORN. Currently, hyperbaric oxygen therapy (HBOT) plays a role in treating wounds in patients with ORN. HBOT may be used as an adjunctive treatment for surgery to accelerate the healing process in patients with ORN. Further studies on the effects of HBOT are needed to support the benefits of its use in ORN patients.

Materials and methods

The idea of ​​this study was to determine the influence of HBOT in patients with ORN. This study was conducted from 2011 to 2017 at Srinagarind Hospital by Khon Kaen University in Thailand. 84 patients were included in this study. The inclusion criteria for this study were all patients with ORN who received HBOT as an adjunctive prophylactic treatment before and after the procedure.

All patients had evidence of previous radiation therapy for head and neck cancer. The criteria for staging were the following: 

  • Stage 1 represented by bones exposed to radiotherapy but asymptomatic
  • Stage 2 was represented by patients with bones exposed to radiotherapy and symptoms such as pain, soft tissue inflammation, or even infection.
  • Stage 3 was represented by patients with symptoms and signs similar to those in stage 2, combined with pathological fracture or skin fistula. 

Medical history, physical examination, and plain radiography were performed in all patients with uncomplicated conditions, and those patients with severe manifestations required a computed tomography, especially those in stage 3. The main result of the study was wound healing which was defined by the complete coverage of soft tissues, without any infection, inflammatory process or fistula. Evaluation of wound healing was documented after treatment and at least a 6-month break to examine the patient's condition in the absence of the disease.

All patient demographics and clinical data were recorded, including age, sex, primary cancer types, ORN stages, surgical procedures, HBO therapy (total oxygenation time and number of treatments applied) and wound healing outcome. As a treatment protocol, patients were treated daily with HBO before surgery and after surgery. If, however, the wound did not heal, an extension of treatment was considered. Also, patients were treated daily with HBO at 2.4 absolute atmospheres for 90 min. The surgical procedure for patients with stage 1 and 2 ORN was tooth extraction, while stage 3 was bone debridement.

Statistical analysis

The generalized linear model (GLM) was used to determine the correlation between variables and HBOT treatment outcomes. This model was used to determine significant variables that were independently associated with HBOT. Poisson regression was used to correct GLM overuse using the Bootstrapping, as the number of HBOTs can vary. HBOT outcomes were adjusted for age, sex, primary cancer, and ORN stages.

This study was approved by the Ethics Committee of Khon Kaen University for Human Research (HE611060).

What are the effects of oxygen therapy on the body?

  • Decreases inflammation
  • Increases the body's oxygen saturation by 20-30%
  • Increases the body's immunity
  • Increases blood circulation and stimulates the formation of new capillaries
  • Decreases toxins in the body
  • Stimulates the production of new blood cells
  • Increases healing rate
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Results

84 patients with ORN were included in this study. The mean age of the patients included in this study was 58-78 years. Both sexes were included almost equally (54.76% were men and 45.24% were women). Also, the average number of total HBOT treatments was 29.83. Most patients had primary oral cancer (70.24%), followed by cancer of the nasopharynx (23.81%) and cancer of the throat (5.95%). Also, most patients were in stage 1, more precisely 63.10%, only 8.33% of patients were in stage 2, and in stage 3, were 28.57% of patients.

Univariate analysis was performed, and the results revealed that there was only one significant variable that was associated with the number of HBOT treatments, resulting in healed wounds. The regression analysis of the effects showed that stage 3 of the ORN was negatively correlated with the number of HBOT treatments. Multivariate analysis showed the same results, showing that HBOT therapy has a beneficial effect on patients with ORN. 

ORN is a complication of radiation therapy in head and neck cancer. ORN creates a problem for a complex therapeutic process, such as tissue transfer. The results of the treatment are often not as expected, and an unfavorable outcome may occur. Some procedures, such as tooth extraction or even debridement, can cause a progression of the ORN. The doctor must consider the prevention protocols before performing specific procedures on the jaw. Currently, several previous studies have highlighted that HBOT has a significant role in treating patients with ORN. 

Patients with ORN included in this study were treated with HBOT as adjunctive and prophylactic treatment. This study determined the outcome of HBOT treatment. Poisson regression analysis showed that in stage 3 of the ORN patients had very good results from HBOT treatment, which led to a wound healed analyzed using both univariate and multivariate analyzes. Significantly, stage 3 required a lower number of HBOT treatments compared to stage 2, because stage 3 patients had already undergone bone debridement, while bone debridement was not performed in stage 2 disease. Stage 3 ORN has severe bone necrosis and has a more severe manifestation than stage 2. Consequently, patients with stage 3 ORN have performed bone debridement before or bone resection.

Therefore, some studies claim that HBOT didn't play a major role in determining wound healing because the problematic bones have already been removed. Therefore, fewer HBOT treatments were required for stage 3 patients to enhance wound healing compared to the effects of this therapy in stage 2 patients. Compared to other studies, these results were consistent with previous studies and have shown that specific HBOT techniques have significantly provided an advantage in prophylactic use in patients who need a tooth extraction and are at risk of developing ORN. Shaw suggested that the unfavorable results of ORNs can be prevented with the help of HBOT techniques applied before any surgery.

There is still controversy over the use of HBOT in ORN. Also, it was found that stage 1 of the ORN also required a small number of HBOT treatments because the lesion was in an early and less severe stage. HBOT was effective in stage 1. Therefore, patients with stage 1 ORN could be cured simply by treatment with a small number of HBO treatments without surgery.

The most appropriate treatment for stage 2 patients who have less bone necrosis compared to stage 3 has often been difficult to plan because the lesion is not severe enough to require early surgery, which includes bone debridement or bone resection. Therefore, these patients can be cured with conservative treatment. Stage 2 patients needed a large number of HBOT treatments for effective wound healing. These results show that the success rate of HBOT at this stage is not as high as in the first and third stages. 

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In contrast, if patients with stage 2 ORN undergo an early bone debridement or bone resection process and are subsequently treated with HBO, they will gain a greater clinical advantage compared to delayed surgery. Therefore, surgical therapy should be considered early for patients with ORN in stages 2 and 3 to heal the wounds and reduce the length of hospital stay for HBOT treatment. 

Conclusion

HBOT has played a significant role in improving wound healing in patients with ORN in stages 1 and 3. Also, patients with stage 2 diabetes significantly required the highest number of HBOT treatments compared to other types of ORN for the effects of this technique to be seen in wound healing, while stage 3 patients who have gone through the process of bone debridement have had the highest success rate following HBOT treatments. Bone debridement essentially improves wound healing in ORN patients with severe manifestations, leading to the use of fewer HBOT treatments.

IN CASE YOU HAVEN'T ALREADY HEARD ABOUT US

Centrokinetic is the place where you will find clear answers and solutions for your motricity problems. The clinic is dedicated to osteoarticular diseases and is divided into the following specialized departments:

  • Orthopedics , a department composed of an extremely experienced team of orthopedic doctors, led by Dr. Andrei Ioan Bogdan, primary care physician in orthopedics-traumatology, with surgical activity at Medlife Orthopedic Hospital, specialized in sports traumatology and ankle and foot surgery. .
  • Pediatric orthopedics , where children's sports conditions are treated (ligament and meniscus injuries), spinal deformities (scoliosis, kyphosis, hyperlordosis) and those of the feet (hallux valgus, hallux rigidus, equine larynx, flat valgus, hollow foot).
  • Neurology , which has an ultra-performing department, where consultations, electroencephalograms (EEG) and electromyography (EMG) are performed. 
  • Medical recovery  for adults and  children , department specialized in the recovery of performance athletes, in spinal disorders, in the recovery of children with neurological and traumatic diseases. Our experience is extremely rich, treating over 5000 performance athletes.
  • Medical imaging , the clinic being equipped with ultrasound and MRI, high-performance devices dedicated to musculoskeletal disorders, and complemented by an experienced team of radiologists: Dr. Sorin Ghiea and Dr. Cosmin Pantu, specialized in musculoskeletal imaging.

Find the latest news by following the Facebook and YouTube accounts of the Centrokinetic clinic.  

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