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Hyperbaric Oxygen Therapy For Refractory Osteomyelitis

Medical information reviewed by: RAMONA HOTNOG , Kinetoterapeut
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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 refractory osteomyelitis?

Osteomyelitis is an infection of the bone or marrow caused by bacteria or mycobacteria. It is difficult to treat due to the relative paucity of blood vessels in bone and the fact that many antimicrobials do not penetrate bone well. Refractory osteomyelitis is chronic osteomyelitis that does not respond or that returns after appropriate treatment. Patients presenting with osteomyelitis to the spine, skull, or sternum have a high risk for morbidity and mortality from this infection

Types of treatment

The standard treatment for chronic and refractory osteomyelitis includes surgical debridement and culture-directed antibiotics. Hyperbaric oxygen treatments can be considered an American Heart Association (AHA) Class II recommendation for the treatment of chronic, refractory osteomyelitis. In patients with Wagner grade 3 or 4 diabetic foot ulcers (DFU) with osteomyelitis, adjunctive hyperbaric oxygen therapy is an AHA Class I intervention. Recent studies have postulated that up to 20% of patients presenting to Wound Care Centers for treatment of Wagner 3 Diabetic foot ulcers already have Osteomyelitis. Infection in bone is one of the causes of a nonhealing wound and should be suspected and tested for sooner rather than later when a patient presents with a chronic, nonhealing wound. 

Etiology

In infants and children, Staphylococcus and Streptococcus are the most common organisms isolated after hematogenous spread. In adults, it is usually S. aureus. The infection can be caused by hematogenous spread or by direct inoculation of microorganisms into the bone. Intravenous drug abuse has been linked to hematogenous osteomyelitis involving the long bones or the vertebrae.

Chronic refractory osteomyelitis is a subset of osteomyelitis that does not respond to standard antibiotic courses and surgical debridement. To be considered "chronic" and "refractory" most sources state that the infection must have been under appropriate culture-directed antibiotic therapy and surgical debridement as warranted for at least 6 weeks without improvement or healing. A problem commonly seen in the wound clinic is the patient who whether through nonadherence with medical treatment, or lack of awareness on the part of the treating physician receives too short a course of antibiotic therapy or lack of follow-up imaging and lab work to assess the response to treatment. These patients invariably return months later with a re-opened wound or draining sinus as the body tries to rid itself of the indolent infection in the bone.

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Epidemiology

Approximately one in 675 United States hospital admissions each year (50,000 cases annually) is due to osteomyelitis. Patients with diabetes, intravenous (IV) drug abusers and other immunocompromised individuals are at increased risk for osteomyelitis.
Post-traumatic osteomyelitis accounts for almost 50% of cases. Other major causes are neuropathy (mostly in diabetics) and hematogenous seeding (primarily seen in children).

Overall, resolution and healing rates for primary osteomyelitis treated with surgery and antibiotics is between 35% and 100%. It can be inferred that between 70% and 80% of patients treated for primary osteomyelitis will be cured. Long-term osteomyelitis recurrence rates can range between 20% and 30 %. When appropriate medical and surgical interventions fail, the infection progresses or recurs, or the infection is in an area associated with high morbidity and mortality, adjunctive hyperbaric oxygen treatments should be considered. 

Pathophysiology

S. aureus is the most common pathogen cultured in osteomyelitis.

Osteomyelitis is divided according to the Cierny-Mader Classification in:
  • First stage: Medullary osteomyelitis (confined to the medullary cavity of the bone)
  • Second stage: Superficial cortical bone infection (most often results from direct inoculation or contiguous wound infection)
  • Third stage: Localized osteomyelitis (usually involves both cortical and medullary bone)
  • Forth stage: Diffuse osteomyelitis (involves the entire thickness of the bone and results in structural instability, such as with an infected nonunion fracture)

Histopathology

Most infectious disease specialists advocate obtaining a bone culture from the site of the infection to treat with culture directed therapy. Bone is sometimes visible or palpable in chronic wounds and can easily be obtained in the clinic using a rongeur. For deeper wounds or if there is no way to obtain bone in the clinic, patients will need referral either to surgery or interventional radiology to obtain a specimen for gram stain, AFB, and culture and sensitivity. 

History and Physical

Many patients who are treated for chronic non-healing wounds will have underlying osteomyelitis as the cause of their failure to heal the wound. Wounds that fail to close, close but reopen, have draining sinuses or occur over areas where patients may have implanted hardware warrant a high index of suspicion for osteomyelitis. Bone infection in and around the total joint prosthesis can have catastrophic outcomes. 

Evaluation

Lab tests such as erythrocyte sedimentation rate and C-reactive protein should be checked. If these are elevated, there is a high likelihood that the patient has osteomyelitis. MRI is the gold standard for imaging osteomyelitis. Osteomyelitis often does not show up on plain film radiographs. A bone biopsy should be obtained for culture-directed antibiotics to be ordered. an interprofessional team consisting of a surgeon, infectious disease specialist, and wound and hyperbaric medicine specialist is often needed to manage these patients effectively.

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

Treatment / Management

Surgical debridement and culture-directed antibiotics are the mainstays of treatment. For patients who do not respond to appropriate therapy for 4 to 6 weeks, the diagnosis of chronic refractory osteomyelitis (CRO) becomes appropriate. These patients should be referred for adjunctive hyperbaric oxygen therapy. Hyperbaric oxygen improves the penetration of certain antibiotics (cephalosporins and aminoglycosides) into the bone and stimulates osteogenesis. Mader and Niinikoski showed that infected bone has decreased oxygen content. Hyperbaric oxygen treatment increases the oxygen content to normal or above normal levels during treatment. The leukocyte-mediated killing of gram-positive organisms like S. aureus as well as some gram-negative microbes is restored when the oxygen content of the infected bone is increased with hyperbaric oxygen treatment. The transport of antibiotics such as aminoglycosides and cephalosporins into the infected bone is improved and increased with adjunctive hyperbaric oxygen treatment.
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Prognosis

Patients who are diagnosed on time have an antibiotic therapy aimed at the appropriate culture, surgical debridement if indicated and the usual local care of wounds can do very well and can be treated completely until the wound closes. Those with uncontrolled diabetes or other comorbidities tend not to react as well. Long-term treatment and subsequent care should be emphasized to the patient, as well as the importance of a multidisciplinary treatment protocol. 

Complications

The biggest complication is the failure to have a high rate of suspicion and not to make the diagnosis in time. This can lead to serious injury problems and can lead to major amputation when one leg or lower limb is involved. 

Deterrence and Patient Education

Diabetic patients should be instructed to seek care for any wound as soon as it is discovered and to see a Podiatrist for diabetic foot care regularly as well as regular visits with their Primary Care Physician and Endocrinologist. Good glycemic control prevents infection and the loss of function of the White blood cells that lead to infections in poorly controlled diabetic patients. 

Improving the results of the healthcare team

The patient with osteomyelitis must be treated by a multidisciplinary team. This team should consist of a physician specializing in the treatment of lesions and a specialist in hyperbaric oxygen therapy, podiatric, general, or vascular surgeons, interventional radiologists, and specialists in infectious diseases. Osteomyelitis is usually treated with IV antibiotics, but chronic or recalcitrant cases can be treated with HBO therapy. Patients must understand that HBO therapy is not a substitute treatment, but an adjunctive treatment to antibiotics. Limited cases indicate that HBO therapy may help improve healing.


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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