Hyperbaric Oxygen Therapy Use in Trauma and Orthopedic Surgery
Hyperbaric Oxygen Therapy Use in Trauma and Orthopedic Surgery
Great advancements were made in the 1950s with HBOT (Hyperbaric Oxygen Therapy). When evaluated and successfully applied to diversified pathology further improvements were achieved through more efficient formulas.
The principle involved resolving ischemia, a restriction in blood supply to tissues, causing a shortage of oxygen and glucose needed to keep tissue alive, with the best etiological agent possible pure oxygen.
The patient is placed in a hyperbaric chamber, where atmospheric pressure is gradually increased. At this pressure level, the patient uses a simple breathing mask to inhale pure oxygen, similar to those existing on airplanes.
There is a natural limitation to the amount of oxygen in red blood cells, as its oxygen transporter, hemoglobin can only bind to so much oxygen. HBOT increase in gas pressure addresses this limitation increasing the partial pressure of oxygen gas, forcing dramatically more oxygen to be dissolved in blood. In fact, 9 times that of hemoglobin saturated red blood cells. This saturation of oxygen in the blood allows the extra oxygen to be diffused or transported to the surrounding body tissues. According to Krogh principle, a normal capillary blood-vessel active at atmospheric pressure will be able to supply tissue to a 30 micron radius. When active inside the hyperbaric chamber, the same capillary vessel will provide oxygen for all tissues to a 300 micron radius. This massive uptake of oxygen and its complete solubility in blood explains why red blood cell deprived animals survived for days inside the chamber, until fresh red blood cells emerged from the marrow.
Local and general tissue ischemia can be triggered by various pathological events like trauma, infection or some kind of vascular impairment. Ischemia can be regarded as a disease by itself for example when affecting the heart or the brain during a stroke, the peripheral limb tissue in arterial disease or bony structures in primitive avascular necrosis.
It will also manifest in many other diseases such as a physio-pathological event – for example as seen in retinopathy or tinnitus, where localized ischemia of blood vessels nourishing the optic or acoustic nerves causes variable degrees of degeneration and subsequent loss of sight and hearing.
Infected tissues also suffer from ischemia because the blood vessels are obstructed with thrombosis (a blood clot). Local blood flow of tissue will decrease to alarming or even lesion inducing levels. The same thing happens inside lung tissue affected by pneumonia or with tissues neighboring a contusion area.
In our opinion, the impact of this method in trauma and orthopedic surgery could be far greater if logistics were simplified and prices decreased. However, the intent of this article is focus on the medical value of the treatment.
Our intent is to emphasize the importance of HBOT in three major pathological entities: fractures, avascular necrosis of bones and bone infections.
In trauma cases i.e. fractures the actual discontinuity in the structure of the bone (the crack line on the x-ray) is actually bordered with ischemic tissue 1-3 cm wide, on both sides of the line. It is extremely relevant to understand that a great deal of the time involved in fracture repair is consumed by actions meant to recycle all debris in that particular area. The subsequent local osteoporosis is partial proof.
It is also well known that under normal circumstances, the differentiation and multiplication of osteoblast (bone generating cells) occurs 3 weeks after the traumatic event. It is also relevant that differentiation of osteoblast needs sufficient amounts of oxygen. Lack of oxygen may divert differentiation of fibroblast towards less demanding cells like chondroblast or cartilage formatting cells, explaining many failures in the evolution of otherwise well treated fractures. Calcium and phosphorus mineral salts start depositing shortly after.
Dong Wu, Jos Malda et.al. presented in 2007 extensive reports of related research, demonstrating that in patients undergoing HBOT, differentiation and multiplication of osteoblast occurred within 3 days from the fracture event, and the mineral apposition within 4-6 days. This explains why fractures benefiting from HBOT may consolidate 2-3 times faster. In our experience of over 100 cases, we calculated an average healing rate 2.5 times faster than normal. We employed a simple treatment of 5 days TS240/90 HBOT for standard uncomplicated fractures, post-operatively and more for opened fractures. With this approach, post-operative immobilization became much shorter or even optional and rehabilitation was a much easier task, not to mention economical advantages of a shorter treatment.
Avascular necrosis (a disease where there is cellular death (necrosis) of bone components due to interruption of the blood supply) of the femoral neck is a well known disease which dramatically affects young male patients especially. Classic treatment (like de-compressive drilling) proves inconstant and results are unreliable. The association of HBOT (even without surgery for early stages like I II by Ficat) may lead to restoration to the patient’s original condition, as proven by many of our almost 350 patients. We are currently working on a 4 year follow up with bi-annual MRI monitoring and no significant relapse has been registered yet. We believe that this is a result of an HBOT side effect called neo-angiogenesis (formation of new capillaries). The newly formed blood vessels within formerly necrotic areas apparently sustain revived bone for a long time.
Bone infection remains a nightmare for surgeons and patients as well. In our opinion, classic surgical methods (like Papineau or Gentamicine pearls) are obsolete and prove a disarming rate of success (if well defined). Starting with the assessment of our cases, we have thought of a new approach. The concept is that if one part of a bone is infected, the rest of the bone is infected and should be treated as such. Thus we no longer encourage a topic approach.
We perfected a proceeding that involves surgery (sometimes repeated), use of bone substituent with standard or custom antibiotic mixture and HBOT. At the above mentioned partial pressure, oxygen is bound to kill any germ it makes contact with. Neo-angiogenesis will open blood vessels in all compromised (but not yet destroyed) areas, ensuring further penetration of oxygen and antibiotics. HBOT will enhance antibiotic activity while cutting costs and the toxic effect on the patient. Even if more expensive than the classic approach, this proceeding is much safer in our opinion and it will provide good results in a comparatively shorter time, without relapses. We estimate a 99% success rate with a correctly performed procedure. However, bone infections may require a larger number of HBOT proceedings, sometimes exceeding 100.
We are currently working on more detailed reports concerning our positive experience with HBOT associated to trauma and orthopedics cases.
Dr. Marius Enescu MD, PhD
Trauma and Orthopedic Surgery