Key Takeaways

• Chronic refractory osteomyelitis (CROM): HBOT is an adjunct after persistent/recurrent infection despite debridement and culture-directed antimicrobials; evidence is Level II/moderate observational, Grade 2B, with no large high-quality RCTs.
• HBOT protocols: Typical treatment is 30–40 sessions at 2.0–2.5 ATA for ~90 minutes; integrate with debridement, antibiotics, and optimization of vascular supply, nutrition, glycemic control, and host factors.
• Clinical considerations: Confirm refractory disease and assess risks; adverse events include barotrauma, rare oxygen-induced seizures, hypoglycemia, transient myopia, and claustrophobia. Multidisciplinary selection is critical for infection control, healing, and limb preservation.

Hyperbaric oxygen therapy (HBOT) is an adjunctive treatment for selected patients with chronic refractory osteomyelitis (CROM), generally defined as persistent or recurrent bone infection despite appropriate surgical debridement and an adequate course of culture-directed antimicrobial therapy.

Although there are no large, high-quality randomized controlled trials demonstrating efficacy, multiple retrospective series, prospective cohort studies, and mechanistic data suggest improved infection control and limb salvage when adding HBOT to standard care in carefully selected patients. Consequently, the evidence is generally considered Level II (moderate-quality observational evidence), resulting in a Grade/Level 2B recommendation in many evidence-based grading systems rather than Level I evidence.¹ 

The Undersea and Hyperbaric Medical Society recognizes CROM as an accepted indication for HBOT, and many insurers provide coverage when documentation demonstrates failure of standard therapy.¹ 

HBOT should not replace surgery or antibiotics. One should incorporate it into a multidisciplinary treatment plan that includes:

• Adequate surgical debridement whenever feasible
• Culture-directed antimicrobial therapy
• Optimization of vascular supply, nutrition, glycemic control, and other host factors

Q: What are the most important clinical considerations?

The first step is confirming that the patient truly has CROM, supported by clinical findings together with appropriate imaging, microbiology, pathology, and documentation that standard treatment has failed.

One should individualize treatment decisions through a multidisciplinary approach involving infectious disease, orthopedic or surgical specialists, wound care, and hyperbaric medicine.

There are important clinical situations where aggressive surgical resection carries substantial morbidity or may not be technically feasible. Examples include osteomyelitis involving the sternum, skull base, vertebrae, pelvis, or selected diabetic foot infections where limb preservation is a priority. In these settings, HBOT may improve tissue oxygenation, enhance leukocyte oxidative killing, stimulate angiogenesis, promote osteogenesis, and augment certain antibiotic activity, thereby serving as a valuable adjunct to medical and surgical management.

The key takeaway is that appropriate patient selection and documentation of refractory disease are critical before recommending HBOT.

Q: What practical considerations for HBOT in these patients do you want WoundCon attendees to take away?

The most important principle is that HBOT is an adjunct, not a standalone, treatment. Outcomes are best when HBOT is integrated with appropriate surgery, culture-directed antibiotics, and comprehensive medical management.

Before initiating therapy, the hyperbaric physician should perform a careful risk-benefit assessment. HBOT has an excellent safety profile when delivered according to established protocols, but clinicians should recognize potential adverse events, including:

• Middle ear or sinus barotrauma (most common)
• Oxygen-induced seizures (rare and typically self-limited)
• Pulmonary barotrauma (very rare)
• Hypoglycemia in patients with diabetes
• Transient visual changes (myopic shift)
• Claustrophobia
• Careful assessment of patients with severe heart failure, particularly those with reduced ejection fraction, although this is not an absolute contraindication.¹

Typical treatment protocols consist of 30–40 treatments at 2.0–2.5 ATA for approximately 90 minutes, with additional treatments considered based on clinical response.

The message I want attendees to remember is simple:

HBOT is not a panacea. It is most effective when incorporated into a comprehensive, multidisciplinary treatment strategy that combines adequate debridement whenever feasible, culture-directed antimicrobial therapy, optimization of host factors, and careful patient selection. In appropriately selected patients with chronic refractory osteomyelitis, HBOT can improve the likelihood of infection control, wound healing, and limb preservation.