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Chronic Osteomyelitis: How Hyperbaric Oxygen Therapy Supports Healing

Updated: May 7

What Is Chronic Refractory Osteomyelitis (CRO)?


Chronic refractory osteomyelitis (CRO) is a persistent and often recurrent bone infection that poses significant treatment challenges. When surgery and antibiotics alone are not enough, hyperbaric oxygen therapy (HBOT) offers an evidence-based adjunct that supports healing and plays a valuable role in improving treatment response. As a prototypical "problem wound," CRO requires meticulous care planning, close coordination among specialties, and a strong commitment to patient-centered care—HBOT serves as a vital tool within this broader, multidisciplinary approach.


Chronic Refractory Osteomyelitis





Understanding Chronic Refractory Osteomyelitis


CRO is both an infectious and ischemic condition. In response to infection, the body produces dense fibrous tissue that walls off the affected area. This impairs oxygen delivery and reduces tissue oxygen tension (pO₂) to levels below the 30–40 mmHg threshold required for essential healing processes. When pO₂ drops below 30 mmHg, leukocytes can no longer perform phagocytosis, and systemic antibiotics struggle to penetrate the infected bone, and ischemia further impedes the delivery of high-dose antibiotics into the affected area.


Why HBOT Is an Important Adjunct in CRO Treatment


CRO is characterized by recurrent flare-ups resulting in pain, drainage, or other signs of acute inflammation. While not a substitute for antibiotics or surgery, HBOT serves a critical adjunctive role in managing complex osteomyelitis cases. By increasing tissue oxygen tension to therapeutic levels (often exceeding 150 mmHg), HBOT:


  • Raises tissue pO₂ levels above 30 mmHg, promoting osteogenesis, neovascularization, and the activity of fibroblasts and osteoblasts to fill dead space with vascularized, structurally sound tissue

  • Improves antibiotic delivery and leukocyte effectiveness by enhancing vascularity

  • Activates osteoclasts to clear necrotic bone debris


These combined effects help reverse chronic hypoxia, promote tissue repair, and support infection control in patients who have failed conventional therapy. Notably, leukocyte-mediated bacterial killing has been shown to improve significantly at oxygen tensions above 30 mmHg and peak near 150 mmHg—levels achievable only through HBOT. This underscores the therapy’s unique ability to enhance immune response in infected, ischemic bone. HBOT has also demonstrated clinical benefit in cases where antibiotic therapy alone has proven insufficient, reinforcing its value as an adjunctive treatment modality. While HBOT does not exert a direct bactericidal effect against most pathogens—aside from certain anaerobes—it enhances the host immune response and contributes meaningfully to the overall healing environment.


Who Is a Candidate for HBOT?


According to Medicare coverage criteria, HBOT is considered medically necessary for patients with chronic refractory osteomyelitis that is unresponsive to conventional medical and surgical management. This typically includes cases where:


  • The infection has persisted for at least six weeks

  • There is no improvement following an adequate course of standard wound therapy, including appropriate antibiotic treatment and surgical intervention if indicated

  • Diagnostic studies (e.g., imaging or bone cultures) confirm the ongoing presence of osteomyelitis


Clinical evidence supports the adjunctive use of HBOT in managing these cases, with studies demonstrating improved outcomes when HBOT is combined with standard therapies.


Shared Health Services Spotlight


With more than 25 years of experience in wound care and hyperbaric program development, Shared Health Services equips hospitals and healthcare providers with the resources, tools, and peer-to-peer expertise needed to build successful, sustainable HBOT programs. We work directly with center staff—serving as trusted liaisons—to provide clinical guidance, compliance support, and training aligned with the highest standards of care. Our goal is to empower teams, elevate outcomes, and strengthen local wound care efforts through proven strategies and hands-on collaboration—especially when it comes to identifying and managing high-acuity cases like CRO, which may represent an overlooked portion of potential HBOT referrals.


References


  1. Esterhai J, Pisarello J, Brighton C, et al. Adjunctive hyperbaric oxygen therapy in the treatment of chronic refractory osteomyelitis. The Journal of Trauma. 1987;27(7):763–768.


  2. Goldman RJ. Hyperbaric oxygen therapy for wound healing and limb salvage: a systematic review. PM&R: The Journal of Injury, Function, and Rehabilitation. 2009;1(5):471–479.


  3. Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. Journal of Bone and Joint Surgery. 2004;86-A(10):2305–2318.


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