Osteomyelitis represents an inflammatory process with a bacterial infection involving bone.
The term “refractory osteomyelitis” refers to failure to heal or recurrence despite adequate surgical and antibiotic therapy.
A unique form of refractory osteomyelitis, “malignant otitis externa,” is a progressive and potentially fatal infection of the ear canal and base of the skull. Hyperbaric oxygen is a useful adjunct to antibiotic therapy and, when feasible, surgical debridement.

Causes Many different types of bacteria can cause osteomyelitis. However, infection with a bacterium called Staph. aureus is the most common cause. Infection with a fungus is a rare cause.The long bones of the leg (femur, tibia and fibula) are the most commonly affected. However osteomyelitis can affect any bone.
Sources If some bacteria settle on a small section of bone, they can multiply and cause infection. Bacteria can get to bone:
Via the bloodstream. Bacteria sometimes get into the blood from an infection in another part of the body and then travel to a bone. Even if you are healthy, bacteria can sometimes get into the blood from the nose or bowel (gut).
Following an injury. Bacteria can spread to bone if you have a deep cut on the skin. In particular, if you have a broken bone which you can see through the cut skin.
Symptoms Local (wound infection with erythemia(redness), heat swelling, tenderness,pain and drainage).
Systemic (fever, chills, dehydration, lethargy and even organ failure.
If osteomyelitis develops following a fracture to a bone then the symptoms include increasing redness, swelling, and pain around the fracture site. Pus may come out from a skin wound over a fracture.
HBO in the case of Refractory Osteomyelitis Hyperbaric oxygen increases the oxygen concentration in infected tissues, including bone, and kills or inhibits the growth of organisms which prefer low oxygen concentrations. These effects occur through the oxygen-induced production of toxic oxygen-radicals or through an indirect effect mediated through the white blood cells. In addition hyperbaric oxygen enhances the activity of some antibiotics, speeds up new bone formation (osteogenesis) and helps in removing necrotic (dead) bone (osteoclastic function). Hyperbaric oxygen also provides adequate oxygen for new vessel formation (angiogenesis).
Referral Criteria for Hyperbaric Oxygen Therapy.
ECHM Indication
HBO is recommended in chronic refractory osteomyelitis defined as an acute bone infection persisting more than six weeks despite adequate surgical and antibiotic therapy.
HB02 is adjunctive and must be used with appropriate antibiotics (determined by bone culture and sensitivity testing), surgical debridement, nutritional support, and reconstructive surgery.
Treatment Antibiotics
Surgery
Hyperbaric Oxygen Therapy
Duration of treatment Standard treatment involves 40 sessions of Hyperbaric Oxygen Therapy administered on a daily basis. Individual sessions last approximately 2 hrs with patient breathing oxygen for 90 minutes at 2.4 atmospheres.
Evidence for HBO 1. Brett B. Hart, Refractory Osteomyelitis. Hyperbaric Oxygen Therapy Committee Report 2003. Undersea and Hyperbaric Medical Society, 2003
2. Strauss MB: The role of Hyperbaric Oxygen in the surgical management of chronic refractory osteomyelitis, in Hyperbaric Surgery. 2002, Best Publishing Co. Flagstaff, AZ.
3. Chen CE, Ko JY, Fu TH, Wang CJ.: Results of chronic osteomyelitis of the femur treated with hyperbaric oxygen: a preliminary report. Chang Gung Med J. 2004 Feb; 27(2):91-7
4. Mendel V, Simanowski HJ, Scholz HCh: Synergy of HBO2 and a local antibiotic carrier for experimental osteomyelitis due to Staphylococcus aureus in rats. Undersea Hyperb. Med. 2004 Winter; 31(4):407-16.
5. Mader JT, Calhoun J. Osteomyelitis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious diseases. New York: Churchill Livingston 1995: 1039-1051
6. Slack WK, Thomas DA, Perrins DJD. Hyperbaric oxygenation in chronic osteomyelitis. Lancet 1965; 1: 1093 – 1094