ROLE OF HBOT IN ACUTE MUSCULO-SKELETAL TRAUMA
MILANO, 4-8 September 1996
RECOMMENDATIONS OF THE JURY*
therapy has to be considered as an adjunctive treatment modality.
Optimal surgery and resuscitation have to be done before or simultaneously.
|QUESTION 1- Can HBOT prevent post-traumatic bone hypoxia and post-traumatic edema ?
Until now there
is not sufficient evidence to definitively state that HBO can prevent bone
hypoxia, and edema. However there is experimental and clinical evidence supporting
that HBO act to correct post-traumatic tissue edema and delayed bone healing.
(Type 2 statement)
|QUESTION 2- Which is the role of HBOT in prevention of reperfusion injury ?
There is some experimental evidence showing a positive effect of HBO in preventing reperfusion injury, but there is not sufficient clinical evidence. However, no study showed a detrimental effect of HBO in increasing the oxydative stress, in injured tissue. (Type 3 statement)
is strongly recommended that well conducted clinical studies have to be undertaken,
because of the existing experimental evidence. (Type 1 recommendation).
|QUESTION 3- Which is the role of HBOT in prevention of post-traumatic superimposed infections ?
procedure of choice is surgery (repeated if necessary), but HBO can be recommended
as an adjunctive treatment to enhance antibiotic efficacy, to improve tissue
oxygenation and prevent superinfections. (Type 2 statement)
|QUESTION 4 and 5- Which is the role of HBOT in improving tissue salvage after acute and subacute musculo-skeletal trauma?
In case of severe
tissue damage, with dubious vitality, there is experimental and clinical evidence
that HBO improves tissue salvage and clinical outcome. (Type 2 statement)
|QUESTION 6- What is the role of HBOT in improving the final clinical outcome in acute and subacute musculo-skeletal trauma?
In cases of open fractures with extensive soft tissue and/or vascular damage (corresponding with type III B/C of Gustillo's classification) adjunctive HBOT is recommended. (Type 2 recommendation)
In less severe cases HBOT adjunctive to surgery can be used in compromised hosts. (Type 3 recommendation)
In every cases HBO is considered, measurement of transcutaneous oxygen pressure is recommended as an index for the definition of the indication and of the evolution of treatment. (Type 2 recommendation)
The cost of the use of adjunctive HBO will be at least compensated by the decrease in morbidity in these patients (e.g. lower amputation rate). (Type 2 statement)
Classification of open fractures
and place for HBO
as determined by the third ECHM Consensus Conference
|small (< 1 cm) laceration from inside to outside
less than 1 %
|often managed without formal surgical debridement
|laceration more than 1 cm long without or with minimal soft tissue injury
less than 5 %
|excellent results with immediate surgical debridement and later delayed primary closure
|crush injury component; adequate soft tissue coverage
infection 4 %
amputation 0 %
|complication rates little different from types I and II fractures
|inadequate (loss of sufficient) soft tissue to cover bone and close wound
infection 52 %
amputation 16 %
|external skeletal fixation and free grafts have greatly advanced the management of these fractures; complication rates remain high
HBO (type 2 recommendation)
infection 42 %
amputation 42 %
|these complication rates exist after arterial repair
HBO (type 2 recommendation)