SLR - February 2022 - Christopher A. Bergen
Reference: Jirangkul P, Baisopon S, Pandaeng D, Srisawat P. Hyperbaric oxygen adjuvant therapy in severe mangled extremities. Injury. 2021 Nov; 52(11):3511-3515Level of Evidence: IV
Scientific Literature Review
Reviewed By: Christopher A. Bergen, DPM
Residency Program: St. Mary’s General Hospital – Passaic, NJ
Podiatric Relevance: The management of severely damaged extremities causing injury to multiple structures including bones, muscles, tendons, bloaod vessels, and skin has always posed a difficult task for the podiatric physician. The treatment often requiring medical and surgical management is frequently complicated when vascular injury ensues leading to an ischemic limb, oftentimes necessitating amputation. For over 30 years the Mangled Extremity Severity Score (MESS) has been used to determine whether to proceed with limb salvage or empiric amputation with typically a score of seven or higher resulting in likely amputation. Hyperbaric oxygen therapy (HBOT) is one of the new treatment modalities, although first described in the early 1960s for the treatment of chronic wounds with a recent study revealing its benefits for traumatic crush injuries. This article reports the role of adjunctive HBOT for severely mangled extremities (MESS of seven or higher).
Methods: This prospective study included 18 patients who sustained severe crush or blast injuries of their extremities resulting in a MESS score of seven or greater with no desire for amputation between January 2008 - January 2018. All patients received initial medical and surgical intervention consisting of shock management, tetanus prophylaxis, IV antibiotics, irrigation and debridement with stabilization of fracture within eight hours, in addition all other surgical procedures of vascular repair, soft tissue reconstruction and skin coverage were performed as necessary. HBOT was conducted inside a mono or multi-place hyperbaric chamber performed within 48 hours of the injury twice daily for the first three days and once daily in the subsequent following days depending on severity. The success of outcomes was based on the incidence of acute complications after HBOT treatment including oxygen toxicity, recurrent infection, breakdown of wound coverage and ischemic limb that required amputation. In addition, radiographic assessment of extremities with fractures were evaluated for bone union time.
Results: At conclusion of the study all patients received HBOT of at least 12 sessions over approximately nine days totaling an average of 19.17 hours of administration time. Complete wound healing without tissue necrosis requiring surgical excision was obtained in majority of the cases with an average time of wound closure being 25.94 days. Only one patient required a below the knee amputation. Thirteen patients who sustained a fracture were clinically and radiographically healed with an average bone union time of 122.94 days. No adverse effects of HBOT or significant medical complications occurred during HBOT in this study.
Conclusions: This study demonstrated HBOT as a feasible adjunct treatment option with conventional current standard treatments among patients with severe extremity injuries. It revealed HBOT can be initiated immediately after surgery without evidence of complications. The authors provided that earlier administration of HBOT could prevent complications, promote granulation tissue and wound healing, minimize the frequency of surgical procedures, and reduce the risk and extent of limb amputation. These results show HBOT as a promising treatment in the armamentarium of the podiatric physicians in the treatment of limb salvage when faced with complex and challenging lower limb injuries.