INTRODUCTION: Hyperbaric oxygen treatment (HBOT) is sometimes used in the management of open fractures and severe soft tissue crush injury, aiming to reduce complications and improve outcomes. METHODS: Patients with open tibial fractures were randomly assigned within 48 hours of injury to receive standard trauma care or standard care plus 12 sessions of HBOT. The primary outcome was the incidence of necrosis or infection or both occurring within 14 days of injury. RESULTS: One-hundred and twenty patients were enrolled. Intention to treat primary outcome occurred in 25/58 HBOT assigned patients and 34/59 controls (43% vs 58%, odds ratio (OR) 0.55, 95% confidence interval (CI) 0.25 to 1.18, P = 0.12). Tissue necrosis occurred in 29% of HBOT patients and 53% of controls (OR 0.35, 95% CI 0.16 to 0.78, P = 0.01). There were fewer late complications in patients receiving HBOT (6/53 vs 18/52, OR 0.22, 95% CI 0.08 to 0.64, P = 0.007) including delayed fracture union (5/53 vs 13/52, OR 0.31, 95% CI 0.10 to 0.95, P = 0.04). Quality of life measures at one and two years were superior in HBOT patients. The mean score difference in short form 36 was 2.90, 95% CI 1.03 to 4.77, P = 0.002, in the short musculoskeletal function assessment (SMFA) was 2.54, 95% CI 0.62 to 4.46, P = 0.01; and in SMFA daily activities was 19.51, 95% CI 0.06 to 21.08, P = 0.05. CONCLUSIONS: In severe lower limb trauma, early HBOT reduces tissue necrosis and the likelihood of long-term complications, and improves functional outcomes. Future research should focus on optimal dosage and whether HBOT has benefits for other injury types.

Centre of Hyperbaric Medicine Ostrava City Hospital Ostrava Czech Republic

Corresponding author Dr Ian Millar The Alfred Hyperbaric Service PO Box 315 Prahran Victoria 3181 Australia

Department of Anaesthesiology and Perioperative Medicine Alfred Health and Monash University Melbourne Victoria Australia

Department of Biomedical Sciences Faculty of Medicine University of Ostrava Ostrava Zabreh Czech Republic

Department of Diving and Hyperbaric Medicine Royal Hobart Hospital Hobart Tasmania Australia

Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia

Department of Intensive Care and Hyperbaric Medicine Alfred Health Melbourne Victoria Australia

Department of Molecular Medicine and Surgery Karolinska Institutet at Karolinska University Hospital Stockholm Sweden

Department of Orthopaedic Surgery Alfred Health Mebourne Victoria Australia

Department of Physiology and Pharmacology Section for Anesthesiology and Intensive Care Medicine Karolinska Institutet at Karolinska University Hospital Stockholm Sweden

Health Data Research UK Swansea University Swansea United Kingdom

Hyperbaric Medicine Unit Department of Anesthesia Hospital Pedro Hispano Matosinhos Portugal

Prehospital Emergency and Trauma Research Unit Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia

School of Medicine University of Tasmania Tasmania Australia

See more in PubMed

James PB. Hyperbaric oxygen treatment for crush injury. BMJ. 1994;309(6967):1513. doi: 10.1136/bmj.309.6967.1513b. PubMed DOI PMC

Myers RA. Hyperbaric oxygen therapy for trauma: crush injury, compartment syndrome, and other acute traumatic peripheral ischemias. Int Anesthesiol Clin. 2000;38(1):139–51. doi: 10.1097/00004311-200001000-00009. PubMed DOI

Myers RA, Schnitzer BM. Hyperbaric oxygen use. Update 1984. Postgrad Med. 1984;76(5):83–6, 89–91,–94–5. doi: 10.1080/00325481.1984.11698755. PubMed DOI

Greaves I, Porter K, Smith JE, et al. Consensus statement on the early management of crush injury and prevention of crush syndrome. J R Army Med Corps. 2003;149:255–9. doi: 10.1136/jramc-149-04-02. PubMed DOI

Ishii Y, Ushida T, Tateishi T, Shimojo H, Miyanaga Y. Effects of different exposures of hyperbaric oxygen on ligament healing in rats. J Orthop Res. 2002;20:353–6. doi: 10.1016/S0736-0266(01)00094-8. PubMed DOI

Zamboni WA, Brown RE, Roth AC, Mathur A, Stephenson LL. Functional evaluation of peripheral-nerve repair and the effect of hyperbaric oxygen. J Reconstr Microsurg. 1995;11:27–9. doi: 10.1055/s-2007-1006507. PubMed DOI

Zhao DW. Therapeutic effect of hyperbaric oxygen on recovery of surgically repaired peripheral nerve injury. Zhonghua Wai Ke Za Zhi. 1991;29:118–120,143. PubMed

Strauss MB. The roles of hyperbaric oxygen in crush injury and other acute traumatic ischemias. In: Whelan HK Kindwall EP, editors. Hyperbaric medicine practice, 4th. North Palm Beach: Best Publishing; 2017.

Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial. J Trauma. 1996;42(2):333–39. doi: 10.1097/00005373-199608000-00023. PubMed DOI

Lindstrom T, Gullichsen E, Lertola K, Niinikoski J. Effects of hyperbaric oxygen therapy on perfusion parameters and transcutaneous oxygen measurements in patients with intramedullary nailed tibial shaft fractures. Undersea Hyperb Med. 1998;25:87–91. PubMed

Bennett MH, Stanford R, Turner R. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union. Cochrane Database Syst Rev. 2005;(1):CD004712. doi: 10.1002/14651858.CD004712.pub2. PubMed DOI

Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24:742–6. doi: 10.1097/00005373-198408000-00009. PubMed DOI

Court-Brown CM. The epidemiology of fractures. In: Rockwood CA Bucholz CM, editors. Rockwood and Green’s fractures in adults, 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2010. p. 18- 22.

Lua J, Tan VH, Sivasubramanian H, Kwek E. Complications of open tibial fracture management: risk factors and treatment. Malays Orthop J. 2017;11:18–22. doi: 10.5704/MOJ.1703.006. PubMed DOI PMC

Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatut L, Simon P, et al. Distal tibia fractures: management and complications of 101 cases. Int Orthop. 2010;34:583–8. doi: 10.1007/s00264-009-0832-z. PubMed DOI PMC

Harris AM, Althausen PL, Kellam J, Bosse M, Castillo R. Lower Extremity Assessment Project (LEAP) Study Group. Complications following limb-threatening lower extremity trauma. J Orthop Trauma. 2009;23:1–6. doi: 10.1097/BOT.0b013e31818e43dd. PubMed DOI

Thom SR. Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg. 2011;127(Suppl 1):131S–141S. doi: 10.1097/PRS.0b013e3181fbe2bf. PubMed DOI PMC

Strauss MB. Why hyperbaric oxygen therapy may be useful in treating crush injuries and skeletal muscle-compartment syndrome. Undersea Hyperb Med. 2012;39:799–800. PubMed

Cimsit M, Uzun G, Yildiz S. Hyperbaric oxygen therapy as an anti-infective agent. Expert Rev Anti Infect Ther. 2009;7:1015–26. doi: 10.1586/eri.09.76. PubMed DOI

Kaide CG, Khandelwal S. Hyperbaric oxygen: applications in infectious disease. Emerg Med Clin North Am. 2008;26:571–95, xi. doi: 10.1016/j.emc.2008.01.005. PubMed DOI

Rocha FS, Gomes Moura CC, Rocha Rodrigues DB, Zanetta-Barbosa D, Nakamura Hiraki KR, Dechichi P. Influence of hyperbaric oxygen on the initial stages of bone healing. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;120:581–7. doi: 10.1016/j.oooo.2015.06.039. PubMed DOI

Grassmann JP, Schneppendahl J, Hakimi AR, Herten M, Betsch M, Lögters TT, et al. Hyperbaric oxygen therapy improves angiogenesis and bone formation in critical sized diaphyseal defects. J Orthop Res. 2015;33:513–20. doi: 10.1002/jor.22805. PubMed DOI

Costa Maia MC, Camacho OF, Pinto Marques AF, Coelho PMB. Hyperbaric oxygen therapy treatment for the recovery of muscle injury induced in rats. Diving Hyperb Med. 2013;43:222–5. PubMed

Francis A, Baynosa RC. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care (New Rochelle). 2017;6:23–32. doi: 10.1089/wound.2016.0707. PubMed DOI PMC

Lerche CJ, Christophersen LJ, Kolpen M, Nielsen PR, Trøstrup H, Thomsen K, et al. Hyperbaric oxygen therapy augments tobramycin efficacy in experimental Staphylococcus aureus endocarditis. Int J Antimicrob Agents. 2017;50:406–12. doi: 10.1016/j.ijantimicag.2017.04.025. PubMed DOI

Kolpen M, Mousavi N, Sams T, Bjarnsholt T, Ciofu O, Moser C, et al. Reinforcement of the bactericidal effect of ciprofloxacin on Pseudomonas aeruginosa biofilm by hyperbaric oxygen treatment. Int J Antimicrob Agents. 2016;47:163–7. doi: 10.1016/j.ijantimicag.2015.12.005. PubMed DOI

Millar IL, McGinnes RA, Williamson O, Lind F, Jansson K-A, Hajek M, et al. Hyperbaric oxygen in lower limb trauma (HOLLT); protocol for a randomised controlled trial. BMJ Open. 2015;5(6):e008381. doi: 10.1136/bmjopen-2015-008381. PubMed DOI PMC

Swiontkowski MF, Engelberg R, Martin DP, Agel J, et al. Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 1999;81:1245–60. doi: 10.2106/00004623-199909000-00006. PubMed DOI

Sox HC, Lewis RJ. Pragmatic trials: practical answers to “real world” questions. JAMA. 2016;316:1205–6. doi: 10.1001/jama.2016.11409. PubMed DOI

Roje Z, Roje Z, Eterović D, Druzijanić N, Petrićević A, Roje T, et al. Influence of adjuvant hyperbaric oxygen therapy on short-term complications during surgical reconstruction of upper and lower extremity war injuries: retrospective cohort study. Croat Med J. 2008;49:224–32. doi: 10.3325/cmj.2008.2.224. PubMed DOI PMC

Huang KC, Tsai YH, Hsu RW. Hyperbaric oxygen therapy facilitates surgery on complex open elbow injuries: preliminary results. J Shoulder Elbow Surg. 2007;16:454–60. doi: 10.1016/j.jse.2006.10.011. PubMed DOI

Yamada N, Toyoda I, Doi T, Kumada K, Kato H, Yoshida S, et al. Hyperbaric oxygenation therapy for crush injuries reduces the risk of complications: research report. Undersea Hyperb Med. 2014;41:283–9. PubMed

Chiang IH, Tzeng YS, Chang SC. Is hyperbaric oxygen therapy indispensable for saving mutilated hand injuries? Int Wound J. 2017; 14: 929- 36. 10.1111/iwj.12730 PubMed DOI PMC