Bone Fractures

Written By Elizabeth Gaffney

HBOT for Bone Fractures (Recovery Phase)

Introduction

Hyperbaric Oxygenation (HBO) is a form of therapy directed to significantly increase the partial pressure of oxygen in the blood and in the tissues of the patients to the levels significantly exceeding those achieved in normobaric
conditions. HBO has a potential role in enhancing the healing or broken bones and improving outcomes for patients with fractures. HBO enhances oxygen delivery to the affected tissues, promotes angiogenesis, reduces inflammation and supports tissue repair, and several studies and reports indicate that HBO may promote bone growth, accelerate healing and prevent complications in bone fractures.

Mechanisms of Action of HBOT

HBOT may benefit patients with fractures through several mechanisms, primarily by enhancing oxygen delivery to tissues, enhancing angiogenesis and accelerating healing (Cannellotto et al., 2024). Hyperbaric Oxygen Therapy (HBOT) consists of breathing oxygen at a pressure higher than local atmospheric pressure for the treatment or prevention of specific diseases. There is a general consensus that the term HBOT can only be applied when the partial pressure of oxygen in breathing mixture exceeds 1.5 absolute atmosphere (ATA) for a minimum period of 60 minutes (excluding compression and decompression) for multiple sessions.

1. Enhanced oxygenation: Healing relies on an adequate blood supply to the damaged site, but fractures may compromise local blood flow, leading to tissue hypoxia (Lu et al., 2008), which hinders the repair process (Dickson et al., 1995; Lu et al., 2007). HBOT increases the amount of dissolved oxygen in plasma, thus improving oxygen delivery to hypoxic tissue (Cannellotto et al., 2024). Hyperoxia increases tissue vascularisation, promotes fracture healing in uncomplicated fractures, and improves bone repair in ischemia-induced delayed fracture union (Lu et al., 2013), and thus HBOT may be beneficial when fractures are accompanied by ischaemia.

2. Angiogenesis: Angiogenesis is essential for healing fractures and HBOT stimulates blood vessel formation by promoting the release of angiogenic growth factors, such as VEGF and FGF (De Wolde et al., 2021). These growth factors encourage new blood vessel formation at the fracture site, supporting nutrient exchange and facilitating the delivery of cells essential for healing (Saran et al., 2014).

3. Stimulation of osteogenesis and bone remodelling: HBOT influences osteoblast and osteoclast activity and promotes bone mineralisation, facilitating the formation of new bone matrix (Wu et al., 2007; Al Hadi et al., 2015; Yu et al., 2022). In addition, HBOT increases collagen synthesis (Kawada et al., 2013; Al Hadi et al., 2015), an essential component of the extracellular matrix that provides structural support for new bone tissue.

4. Reduced inflammation and modulation of the immune response: Inflammation is a crucial part of the early stages of bone healing, but excessive or prolonged inflammation can be detrimental, leading to delayed healing or non-union (Loi et al., 2016). HBOT can modulate the inflammatory response by reducing levels of pro-inflammatory cytokines, such as TNF-α and IL-1β (De Wolde et al., 2021). Additionally, HBOT reduces oxidative stress and modulates the immune response, which helps to prevent further tissue damage at the fracture site.

Benefits of HBOT for Patients with Fractures

HBOT is generally well tolerated and serious side effects are rare (Camporesi, 2014; Zhang et al., 2023). For patients with fractures, HBOT offers several potential benefits, including accelerated healing times, pain relief, and a lower risk of complications. These benefits make HBOT an attractive option, particularly for patients with complex or non-healing fractures, as well as those with comorbidities that impair natural bone healing.

1. Accelerated healing times: HBOT as an adjunctive treatment in fracture management may shorten healing times. By enhancing oxygen availability, promoting angiogenesis, reducing inflammation, and stimulating osteogenesis, HBOT may support faster fracture healing (Kawada et al., 2013; Al Hadi et al., 2015; Yu et al., 2022). This accelerated recovery may be especially beneficial for individuals with slow or impaired healing of fractures, such as in smokers (Ueng et al., 1999; Castillo et al., 2005; Demirtaş et al., 2014).

2. Improved pain management: HBOT can reduce pain in several clinical scenarios (Sutherland et al., 2016) and hyperoxia can reduce reliance on drugs in orthopaedic conditions (Slade et al., 2016; Hallak et al, 2024). HBOT may help patients manage fracture-related pain and reduce the need for painkillers.

3. Reduced risk of complications: Fractures – particularly open fractures – are prone to infections such as osteomyelitis (Kortram et al., 2017). HBOT may reduce the risk of these complications by preventing bacterial growth (Memar et al., 2019) and supporting immune function (De Wolde et al., 2021). In particular, HBOT is beneficial in the treatment of refractory osteomyelitis (Savvidou et al., 2018; Hanley et al., 2022), For complex or infected fractures, HBOT’s antimicrobial effects may prevent the need for further surgical interventions or prolonged antibiotic use.

4. Enhanced healing in patients with comorbidities: Patients who smoke (Castillo et al., 2005) or with comorbidities such as diabetes (Chen et al., 2022), often experience delayed or incomplete bone healing (Marin et al., 2018). HBOT can be especially beneficial in these populations by compensating for the impaired oxygen delivery and compromised immune function associated with these conditions. In diabetic patients, HBOT improves healing outcomes (Goldman et al., 2009) by counteracting tissue hypoxia and enhancing immune cell function and may improve bone healing (Chen et al., 2022). HBOT may also ameliorate the negative effects of nicotine on fracture healing (Demirtaş et al., 2014).

Evidence Supporting HBOT of Fractures

Despite the latest Cochrane review on HBOT for promoting fracture healing concluding that there was insufficient evidence to support the effectiveness of HBOT for the management of bone fractures (Bennett et al., 2014), numerous studies support the therapeutic potential of HBOT in fracture management, although more large-scale, randomised controlled trials are necessary to establish definitive guidelines. HBOT is approved by the FDA for the treatment of crush injuries, which often include fractures.

1. Preclinical animal studies: Many studies have reported the benefits of HBOT for bone fracture healing in several animal models, including mice (Kawada et al., 2013), rats (Kuskucu et al., 2004; Demirtaş et al., 2014), rabbits (Ueng et al., 1998; Ueng et al., 1999; Chen et al., 2017; Yu et al., 2022) and cats (Kerwin et al., 2000). Benefits of HBOT include accelerated healing, increased bone mineral density and improved incorporation of bone grafts.

2. HBOT for crush injuries: HBOT for crush injuries, which often involve bone fractures, is approved by the FDA and The Undersea and Hyperbaric Medical Society (UHMS). A number of reviews have highlighted the efficacy of HBOT in treating crush injuries associated with factures (Myers, 2000; Buettner & Wolkenhauer, 2007). In a systematic review of nine studies involving 150 patients, many of whom had fractures, who underwent HBOT as an adjunct treatment for acute traumatic ischemia and crush injury, eight of the studies showed that HBOT (100% O2, 2–3 ATA, 60–120 mins, ~12 sessions on average) could be beneficial if administered early (Garcia-Covarrubias, 2005). In the latest review, HBOT was recommended for the treatment of crush injuries with open fractures (Aydın & Kaya, 2024).

3. HBOT for osteomyelitis and infected fractures: The UHMS has published guidelines for HBOT (≥2 ATA) for refractory osteomyelitis and HBOT is recognised by the US FDA for the treatment of severe bone infections. A systematic review of the literature by Savvidou et al. (2018) included 45 studies and showed that overall, 73.5% of patients had a successful outcome and no reported relapse following HBOT. Another review (Hart, 2021) concluded that adjunctive HBOT (100% O2, 2–3 ATA, 90–120 mins, 20–40 daily sessions) combined with antibiotics and surgical debridement improved infection resolution rates. For example, patients with bacterial spinal osteomyelitis together with significant comorbidities and risk factors for poor healing were treated with 30 daily sessions of HBOT (100% O2, 2 ATA, 90 mins), which cured the infection in five out of six patients (Ahmed et al., 2009). Other studies have shown similar results, particularly in immune-compromised patients (Delasotta et al., 2013; Rendina, 2018), and in patients with infected tibial non-union fractures (Komurco et al., 2002).

3. Prevention of complications following fracture: HBOT may be beneficial in helping to prevent complications of bone fractures, including avascular necrosis in displaced talar neck fractures (Mei-Dan et al., 2008) and rates of infection in intra-articular calcaneal fractures (Xu et al., 2014).

Conclusion

HBOT is a promising adjunctive treatment for fractures, particularly in cases involving infection or in patients with comorbidities. By enhancing oxygen delivery, promoting angiogenesis, modulating inflammation, and stimulating bone formation, HBOT may support faster and more effective fracture healing. Animal studies and clinical evidence suggest that HBOT may improve outcomes in patients with compromised healing and reduce the risk of complications in infected fractures. HBOT is a safe and potentially valuable tool in the management of fractures, providing benefits that could improve recovery times and patient outcomes.

References

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Elizabeth Gaffney https://www.sourceprojects.co
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