Influence of Adjuvant Hyperbaric Oxygen Therapy on Short-term Complications During Surgical Reconstruction of Upper and Lower Extremity War Injuries: Retrospective Cohort Study

Abstract

Cilj Odrediti utjecaj liječenja hiperbaričnom oksigenacijom (HBO) na kratkoročne komplikacije složenih ratnih ozljeda gornjih i donjih udova u ranjenika koji su bili i koji nisu bili liječeni u skladu s kirurškom strategijom Organizacije Sjeverno-atlantskog sporazuma (NATO). Postupci Retrospektivno smo analizirali podatke o kohorti 388 muških bolesnika na kojima je izveden rekonstruktivni kirurški zahvat ratnih ozljeda Gustilo tipa III A, B i C na udovima na Odjelu za rekonstruktivnu kirurgiju Sveučilišne bolnice u Splitu u razdoblju između 1991. i 1995. godine. Analizirani su pojava glavnih komplikacija ozljeda (duboka infekcija, osteomijelitis, liza kožnog presadka i nekroza tkivnoga presatka) za vrijeme hopitalizacije, te vrijeme od ranjavanja do stvaranja granulacijskog tkiva s obzirom na korištenje HBO liječenja kao rizičnog čimbenika. Izračunat je omjer izgleda (OR) s 95% rasponom pouzdanosti (CI) za pojavu komplikacija uzimajući u obzir adjuvantno liječenje HBO, a on je potom logističkom regresijom prilagođen s obzirom na kiruršku strategiju NATO-a. Rezultati Od 388 bolesnika, 310 (80%) su liječeni u skladu s kirurškom strategijom NATO-a, a 99 (25%) ih je primilo adjuvantnu HBO. Duboka infekcija mekog tkiva razvila se u 196 (68%) bolesnika koji nisu primili HBO i u 35 (35%) koji su je primili (P<0.001). Osteomijelitis se razvio u 214 (74%) bolesnika koji nisu primili HBO i u 62 (63%) bolesnika koji su je primili (P=0.030). Liza kožnog presadka pojavila se u 151 (52%) bolesnika koji nije primio liječenje s pomoću HBO i u 23 (23%) bolesnika koji su ga primili (P<0.001, χ2 test). Nekroza tkivnoga presatka pojavila se u 147 (51%) bolesnika koji nije primio HBO i u 15 (15%) koji su je primili (P<0.001). Medijan vremena do stvaranja granulacijskog tkiva bio je 9 (5-57) dana u bolesnika koji su primili adjuvantno liječenje HBO i 12 (1-12) dana u bolesnika koji ga nisu primili (P<0.001, Mann-Whitney test). Rezultati su ostali dosljedni i u skupinama bolesnika stratificiranim prema stupnju ozbiljnosti ozljede i nisu se promijenili ni nakon prilagođavanja s obzirom na kiruršku strategiju NATO-a. Utjecaj adjuvantnog liječenja s pomoću HBO bio je veći u bolesnika koji su razvili duboku infekciju mekog tkiva a nisu bili liječeni u skladu s NATO strategijom (OR, 10.7 vs OR, 3.8; P=0.031 za interakciju). Zaključak Adjuvantno liječenje s pomoću HBO smanjilo je učestalost komplikacija ozljeda u ranjenika s ozljedama Gustilo tipa III i skratilo je vrijeme do stvaranja granulacijskog tkiva. U ranjenika koji nisu bili liječeni u skladu s doktrinom NATO-a HBO se pokazala važnijom u za sprječavanje duboke infekcije mekog tkiva, ali ne i nekroze tkivnog presatka.Aim To determine the effects of hyperbaric oxygen (HBO) therapy on shortterm complications of complex war wounds to the upper and lower extremities in patients who were and those who were not treated according to North Atlantic Treaty Organization (NATO) emergency war surgery recommendations. Method We retrospectively analyzed data of 388 male patients undergoing reconstructive surgery for Gustilo type III A, B, and C war wounds to the extremities at the Department of Reconstructive Surgery, Split University Hospital Center, between 1991 and 1995. The occurrence of main wound complications (deep infection, osteomyelitis, skin grafts lyses, and flap necrosis) during hospitalization and time from wounding to granulation formation were analyzed with respect to the use of HBO therapy as a risk factor. Odds ratio (OR) with 95% confidence intervals (CI) was calculated for the occurrence of wound complications with respect to HBO therapy and adjusted for NATO surgical strategy by logistic regression. Results Of 388 patients, 310 (80%) were initially treated according to the NATO surgical strategy and 99 (25%) received HBO therapy. Deep soft-tissue infection developed in 196 (68%) patients who did not receive HBO therapy and in 35 (35%) who received it (P<0.001, χ2 test). Osteomyelitis developed in 214 (74%) patients who did not receive HBO therapy and in 62 (63%) who received it (P = 0.030). Skin graft lysis occurred in 151 (52%) patients who did not receive HBO therapy and in 23 (23%) who received it (P<0.001). Flap necrosis occurred in 147 (51%) patients who did not receive HBO therapy and in 15 (15%) who received it (P<0.001). Median time to granulation formation was 9 (5-57) days in patients who received HBO therapy, and 12 (1-12) days in those who did not (P<0.001, Mann-Whitney test). These results were consistent over the groups of patients stratified according to the wound severity and remained unaltered after the adjustment for NATO surgical strategy. The effect of HBO therapy was greater in non-NATO than in NATO treated patients in case of deep soft-tissue infection (OR, 10.7 vs OR, 3.8; P = 0.031 for interaction). Conclusion HBO therapy reduced the frequency of wound complications in patients with Gustilo type III wounds and shortened the time to granulation formation. HBO therapy was more effective in non-NATO than in NATO treated patients for the prevention of deep soft-tissue infection but not flap necrosis