INVITED COMMENTARY Discussion of ‘‘Effects of hyperbaric oxygen on the replanted extremity subjected to prolonged warm ischemia’’ M. Felix Freshwater Division of Plastic Surgery, University of Miami School of Medicine, 9100 S Dadeland Blvd Ste 502, Miami, FL 33156-7815, USA Received 20 January 2009; accepted 4 February 2009 The authors are to be commended for developing an animal model for evaluating the potential value of hyperbaric oxygen (HBO). However, more work must be done before we ask our hospitals to purchase HBO chambers. Two prongs are necessary for the introduction of any new therapy: efficacy and safety. At first glance, it appears that HBO was efficacious in salvaging more limbs subjected to prolonged warm ischemia times than controls. However, Table 1 shows that the control limbs were done prior to the HBO limbs. Hence, there is the possibility that an error due to the learning curve of performing rat limb replants may have been introduced. I hope that the authors will use their model and perform a randomized study. Clinicians know that limb replantation has major consequences including fluid loss, edema and acidosis. We typically treat these effects with fluid replacement, limb elevation and fasciotomies. Thus, the possibility exists that the effects of HBO were a substitute for these other modalities that we routinely use for major limb replantation and that if both groups of rats had received these modalities there would have been no difference in limb survival. More disturbing are the following facts: the control group of 11 rats had no deaths while the HBO group had 3 out of 12 rats die e a 25% postoperative mortality rate! (chi-square analysis with 1 degree of freedom: Pearson’sZ 4.439, pZ 0.0351) Clearly, this mortality rate is unacceptable. We must learn if we can deliver HBO with no additional mortality compared to a control group while yielding statistically significantly improved limb survival. DOI of original article: 10.1016/j.bjps.2008.12.027. E-mail address: [email protected] 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.02.051 Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 538

Discussion of “Effects of hyperbaric oxygen on the replanted extremity subjected to prolonged warm ischemia”

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Page 1: Discussion of “Effects of hyperbaric oxygen on the replanted extremity subjected to prolonged warm ischemia”

Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 538

INVITED COMMENTARY

Discussion of ‘‘Effects of hyperbaric oxygenon the replanted extremity subjectedto prolonged warm ischemia’’

M. Felix Freshwater

Division of Plastic Surgery, University of Miami School of Medicine, 9100 S Dadeland Blvd Ste 502,Miami, FL 33156-7815, USA

Received 20 January 2009; accepted 4 February 2009

The authors are to be commended for developing an animalmodel for evaluating the potential value of hyperbaricoxygen (HBO). However, more work must be done beforewe ask our hospitals to purchase HBO chambers.

Two prongs are necessary for the introduction of anynew therapy: efficacy and safety. At first glance, it appearsthat HBO was efficacious in salvaging more limbs subjectedto prolonged warm ischemia times than controls. However,Table 1 shows that the control limbs were done prior to theHBO limbs. Hence, there is the possibility that an error dueto the learning curve of performing rat limb replants mayhave been introduced. I hope that the authors will use theirmodel and perform a randomized study. Clinicians knowthat limb replantation has major consequences includingfluid loss, edema and acidosis. We typically treat these

DOI of original article: 10.1016/j.bjps.2008.12.027.E-mail address: [email protected]

1748-6815/$-seefrontmatterª2009BritishAssociationofPlastic,Reconstrucdoi:10.1016/j.bjps.2009.02.051

effects with fluid replacement, limb elevation andfasciotomies. Thus, the possibility exists that the effects ofHBO were a substitute for these other modalities that weroutinely use for major limb replantation and that if bothgroups of rats had received these modalities there wouldhave been no difference in limb survival.

More disturbing are the following facts: the controlgroup of 11 rats had no deaths while the HBO grouphad 3 out of 12 rats die e a 25% postoperative mortalityrate! (chi-square analysis with 1 degree of freedom:Pearson’sZ 4.439, pZ 0.0351) Clearly, this mortality rateis unacceptable. We must learn if we can deliver HBOwith no additional mortality compared to a control groupwhile yielding statistically significantly improved limbsurvival.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

mailto:[email protected]