Hyperbaric oxygen therapy for nonischemic diabetic ulcers: A systematic review

Diabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.     

Efficacy of Hyperbaric Oxygen Therapy in Diabetic Foot Ulcers Based on Wagner Classification

Diabetic foot ulcer is a common chronic complication of diabetes mellitus. In addition to conventional primary therapy, there are adjuvant therapy methods such as hyperbaric oxygen therapy for the healing of diabetic foot ulcer wounds. The present study aimed to determine the efficacy of hyperbaric oxygen therapy in diabetic foot ulcers based on Wagner classification. It was performed retrospectively from prospectively collected data. One hundred thirty patients with diabetic foot ulcers were assessed in 2 groups: 1 group received hyperbaric oxygen therapy; the other group did not. Patients were examined according to age, sex, ulcer grade based on Wagner classification; ulcer healing status; whether hyperbaric oxygen therapy was received; duration of diabetes in years; HbA1C, sedimentation, C-reactive protein levels; and presence of accompanying diseases, including peripheral arterial disease, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, neuropathy, and retinopathy. The mean follow-up period was 19.5?±?4.45 months (range 12 to 28 months). Seventy-one (54.6%) patients received hyperbaric oxygen therapy, and 59 (45.4%) patients did not. All patients in Wagner grade 2 healed in both groups. In the group that received hyperbaric oxygen therapy for grade 3 and 4 patients, 35 (87.5%) and 11 (84.6%) healed, respectively. In total, 60 (84.5%) patients in the group that received hyperbaric oxygen therapy healed. The subgroup comparison conducted according to Wagner classification revealed no differences between the 2 groups of grades 2 and 5 patients. It also revealed that treatment had higher levels of efficacy in the healing of ulcers in grade 3 and 4 patients.     

Bone allograft contamination in multiorgan and tissue donors

Fifty patients with chronic diabetic foot ulcers in whom conventional therapy had failed were treated with topical hyperbaric oxygen alone (15 patients) or in combination with a low energy laser (35 patients). Eleven of these patients were treated on an ambulatory basis with topical hyperbaric oxygen. The mean time the ulcer was present before therapy was 9 ± 6.6 months. The mean number of treatments was 25 ± 13, and the mean duration of therapy was 3 ± 1.8 months. Forty-three of the 50 patients were cured. No adverse reactions were noted. Our impression is that topical hyperbaric oxygen alone or in combination with a low power laser are valuable adjuvants to conventional therapy for diabetic foot ulcers. Received: 3 January 1997     

Treatment of diabetic foot ulcers with hyperbaric oxygen

The delivery of oxygen to the wound site is crucial in healing diabetic foot ulcers, and impairment of this process in people with diabetes leads to delayed wound repair. Hyperbaric oxygen therapy works by elevating the plasma oxygen level. Fibroblasts synthesise and modify collagen, and both these activities require relatively high partial pressures of oxygen. Hyperbaric oxygen can promote healing by stimulating fibroblast activity and collagen formation. Increasing oxygen tensions also has a direct and toxic effect on anaerobes, therefore hyperbaric oxygen therapy has a special role in treating diabetic foot infections. Studies on hyperbaric oxygen therapy in general show it to be a beneficial adjunctive therapy for diabetic foot ulcers. However much of the work is anecdotal and more controlled trials are required.     

Prevention and treatment of diabetic foot wounds

The diabetic foot ulcer is one of the most common and devastating complications of diabetes mellitus. These ulcers account for most of the hospital admissions for patients with diabetes, and they represent a common precursor for amputation. When a diabetic foot ulcer becomes infected, gangrene and amputation can follow in rapid succession. Recent reviews concerning diabetic foot lesions and amputations have stressed the magnitude and importance of aggressive management. This management is complicated, and typically requires radical débridement, appropriate antibiotics, non-weight-bearing, and vascular surgery when indicated. A variety of adjunctive therapy can be helpful, including hyperbaric oxygen and topical growth factors. The most important step in preventing ulceration of the foot is patient education in foot care.     

Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy?

Although hyperbaric oxygen therapy has been used for diabetic foot ulcer since the 1980s, there is little information on its efficacy. The aim of this study is to evaluate whether hyperbaric oxygen can decrease major amputation rates and to determine the predictive factors. A total of 184 consecutive patients were treated with hyperbaric oxygen therapy as an adjunct to standard treatment modalities for their diabetic foot ulcer. Of these patients, 115 were completely healed, 31 showed no improvement and 38 underwent amputation. Of the amputations, nine (4.9%) were major amputations (below knee) and 29 were minor. Major amputations were associated with the Wagner grade (p < 0.0001), with the age of the patients (p = 0.028) and with the age of the wounds (p = 0.018). Hyperbaric oxygen therapy can help to reduce the major amputation rates in diabetic foot ulcer. However, further large, multicentre, randomised controlled studies are needed to make more accurate conclusions.     

Hyperbaric oxygen therapy of diabetic foot ulcers, transcutaneous oxymetry in clinical decision making

The foot ulcer is one of most common and devastating complications of diabetes and is associated with considerable morbidity and mortality. The major causes of these ulcers are ischemia/hypoxia, neuropathy, and infection, and they often coexist. Despite conventional therapy including revascularization procedures when appropriate, three situations lead frequently to amputation: persistent critical limb ischemia, soft tissue infection, and impaired wound healing from osteomyelitis. In these conditions, hyperbaric oxygen therapy may be used as an adjunctive treatment and is associated with a better outcome. Randomized, prospective, controlled trails have shown the benefit of hyperbaric oxygen therapy in diabetic ulcers of the lower extremity. Transcutaneous oxygen measurement performed under hyperbaric oxygen therapy has a prognostic significance when used to select patients who are the most likely to benefit from therapy. Hyperbaric oxygen should be added to conventional treatment if the transcutaneous oxygen tension close to the trophic lesion in 2.5 ATA hyperbaric oxygen is over 200 mmHg. Peri-wound transcutaneous oxygen tensions over 400 mmHg in 2.5 ATA hyperbaric oxygen or over 50 mmHg in normobaric pure oxygen predict healing success with adjuncted hyperbaric oxygen therapy with high accuracy.     

A prospective study: hyperbaric oxygen therapy in diabetics with chronic foot ulcers

Research suggests that hyperbaric oxygen therapy may have beneficial effects on ulcer healing and amputation rates in diabetic patients. This paper describes the design of a study that is evaluating its effects on chronic diabetic foot ulcers.     

Hyperbaric oxygen in the treatment of a diabetic foot ulcer

Although simultaneous pancreas and kidney transplant improves most complications of type 1 diabetes, suppression of the immune system increases the risk for infection. The authors report the case of a patient who, despite receiving a simultaneous pancreas and kidney transplant, subsequently developed neuro-ischemic ulcers of his right foot requiring repeated amputations. He then developed an infected ulcer of his remaining right big toe, with significant implications for his mobility. This ulcer proved resistant to multiple courses of antibiotics and care in a specialist foot clinic but resolved completely following a course of hyperbaric oxygen therapy. The role of hyperbaric oxygen in diabetic foot ulcers is not yet fully established but should be considered in resistant cases with vascular insufficiency and a significant infective component.     

负压创面治疗联合高压氧治疗糖尿病足的临床疗效

目的 探讨负压创面治疗联合高压氧治疗糖尿病足的临床疗效.方法 采用回顾性病例对照研究分析江苏大学附属人民医院整形烧伤科自2013年2月至2017年12月收治的46例糖尿病足患者的临床资料,根据治疗方法分为对照组(24例)和联合治疗组(22例).糖尿病足创面按Wagner分级为3～5级;共46足.对照组采用控制血糖、抗感...     

Intralesional allogeneic adipose-derived stem cells application in chronic diabetic foot ulcer: Phase I/2 safety study

BackgroundImpaired wound healing is a major cause of morbidity in diabetic patients by causing chronic ulcers. This study aimed to investigate the safety and outcomes after intralesional allogeneic adipose-derived mesenchymal stem cells injection in chronic diabetic foot ulcers.MethodsTwenty patients (12 male and eight female) were involved in the study. We randomized the patients into two groups of 10 patients each. The study group was treated with allogeneic adipose-derived mesenchymal stem cells injection with standard diabetic wound care. The control group received only standard diabetic wound care. Patient demographics, wound characteristics, wound closure time, amputation rates and clinical scores were evaluated.ResultsThe mean age was 57.3 ± 6.6 years. The mean follow-up duration was 48.0 (range, 26–50) months. Wound closure was achieved in 17 of 20 lesions (study group, 9 lesions; control group, 8 lesions; respectively). The mean time to wound closure was 31.0 ± 10.7 (range, 22–55) days in the study group, 54.8 + 15.0 (range, 30–78) days in the control group (p = 0.002). In three patients, minor amputations were performed (one patient in study group; two patients in the control group, p = 0.531). There was a significant difference between groups in terms of postoperative Short Form 36- physical functioning (p = 0.017) and Short Form 36-general health (p = 0.010).ConclusionAllogeneic adipose-derived mesenchymal stem cells injection was found to be a safe and effective method with a positive contribution to wound-healing time in the treatment of chronic diabetic foot ulcers.     

The diabetic foot seen by the surgeon. Personal experience

BACKGROUND: The aim of this study is to evaluate a major amputation risk criterion in diabetic patients with trophic lesions of the foot. The records of a series of 100 consecutive patients (65 males and 35 females) with diabetic foot ulcer treated in our surgical facilities between January 1992 and December 1997, in collaboration with diabetologists and podiatrists, have been reviewed retrospectively. METHODS: In 26 cases the ulcer involved both limbs and, therefore, the feet observed in this study have been 126. Accurate diagnosis of the underlying cause was the first step and in cases with a poor blood supply (69 limbs; 55%) unresponsive to medical therapy (44 limbs) vascular reconstruction (37 limbs), spinal cord stimulator (SCS) implantation (3 limbs) or major amputation (4 limbs) were performed. According to Wagner grading there were 42 grade 2 ulcers (33%), 38 grade 3 (30%), 43 grade 4 (34%) ad 3 grade 5 (3%). RESULTS: One patient died postoperatively after SCS implantation. All but 4 neuropathic ulcers (53 limbs) healed in a mean time (+/- SD) of 5.2 +/- 3.8 months and all but 10 vascular ulcers (59 limbs) healed in a mean time of 6.3 +/- 4.1 months. Of the latter group in 4 cases the patient died before ulcer healing while in 6 cases (8.7%) a major amputation was performed (in 2 cases after vascular reconstruction procedures). Minor amputations of the forefoot have been performed in 23 instances (33%) of vascular ulcer and in 10 cases (17%) of neuropathic ulcer. CONCLUSIONS: Since ischemia is the main risk factor for amputation, it is suggested that a particular effort should be made in improving the vascular diagnostic, both clinical and strumental, capabilities of our diabetologists and podiatrists in order to detect the vascular insufficiency in earlier stages.     

A systematic review and meta-analysis of hyperbaric oxygen therapy for diabetic foot ulcers with arterial insufficiency

BackgroundDiabetic foot ulcers (DFUs) are frequently associated with peripheral arterial occlusive disease (PAOD) and may ultimately lead to amputations of the lower extremity. Adjuvant hyperbaric oxygen treatment (HBOT) might foster better wound healing and lower amputation rates in patients with DFU and PAOD. A systematic review was conducted to assess the effects of HBOT as an adjunctive therapy to standard treatment for patients with DFUs with PAOD.MethodsSystematic review using the MEDLINE, EMBASE, and Cochrane CENTRAL databases (from inception to October 2018). All original, comparative studies on the effect of HBOT on DFUs with PAOD were eligible. The primary outcome measures were amputation rate, amputation-free survival, complete ulcer healing, and mortality.ResultsEleven studies, totaling 729 patients, were included for analysis, including 7 randomized clinical trials, 2 controlled clinical trials, and 2 retrospective cohorts. Four were used for quantitative synthesis. Meta-analysis showed a significantly fewer major amputations in the HBOT group (10.7% vs 26.0%; risk difference, −15%; 95% confidence interval [CI], −25 to −6; P = .002; number needed to treat, 7; 95% CI, 4-20). No difference was found for minor amputations (risk difference, 8%; 95% CI, −13 to 30; P = .46). Three studies reporting on complete wound healing showed contrasting results. No significant difference was found for mortality or amputation-free survival.ConclusionsCurrent evidence shows that adjuvant HBOT improves major amputation rate, but not wound healing, in patients with DFUs and PAOD. Given the wide range of patients included in the trials, better patient selection may help define which patients with DFUs and PAOD benefit most from HBOT as standard adjunctive treatment.     

Clinical research on the bio‐debridement effect of maggot therapy for treatment of chronically infected lesions

Objective: To evaluate the bio‐debridement effect of maggot therapy for treating chronically infected lesions. Methods: A retrospective study was conducted of 25 patients with diabetic foot ulcers and 18 patients with pressure ulcers after spinal cord injury treated by maggot therapy or traditional dressing. Changes in the lesions were observed and bacterial cultures tested. Results: All ulcers healed completely. The times taken to achieve bacterial negativity, granulation and healing of lesions were all significantly shorter in the maggot therapy group than in the control group, both for diabetic foot ulcers (P < 0.05) and pressure ulcers (P < 0.05). Conclusion: Maggot therapy is a safe and effective method for treating chronically infected lesions.     

Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study

Non healing diabetic foot ulcers and the resulting potential amputations present significant costs to the health care system and reduce patient quality of life. The goal of diabetic foot ulcer treatment is to obtain wound closure as expeditiously as possible. The use of platelet-rich plasma (PRP) to enhance wound healing has increased dramatically over the last decade. However, controversies exist in the literature regarding the added benefit of this procedure. The aim of this study is to investigate the efficiency of platelet releasate on the healing of chronic diabetic ulcers in comparison with platelet-poor plasma (PPP). This study included 24 patients with chronic diabetic ulcers. They were systematically randomised into two groups: PRP group (n = 12) and PPP group (n = 12). The results showed that healing in PRP group was significantly faster (P < 0·005). PRP enhances healing of chronic diabetic foot ulcers.     

Dose-dependent hyperbaric oxygen stimulation of human fibroblast proliferation

Diabetic wounds are characterized by a prolonged wound healing process with insufficient formation of granulation tissue. Systemic hyperbaric oxygen therapy has been observed to improve the healing of these wounds. However, the mechanism(s) responsible for these findings are not yet fully elucidated. In the present study we have studied the in vitro effects of hyperbaric oxygen on proliferation of human fibroblasts from normal skin and from chronic foot ulcers in non-insulin-dependent diabetics. A 1-hour exposure to hyperbaric oxygen at oxygen pressures between 106 and 300 kPa (795 to 2250 mm Hg) increased the proliferation in both diabetic and normal fibroblasts. The stimulatory effect was dose-dependent, with a peak increase in cell proliferation at 250 kPa and 200 kPa for normal and diabetic cells, respectively. The effects were not due to hydrostatic pressure per se. These results suggest that hyperbaric oxygen could stimulate fibroblast activity in the diabetic wound, a finding that could explain the enhanced formation of granulation tissue seen clinically in wounds treated with hyperbaric oxygen. We also speculate that mechanisms other than just increased oxygen availability may be responsible for our findings.     

Diabetic foot ulcers treated with hyperbaric oxygen therapy: a review of the literature

Hyperbaric oxygen therapy (HBO) has been used as an adjunct for healing diabetic foot ulcers (DFUs) for decades. However, its use remains controversial. A literature search was conducted to locate clinical studies and assess the available evidence. Ten prospective and seven retrospective studies evaluating HBO for DFUs were located. These were reviewed and the outcomes were discussed. One study reported no difference in outcomes between patients receiving hyperbaric oxygen and the control group. However, their regime differed from all other studies in that the patients received hyperbaric oxygen twice rather than once daily. Reduced amputation rates and improved healing were the most common outcomes observed.     

Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions,Reamputations, and Complications

AimsThe optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations.MethodsData were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients.ResultsMajor amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively.ConclusionsAlthough short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.     

Zehenamputation und Strahlresektion

BackgroundAlthough toe amputation and ray resection are suitable for the treatment of many pathologies, diabetic foot syndrome is the main cause for these amputations. In recent years there has been an increase in minor amputations compared to major amputations. By avoiding or turning away from major amputations, the minor amputations of the foot and their procedures have become the focus of surgical attention.Material and MethodsThe aim of this overview is to present the surgical technique of toe amputation and ray resection and its results in the current literature.ConclusionsToe amputations and ray resections are safe minor amputation procedures for many indications and offer quick weight bearing postoperatively. Despite good primary healing rates, interdisciplinary perioperative treatment in diabetic patients is substantial to keep re-amputation and mortality rates low.     

A retrospective study of diabetic foot ulcers treated with hyperbaric oxygen therapy

A retrospective review of patient medical records was conducted to assess what factors influence the outcomes of diabetic foot ulcers treated with hyperbaric oxygen (HBO) therapy. Patients referred to the Diving Diseases Research Centre for HBO therapy for the treatment of diabetic foot ulcers during a 2‐year period were included in this study. Data collected from 30 sets of patient records were entered into SPSS and statistical analysis was undertaken to investigate whether any underlying pathologies or confounding factors appeared to influence patient outcome. A 73·3% of patients achieved a successful outcome of partial healing, major amputation no longer required, amputation level lower than anticipated prior to HBO or healing at the end of HBO therapy and 70% remained successful 3 months later. A 13·3% of patients were lost to follow‐up at 3 months and one patient (3·3%) had a major amputation. Steroid therapy, peripheral vascular disease, previous minor amputation, type of diabetes, previous HBO therapy, larvae therapy, the use of interactive dressings and haemoglobin A1c levels were all observed to have had a significant relationship with patient outcome (P < 0·05). These results were compared with data from other published research conducted in this area on similar patient groups. A larger scale study focussing on the factors found to be significant in this study is recommended. An improvement of patient documentation would allow patient outcomes to be more consistently monitored in the future.