Hyperbaric oxygen (HBO) therapy in treatment of diabetic foot ulcers: Long-term follow-up
Introduction
Nonhealing foot ulcer is a common and expensive complication in diabetic patients and may lead to amputation. Almost 50% of all amputations not due to trauma are performed in diabetic patients (Boulton, Connor, & Cavanagh, 1994). The three most common causes of amputations are ischemia, infection, and retarded wound healing Boulton et al., 1994, Larsson & Apelqvist, 1995. Retarded wound healing is related to impaired oxygenation of the skin as well as impaired cellular function secondary to hyperglycemia Boulton et al., 1994, Hehenberger, 1997, Kalani et al., 1999, Tooke, 1989 The processes involved in ulcer healing are increased oxygen demanding thus a sufficient supply of blood is of great importance. Disturbances both in the macro- and microcirculation may cause local relative ischemia leading to impaired oxygen supply to the ulcer area.
Treatment of diabetic foot ulcer includes improvement of microcirculation of the skin; that is treatment of edema, anemia, and off-loading. In patients with ischemia due to advanced arterial insufficiency, the prognosis is poor without vascular reconstruction or angioplasty Kalani et al., 1999, McNeely et al., 1995.
Hyperbaric oxygen (HBO) therapy is a medical treatment in which a patient breathes 100% oxygen (O2) inside a pressurized treatment chamber. It increases blood and tissue oxygen content in hypoxic tissues, which may help maintain cellular integrity and function. Intermittent HBO may help in salvaging marginally perfused tissues. It also improves (a) infection control due to enhanced mobility and bacteria-killing ability of leukocytes, (b) granulation tissue formation due to stimulation of fibroblast proliferation and collagen synthesis, and (c) microcirculation due to edema reduction and angiogenesis Hunt & Pai, 1972, Knighton et al., 1981. It is used to treat a variety of infected, hypoperfused, and hypoxic problem wounds including chronic diabetic foot ulcers (Cianci & Hunt, 1993) and selected cases of limb-threatening foot lesions with microvascular ischemia (Faglia et al., 1996).
The present study was undertaken to investigate the long-term effect of adjunctive HBO therapy in the treatment of chronic foot ulcers in diabetic patients with peripheral hypoxia.
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Research design and methods
Thirty-eight diabetic patients with chronic foot ulcers and local hypoxia were investigated from 1991 to 1995. Characteristics of the patients are shown in Table 1. Chronic foot ulcer and local ischemia were defined as ulcer duration >2 months and transcutaneous oxygen tension (tcPO2) <40 mmHg, respectively. The mean age was 60±13 years, and the diabetes duration was 27±14 years. All patients were investigated by angiography and evaluated by vascular surgeons. Because of the extensive distal
Results
Characteristics of the two groups of patients either treated with HBO (n=17), or conventionally (n=21), are shown in Table 1. The mean ulcer area at baseline was significantly greater in HBO group as compared to conventional group (1077±1528, 449±924 mm2, P=.03; Table 1). Type 1 diabetes was slightly more common in HBO group (65%) compared to the conventional group (43%) and the mean age of patients treated with HBO was significantly lower than the mean age of patients treated conventionally
Discussion
Our results are in agreement with other prospective randomized or comparative studies showing positive effects of adjunctive HBO therapy on ulcer healing and reduction of amputation rate in diabetic patients with chronic foot ulcer and local hypoxia.
Previously published controlled, prospective trials have focused on patients with diabetic foot infections and partial foot gangrene. Baroni et al. (1987) reported that 89% (16 of 18 patients) healed in the HBO group, whereas only 10% (1 of 10
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