A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

By Kazu Suzuki, DPM, CWS; Clinical Editor: John S. Steinberg, DPM

What The Clinical Evidence Reveals

   Diabetic foot wounds are precursors to 85 percent of major leg amputations, which lead to increased morbidity and mortality rates rivaling that of many cancers.8 The medical, rehabilitation, social and emotional costs of major leg amputations are all enormous. The concept of “limb preservation” advocates best practice wound care and multidisciplinary team approaches, which are known to save “at-risk” limbs.    In 2005, Kranke, et al., systematically reviewed “HBO and chronic wounds” based on publications from 1966 to 2003, including five randomized controlled trials (RCT).9 This review came to the conclusion that HBO for diabetic foot ulcers “significantly reduced the risk of major amputation and may improve the chance of healing at one year.” The study also suggested that “the application of HBOT to these patients may be justified where HBOT facilities are available.” The analysis predicts surgeons avoided one major leg amputation per four patients treated via HBO.    In March 2007, a similar conclusion was published by the Canadian Agency for Drugs and Technology in Health with the report “Adjunctive HBOT for Diabetic Foot Ulcer.” In this report, adjunct HBO therapy in diabetic foot ulcer treatment was more effective and healed more wounds versus standard care (SC) alone, and subsequently lowered the incidence of major leg amputations (11 percent for the HBO group versus 32 percent for standard care).10 Moreover, this review calculates the economic benefit of avoiding major leg amputations, which translates to significantly lower treatment costs ($40,695 HBO versus $49,786 SC) and increased “quality of life years” (3.64 HBO versus 3.01 SC).

A Guide To Indications For HBO In Non-Diabetic Wounds

   Although the clinical evidence is less robust in these “non-diabetic wound” indications, HBO treatments are nonetheless effective and reimbursable by Medicare and most payors.     Refractory osteomyelitis. This condition, also called chronic osteomyelitis, is one of the hardest diseases to treat. It necessitates multiple surgical interventions, weeks of IV antibiotics and lifetime suppressive oral antibiotic therapies. Hyperbaric oxygen therapy is synergistic with many antibiotics and also has a direct suppressive effect on anaerobic organisms. Consequently, HBO can arrest infections in 60 to 85 percent of refractory osteomyelitis cases.4 The UHMS Oxygen Therapy Committee Report 2003 indicated AHA level II-b for this indication, based on cohort and case-controlled studies.1    Failed skin flaps and grafts. Hyperbaric oxygen therapy is helpful in wound bed granulation and is valuable in salvaging failed skin flaps and grafts by direct oxygenation. One can also utilize HBO for dehiscence after surgical closure of minor foot amputations (e.g. partial ray, TMA, etc.) treated as “failed flaps.” A comprehensive evidence-based review of HBO use on flaps and grafts by Friedman, et al., concludes that although more RCTs are desirable, there is “enough animal evidence and observational data to warrant the application of HBO in selective situations.”11    Arterial insufficiency ulcers. Medicare recently decided to reimburse HBO treatments for ischemic ulcers that failed to improve after revascularization procedures. Medicare stated that “Arterial insufficiency ulcers may be treated with HBO therapy if they are persistent after reconstruction surgery has resolved large vessel function.” This decision is limited to the Medicare Fiscal Intermediary of Florida and Ohio. However, this policy is expected to extend across the nation in the near future. The Wound Healing Society rates the literature on HBO treatment for arterial insufficiency ulcers as Evidence 1-b.12

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