A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds
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
When it comes to severe foot and ankle wounds, advanced wound care modalities, such as VAC therapy, skin substitutes and surgical reconstructions (flaps and grafts) are justified by clinical evidence as providing superior efficacy over conventional treatments. While HBO may appear “exotic,” this treatment is one of the safest and effective modalities for reducing major leg amputations from diabetic foot ulcers in statistically significant fashion.
Increasing incidences of diabetes and peripheral vascular disease, and growing Medicare/senior populations yield many patients who are candidates for HBO treatments. It is our duty to present this valuable adjunctive treatment to our patients as it has been proven to save limbs and lives.