Diabetic Wounds of the Lower Extremity and Hyperbaric Oxygen
Many patients with diabetes develop skin ulcers on the feet. The wounds are most often found by the sole of the foot and around the heel. Bacteria can cause an infection through small cracks (fissures) that can develop in the dry skin around the heel and on other parts of the foot. The fissures also can occur through corns, calluses, blisters, hangnails, or ulcers. If left untreated, the bacterial infection can destroy skin, tissue, and bone and can even spread throughout the body.
These non-healing wounds result from the inflammation and degeneration of peripheral nerves which can be a complication of diabetes. If the foot wound is not treated properly, hospitalization and possibly amputation could result by allowing anaerobic organisms to flourish. For patients with diabetes with accelerated atherosclerosis (hardening of the arteries), their resistance to infection is reduced and the lower extremity amputation rate is increased.
Most hyperbaric oxygen treatment is used as an adjunctive therapy in the management of diabetes complications, particularly diabetic foot ulcers that often result in amputation of toes, feet, or legs. Early, aggressive wound care strategies, combined with hyperbaric oxygen therapy treatment, can prevent osteomyelitis (inflammation of bone) and amputations and help improve the quality of life for patients with diabetes.
Referral Protocol: Refer at 30 days when the diabetic wound has not shown significant progress with conventional treatment:
- Wound is classified as Wagner Grade III or higher (defined as penetrating deeper layers reaching tendon, bone or joint capsule with abscess, osteomyelitis or tendonitis extending to those structures)
- Patient has failed adequate course of standard wound therapy (30 days of assessment and correction of vascular abnormalities, optimization of nutritional status and glucose control, debridement, moist wound dressing, off-loading, and treatment of infection)
Hyperbaric oxygen therapy delivered at HyOx works to improve and heal the hypoxic areas through a significant increase in oxygen to the tissues. The elevation in oxygen tension in ischemic (restricted in blood supply) and infected wound tissue induces healing by enhancing fibroblast (a cell in connective tissue which produces collagen and other fibers) replication, collagen synthesis and the neovascularization (natural formation of new blood vessels) process. It works best as an adjunctive therapy to multi-disciplinary wound care.
Chronic, Non-Healing Wounds
When wounds don’t respond to traditional medical and surgical care methods, hyperbaric oxygen therapy is a scientifically proven adjunct therapy used to expedite the healing process. Problem wounds have poor blood flow and are often infected. Contributing factors are a patient’s age, nutrition, radiation damage, smoking, and medical conditions such as diabetes, kidney disease or immune diseases.
Many non-healing wounds result from vascular insufficiency ulcers, complications from diabetes, radiation necrosis, soft tissue infections, compromised amputation sites, bone infection (refractory osteomyelitis), and traumatic wounds from crush injuries. Where there is hypoxia (inadequate blood flow), the ability for a wound to heal is halted by reduced fibroblast and collagen production and capillary growth. It also creates the ideal environment for infection by impairing the leukocytes (white blood cells) from killing bacteria.
- At the time of biopsy or debridement of necrotizing soft tissue infections like necrotizing fasciitis when the fascia is necrotic with reduced tissue oxygen saturation.
- When chronic refractory osteomyelitis are not responding to a four to six week course of antibiotics and surgical debridement (Cierny-Mader system Stage 3 and 4)
Hyperbaric oxygen therapy delivered at HyOx works to make collagen, help the white blood cells fight off infection and promote fibroblast (wound healing cells) and new blood vessel growth. Treatment duration depends on the severity of the wound. Wounds respond best to hyperbaric oxygen therapy when they’ve become acutely or chronically compromised by hypoxia (lack of oxygen) and infection.
Compromised Skin Grafts and Flaps
Skin grafting is a surgical procedure to place skin or skin substitute over a burn or non-healing wound to permanently replace damaged or missing skin or provide a temporary wound dressing. Sometimes these grafts fail (or become compromised) due to poor blood flow, swelling, or infection.
Hyperbaric oxygen therapy is an extremely effective therapy for tissues affected by a burn, radiation therapy, or in patients with decreased perfusion or hypoxia. Some skin grafts (from a severe burn) or flaps (a graft which is moved and reattached along with the blood vessel that supplies it) may have trouble healing from swelling or poor blood flow.
Referral Protocol: Immediately, when post-surgical or amputation site shows signs of dehiscence, necrosis, blistering, erythema, and/or infection.
Hyperbaric oxygen therapy delivered at HyOx works to maximize the viability of the compromised tissue, make collagen and reduce the need for re-grafting and repeat flap procedures. The treatment prepares a vascular and cellular tissue within the radiated wound to enable a surgeon to successfully remove damaged tissue or foreign objects from and later reconstruct the wound.
Benefits of Hyperbaric Oxygen Therapy for Problem Wounds
- Accelerates healing of chronic wounds by maximizing oxygen delivery through the blood’s plasma to encourage growth of new blood vessels (angiogenesis) in oxygen-deprived tissue – normal steps to wound healing are impaired due to inadequate perfusion and oxygen availability
- Improves edema and reduces infection for wound healing
- Boosts the outcomes of diabetic foot ulcers when treated at four weeks – the standard of care for advanced healing and the marker for reassessing wound healing progress and commencing covered and effective advanced wound healing methods (1)
- Promotes fibroblast, collagen disposition, angiogenesis (2) , resistance to infection (3) and intracellular leukocyte bacterial killing – all oxygen sensitive responses essential to normal wound healing
- Promotes tissue growth for wound healing by stimulating vascular endothelial growth factor and increased granulation tissue formation and wound closure (4)
- Decreases the risk of amputation in patients with ischemic, infected, Wagner Grade III or worse diabetic lower extremity wounds and foot ulcers (5)
- Helps resolve infections combined with antibiotic and surgical strategy/debridement by helping augment the transport of certain antibiotics across bacterial cell walls (antibiotic transport does not occur if oxygen tension levels are below 20 to 30 mmHg) (6)
- Stops alpha-toxin production in gas gangrene and inhibits bacterial growth which enables the body to utilize its own host defense mechanisms (7)
- Speeds wound healing and recovery of soft tissues and bone affected by radiation therapy’s fibro-atrophic effect manifested by vascular changes characterized by obliterative endarteritis
(1) Sheehan, P, Jones P, Caselli A, et al. Percent changes in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of healing in a 12-week prospective trial. Diabetes Care, 2003; 26(6): 1879-1882.
(2) Hopf HW, et al. Hyperoxia and angiogenesis. Wound Rep Regen 2005; 13 (6): 558-564.
(3) Grief R, Akca O, et al. Supplemental perioperative oxygen to reduce the incidence of surgical wound infection. New England Journal of Medicine 2000; 342 (3): 161-167.
(4) Sheikh AY, Gibson JL, Rollins MD, Hopf HW, Hussain Z, Hunt TK. Effect of hyperoxia on vascular endothelial growth factor levels in a wound model. Arch Surg 2000; 135: 1293-1297.
(5) Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
(6) Mader JT, et al. Hyperbaric oxygen as adjunctive therapy for osteomyelitis. Infect Dis Clin North Am, 1990. 4(3): 433-40.
(7) Hill GB, Osterhout S. Experimental effects of hyperbaric oxygen on selected clostridial species I in vitro studies and II in vivo studies in mice. J Infect Dis 1972; 125:
(8) Marx RE, EHler WJ, Tayapongsak P, Pierce LW. Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg 1990; 160: 519-524.