Dr.Mohab-Ahmed-Shafei-ood0a3o399bdvs5ypzi544obedxkbgs9pn0e5ywm9k

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Endocrine, Family Medcine, Medical Nov 21, 2020 0

Diabetic ulcers are the most common foot injuries leading to lower extremity amputation.

Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance.

The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications.

Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation.

Does Hyperbaric Heal Diabetic Foot Ulcers Faster?

A new randomized controlled trial (RCT) on the use of hyperbaric oxygen therapy (HBOT) for diabetic foot ulcers (DFUs) has been published in the high-quality diabetes journal, Diabetes Care. The RCT found that HBOT did not improve healing or amputation rates in patients with ischaemic DFUs compared to usual care. But, these findings have created some controversy; so what is the full story?

What do we know about HBOT in DFU?

The use of HBOT has long been thought to be beneficial in healing DFUs. The theory behind the benefit is that it increases the amount of oxygen to the tissue at the site of the DFU which in turn heals the DFU quicker. But in practice we don’t categorically know if this is the case, as the studies in this area have varied considerable in patients studied, methodology used and findings.

For instanc<script async src=”https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js”></script>
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</script>e the recent Cochrane Review concluded, “in people with foot ulcers due to diabetes, HBOT significantly improved the ulcers healed in the short term, but not the long term, and the trials had various flaws in design and/or reporting that means we are not confident in the results.” And the International Diabetic Foot wound healing guidelines recommend to “consider the use of systemic hyperbaric oxygen therapy, even though further blinded and randomised trials are required to confirm its cost-effectiveness, as well as to identify the population most likely to benefit from its use.”

However, after considering the theory and studies most experts think HBOT should be most beneficial in people with ischaemic DFUs. Which is exactly what this new RCT from the Netherlands hoped to look at.

What did this new study do then?

Well this was a large multi-centre RCT investigating HBOT in patients with ischaemic DFUs only. The study recruited patients from 24 hospitals in the Netherlands and one in Belgium. Patients needed to have diabetes, an ulcer on their lower leg, and a toe pressure <50mmHg. They then collected a whole range of baseline characteristics, including; demographic, diabetes history, comorbidity history, medication, PAD and DFU characteristics.

Patients were then randomized to receive a HBOT intervention of up to 40 x 90 minute sessions of HBOT (5 days per week until healed or 40 sessions) or no HBOT (control group). Otherwise according to the authors all patients in both groups received revascularization if required and standard care decided on by their treating clinicians, such as debridement, offloading and antibiotics if needed.

Patients were then followed up at 3, 6 and 12 months. The main outcomes they were looking for at each follow up visit were if the ulcer had healed, they had an amputation or died. They also measured quality of life and costs but the authors say they will report those findings in a future article.

So what did they find?

First, they recruited 120 eligible patients (60 in the HBOT intervention; 60 control). Both groups had the same baseline characteristics, except the HBOT group was younger and had higher HbA1c.

Second, after 12 months they found statistically similar results in both groups: for DFUs that had completely healed (50% HBOT; 47% control), average time to healing (202 days HBOT; 217 control), amputations (37% HBOT; 48% control), deaths (8% HBOT; 15% control), and those that were still alive and had not had a major amputation called ‘amputation free survival’ (82% HBOT; 68% control). But, they also found that only 39 (65%) in the HBOT group completed most (>75%) of their HBOT treatments.

So lastly, they compared the 39 patients who completed most of their planned HBOT treatments to all the other 81 patients. They still found no statistical differences for those completely healed (57% HBOT; 44%), but did find more amputation free survival in the HBOT group (92% HBOT; 67% control).

Does Hyperbaric Heal Diabetic Foot Ulcers Faster than other measures?

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