Problem Wounds and Diabetic Foot Ulcers

At London Hyperbaric Medicine we have great experience in the assessment and treatment of non-healing (hypoxic) problem wounds as well as Diabetic Foot Ulcers which have not responded to standard care. There is good evidence to suggest that Hyperbaric Oxygen Therapy may be of benefit to patients suffering from these and other related conditions.

A chronic (non-healing) wound or the so-called ‘problem wound’ is defined as any wound that fails to heal within a reasonable period of time by the use of conventional medical or surgical techniques.
This is a common condition that prompts multiple medical visits, prolonged hospitalisation, and fastidious nursing care. Non-healing wounds of the lower extremities are the most common although they may occur anywhere on the body.

Factors impairing Wound Healing
  • Advanced age
  • Nutritional Deficits
  • Vascular insufficiency
  • Diabetes Mellitus
  • Soft Tissue Infections
  • Tobacco
  • Radiation Damage
  • Tissue Hypoxia
    • Venous insufficiency and ischemia
  • Local factors
    • Bacterial load
    • Presence of necrotic tissue
    • Dead space motion
  • Poor management of the wound
    • Untrained nurses
    • Inappropriate dressings
Assessment A full and thorough assessment of a poorly healing wound is the key to successful treatment. Particular attention must be given to identifying and treating the root factors that may contribute to the wound’s inability to heal, such as poor nutrition, medications and underlying medical conditions.
Other tools are;

  • Photographic and Wound Mapping
  • Blood Pressure Measurements (Doppler evaluation of arterial circulation)
  • Transcutaneous oximetry (oxygen measurements)
  • Ultrasound investigations
  • Wound Culture
Treatment Modern equipment and techniques in combination with tried and tested surgical procedures are used to ensure that the wound is given the best possible chance of rapid healing. Some of the techniques used are;

  • Conservative debridement
  • Wound dressings and appropriate care
  • Hyperbaric Oxygen Therapy
  • Wound irrigation
  • Lymph drainage
  • Larval Therapy
  • VAC Therapy
  • Ultrasound
  • Patient education
HBO in the Treatment of Non-Healing Wounds Local-Tissue Hypoxia and Infection are the primary defects underlying problem wounds in the absence of nutritional deficits and other factors. Hyperbaric oxygen specifically treats both of these underlying factors.
Hyperbaric oxygen increases the oxygen concentration in infected tissues, including bone, and kills or inhibits the growth of organisms, which prefer low oxygen concentrations.
HBO promotes healing by;

  • Enhancing collagen synthesus
  • Enhancing fibroblast replication
  • Enhancing new vascularisation

HBO is adjunctive and must be used with appropriate antibiotics (determined by bone culture and sensitivity testing), surgical debridement, nutritional support, and reconstructive surgery.

Referral Criteria for Hyperbaric Oxygen Therapy Any hypoxic wound that fails to heal within a reasonable period of time by the use of conventional medical or surgical techniques.
Accurate prediction of wound healing potential is essential to avoid increased morbidity and mortality rated which accompany ischaemic breakdown of failed debridement, amputation and revascularization.Transcutaneous oximetry is used as a reliable indicator to determine healing potential of non-healing wounds.
Duration of treatment Standard treatment involves 30 to 40 sessions of Hyperbaric Oxygen Therapy administered on a daily basis. Individual sessions last approximately 2 hrs with patient breathing 100% oxygen for 90 minutes at 2.4 atmospheres.Wounds are monitored and dressed on a daily basis. Assessments are carried out after every 10 treatments.
Evidence/References for HBO Mattieu D. Handbook on Hyperbaric Medicine, Chap 2.2.9. 401-427, 2006 Springer
Cianci P. Adjunctive hyperbaric oxygen in the treatment of problem wounds: An economic analysis. In Kindwall E, ed Proceedings of 8th Intl. Congress on HBO. San Pedro, C.A. Best Pub. 1984:213-216
Cianci P, Petrone G, Drager S – Salvage of the problem wound and potential amputation with wound care and adjunctive hyperbaric oxygen therapy: An economic analysis. J. Hyperbaric Med. 1988;3:127-141Hunt TH. The physiology of wound healing. Ann Emerg. Med. 1988; 17:1265-1273
Wattel F, Mathieu D, Coget JM, Billard V. Hyperbaric oxygen therapy in chronic vascular wound management.Angiology 2000; 41(1): 59-65
Kranke P, Bennett M, Roeckl-Wiedmann I, Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst. Rev.
McEwan AW,Chronic venous ulcer. Hyperbaric oxygen treatment is a cost effective option. BMJ 1997;315(7101):189Cochrane – chronic wounds 2004-2007DFU HBO in diabetics, Londahl XXDiabetic Foot Ulcers- cost effectivenesskalani M HBO therapy in Treatment of diabetic foot ulcers- Long term Follow-up 2002