Hyperbaric oxygen therapy for wound healing and limb salvage: a systematic review.

This article is a systematic review evaluating published clinical evidence of the efficacy of hyperbaric oxygen therapy (HBOT) for wound healing and limb salvage. The data source is the Ovid/Medline database for key word "Hyperbaric Oxygenation" with search limits (human studies, 1978-2008). Results were combined by Boolean AND with 1 of the 3 following searches: (a) wound healing (10 permutations); (b) compromised flap or graft (3); and (c) osteomyelitis (1). The author evaluated 620 citations, of which 64 reported original observational studies and randomized controlled trials (RCTs) on HBOT and healing outcomes. All citations with 5 subjects were selected for full text review (44 articles) and evaluated according to GRADE criteria for high, medium, low, or very low level of evidence. A Cochrane review identified 1 additional study with a low level of evidence. This systematic review discusses and tabulates every article of high or moderate level of evidence. For patients with diabetic foot ulcers (DFU) complicated by surgical infection, HBOT reduces chance of amputation (odds ratio [OR] 0.242, 95% CI: 0.137-0.428) (7 studies) and improves chance of healing (OR 9.992, 95% CI: 3.972-25.132) (6 studies). Positive efficacy corresponds to HBOT-induced hyperoxygenation of at-risk tissue (7 studies) as measured by transcutaneous oximetry. HBOT is associated with remission of about 85% of cases of refractory lower extremity osteomyelitis, but an RCT is lacking to clarify extent of effect. There is a high level of evidence that HBOT reduces risk of amputation in the DFU population by promoting partial and full healing of problem wounds. There is a moderate level of evidence that HBOT promotes healing of arterial ulcers, calciphylactic and refractory vasculitic ulcers, as well as refractory osteomyelitis. There is a low to moderate level of evidence that HBOT promotes successful "take" of compromised flaps and grafts.

Electrotherapy reoxygenates inframalleolar ischemic wounds on diabetic patients: a case series.

OBJECTIVE: To retrospectively evaluate the ability of high voltage pulsed current (HVPC) to increase microcirculation in critically ischemic wounds (transcutaneous oxygen [TcPO(2)] less than 10 mm Hg) and, as a result, to improve wound healing. DESIGN AND METHODS: Clinical case series with successive adult diabetic subjects (3 men and 3 women) with nonsurgical ischemic malleolar or inframalleolar skin lesions, each subject serving as his or her own control. Wound area and TcPO(2) were measured periodically. Presence of distal arteriosclerosis was assessed on 5 patients by 2-dimensional, time-of-flight magnetic resonance angiography. End point was either complete wound closure or leg amputation. RESULTS: Maximum mean TcPO(2) was 2 +/- 2 mm Hg at the wound edge before the start of electrotherapy. After electrotherapy began, maximum TcPO(2) was 33 +/- 18 mm Hg (N=6; P<.05, Wilcoxon signed rank test). After treatment with HVPC, 4 patients' wounds healed and 2 patients underwent amputation. As expected, healed patients initially deteriorated after the start of treatment, but their wounds began healing when the perilesion TcPO(2) measurement exceeded 20 mm Hg. Thereafter, the wounds closed at a predictable rate. Complete closure occurred for patients who had a relatively low atherosclerotic burden. CONCLUSION: The results of this clinical case series suggest that electrotherapy can improve periwound microcirculation of ischemic inframalleolar skin lesions.