SLR - August 2020 - Hoda Naei

A Systematic Review and Meta-Analysis Of Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers with Arterial Insufficiency

Reference: Robin J. Brouwer, MD,a Rutger C. Lalieu, MD,b Rigo Hoencamp, MD, PhD,a,c,d Rob A. van Hulst, MD,e and Dirk T. Ubbink, MD,f Leiderdorp, Rijswijk, Utrecht, Leiden, and Amsterdam, The Netherlands A Systematic Review and Meta-Analysis Of Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers with Arterial Insufficiency J Vasc Surg. 2020 Feb;71(2):682-692.e1.

Scientific Literature Review

Reviewed By: Hoda Naei, DPM
Residency Program: Beaumont Hospital – Farmington Hills, MI 

Podiatric Relevance: Hyperbaric oxygen therapy (HBOT) has been used for many years in wound care centers for diabetic wounds. As podiatric surgeons we are always looking for the most comprehensive methods for limb salvage. Wounds that are accompanied by vascular insufficiency make it very difficult if not impossible to heal. HBOT has been one method to improve local tissue oxygenation to wounds. 

Methods: A systemic review was done about the effect of Hyperbaric oxygen therapy on diabetic foot infections with ischemia. They looked at 11 articles between the years 1990 to 2018. Peripheral arterial occlusive disease was defined as ankle-brachial pressure index <0.9, a toe-brachial pressure index (TBI) <0.70, and a toe pressure (TBP) <30 mmHg, TcpO2 on the dorsum of the foot <30 mmHg. The studies' results were analyzed based on amputation rate/amputation-free survival (AFS), complete ulcer healing, and mortality. Other factors were also looked at and measured as secondary outcomes including the time of wound completion, quality of life of patient TcpO2 values before, during, and after the treatment, need for additional surgery, adverse effects of HBOT, and costs,

Results: It was demonstrated that major amputation rate was significantly lower in groups treated with HBOT (10.7 percent) compared to the control group (26.0 percent), but not much difference in minor amputation rate. There was no significant difference in healing time or mortality rate between HBOT and control group. Two out of the three articles that looked at the time of ulcer healing did not find a significant difference in wound healing in the HBOT group vs the control group. There were side effects from HBOT including middle ear barotrauma, middle ear perforation, ear pain, barotraumatic otitis, cataracts, oxygen-induced seizure. No significant difference in the quality of life was noted between the two groups. 

Conclusions: In conclusion, the only significant difference that HBOT had on patients with peripheral arterial occlusive disease is the decreased rate of major limb amputation. Based on this article HBOT does not seem like the sole treatment option for patients who have vascular disease and a principles-based, multi-modal approach encompassing infection management, vascular optimization and aggressive local wound care would result in optimal outcomes. Future studies would be warranted to assess the effects in the patients with both micro- and macrovascular occlusive disease with diabetes and concurrent tissue loss. 

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