1
|
van der Wal GE, Dijkstra PU, Geertzen JH. Lisfranc and Chopart amputation: A systematic review. Medicine (Baltimore) 2023; 102:e33188. [PMID: 36897730 PMCID: PMC9997832 DOI: 10.1097/md.0000000000033188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/14/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Lisfranc and Chopart amputations are historically controversial procedures. To obtain evidence for the pros and cons we performed a systematic review to analyze wound healing, the need for re-amputation at a higher level, and ambulation after a Lisfranc or Chopart amputation. METHODS A literature search was performed in 4 databases (Cochrane, Embase, Medline, and PsycInfo), using database-specific search strategies. Reference lists were studied to include relevant studies that were missed in the search. Of the 2881 publications found, 16 studies could be included in this review. Excluded publications concerned editorials, reviews, letters to the editor, no full text available, case reports, not meeting the topic, and written in a language other than English, German, or Dutch. RESULTS Failed wound healing occurred in 20% after Lisfranc amputation, in 28% after modified Chopart amputation, and 46% after conventional Chopart amputation. After Lisfranc amputation, 85% of patients were able to ambulate without prosthesis for short distances, and after modified Chopart 74%. After a conventional Chopart amputation, 26% (10/38) had unlimited household ambulation. CONCLUSIONS The need for re-amputation because wound healing problems occurred most frequently after conventional Chopart amputation. All 3 types of amputation levels do, however, provide a functional residual limb, with the remaining ability to ambulate without prosthesis for short distances. Lisfranc and modified Chopart amputations should be considered before proceeding to a more proximal level of amputation. Further studies are needed to identify patient characteristics to predict favorable outcomes of Lisfranc and Chopart amputations.
Collapse
Affiliation(s)
- Gesiena E. van der Wal
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
| | - Pieter U. Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, The Netherlands
| | - Jan H.B. Geertzen
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
| |
Collapse
|
2
|
Leenstra B, Wijnand J, Verhoeven B, Koning O, Teraa M, Verhaar MC, de Borst GJ. Applicability of Transcutaneous Oxygen Tension Measurement in the Assessment of Chronic Limb-Threatening Ischemia. Angiology 2020; 71:208-216. [PMID: 31387360 PMCID: PMC6987479 DOI: 10.1177/0003319719866958] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Transcutaneous oxygen tension measurement (TcPO2) is widely applied for the evaluation of chronic limb-threatening ischemia (CLTI). Nevertheless, studies that focused on the clinical value of TcPO2 have shown varying results. We identified factors that potentially play a role in TcPO2 measurement variation such as probe placement, probe temperature, and the use of a reference probe. In this review of the current literature, we assessed the application of these factors. A systematic search was conducted. Parameters that were assessed were probe placement, probe temperature, and mentioning and/or use of a reference probe. In total, 36 articles were eligible for analysis. In 24 (67%) studies, probes were placed on specific anatomical locations. Seven (19%) studies placed probes, regardless of the location of the ulcer, adjacent to an ischemic lesion or ulcer (perilesion). Selected temperature setting of the probe differed; in 18 (50%), a default probe temperature of 44°C was selected, and in 13 (36%), a different temperature was selected. In 31 (84%) studies, the use of a reference probe was not reported. Transcutaneous oxygen tension measurement is applied diversely in patients with CLTI. Homogeneity in TcPO2 protocols is warranted for reliable clinical application and to compare future TcPO2 research.
Collapse
Affiliation(s)
- Bernard Leenstra
- Department of Vascular Surgery, UMC Utrecht, CX Utrecht, the
Netherlands
| | - Joep Wijnand
- Department of Vascular Surgery, UMC Utrecht, CX Utrecht, the
Netherlands
| | - Bart Verhoeven
- Department of Vascular Surgery, Jeroen Bosch Ziekenhuis, Henri Dunantstraat,
GZ ‘s-Hertogenbosch, the Netherlands
| | - Olivier Koning
- Department of Vascular Surgery, Jeroen Bosch Ziekenhuis, Henri Dunantstraat,
GZ ‘s-Hertogenbosch, the Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, UMC Utrecht, CX Utrecht, the
Netherlands
- Department of Vascular Surgery, Jeroen Bosch Ziekenhuis, Henri Dunantstraat,
GZ ‘s-Hertogenbosch, the Netherlands
- Department of Nephrology and Hypertension, UMC Utrecht, Heidelberglaan, CX
Utrecht, the Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, UMC Utrecht, Heidelberglaan, CX
Utrecht, the Netherlands
| | - Gert J. de Borst
- Department of Vascular Surgery, UMC Utrecht, CX Utrecht, the
Netherlands
| |
Collapse
|
3
|
de Smet GHJ, Kroese LF, Menon AG, Jeekel J, van Pelt AWJ, Kleinrensink GJ, Lange JF. Oxygen therapies and their effects on wound healing. Wound Repair Regen 2017; 25:591-608. [PMID: 28783878 DOI: 10.1111/wrr.12561] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 07/03/2017] [Indexed: 12/13/2022]
Abstract
Oxygen is an important factor for wound healing. Although several different therapies investigated the use of oxygen to aid wound healing, the results of these studies are not unequivocal. This systematic review summarizes the clinical and experimental studies regarding different oxygen therapies for promoting wound healing, and evaluates the outcomes according the methodological details. A systematic literature search was conducted using Embase, Medline, Web of Science, Cochrane, PubMed publisher, and Google Scholar libraries. Clinical and experimental studies investigating oxygen for wound healing were selected. Included articles were categorized according to the kind of therapy, study design, and wound type. The methodological details were extracted and analyzed. Sixty-five articles were identified and divided in three different oxygen therapies: Local oxygen therapy, hyperbaric oxygen therapy, and supplemental inspired oxygen therapy. More than half of the included local oxygen and hyperbaric oxygen studies had one or more significant positive outcomes, 77 and 63%, respectively. Supplemental inspired oxygen therapy during gastrointestinal and vascular surgery was more likely to have a positive result than during other surgical interventions reducing surgical site infections. These many positive outcomes promote the use of oxygen treatment in the stimulation of wound healing. However, the lack of clinical studies and vast methodological diversity made it impossible to perform a proper comparison within and between the different therapies. Further randomized clinical studies are warranted to examine the value of these therapies, especially studies that investigate the more patient-friendly oxygen dressings and topical wound oxygen therapies. Also, to achieve more solid and consistent data, studies should use more standardized methods and subjects.
Collapse
Affiliation(s)
- Gijs H J de Smet
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Leonard F Kroese
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anand G Menon
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Surgery, Havenziekenhuis, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Antoon W J van Pelt
- Department of Oral Function, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Surgery, Havenziekenhuis, Rotterdam, The Netherlands
| |
Collapse
|
4
|
Wang Z, Hasan R, Firwana B, Elraiyah T, Tsapas A, Prokop L, Mills JL, Murad MH. A systematic review and meta-analysis of tests to predict wound healing in diabetic foot. J Vasc Surg 2016; 63:29S-36S.e1-2. [DOI: 10.1016/j.jvs.2015.10.004] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/08/2015] [Indexed: 12/13/2022]
|
5
|
Jones LM, Rubadue C, Brown NV, Khandelwal S, Coffey RA. Evaluation of TCOM/HBOT practice guideline for the treatment of foot burns occurring in diabetic patients. Burns 2015; 41:536-41. [DOI: 10.1016/j.burns.2014.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/31/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
|
6
|
Jones LM, Coffey R, Khandelwal S, Atway S, Gordillo G, Murphy C, Fries JA, Dungan K. A clinician's guide to the treatment of foot burns occurring in diabetic patients. Burns 2014; 40:1696-701. [DOI: 10.1016/j.burns.2014.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/28/2014] [Accepted: 01/28/2014] [Indexed: 01/22/2023]
|
7
|
Carlson RM, Smith NC, Dux K, Stuck RM. Treatment of postoperative lower extremity wounds using human fibroblast-derived dermis: a retrospective analysis. Foot Ankle Spec 2014; 7:102-7. [PMID: 24521756 DOI: 10.1177/1938640014522097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Human fibroblast-derived dermis skin substitute is a well-studied treatment for diabetic foot ulcers; however, no case series currently exist for its use in healing postoperative wounds of the lower extremity. A retrospective analysis was conducted on 32 lower extremity postoperative wounds treated weekly with human fibroblast-derived dermis skin substitute. Postoperative wounds were defined as a wound resulting from an open partial foot amputation, surgical wound dehiscence, or nonhealing surgical wound of the lower extremity. Wound surface area was calculated at 4 and 12 weeks or until wound closure if prior to 12 weeks. Postoperative wounds treated with weekly applications showed mean improvement in surface area reduction of 63.6% at 4 weeks and 96.1% at 12 weeks. More than 56% of all wounds healed prior to the 12-week endpoint. Additionally, only one adverse event was noted in this group. This retrospective review supports the use of human fibroblast-derived dermis skin substitute in the treatment of postoperative lower extremity wounds. This advanced wound care therapy aids in decreased total healing time and increased rate of healing for not only diabetic foot wounds but also postoperative wounds of the lower extremity, as demonstrated by this retrospective review.
Collapse
Affiliation(s)
- Russell M Carlson
- ORA Orthopedics, Moline, Illinois, and Genesis Wound and Hyperbaric Medicine Institute, Davenport, Iowa (RMC)
| | | | | | | |
Collapse
|
8
|
Sahni T, Shweta G, Sapna V. Hyperbaric oxygen therapy heals diabetic wounds. APOLLO MEDICINE 2014. [DOI: 10.1016/j.apme.2014.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
9
|
Abstract
Hyperbaric oxygen therapy (HBO) has been used as an adjunct for healing diabetic foot ulcers (DFUs) for decades. However, its use remains controversial. A literature search was conducted to locate clinical studies and assess the available evidence. Ten prospective and seven retrospective studies evaluating HBO for DFUs were located. These were reviewed and the outcomes were discussed. One study reported no difference in outcomes between patients receiving hyperbaric oxygen and the control group. However, their regime differed from all other studies in that the patients received hyperbaric oxygen twice rather than once daily. Reduced amputation rates and improved healing were the most common outcomes observed.
Collapse
Affiliation(s)
- Alexandra J Bishop
- Diving Diseases Research Centre, The Hyperbaric Medical Centre, Plymouth, Devon, UKDepartment of Wound Healing, Cardiff University, Cardiff, UK
| | | |
Collapse
|
10
|
Abstract
The widespread use of HBO as an adjunctive treatment of diabetic foot ulcers has been founded on weak scientific evidence, but the consistency in positive outcomes in trials evaluating HBO on ulcer healing is noteworthy, not least as these results are in concert with data from in vitro and physiologic studies supporting the theoretical framework of HBO reversing hypoxia-induced abnormality. The long-term ulcer-healing rates of the nonrandomized controlled studies before the recent study by Margolis and colleagues, 77% with HBO versus 25% with standard treatment, are in concert with 1-year follow-up data from the 2 double-blind RCTs, 54% versus 25%. These 2 trials have put the use of HBO on firmer ground, but several issues, including health economics, developing robust selection criteria for treatment, optimizing treatment protocols, and identifying standards for when to start and stop treatment, remain to be elucidated. Not least, outcomes from further high-quality studies are needed. At present, HBO may be used as an adjunctive therapy in a select group of patients with diabetic foot ulcers that are difficult to heal.
Collapse
Affiliation(s)
- Magnus Löndahl
- Department of Clinical Sciences, Lund University, Lund S-221 85, Sweden.
| |
Collapse
|
11
|
Feldman-Idov Y, Melamed Y, Linn S, Ore L. Prognostic factors predicting ischemic wound healing following hyperbaric oxygenation therapy. Wound Repair Regen 2013; 21:418-27. [PMID: 23590699 DOI: 10.1111/wrr.12038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 02/06/2013] [Indexed: 11/26/2022]
Abstract
Identifying patients who benefit from hyperoxygenation therapy is important, because treatment is time-consuming and involves high costs and complications (minor). Our objective was to develop a model for predicting therapy outcome based on population of patients with and without diabetes. A retrospective cohort study was carried out in a major hospital in Israel. All 385 patients treated between 1/1/1998 and 1/1/2007 for ischemic nonhealing lower extremities wounds were included. Data on medical history, demographic, transcutaneous oximetry, wounds, treatment, and outcome characteristics were collected. Eight factors were identified to optimally predict wound healing: (1) number of hyperbaric oxygenation treatments (odds ratio [OR] = 1.034, p < 0.001), (2) transcutaneous oximetry values at hyperbaric conditions (OR = 1.001, p = 0.019), (3) wound duration (OR = 0.988, p = 0.022), (4) absence of heart disease (OR = 3.304, p < 0.001), (5) being employed (OR = 3.16, p = 0.008), (6) low socioeconomic status (OR = 2.50, p = 0.004), (7a) good/partial granulation wound appearance (OR = 2.73, p = 0.022), (7b) wounds covered with fibrin (OR = 3.16, p = 0.015), and (8) absence of anemia (OR = 2.13, p = 0.016). The model's sensitivity is 78.7%, specificity is 62.9%, and accuracy is 71.8%. We suggest using our model as an adjunct to patients' clinical evaluation. Also, we recommend initiating hyperoxygenation therapy no later than 2 months after wound appearance.
Collapse
Affiliation(s)
- Yulie Feldman-Idov
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.
| | | | | | | |
Collapse
|
12
|
Abstract
A retrospective review of patient medical records was conducted to assess what factors influence the outcomes of diabetic foot ulcers treated with hyperbaric oxygen (HBO) therapy. Patients referred to the Diving Diseases Research Centre for HBO therapy for the treatment of diabetic foot ulcers during a 2-year period were included in this study. Data collected from 30 sets of patient records were entered into SPSS and statistical analysis was undertaken to investigate whether any underlying pathologies or confounding factors appeared to influence patient outcome. A 73.3% of patients achieved a successful outcome of partial healing, major amputation no longer required, amputation level lower than anticipated prior to HBO or healing at the end of HBO therapy and 70% remained successful 3 months later. A 13.3% of patients were lost to follow-up at 3 months and one patient (3.3%) had a major amputation. Steroid therapy, peripheral vascular disease, previous minor amputation, type of diabetes, previous HBO therapy, larvae therapy, the use of interactive dressings and haemoglobin A1c levels were all observed to have had a significant relationship with patient outcome (P < 0.05). These results were compared with data from other published research conducted in this area on similar patient groups. A larger scale study focussing on the factors found to be significant in this study is recommended. An improvement of patient documentation would allow patient outcomes to be more consistently monitored in the future.
Collapse
Affiliation(s)
- Alexandra J Bishop
- Diving Diseases Research Centre, The Hyperbaric Medical Centre, Plymouth, Devon, UK.
| | | |
Collapse
|
13
|
Mills BJ. Wound healing: the evidence for hyperbaric oxygen therapy. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2012; 21:28-34. [PMID: 23131915 DOI: 10.12968/bjon.2012.21.sup20.s28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This article reviews evidence for the promotion of healing using hyperbaric oxygen therapy (HBOT). HBOT is an adjuvant wound therapy that has been suggested to be beneficial for the healing of wounds for over 40 years. Current approved treatments provide 100% oxygen to a patient who is in a multi-place compression chamber accompanied inside the chamber by a trained attendant. Its ability to increase the arterial partial pressure of oxygen in the human body and facilitate oxygen transport when the body's oxygen transport system has been compromised makes it appropriate for a number of indications. Oxygen is essential for normal wound healing and contributes to a number of processes required for a healing wound. HBOT is an additional therapy and lacks the capacity to heal wounds without the application of approved wound care practice. Animal studies and clinical trials have demonstrated the benefits of HBOT on the hypovascular-hypocellular-hypoxic environment of a chronic wound when the wound has not responded to other treatments. Evidence suggests that the addition of HBOT is effective in the healing of diabetic foot ulcers but that presently this benefit is not evident at long-term follow up.
Collapse
Affiliation(s)
- Benjamin J Mills
- Florence Nightingale School of Nursing & Midwifery, Kings College London
| |
Collapse
|
14
|
The Use of Transcutaneous Oximetry to Predict Healing Complications of Lower Limb Amputations: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2012; 43:329-36. [DOI: 10.1016/j.ejvs.2011.12.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 12/05/2011] [Indexed: 11/18/2022]
|
15
|
Rodrigues LM, Pinto PC, Fluhr JW. In vivo assessment of peripheral vascular function by tcpO₂ and skin blood flow modelling. Exp Dermatol 2011; 21:38-42. [PMID: 22151389 DOI: 10.1111/j.1600-0625.2011.01398.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There are multiple techniques and methods to assess peripheral vascular function in vivo but not without limitations. More discriminative, sensitive and also practical evaluation strategies are needed to fully characterize the peripheral vascular function. In the present work, a new quantitative descriptor, the 'elimination half-life time' was developed from flow-related variables as a non-invasive microcirculatory rate parameter to describe vascular dynamics. Fifty-four healthy volunteers and six type 2 diabetic patients, both genders, were submitted to a dynamical procedure consisting in the inhalation of a 100% saturated atmosphere of oxygen for 10 min. The tcpO(2) and microcirculatory blood flow [Laser Doppler Flowmetry (LDF)] were measured in a randomly selected leg with a Periflux 5000 system before, during and after the procedure. A monocompartmental model was adjusted to tcpO(2) and LDF data. The tcpO(2) constant elimination rate, expressed as the Oxygen elimination half-life, was used as an indicator of the vulnerability of peripheral tissue and compared in healthy versus non-healthy individuals. Under normal conditions, the saturated ventilation increases the tissue's O(2) availability, as an expression of the natural capacity to adjust the tissue hemodynamics to new metabolical/perfusion conditions. Diabetic patients are expected to suffer vascular impairment and ischemia. Under O(2) overloading conditions, those hypoxic territories tend to uptake all the delivered oxygen, expressed as a significant increase in the O(2) elimination half-life. This approach allows to propose 'elimination half-life time' as the first quantitative descriptive parameter combining miogenic, hemodynamic and metabolic aspects of the microcirculatory physiology and to help to identify the individual's vascular vulnerability.
Collapse
|
16
|
Tiaka EK, Papanas N, Manolakis AC, Maltezos E. The role of hyperbaric oxygen in the treatment of diabetic foot ulcers. Angiology 2011; 63:302-14. [PMID: 21873346 DOI: 10.1177/0003319711416804] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetic foot ulcers are still extremely difficult to heal. Therefore, therapeutic options to improve healing rates are continuously being explored. Hyperbaric oxygen (HBO) has been used in addition to standard treatment of the diabetic foot for more than 20 years. Evidence suggests that HBO reduces amputation rates and increases the likelihood of healing in infected diabetic foot ulcers, in association with improved tissue oxygenation, resulting in better quality of life. Nonetheless, HBO represents an expensive modality, which is only available in few centers. Moreover, adverse events necessitate a closer investigation of its safety. Finally, it is not entirely clear which patients stand to benefit from HBO and how these should be selected. In conclusion, HBO appears promising, but more experience is needed before its broad implementation in the routine care of the diabetic foot.
Collapse
Affiliation(s)
- Elisavet K Tiaka
- Outpatient Clinic of the Diabetic Foot, Second Department of Internal Medicine, Democritus University of Thrace, Greece
| | | | | | | |
Collapse
|
17
|
Svensson H, Apelqvist J, Larsson J, Lindholm E, Eneroth M. Minor amputation in patients with diabetes mellitus and severe foot ulcers achieves good outcomes. J Wound Care 2011; 20:261-2, 264, 266 passim. [PMID: 21727875 DOI: 10.12968/jowc.2011.20.6.261] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To analyse the outcome of minor amputations (through, or distal to, the ankle joint) in patients with diabetes. METHOD All diabetic patients in a defined population undergoing one or more minor amputation between 1982 and 2006 were investigated according to a standardised protocol and were followed until final outcome (healing or death). A total of 410 consecutive amputations in 309 patients with a median age of 73 (32-93) years were identified. RESULTS In 94% of amputations, deep infection (39%) and/or gangrene (55%) was present. Severe peripheral vascular disease or critical limb ischaemia was present in 61% of amputations. 261/410 (64%) of the amputations healed at a level below the ankle joint; 69/410 (17%) healed after a re-amputation above the ankle joint; in 76/410 of amputations (19%), the patient died before healing could occur. In surviving patients, 79% of the amputations healed below the ankle. Median healing time for amputations that healed below the ankle was 26 (2-250) weeks; 21% of amputations required a re-amputation above the ankle. None of the analysed parameters excluded the possibility of healing below the ankle. CONCLUSION In this population-based survey, the goal of avoiding major amputation was achieved in almost two thirds of minor amputations, but at the price of long healing times. In almost all amputations, the patient had deep infection and/or gangrene. In spite of this, 64% of all amputations, and 79% of amputations in surviving patients, healed at a level below the ankle. This indicates that minor amputations in these patients are worthwhile. DECLARATION OF INTEREST None.
Collapse
Affiliation(s)
- H Svensson
- Department of Orthopaedics, Skane University Hospital, Malmö, Sweden.
| | | | | | | | | |
Collapse
|
18
|
Löndahl M, Katzman P, Hammarlund C, Nilsson A, Landin-Olsson M. Relationship between ulcer healing after hyperbaric oxygen therapy and transcutaneous oximetry, toe blood pressure and ankle-brachial index in patients with diabetes and chronic foot ulcers. Diabetologia 2011; 54:65-8. [PMID: 20957342 DOI: 10.1007/s00125-010-1946-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Accepted: 09/01/2010] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS The randomised, double-blind, placebo-controlled Hyperbaric Oxygen Therapy (HBOT) in Diabetic Patients with Chronic Foot Ulcers (HODFU) study showed beneficial effect of HBOT. As this treatment is expensive and time-consuming, being able to select patients for therapy would be very useful. The aim of this study was to evaluate whether circulatory variables could help in predicting outcome of HBOT. METHODS All HODFU study participants who completed therapy, predefined as receiving at least 36 out of 40 scheduled HBOT/placebo sessions, were included in this study (n = 75). Baseline transcutaneous oximetry (TcPO₂), toe blood pressure (TBP) and ankle-brachial index (ABI) were measured. Ulcer healing rate was registered at the 9-month follow-up visit. An ulcer was considered healed when it was completely epithelialised and remained so at the 12-month follow-up. RESULTS In the HBOT group TcPO₂ were significantly lower for patients whose ulcer did not heal as compared with those whose ulcers healed. A significantly increased healing frequency was seen with increasing TcPO(2) levels in the HBOT group (TcPO₂/healing rate: <25 mmHg/0%; 26-50 mmHg/50%; 51-75 mmHg/73%; and >75 mmHg/100%). No statistically significant relation between the level of TBP or ABI and healing frequency was seen. CONCLUSIONS/INTERPRETATION Our results indicate that TcPO₂ in contrast to ABI and TBP correlates to ulcer healing following HBOT. We suggest HBOT as a feasible adjunctive treatment modality in diabetic patients with chronic non-healing foot ulcers when basal TcPO₂ at the dorsum of the foot is above 25 mmHg. TRIAL REGISTRATION NCT00953186 FUNDING Mrs Thelma Zoegas Foundation and Faculty of Medicine, Lund University.
Collapse
Affiliation(s)
- M Löndahl
- Institution for Clinical Sciences in Lund, Lund University, Sweden.
| | | | | | | | | |
Collapse
|
19
|
Chen CE, Ko JY, Fong CY, Juhn RJ. Treatment of diabetic foot infection with hyperbaric oxygen therapy. Foot Ankle Surg 2010; 16:91-5. [PMID: 20483142 DOI: 10.1016/j.fas.2009.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Revised: 05/19/2009] [Accepted: 06/18/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study was performed to evaluate the effectiveness of hyperbaric oxygen therapy (HBOT) in the treatment of the infected diabetic foot. METHODS Forty-two patients with 44 infected diabetic feet receiving HBOT were divided into two groups. One group of 21 patients with 21 feet received <10 sessions of HBOT. The other 21 patients with 23 feet received >10 sessions of HBOT. RESULTS In patients who received <10 sessions of HBOT, seven patients achieved satisfactory wound healing. Feet were preserved in 33.3%. In patients with >10 sessions of HBOT, 16 patients with 18 feet achieved good wound healing. Of these patients, 78.3% preserved their feet. This group of patients received an average of 22.8 HBOT treatments. CONCLUSIONS Adjunctive HBOT has a positive effect on wound healing in diabetic foot with infection. The effect of HBOT seems dose dependent because the amputation rate is decreased in patients who receive adequate HBOT.
Collapse
Affiliation(s)
- Chin-En Chen
- Department of Orthopedic Surgery, Golden Hospital, 12-2, Minsheng E. Rd., Pingtung City 900, Taiwan, ROC.
| | | | | | | |
Collapse
|
20
|
Goldman RJ. Hyperbaric Oxygen Therapy for Wound Healing and Limb Salvage: A Systematic Review. PM R 2009; 1:471-89. [DOI: 10.1016/j.pmrj.2009.03.012] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Revised: 03/02/2009] [Accepted: 03/08/2009] [Indexed: 11/30/2022]
|
21
|
Kaya A, Aydin F, Altay T, Karapinar L, Ozturk H, Karakuzu C. Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy? INTERNATIONAL ORTHOPAEDICS 2008; 33:441-6. [PMID: 18654777 DOI: 10.1007/s00264-008-0623-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 05/21/2008] [Accepted: 05/27/2008] [Indexed: 12/20/2022]
Abstract
Although hyperbaric oxygen therapy has been used for diabetic foot ulcer since the 1980s, there is little information on its efficacy. The aim of this study is to evaluate whether hyperbaric oxygen can decrease major amputation rates and to determine the predictive factors. A total of 184 consecutive patients were treated with hyperbaric oxygen therapy as an adjunct to standard treatment modalities for their diabetic foot ulcer. Of these patients, 115 were completely healed, 31 showed no improvement and 38 underwent amputation. Of the amputations, nine (4.9%) were major amputations (below knee) and 29 were minor. Major amputations were associated with the Wagner grade (p < 0.0001), with the age of the patients (p = 0.028) and with the age of the wounds (p = 0.018). Hyperbaric oxygen therapy can help to reduce the major amputation rates in diabetic foot ulcer. However, further large, multicentre, randomised controlled studies are needed to make more accurate conclusions.
Collapse
Affiliation(s)
- Ahmet Kaya
- Department of Orthopaedics and Traumatology, Tepecik Training and Research Hospital, Izmir, Turkey.
| | | | | | | | | | | |
Collapse
|
22
|
Abstract
As the incidence of diabetes mellitus is increasing globally, complications related to this endocrine disorder are also mounting. Because of the large number of patients, foot ulcers developing in the feet of diabetics have become a public health problem. The predisposing factors include abnormal plantar pressure points, foot deformities, and minor trauma. Vulnerable feet usually already have vascular insufficiency and peripheral neuropathy. The complex nature of these ulcers deserves special care. The most useful prognostic feature for healing remains the ulcer depth, ulcers heal poorly if they clearly involve underlying tendons, ligament or joints and, particularly, when gangrenous tissue is seen. Local treatment of the ulcer consists of repeated debridement and dressing. No 'miraculous' outcome is expected, even with innovative agents like skin cover synthetics, growth factors and stem cells. Simple surgery like split skin grafting or minor toe amputations may be necessary. Sophisticated surgery like flap coverages are indicated for younger patients. The merits of an intact lower limb with an abnormal foot have to be weighed against amputation and prosthesis in the overall planning of limb salvage or sacrifice. If limb salvage is the decision, additional means like oxygen therapy, and other alternative medicines, might have benefits. The off-loading of footwear should always be a major consideration as a prevention of ulcer formation.
Collapse
Affiliation(s)
- P C Leung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Room 74026, 5th Floor, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong.
| |
Collapse
|
23
|
Berendt AR. Counterpoint: hyperbaric oxygen for diabetic foot wounds is not effective. Clin Infect Dis 2006; 43:193-8. [PMID: 16779746 DOI: 10.1086/505223] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 04/14/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Diabetic foot ulceration is common, affecting 1.0%-4.1% of diabetic persons per year and up to 25% in a lifetime. Diabetic foot ulcers are multifactorial in origin, and many are slow to heal and/or are complicated by infection, frequently leading to amputation. Hyperbaric oxygen therapy has been suggested for numerous indications, and it is recognized by funding agencies for a smaller number including diabetic foot wounds. METHODS I reviewed the literature about the history and practice of hyperbaric oxygen therapy and key issues relevant to efficacy, effectiveness, and cost-effectiveness. RESULTS Although recognized for reimbursement by Medicare and major insurers, the evidence base for hyperbaric oxygen therapy for diabetic foot care remains weak. A systematic review for the Cochrane Collaboration concluded that hyperbaric oxygen therapy may have value in treating diabetic wounds, but the studies reviewed all had methodological weaknesses, and the positive effect of treatment was not seen in the single reviewed randomized trial to include a sham treatment arm. Hyperbaric oxygen therapy consumes very substantial resources--and has the potential to consume far more--that could be better spent on other aspects of management or prevention of diabetic foot ulceration. CONCLUSIONS Hyperbaric oxygen therapy should not be offered for diabetic foot wounds until large-scale, adequately blinded, controlled, and powered randomized studies have clearly demonstrated efficacy and cost effectiveness in the healing of ulcers and the prevention of major amputation.
Collapse
Affiliation(s)
- A R Berendt
- Bone Infection Unit, Nuffield Orthopaedic Centre NHS Trust, Headington, Oxford, OX3 7LD, United Kingdom.
| |
Collapse
|
24
|
Hyperbaric Oxygen Therapy: Evidence Based Role in Diabetic Foot. APOLLO MEDICINE 2006. [DOI: 10.1016/s0976-0016(11)60204-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|