HyPerMED Chronic Non-Healing Wounds

HyperMED UPDATE  Cosmetic Complications Do Happen!

If you are considering cosmetic surgery then consider Hyperbaric Oxygenation before and after your procedure to prevent risk and infection. This is extremely important if you smoke or have been a smoker!

Case Study –Gangrene with Osteomyelitis

Mr. PG aged 60, was scheduled for lower limb amputation subsequent to continuing diabetic complications presenting as gangrene of the 4^th toe of the left foot and osteomyelitis of the underlying bone structure. Philip has a long established history of diabetes related and cardiovascular involvement. Several heart attacks, continuing poor diabetic control, carotid artery bypass have severely hampered his lifestyle during the preceding ten years. He suffers varying degrees of memory and mental dysfunction, occasional difficulty in speech complicated with periods of chronic fatigue and tiredness. His foot problem developed over a period of several months, a pressure sore blistered progressively deteriorating.

The patient was extremely motivated to attempt an alternative approach to amputation given the fact that his brother who also suffered similar vascular compromise had an amputation followed by a higher level amputation of the same leg, unfortunately died several days later due to secondary complications.

Doppler investigation performed whilst in hospital, confirmed reduction of peripheral circulatory function with pulses absent. During routine hospital examination, he states that the involved ‘toe was handled extremely rough and felt as though it had been broken’. Additional X rays identified a pathological fracture with secondary bone involvement and infection.

Aggressive wound management including HBOT and topical application of hydrogen peroxide and dressing was administered. In addition to medical management including antibiotics, he was administered injectable vitamins and anti-oxidant and aminoacid preparation taken orally. Philip's wound response was obviously slow initially demonstrating continuing decline with several adjacent toes opening and becoming septic. Additional X-rays confirmed that secondary osteomylitis development had not progressed. Surgery was not ruled out during the initial treatment phase. Opinions varied from removal of the immediate and adjacent toes to lower limb salvage.

Eighty-four 90-minute chamber sessions were initially performed over a 5-month period with significant improvement. Additional doppler investigation confirmed improved peripheral circulation with lower limb pulses present. During the initial 5-month treatment period his wife and family confirmed considerable improvement in regards to his mental function and speech. This was equally matched by his increase in general activity levels. Philip did not attend for treatment for the following 6-months with a further 16 90-minute HBOT sessions performed during a 6-month period after being absent for 6-months. Follow-up X-rays demonstrate the incredible ability of immune function and response absorbing dead bone material and tissue debris replacing them with viable cellular alternatives. His foot condition continues to remain stable, however his diabetic condition continues to fluctuate.

For more - read his testimonial

Case Study – Venous stasis ulcer subsequent to ankle joint replacement

Mr. MB aged 58. His Orthopedic Surgeon referred Morris for an intensive burst of HBOT and appropriate wound management. He had recently received a total ankle replacement that had been going well until he suffered subsequent wound breakdown.

The wound opened in the central area due to venous stasis ulceration with secondary infection. He had been medicated with antibiotics prior to commencing HBOT. A total of 6 HBOT sessions were performed with excellent results.

For more - read his testimonial

Case Study – Peripheral Vascular Disease

Ms. RB aged 40 has a complex history of lower limb injury. Robyn’s original injury occurred during 1982 as a result of a head on motor vehicle accident. She was in the front seat passenger’s side and received injury to her right knee with a compound wound over the patella. She also received injuries to her left foot and chest with extensive soft tissue bruising and damage to her neck and lower back. Prior to her accident she was a highly competitive marathon runner.

Robyn required plastic surgery to close the wound over her knee but continued to suffer knee and lower limb problems. Eventually arthroscopy followed by open surgery to the right knee was performed one-year later. She maintained a reasonable recovery and in fact was able to resume selective general sports and some running activity. Whilst playing a social game of squash she tore her left Achilles tendon which again significantly reduced her activities.

During May 1989 whilst driving her car was involved in another accident, this time she was hit from the driver’s side further injuring her knee, which was smashed up against the car dash. She also suffered extensive strain to her neck and lower back. She was medically examined and immediately fitted with a cervical collar and received intensive physiotherapy to her spine. She also received a course of epidural and cortisone injections into her lower back to reduce both her neck and lower back spasms.

During this same period she began developing circulatory problems involving her right leg. Shortly after her second accident she suffered a third accident further complicating her spine and legs. Her right knee continued to deteriorate and finally she received surface debridement of the joint with little success followed by patellectomy one-year later. She was told that her right knee was ‘pulped’ because of the accidents.

Robyn continued to suffer problems with her legs, suffering extensive pains, limited mobility and considerable swelling of the legs. She was referred to various vascular surgeons for opinion and recommendation. Her condition had further complicated, wound breakdown, skin breakdown, infected ulcers and extensive swelling in both legs indicating significant vascular compromise. She received a total right knee replacement during 1998 and also arthroscopy to her left knee for continued problems. Her right leg, by this stage had been constantly immobilized in a full leg elastoplast bandage due to circulatory dysfunction and wound breakdown. Her general practitioner changed her bandages daily. When bandages were removed they were generally wet and coated with a serous discharge. She was unable to walk without the assistance of aids. She had been informed that if her legs continue to deteriorate she might require above knee amputation.

Robyn’s condition in fact continued to deteriorate and as a last resort Hyperbaric Oxygenation was recommended. Investigations and clinical assessment have included spinal MRI confirming spinal degenerative joint disease and laboratory investigations including DNA PCR detection screen for Mycoplasma and Rickettsia. She tested positive to mycoplasma however species differentiation was not performed. Mycoplasma involvement is a known opportunistic infection that can negatively impact with synovial joint degeneration and wound breakdown (Nicolson 2000).

Treatment has included initially daily 90-minute HBOT sessions, antibiotic therapy and supportive physical therapy including high frequency electrical acupuncture into the lower extremities.

Robyn has improved dramatically. She no longer requires full leg elastoplast bandage supports. Her skin is no longer a ‘grayish-white’ appearance suffering constant breakdown. Her skin colour and tone has improved dramatically. She states that her skin now longer spontaneously breaks down and she does not bruise as easily, as she had grown accustomed Circulatory function and lymph drainage has improved enormously, her legs are no longer swollen and muscle structure is now evident and no longer flaccid in appearance. She no longer complains of pain associated with her treatments including high frequency electrical acupuncture to her lower limbs. Her spine has also improved. She no longer suffers acute spasms that required her to receive epidural and cortisone injections.

Overall her appearance has also improved tremendously. She reports hair that is now growing on her legs, which she states, had ceased many years ago. She has improved mobility, does not require the use of walking aids and reports a significant increase in her lifestyle and social activities.

For more - read her testimonial

Chronic Non-Healing Wounds due to Peripheral Vascular Disorders

Chronic Non-Healing wounds and invariably patients with diabetic related conditions suffering poor circulatory function effect a significant part of an aging population.

Diabetes mellitus affects 5-7% of the total population, more than half the cases being undiagnosed (Cianci 1993).  'Recent reports in the USA indicate that the annual cost of care and management exceeds $20.4 billion. Studies reveal that in excess of 1 million diabetic patients have lower limb ulcers at any one time, and 20% of hospital admissions of diabetic patients are because of lower limb problems'.

The incidence of amputation is 6 per 1,000. Diabetics accounted for 50-70% of the 118,000 amputations performed in the USA in 1983. 9% required amputation of a foot, 31% of the lower leg and 30% we amputated at or above the knee (Knighton 1990). The cost of primary amputation care has been recently reported to exceed US $40,000. Medicare reimbursement for primary amputation is approximately $12,500 (Mackey 1986).

The morbidity and mortality associated with amputations are significant. Same-sided higher amputation will occur in 22% of cases. Contralateral amputations occur in more than 10% of amputees per year. 32% of elderly amputees will die within 4 years and of the surviving 68%, only 40-50% will be successfully rehabilitated (Couch 1977).

The length of hospital stay for primary amputation varies widely but is commonly accepted to be an average of 40.3 days (Block 1981). Six to nine months may be necessary to maximize walking ability (Cianci 1988). The current cost of amputations is in excess of US$1.5 billion yearly. Readmission within a two year period for stump modification and/or reamputation represents an additional $1 billion expenditure. Clearly, amputation is a long way from being an expeditious solution to the problem of foot wounds in diabetic patients (Cianci 1988).

An aggressive, multidisciplinary team approach including Hyperbaric Oxygenation has been demonstrated to improve limb salvage and promote significant cost savings (Cianci 1988).

The compromised Host

The problem of ischemia is exacerbated in the diabetic patient, because diabetics have premature thickening of their capillary basement membranes. This acts as a relative diffusion barrier for oxygen and other substances transported throughout the blood stream. Of all the elements necessary for tissue survival and healing, oxygen is the most flow dependent and probably the most diffusion dependent. In the arteriosclerotic patient, blood flows through a narrowed lumen. The sclerotic vessels do not have the capacity to increase flow to control the infection and heal the wound, so these patients are very vulnerable to secondary infection and complication.

Edema (inflammatory swelling) is another factor that complicates and interferes with the tissue oxygenation process that promotes healing. Edema increases the diffusion distance from the capillary to the target cell. The diffusion of oxygen decreases by the square root of the oxygen concentration in the capillary. Hence edema, which is often associated with infection, malnutrition and heart failure in the compromised host, further interferes with oxygenation at the site of infection.  

The 'typical' Diabetic Foot

The diabetic foot is characterized by sensory, motor and autonomic neuropathy and macro-vascular disease. These complications may lead to ulceration, infections, gangrene and ultimately amputations. Motor neuropathy leads to altered sensory function including pressure sensation abnormalities, and altered sensation and pressure can lead to ulceration. The classical development of ulceration is caused by loss of sensation and painless trauma.

Autonomic neuropathy may cause alterations in blood flow to the extremities with decreased net oxygenation and nutritional support due to arterial insufficiency. Many diabetic patients suffer reduced peripheral flow and tissue oxygenation, even in the presence of palpable pulses. Contributing factors to diabetic neurovascular compromise include increased blood viscosity, platelet aggregation and accelerated capillary endothelial growth (thickening of the end capillary walls) leading to capillary obstruction (Aagenaes 1961, Arenson 1981, McMillan 1966).

The use of Hyperbaric Medicine for the management of diabetic wound management is not new; in fact it has been used since 1943. Modern therapy dates back to the 1960s when Dutch investigators demonstrated the effectiveness of Hyperbaric Medicine in the treatment of gas gangrene and anaemic states.  

Mechanism of Wound Repair

Injuries damage the microvasculature and initiate several significant chemical reactions. ‘Energy poor’ environments characterized by low oxygen tension, low pH and high lactate concentrations emerge. The normal tissue wound healing response includes macrophages that release lactate aerobically and anaerobically. These potent growth factors result in brisk angiogenesis and fibroblast replication at the wound margins. As macrophages move into the injured area, fibroblasts multiply and follow. Endothelial buds then appear from venules and follow the fibroblasts into the hypoxic and highly lactated area. Under the influence of lactate, fibroblasts transcribe collagen genes and synthesize collagen (Knighton 1990).

During the process of collagen deposition, the actual process that fills tissue defects and supports new blood vessels, proceeds in direct proportion to available transcutaneous oxygen pressure. Cell replication also requires oxygen. Fibroblasts and vascular endothelial cells replicate most rapidly at about 40 mmHg whereas epidermal cells replicate best at about 700 mmHg.  Any interference to the oxygen delivery process increases susceptibility to infections (Medawar 1948).

Leukocytes kill most effectively when supplied with an abundance of oxygen (Mader 1980). Phagocytosis stimulates a huge, often 20-fold increase in oxygen consumption producing superoxide, peroxide and other active oxygen species. Oxygen radicals, when released, are lethal to many bacteria and this oxidative mechanism is highly enhanced with increased oxygen tensions (Rabkin J 1987).

Clinical rationale of Hyperbaric Medicine in Wound Healing

Hyperbaric Oxygen Therapy (HBOT) is a means of providing additional oxygen to the tissues of the patient's body. This increased oxygen delivery increases the body's ability to kill bacteria and promote healing. HBOT is recommended as a supplementary therapy, to be used in addition to medical and/or pre/or post-surgical therapy (Jain 1995).

• Hyperoxygenation of the blood elevates the amount of dissolved oxygen and results in the correction of tissue hypoxia. This significantly enhances immune capabilities, enabling greater wound healing, infection control, and alleviation of tissue ischemia and the dissociation of carboxyhemoglobin

• An oxygen pulse of up to 2 hours daily enhances fibroblast migration and mitosis. High lactate levels (originating in wounds and tissue subjected to chronic impaired circulation) and hyperoxia also combine to induce greater collagen synthesis

• Increased fibroblast collagen synthesis enhances capillary growth, which further raises the partial pressure of oxygen in an incremental fashion as neovascularization (new capillary formation within ischemic zones) progresses

• HBOT significantly enhances white blood cell (WBC) function, killing phagocytized bacteria. Elevated oxygen levels increase the oxygen free radicals and hydrogen peroxide formation in the white cell lysosomes, improving antimicrobial activity

• HBOT leads to constriction of blood flow in inflamed and edematous tissue, reversing cellular leakage and fluid loss into surrounding tissue. HBOT reinstates normal lymphatic drainage, reducing painful inflammation and swelling

• Selected prescribed drugs and immune stimulating vitamins (injectables) are enhanced with increased tissue oxygenation

• HBOT brings about the mechanical compression of abnormal ‘bubbles’ in the body secondary to decompression sickness, gas embolism or other iatrogenic sources

• Increased oxygen partial pressure increases the nitrogen gradient, boosting nitrogen elimination from the body. Increased oxygen partial pressure directly reduces the effects of carbon monoxide on tissue

Spinal Cord stimulation may obviate amputation in Diabetic Patients

Recent publication posted by Reuters Health - 'Epidural spinal cord stimulation appears to relieve pain and salvage limbs in diabetic patients with peripheral arterial occlusive disease (PAOD)'. Published September-December 1999 issue of the Journal of Diabetes and Its Complications (J Diabetes Complications 1999;13:293-299).

Italian researchers Drs. Ioannis E. Petrakis and Sciacca V., of the University of Rome, studied 64 diabetic patients with PAOD who had failed conservative or surgical treatment. The patients were classified as Fontaine's stage III and IV, and 'were treated with spinal cord stimulation for rest pain and trophic lesions with dry gangrene.'

After 58 months of follow-up, the researchers found that 38 of the patients achieved greater than 75% pain relief and long-term limb salvage. Another nine patients had partial success, achieving pain relief greater than 50% and avoiding amputation for at least 6 months. The remaining 17 patients underwent amputation, either because the method failed or the device was removed due to technical problems.

A significant increase in pedal transcutaneous oxygen tension within 2 weeks was associated with limb salvage, and was independent of disease stage, the investigators found. A greater than 50% increase in the pedal transcutaneous oxygen tension within 2 months after implantation predicted treatment success, which 'was related to the presence of adequate paresthesia in the painful area during the trial period.'

'In diabetic patients with PAOD, the spinal cord stimulation increases the skin blood flow, is associated with significant pain relief, and could be proven an excellent alternative therapy, improving the life quality,' the authors conclude. However, they suggest that an initial 2-week test period is important to assess patients with a good chance of treatment success, before permanent implantation of the device.

• All patients attending our facility for wound management and diabetic related ischemia, are assessed for clinical acupuncture directed at both the spinal level and extremity inconjunction with appropriate HBOT and medical management 

Conclusion

Hyperbaric Oxygenation is recommended as an adjunctive therapy to current medical and surgical treatment for diabetic and problem wound healing. Adequate tissue oxygen tension is essential for wound healing. In chronic non-union wounds, adequate oxygen tension can only be gained by Hyperbaric Oxygenation (Cianci 1993) and improved with spinal cord stimulation (Ioannis 1999). This results in accelerated tissue oxygenation, enhancement of bacterial killing, fibroblast proliferation, angiogenesis, collagen deposition and ultimately wound repair.

Hyperbaric Medicine is recommended specifically as an adjunctive therapy to accelerate the healing process. Treatments are commenced as daily (and, in many cases, twice daily) 90-minute sessions. Usually an initial 40-60, 90-minute treatment sessions are required to commence the recovery process, in conjunction with other aggressive approaches.

HBOT is not inexpensive. However, compared with the costs of lengthy hospital stay, the real likelihood of amputation and the ongoing costs of rehabilitation care, prosthesis adjustments yearly and repeated surgical procedures (Cianci 1993), HBOT is considered cost effective and is featured on the ‘accepted’ Medicare hospital list for full reimbursement.