Boston ADA

What is the optimal treatment for patients with diabetes and osteitis or osteomyelitis of a bone in the diabetic foot, surgical or medical and is there a role for hyperbaric therapi in treating the diabetic foot ulcer?

There is strong evidence on all sides of these questions, and even stronger opinions, but according to the moderator of the session few broadly accepted answers.

Before the surgical treatment was the only and the best. Nowadays from clinical studies we can obtain very positive results by using antibiotics and local treatment of the ulcer, adding with vessel surgery when the blood pressure in the foot is low.

Medical treatment may work for chronic osteitis when the patient has no visible signs of inflammation – but for most patients the foot also needs a surgical approach.

Clinical studies and clinical experience both show that these acute patients need the surgical approach acute. And relying on just medical treatment too often produces the opposite results. By the time the clinician concludes that antibiotics are ineffective, the infection has progressed to the point of risk for amputation.

Team discussion, a multicenter approach at the hospital with all the experts around the patient, is appropriate for handling of an acute diabetic foot ulcer.

The second debate brought up two principal investigators to argue pro and con the effectiveness of hyperbaric oxygen in treating diabetic foot ulcers in a patient with a rather stable foot ulcer after the acute period.

Magnus Londahl, MD, Ph D, from SUS Lund Univ Sweden was the principal investighator for Hyperbaric Oxygen Therapy as Adjunctive Treatment of Chronic Diabetic Foot Ulcers, the HODUFU study. His results suggests that hyperbaric oxygen therapy HBOT is effective and works. The data is published in a referee controlled journal. Ludwik Federko, assoc prof of anesthesiology, MD Ph D from Univ Toronoto, Canada, was principal investigator for a study showing data at a meeting for 2 years ago but not yet published – his interpretation of the literature and hos own research suggest that HBOT is not effective.

The diabetic foot is suffering from microvasculatur disease, said Dr Londahl, and we have evidence that HBOT enhances the lymphocytes to fight the infection and also mobilizes stem cells to repair tissue damage. Together with randomized clinical trials of good quality, Londahl said, it is supporting the use of HBOT to improve outcomes in the long run, in selected groups of patients with diabetic foot ulcers.

But Dr Fedorko said that recently published evidence as well as his own data evidence as well as his own randomized placebo-controlled trial of HBOT for diabetic ulcer showed no clinical benefits, not even non-significant trends. ”In this population of patients, HBOT is potentially harmful because it takes limited resources from many patients away from medical care, debridement, and other modulaties that we know are effective.” This information was also printed as the last words in a brief summary in a journal, Diabetes Dispatch, handed out to all the delegates at the meeting

In  Sweden from Febr 17 2015 in the National Guidelines, Nationella Riktlinjer for Diabetes, HBOT in specisl situations got for the first time a priority, prio 9, in a range from 1-10, 1 highest, and 10 lowest. Local vacuum treatment of foot ulcers in special situations got a priority. also the first time, prio 6

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