title: Hyperbaric oxygen for the treatment of diabetic foot ulcers: a systematic review.
abstract: OBJECTIVE
  A systematic review of randomized clinical trials (RCTs) to assess the additional value of hyperbaric oxygen therapy (HBOT) in promoting the healing of diabetic foot ulcers and preventing amputations was performed.
  
  
  METHODS
  MEDLINE, Embase, and the Cochrane Library were searched to identify RCTs in patients with diabetic foot ulcers published up to August 2013. Eligible studies reported the effectiveness of adjunctive HBOT with regard to wound healing, amputations, and additional interventions.
  
  
  RESULTS
  Seven of the 669 identified articles met the inclusion criteria, comprising 376 patients. Three trials included 182 patients with ischaemic ulcers, two trials studied 64 patients with non-ischaemic ulcers, and two trials comprising 130 patients did not specify ulcer type. Two trials were of good methodological quality. Pooling of data was deemed inappropriate because of heterogeneity. Two RCTs in patients with ischaemic ulcers found increased rates of complete healing at 1-year follow-up (number needed to treat (NNT) 1.8 (95% CI: 1.1 to 4.6) and 4.1 (95% CI: 2.3 to 19)), but found no difference in amputation rates. A third trial in ischaemic ulcers found significantly lower major amputation rates in patients with HBOT (NNT 4.2, 95% CI: 2.4 to 17), but did not report on wound healing. None of the RCTs in non-ischaemic ulcers reported differences in wound healing or amputation rates. Two trials with unknown ulcer types reported beneficial effects on amputation rates, although the largest trial used a different definition for both outcomes. HBOT did not influence the need for additional interventions.
  
  
  CONCLUSIONS
  Current evidence shows some evidence of the effectiveness of HBOT in improving the healing of diabetic leg ulcers in patients with concomitant ischaemia. Larger trials of higher quality are needed before implementation of HBOT in routine clinical practice in patients with diabetic foot ulcers can be justified.
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Electronic address: R.M.Stoekenbroek@amc.uva.nl.
authors.forename: R M
authors.initials: RM
authors.lastname: Stoekenbroek
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: T B
authors.initials: TB
authors.lastname: Santema
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: D A
authors.initials: DA
authors.lastname: Legemate
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: D T
authors.initials: DT
authors.lastname: Ubbink
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Hyperbaric Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: A
authors.initials: A
authors.lastname: van den Brink
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: M J W
authors.initials: MJ
authors.lastname: Koelemay
mesh_terms: D000671:Amputation, Surgical; D003131:Combined Modality Therapy; D017719:Diabetic Foot / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D006931:Hyperbaric Oxygenation; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage; D012039:Regional Blood Flow; D016896:Treatment Outcome; D014945:Wound Healing
keywords: Diabetes; HBOT; Hyperbaric oxygen; Ulcers; Wounds