The following case studies are intended to show the efficacy of hyperbaric oxygen therapy for wound healing. The photographs are graphically explicit and may be inappropriate for some viewers.
CASE STUDY: Diabetic Foot Ulcer
Robert M. Joseph DPM, PHD from Robert Joseph Podiatry, Dayton Ohio. 12/1/2010
BACKGROUND:
Wounds remain the most prevalent cause for hospitalization in those with diabetes. An estimated 80% of diabetes associated amputations are related to a wound. Hence, prevention and prompt treatment of diabetic foot ulceration is imperative to amputation prevention.
Patient:
66 year old male presented with a longstanding history of diabetes, peripheral neuropathy, and chronic ulceration of the great toe of 1.5 yrs duration. The wound failed to respond to local wound care and use of custom shoe wear to reduce ulcer pressure and promote healing. The patient suffered multiple episodes of cellulitis prior to seeing a wound specialist. (Figure 1)
Figure 1
Clinical Findings:
2.5 cm ulceration beneath the interphalangeal joint of the great toe without extension of the wound to bone. Mixed necrotic and granular wound bed was noted as well as periwound callus formation. Limited metarsalphalageal joint range of motion was noted with periarticular spurring noted at the first metatarsalphalangeal joint on radiograph. (Fig 2)
Figure 2
Assessment:
Chronic neurotrophic ulceration caused by complications of diabetic peripheral neuropathy and concomitant limited range of motion of the great toe associated with Hallux Rigidus deformity. Hallux rigidus (loss of great toe motion) resulted in increased pressure beneath the great toe and subsequent ulceration due to advanced peripheral neuropathy. Poor glycemic control and lack of patient education regarding the risk of diabetic foot complications and preventative foot care complicated his condition.
Treatment:
The patient underwent resection of the base of the proximal phalanx of the great toe and removal of perarticular impingement of the first metatarsalphalaneal joint to improve range of motion of the joint and reduce ulcer pressure. (Fig 3)
Figure 3
Results:
The procedure successfully increased joint motion and reduced ulcer pressure which enabled wound healing. The ulcer resolved after 6 weeks of continued wound care and has not returned since surgery in 2008. (Fig 4)
Figure 4
Clinical Pearls:
Clinicians should recognize callus formation beneath the great toe as a risk for ulceration and amputation in those with diabetes. In some instances surgical treatment as described above can be utilized for the treatment of ulcerative and pre-ulcerative conditions.
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