Patients presenting with DFUs should be queried as to how long the wound has been present and what treatment, if any, has been tried. Many neuropathic patients are unaware that a wound is present until drainage begins or tissue becomes necrotic and malodorous. This is the classic "fetid foot" presentation. Patients with DM are immunocompromised and often do not mount a fever or elevated white blood cell count in the face of significant infection. 

The patient should have both feet examined at every visit. The toes should be manually separated and interdigital tissue assessed for cracks, fissures, or signs of fungal infection. The patient should be asked about glycemic control and informed that for DFUs to heal the blood sugar must be consistently 150 mg/dL or less. A Semmes-Weinstein 10-gram monofilament test to assess for loss of protective sensation should be performed and result documented. Dorsalis pedis and posterior tibial pulses should be assessed. If these are not palpable, Doppler signals should be assessed and documented. It is recommended that all patients over 50 years of age should undergo a baseline arterial ultrasound with Ankle-Brachial and Toe-Brachial indices and Pulse Volume Recordings. Any abnormality in peripheral circulation warrants referral to a vascular surgeon.

The patient's footwear and gait should be assessed and documented. Many DFUs are caused by inappropriate footwear which causes friction and pressure on the deformed diabetic foot.

The wound is the last thing that should be assessed. The length, width, and depth should be documented in centimeters. Any tunneling or undermining should be noted. The wound bed should be assessed to determine if the wound extends to or probes to the bone. The periwound tissues should be assessed for fluctuance, induration, or maceration from moisture associated with wound drainage. Odor, color, and quality of wound drainage should be noted and documented.

Once the DFU is assessed and staged, it is helpful to obtain certain laboratory and radiographic data.

Baseline CBC with differential count, chemistry with BUN and creatinine, sedimentation rate, and C-reactive protein to assess for osteomyelitis, as well as a glycosylated hemoglobin level are all helpful. If bone involvement is suspected, plain film radiograph followed by MRI or a 3-phase bone scan may be necessary. 

Wounds that are staged as a Wagner 3 or higher that have failed conventional wound care for 30 days should be referred for hyperbaric medicine consultation. Chronic wounds are oxygen starved as are the periwound tissues. The only way to increase oxygen delivery to these hypoxic tissues is with hyperbaric oxygen treatments. Hyperbaric oxygen increases oxygen concentration to the wound, stimulates angiogenesis in and around the wound, facilitates delivery of certain antibiotics to the tissues, stimulates fibroblasts, and encourages migration of growth factors to the wound bed.

Hyperbaric oxygen is, simply, 100% oxygen delivered under supra-atmospheric pressure. The patient is treated in either a multiplace or monoplace pressure vessel for human occupancy or a chamber. Treatments usually are conducted at 2 to 2.4 atmospheres absolute. This pressure is equivalent to 33 feet and 42 feet of sea water. Patients usually are treated for approximately 60 to 90 minutes every day for 30 to 60 treatments. Patients at risk of oxygen toxicity at these hyperoxic levels are given 5-minute air breaks every 30 minutes throughout the treatment, during which time they breathe 21% oxygen from a face mask or handheld mouthpiece. This decreases the risk of seizures from oxygen toxicity to approximately 1:10,000 treatments. 

The mainstay of treatment for DFUs is offloading. DFUs will not heal until they are adequately offloaded and have no sustained pressure on the wound bed. Multiple modalities exist for offloading including custom molded shoe inserts and neuropathic walker boots. Total contact casting is the gold standard to offload DFUs on the weight-bearing surface of the heel. 

Clinical practice guidelines recommending the use of hyperbaric oxygen therapy in the treatment of DFU suggest adding hyperbaric oxygen treatment (HBOT) to patients with Wagner 3 or higher DFU who have recently had a surgical debridement of an infected foot. HBOT delivered acutely in the postoperative period will reduce the risk of major amputation and incomplete reepithelialization. Further recommendations suggest adding HBOT to the standard of care treatment in patients with Wagner 3 or higher DFU that have not shown significant improvement after 30 days of treatment to reduce the risk of major amputation and incomplete reepithelialization. Recommendations also suggest against the use of HBOT in patients with Wagner 2 or lower DFU. [13]

Studies have demonstrated that patients who received hyperbaric oxygen (HBO2) treatment for DFUs healed faster and remained healed at one year, more than their cohorts who were not treated with HBO2.  

• Anaemia

• Arthritis

• Atherosclerosis

• Autonomic neuropathy

• Chronic venous insufficiency

• Diabetic foot infections

• Muscle pain

• Metabolic neuropathies

• Myxedema

• Radicular pain

HBO2 for DFUs has been shown to improve healing rates and decrease the number of major amputations in the diabetic population. Recent research and evidence have driven the new paradigm of aggressive treatment and the attempt to save a limb, if at all possible, to prevent the morbidity and mortality associated with a major amputation. HBO2 is an accepted and approved treatment for DFUs by the Center for Medicare Studies (CMS) and by third-party insurance payers. Patients require careful screening and selection, and the recommendations set forth by CMS and the Undersea and Hyperbaric Medicine Society should be followed. 

The management of a diabetic foot ulcer is very complex and if not treated properly can lead to premature amputation. Patients receiving HBO2 still must be followed for regular wound care visits which include regular measurements of the wound, aggressive surgical debridement, appropriate culture-directed antibiotics, good glycemic control with blood sugar goal of 150 or less at all times, and appropriate offloading. The successful treatment and healing of a DFU require an interprofessional team consisting of a hyperbaric medicine specialist/wound care specialist, primary care physician, podiatrist, wound care nurse, and sometimes, endocrinologist and vascular surgeon.

At each visit, the wound must be examined and complete reliance on HBO for cure is not realistic. Without adequate blood supply, no wound can be expected to heal.[2][5]