Wound healing/plastic surgeryExtracorporeal Shockwave Treatment for Chronic Diabetic Foot Ulcers
Introduction
Chronic diabetic foot ulcer is caused by small-vessel occlusion, usually compounded by neuropathy and infection [1, 2, 3, 4, 5, 6]. Despite the changes in guidelines and classification, the treatment of a diabetic foot ulcer remains challenging and controversial [7, 8, 9, 10, 11, 12]. Angioplasty or bypass surgery is generally ineffective in small-vessel disease and amputation becomes inevitable due to persistent critical limb ischemia, soft-tissue infection, and impaired wound healing with osteomyelitis [13, 14]. Skin grafts with different techniques are performed with the intention to heal the ulcers in selected cases [15]. Many adjunctive therapies are designed for the care of chronic diabetic foot ulcers including hyperbaric oxygen therapy (HBO), ultrasound, recombinant human platelet-derived growth factor-BB, vacuum-assisted wound closure, and acellular matrix with HBO being the most commonly used [13, 16, 17, 18, 19, 20, 21, 22]. The results of different treatment regimens of surgical and nonsurgical are inconsistent, and most studies reported limited success in selected series [19, 20, 21, 22, 23]. Therefore, the development of a new effective and noninvasive method of treatment for chronic diabetic foot ulcer is extremely valuable.
Recently, extracorporeal shockwave treatment (ESWT) was introduced for the treatment of chronic refractory diabetic and nondiabetic skin ulcers, and acute and chronic soft-tissue wounds with encouraging early results in short-term follow-up [24, 25, 26, 27]. The purpose of this study was to evaluate the efficacy of ESWT in the treatment of chronic diabetic foot ulcers and to compare the results with that of HBO and to investigate the regeneration effects with local blood flow perfusion, histomorphological examination, and immunohistochemical analysis.
Section snippets
Patients and Methods
The Institutional Review Board on Human Studies of our hospital approved this study. The declaration of Helsinki protocols were followed, and patients gave their written informed consent prior to participation in the study. The inclusion criteria included patients with recurrent chronic diabetic ulcers of the foot for more than 3 mo duration. Patients with deep wound sepsis or gangrenous changes usually required surgical debridement and wound care until the ulcers became stable but nonhealing
Results
The overall results of treatment are summarized in Table 2. The results showed completely healed in 31%, improved in 58%, and unchanged in 11% for the ESWT group and 22% completely healed, 50% improved, and 28% unchanged for the HBO group (P < 0.001). More than 50% improvement of the ulcer was observed in 89% of ESWT group and 72% of HBO group (P < 0.001). ESWT appears to be more effective than HBO in the treatment of diabetic foot ulcers.
In histomorphological examination, the microscopic
Discussion
The causes of diabetic foot ulcers are multifactorial, including ischemia, hypoxia, neuropathy, and infection, and they often coexist [3, 4, 5, 14, 28]. The management of chronic diabetic foot ulcers require multidisciplinary approaches including control of blood sugar, antibiotics, shoe wear, wound care, and surgery in selected cases with the primary goal to control the diabetic mellitus and to avoid complications [2, 3, 4, 5, 19, 28]. In some cases, amputation becomes inevitable due to
Acknowledgments
Funds were received in total or partial support for the research or clinical study presented in this article. The funding sources were from the National Science Council (95-2314-B-182A-081), Tissue Regeneration Technologies, and National Health Research Institute (NHRI-EX96-9423EP).
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