Other Modalities of Treatment

(a) Local oxygen therapy: Molecular oxygen is essential during the process of inflammation and repair. Local oxygen therapy increases growth factor expression, increases angiogenesis. Local oxygen therapy is not HBOT. Air tight bag and oxygen are the only requirements. It is also available in portable model and in-hospital delivery device. More clinical trials require to prove its efficacy. (b) Ozone therapy: Ozone is a colorless, pungent odor gas. It is an oxidizing agent and is used in medical condition since nineteenth century. It has disinfecting, oxidizing, and deodorizing properties. It also can decolorize. It is used locally with an airtight bag for wound healing. It is used in diabetic foot wounds, ischemic wounds and necrotizing fasciitis. For other conditions it is administered per rectally and intravenously. (c) Hyper baric oxygen therapy: 2–2.5 ATA (atmosphere absolute) pressure is used in hyper baric oxygen therapy. This therapy results in arterial oxygen tension to around 2000 mmHg and that in tissues of around 400 mmHg. The therapy is given for 90–120 min per day. It is much better than local oxygen therapy. It is best used for post revascularization residual ischemia and PVD with non-operable disease. (d) NPWT: For removal of exudates, to reduce toxic material and bacterial load, to increase neovascularization and to reduce wound edema, NPWT is an excellent therapy. −125 to −75 mmHg pressure is used in NPWT.A specialized type of foam or sponge is used. Drug delivery and oxygen delivery devices are available in new generation NPWT devices. It is contraindicated in malignancy, fistula, and over exposed blood vessels and nerves. (e) Electric therapy & Ultrasonic therapy for wound debridement and healing: Though less utilized, electric therapy is useful for chronic wounds. Normal human skin is found to produce steady electrical potential. On injury to skin endogenous electrical current is produced. Electric therapy decreases bacterial infection, increases local perfusion, accelerates wound healing. It is not a form of radiation or heating, but it uses an electromagnetic field with the aim of stimulating healing. Ultrasound remains a controversial modality in wound management. Electrical waves are converted in to sound waves. Ultrasound is used for debridement. The process is known as cavitation. Vapor bubbles are formed near the surface and bubbles then collapse and disrupt the necrotic tissue. Ultrasound also has vasodilation effect which assists in healing. Low –frequency non-contact airborne ultrasound therapy is thought to be very effective in neuropathic diabetic foot ulcers. (f) Extracorporeal shock wave therapy: Extracorporeal shockwave therapy is very well known for urinary stone disease, but a few wound management surgeons use this therapy for wound healing also. Its role is for granulation tissue formation, re-epithelialization and vascular perfusion. There is recruitment of mesenchymal stem cells, anti-inflammatory as well as antimicrobial effect. The therapy is given once or twice weekly. 100–1000 shocks are given at 0.1 mj/mm2. (g) Compression therapy and devices. Wounds of the extremity heal better if there is no edema or swelling. Elevation of the limb, pressure bandage helps wounds to heal. Two layer and four layer compression bandages, inelastic bandages, elastic stockings and pneumatic compression devices are useful for healing process. These are especially useful in venous stasis ulcers. (h) Low level laser therapy: Carbon dioxide laser is used as a debriding device for diabetic foot wounds. Low level laser therapy is used for wound healing where it stimulates metabolic process, activates macrophages and increases microcirculation.