Dear Editors,
1.
We sincerely thank Tan and Wang [1] for their valuable comments on a recent study evaluating the role of Hyperbaric Oxygen Therapy (HBOT) in graft reconstruction of diabetic foot wounds [2]. We welcome the opportunity to clarify several important points regarding the methodology and findings.
First, to address the authors' emphasis on selection bias and heterogeneity in the control group, we agree that retrospective designs inherently limit randomisation. However, the patient grouping reflects real‐life clinical practice. HBOT was administered to patients with vascular insufficiency, osteomyelitis and/or advanced Wagner stages, that is, those with a clinical indication. Patients in the control group were either not indicated for HBOT or had absolute (e.g., untreated pneumothorax) or relative contraindications (e.g., claustrophobia, pulmonary blebs or bullae).
Despite this initial clinical imbalance, the HBOT group showed a significantly shorter time to 50% wound healing (18 days vs. 30.5 days, p < 0.05). Furthermore, in patients who underwent successful vascular intervention, the graft uptake rate was significantly higher in the HBOT group (100% vs. 80%, p = 0.037). These results support that HBOT can offset poor clinical baseline status and improve outcomes even in more complex cases.
Another important topic of discussion is the evaluation of 50% healing time as a clinical endpoint. Although 50% healing time is not a “hard” endpoint like amputation or reoperation, it is a practical and meaningful marker of the wound healing process. A review of the literature shows that early epithelialisation reduces the risk of infection, hospitalisation and limb loss [3, 4]. In the aforementioned study, a significant negative correlation was found between graft uptake rate and healing time (r = −0.418, p < 0.05), indicating that faster healing is associated with better graft outcomes.
In the clinical setting described, HBOT was recommended to patients in the HBOT group because of vascular insufficiency, infection, or delayed wound healing in the pre‐grafting period. After multidisciplinary evaluation, some patients continued to receive HBOT after grafting. However, given that each patient was evaluated individually and the retrospective design of the study, it was not possible to apply the same number of HBOT sessions in all patients in the pre‐ and postoperative periods in a standardised manner.
HBOT has been used in the preoperative period to support granulation tissue formation, increase wound healing, reduce edema, and suppress infection. In the postoperative period, it increased oxygenation and accelerated tissue regeneration. This reflects the holistic and integrated application of HBOT in the treatment process.
It is agreed that prospective, randomised studies with larger samples are necessary to ensure the generalisability of the results. Nevertheless, the discussed study addresses an important gap in the literature, especially in high‐risk diabetic foot patients requiring graft reconstruction. Graft failure has significant clinical and economic consequences. It is of great importance to evaluate complementary therapies such as HBOT, even in moderate‐sized but well‐analysed patient groups. The study achieved statistically significant results and showed consistent benefits across subgroups.
We sincerely appreciate the scientific criticism of Mr. Tan and Wang [1]. Their observations largely overlap with the limitations clearly stated in the original article. However, the findings support the value of HBOT in increasing graft survival and accelerating healing, especially in patients with infection, ischaemic status, and poor tissue perfusion. HBOT should be considered as a valuable adjunctive treatment option in the management of complex diabetic foot wounds requiring reconstructive surgery.
Ethics Statement
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Zaman T. and Yilmaz K. B., “ HBOT in Grafted Diabetic Foot Ulcers: Clarifications and Clinical Implications,” International Wound Journal 22, no. 8 (2025): e70746, 10.1111/iwj.70746.
Funding: The authors received no specific funding for this work.
Data Availability Statement
The authors have nothing to report.
References
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Associated Data
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Data Availability Statement
The authors have nothing to report.