· Advanced age
· Nutritional Deficits
· Vascular insufficiency
· Diabetes Mellitus
· Soft Tissue Infections
· Tobacco
· Radiation Damage
· Tissue Hypoxia
   * Venous insufficiency and ischemia
· Local factors
   * Bacterial load
   * Presence of necrotic tissue
   * Dead space motion
· Poor management of the wound
   * Untrained nurses
   * Inappropriate dressings

A full and thorough assessment of a poorly healing wound is the key to successful treatment. Particular attention must be given to identifying and treating the root factors that may contribute to the wound’s inability to heal, such as poor nutrition, medications and underlying medical conditions.
Other tools are;
· Photographic and Wound Mapping
· Blood Pressure Measurements (Doppler evaluation of arterial circulation)
· Transcutaneous oximetry (oxygen measurements)
· Ultrasound investigations
· Wound Culture

Modern equipment and techniques in combination with tried and tested surgical procedures are used to ensure that the wound is given the best possible chance of rapid healing. Some of the techniques used are;
· Conservative debridement
· Wound dressings and appropriate care
· Hyperbaric Oxygen Therapy
· Wound irrigation
· Lymph drainage
· Larval Therapy
· VAC Therapy
· Ultrasound
· Patient education

Local-Tissue Hypoxia and Infection are the primary defects underlying problem wounds in the absence of nutritional deficits and other factors. Hyperbaric oxygen specifically treats both of these underlying factors.
Hyperbaric oxygen increases the oxygen concentration in infected tissues, including bone, and kills or inhibits the growth of organisms, which prefer low oxygen concentrations.

HBO promotes healing by;
· Enhancing collagen synthesus
· Enhancing fibroblast replication
· Enhancing new vascularisation

HB0 is adjunctive and must be used with appropriate antibiotics (determined by bone culture and sensitivity testing), surgical debridement, nutritional support, and reconstructive surgery.

Any hypoxic wound that fails to heal within a reasonable period of time by the use of conventional medical or surgical techniques.
Accurate prediction of wound healing potential is essential to avoid increased morbidity and mortality rated which accompany ischaemic breakdown of failed debridement, amputation and revascularization.Transcutaneous oximetry is used as a reliable indicator to determine healing potential of non-healing wounds.

Mattieu D. Handbook on Hyperbaric Medicine, Chap 2.2.9. 401-427, 2006 Springer
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