Efficacy, Safety and Economic Benefits of Topical Wound Oxygen Therapy in the Treatment of Chronic Diabetic Foot Ulcers (TWO2DFU)

A Multi-national, Multi-center, Prospective, Randomized, Double Blinded, Placebo-controlled Trial to Evaluate the Efficacy of HyperBox Cyclical Topical Wound Oxygen Therapy (TWO2) in the Treatment of Chronic Diabetic Foot Ulcers

The purpose of this study is to evaluate the efficacy, safety and economical benefits of Cyclical Pressure Topical Wound Oxygen (TWO2) Therapy in the treatment of chronic diabetic foot ulcers. Subjects will wear a standardized off-loading device and use advanced moist wound therapy (AMWT) dressings. Following a 2 week run-in period with the standardized care and after meeting all the eligibility criteria, half the subjects will use the TWO2 device, while the other half will use a sham device.

Study Overview

• Status: Completed
• Conditions: Diabetic Foot Ulcer
• Intervention / Treatment: Device: TWO2 Device; Device: Placebo Device

Detailed Description

Subjects meeting the initial eligibility criteria will enter a 2 week run-in period with a standardized off-loading device, advanced moist wound therapy (AMWT) dressings and will receive sharp debridement. Subjects with wounds that do not decrease more than 30% at the end of the 2 week run-in period and where all other eligibility criteria are met, will be randomized to either the TWO2 device arm, or sham (placebo) device arm.

All subjects will use the TWO2/Sham device for 90 minutes a day at their home or nursing care facility 5 times a week for the treatment phase of up to 12 weeks. Monitoring of the wound will take place with weekly clinic visits for safety and compliance assessment and documentation. Weekly wound photographs and measurements will be taken. Wounds that close at, or before, 12 weeks will continue to use TWO2/sham device, off-loading and AMWT and have an additional visit two weeks later to confirm wound closure. All subjects whether healed or not will enter a follow up period of an additional 12 and 38 weeks.

The maximum duration for participation in the trial is 54 weeks. During the follow-up phase, subjects will receive standard care according to the clinician's recommendation and will be asked not to participate in another wound care trial during this period.

• Study Type: Interventional
• Enrollment (Actual): 73
• Phase: Not Applicable

Contacts and Locations

Study Locations

• France
  • Bobigny, France, 93000
    • Avicenne Hospital
  • Eaubonne, France, 95600
    • Hospital Simone Veil
  • Montpellier, France, 34000
    • Montpellier University Hospital
• Germany
  • Dessau, Germany, 06847
    • Städtisches Klinikum Dessau
• Luxembourg
  • Luxembourg, Luxembourg, L-2540
    • Kirchberg Hospital
• United Kingdom
  • Harrow, United Kingdom, HA1 3UJ
    • Northwick Park Hospital
  • London, United Kingdom, SE5 9RS
    • King's College Hospital
• United States
  • Arizona
    • Phoenix, Arizona, United States, 85012
      • Carl T. Hayden VA Medical Center
  • California
    • Vacaville, California, United States, 95687
      • NorthBay Center for Wounds
  • District of Columbia
    • Washington D.C., District of Columbia, United States, 20422
      • Washington DC VA Medical Center
  • Florida
    • Hialeah, Florida, United States, 33013
      • The Research Center Inc.
    • Miami, Florida, United States, 33012
      • Advanced Research Institute of Miami
    • Miami, Florida, United States, 33134
      • Advanced Research Institute of Miami
  • Illinois
    • Chicago, Illinois, United States, 60141
      • Edward Hines, Jr. VA Hospital
  • Nevada
    • Las Vegas, Nevada, United States, 89119
      • Advanced Foot & Ankle Center
  • Virginia
    • Richmond, Virginia, United States, 23249
      • Hunter Holmes McGuire VA Medical Center
    • Salem, Virginia, United States, 24153
      • Salem VA Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 89 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Subject has a documented diagnosis of Diabetes mellitus Type 1 or 2
• Foot ulcer at or below ankle with duration of more than 4 weeks but no longer than 1 year
• If the index ulcer is a post amputation wound date of surgery must be > 30 days
• 2 week run in period with less than 30% wound size reduction
• University of Texas Grade 1A, 1B, 1C, 1D, 2A, 2B, 2C, or 2D (Appendix I)
• Ulcer is ≥ 1cm2 and ≤ 20cm2 after debridement at start of run-in period
• If more than one ulcer is present on the foot, only the largest is considered in the study (Index ulcer)
• Index ulcer must be ≥ 1cm away from any other ulcers present on the foot
• Adequate perfusion with ABI > 0.7 And TcpO2 > 30mmHg OR skin perfusion > 30mmHG OR Toe pressure > 30mmHg OR Duplex with biphasic waveforms below the knee
• No planned revascularization procedure or vascular surgery within the last/next 30 days
• Subject and/or caregiver are willing and able to comply with all specified care and visit requirements
• Subject has a reasonable expectation of completing the study; according to the Investigator's clinical judgment

Exclusion Criteria:

• Evidence of gangrene on any part of affected limb
• Documented evidence of osteomyelitis on any part of affected limb
• Index ulcer has exposed bone
• Index ulcer exhibits signs of severe clinical infection that requires hospitalization or immediate surgical intervention
• Active Charcot foot on the study limb
• Subject participated in another investigational device, drug or biological trial within last 30 days
• Uncontrolled diabetes: HbA1c > 12 %
• Renal dialysis or creatinine > 2.5
• Known immune insufficiency
• Chronic steroid use or immunosuppressive agents within the last three (3) months or is anticipated to require them during the course of the study
• Active treatment for malignancy (not specific to study limb)
• Patient has a Deep Vein Thrombosis within the last 30 days
• Subject has received growth factor therapy (e.g., autologous platelet-rich plasma gel, becaplermin, bilayered cell therapy, dermal substitute, extracellular matrix) within the screening period
• Subject may not be pregnant at the time of treatment

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Topical Wound Oxygen Device; Application of the Topical Wound Oxygen (TWO2) device that supplies cyclical oxygen pressure directly to the wound site within a sealed and humidified environment for 90 minutes, 5 times a week with Advanced Moist Wound Therapy (AMWT) dressings. Other Names: Topical Wound Oxygen Therapy; TWO2	Device: TWO2 Device; Application of the Topical Wound Oxygen (TWO2) device that supplies cyclical oxygen pressure directly to the wound site within a sealed and humidified environment for 90 minutes, 5 times a week with AMWT dressings.; Other Names: TWO2 Therapy
Placebo Comparator: Placebo Device; Application of placebo device that does not supply cyclical oxygen pressure directly to the wound site within a sealed and humidified environment for 90 minutes, 5 times a week with AMWT dressings.	Device: Placebo Device; Application of placebo device that does not supply cyclical oxygen pressure directly to the wound site within a sealed and humidified environment for 90 minutes, 5 times a week with AMWT dressings.; Other Names: Sham Device, Control Device

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Wound Closure Within 12 Weeks With the Use of Topical Wound Oxygen Therapy (TWO2)	Number of Participants with complete wound closure defined as 100% skin re-epithelialization without dressing requirements which is confirmed by 2 consecutive study visits 2 weeks apart.	12 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Absolute Change in Ulcer Area	Absolute change in ulcer area over 12 weeks in cm2	12 weeks
Ulcer Recurrence	Number of diabetic foot ulcers with recurrence at 12 months	12 months
Number of Amputation Events	Number of amputation events during interventional period of the study.	12 weeks
Incidence of Adverse Events	Incidence of serious adverse events and adverse events	54 weeks
Quality of Life Assessment	The Cardiff Wound Impact Schedule questionnaire to measure quality of life. Measure of well-being items from each scale are summated, physical symptoms, everyday living and social life. The items are rated for the extent of the experience and each item is given a number value. This allows the patients to weight the items included in the scale. The well-being scale is scored on a 5-point Likert scale, with response options from 'strongly agree' to 'strongly disagree'. All three scales are then transformed onto a minimum = 0 up to a maximum = 100, where a low score indicates worse, and a high score indicates better feeling of well-being.	12 weeks
Economic Analysis	Not performed or reported. Economic Analysis is a composite measure of the wound before the study (up to one year) and for the duration of the study. The assessment is obtained by documenting treatment history of the wound that includes types of dressings used, time taken for dressing changes, by whom dressings are changed, and type and duration of hospitalization as well as the administration of the EQ-5D questionnaire at the Baseline visit, weeks 4, 8 and 12 on treatment.	12 weeks
Time to Complete Wound Closure in Weeks	Time to 100% wound closure utilizing Cox proportional hazards model, a statistical measure of difference of time to event (healing). Subjects who withdraw from treatment will be entered into the analysis and censored at the time they withdraw from the trial or are lost to follow up. The analysis will consider covariates that might influence the outcome in the trial.	12 weeks or wound closure

Collaborators and Investigators

• Sponsor: AOTI Ltd.
• Investigators: Principal Investigator: Robert G Frykberg, DPM, Carl T. Hayden VA Medical Center

Publications and helpful links

General Publications

• Frykberg RG, Franks PJ, Edmonds M, Brantley JN, Teot L, Wild T, Garoufalis MG, Lee AM, Thompson JA, Reach G, Dove CR, Lachgar K, Grotemeyer D, Renton SC; TWO2 Study Group. A Multinational, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial to Evaluate the Efficacy of Cyclical Topical Wound Oxygen (TWO2) Therapy in the Treatment of Chronic Diabetic Foot Ulcers: The TWO2 Study. Diabetes Care. 2020 Mar;43(3):616-624. doi: 10.2337/dc19-0476. Epub 2019 Oct 16.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2014
• Primary Completion (Actual): February 5, 2018
• Study Completion (Actual): October 25, 2018

Study Registration Dates

• First Submitted: November 19, 2014
• First Submitted That Met QC Criteria: December 26, 2014
• First Posted (Estimated): December 29, 2014

Study Record Updates

• Last Update Posted (Estimated): October 27, 2025
• Last Update Submitted That Met QC Criteria: October 10, 2025
• Last Verified: October 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Endocrine System Diseases; Vascular Diseases; Cardiovascular Diseases; Diabetes Mellitus; Diabetic Angiopathies; Diabetes Complications; Skin Diseases; Skin Ulcer; Leg Ulcer; Diabetic Neuropathies; Foot Ulcer; Skin and Connective Tissue Diseases; Diabetic Foot
• Other Study ID Numbers: AOTI- TWO2DFU-01

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes