DFU Management Guidelines

Treating diabetic foot ulcer encompasses a multidisciplinary team of physicians, orthopaedics, radiologists, and vascular surgeon. The aim is to ensure revascularization, wound healing with or without debridement, achieving targeted HbA1c, reducing excessive load over foot or limb, and mitigate infections by prescribing antibiotics and assessing complications. Emphasis on the patient's education and nutrition is essential in decreasing recurrence of diabetic foot ulcer.

Offloading

  • Offloading implies reduction, redistribution, or sharing pressures over the ulcer area. It is very essential in managing diabetic foot ulcers successfully and preventing the decrease of plantar pressure. This is achieved by redistributing it to a larger area, to avoid shear and friction, and to accommodate the deformities.
  • A proper cast is imperative for diabetic foot ulcer. A non-removable cast device is clinically effective for neuropathic forefoot and mid-foot ulceration for the immobilization of foot and ankle within the cast, which significantly decreases the sheer force.
  • The total contact cast is a below-knee cast, encroaches the lower limb, and encases the entire foot. It is the main cast for mid and forefoot lesions and for neuropathic non-infected plantar ulcers. Healing occurs in almost 100% cases of ulcers within a time period of 5-8 weeks. For non-cast offloading devices, half shoes are designed to offload either the fore or rear foot. The following choices can be made:

  • Rear foot
    For weight-bearing:
  • Crutches with or without a below-knee cast and a half shoe.

  • For non-weight-bearing:
  • Leg trough, pressure-relieving mattress and flexible heel cast or pillows.

  • Mid-foot
  • Total contact cast, below-knee cast, or fiberglass boot. Felt padding can be shaped to cover the sole of the foot with a cavity at the ulcer site.

  • Forefoot
  • Half shoe; leg- or boot-type cast is the most effective method for offloading; sandals with a foam-filled sink in the sole unit located over the ulcer site.

  • Toe
  • A hole is cut in the part of the shoe overlying the ulcer site to remove the whole toe from shoe.

  • The following steps need to be followed for the overall management of DFUs:

    Control of foot infection
  • Usually most DFUs are relatively superficial at presentation, microorganisms can spread contiguously to the subcutaneous tissues, including fascia, tendons, muscle, joints, and bones.
  • First-generation cephalosporin, clindamycin, fluoroquinolone, linezolid is recommended to avoid these infections.
  • Ticarcillin/clavulanate, piperacillin/tazobactam; second- or third generation Cephalosporin or Third-generation cephalosporin, impinemen can be prescribed to manage moderate infection without systemic involvement.
  • It is advised to prescribe Ticarcillin/clavulanate, piperacillin/tazobactam; + ceftazidime, flucloxacillin + cipro, carbapenem for treating severely infected ulcer with systemic signs.
  • Ticarcillin/clavulanate, piperacillin/tazobactam or carbapenem; second−/third generation cephalosporin + clindamycin or metronidazole can be used for the treatment of Ischemic limb/necrosis/gas forming infections.

  • Control of ischemia
    Revascularization surgery:
  • In case the medical management fails, patients with peripheral ischemia with significant functional disability should go for surgical revascularization. This may reduce the risk of amputation in patients in such patients.
  • The procedures include open (bypass grafting or endarterectomy) or endovascular techniques (angioplasty with or without stent).
  • Extracorporeal shock wave therapy can also be initiated, which acts by increasing angiogenesis and blood supply and cellular proliferation, thus, hastening wound healing.
  • One of the adjunctive therapy which can be used for DFUs are Low-energy lasers

  • Wound debridement
  • If the surface is clean, ulcers heal quickly. Thus, physicians must debride any impediments to healing, such as necrotic tissue and bacteria. Sharp debridement is recommended for the removal of necrotic tissue that extends beyond the ulcer bed.
  • Good results have been reported ulcer is converted to fresh ulcer by excising the ulcer and underlying bony prominences.
  • Various strategies of debridement include physical debridement using wet-to-dry dressing, enzymatic debridement using enzymes like collagenase and papain as ointment preparations, autolytic debridement with the use of moisture retaining dressings, and biological debridement with the use of larvae of common green bottle fly.

  • Wound dressings
  • A warm and moist environment is often necessary for healing post debridement which is provided by dressings. Common problems associated with it include dehydration of the ulcer bed, saturation with exudate, and/or the failure to properly apply antibiotics and growth factors needed to promote angiogenesis and granulation tissue. Non-medicated dressings include paraffin gauze, and medicated dressings include Xeroform.
  • Saline-moistened gauze dressings (wet-to-dry), moisture-retaining and antiseptic dressings, silver dressings, and cadexomer are some of the dressing materials.
  • Chemically treated honey can also be used alone or in combination with sterile dressings.

  • A meta-analysis was done in which people with neuropathic foot ulcers received good wound care reported that 24% of ulcers attained complete healing by 12 weeks and 31% by 20 weeks.


    REFERENCES
    1.https://iwgdfguidelines.org/wp-content/uploads/2019/05/definitions-and-criteria-final.pdf, IWGDF Guidance,2019
    2.https://www.valueinhealthjournal.com/article/S1098-3015(17)30823-9/fulltext
    3. Rastogi A, Bhansali A. Diabetic foot infection: An Indian scenario. J Foot Ankle Surg (Asia-Pacific) 2016;3:71-9.
    4.Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217-28.
    5.Rosyid FN. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017 Oct;5(10):4206-13.
    6. https://surgery.ucsf.edu/conditions--procedures/diabetic-foot-ulcers.aspx
    7. Rogers LC, Frykberg RG, Armstrong DG, Boulton AJ, Edmonds M, Van GH, Hartemann A, Game F, Jeffcoate W, Jirkovska A, Jude E. The Charcot foot in diabetes. Journal of the American Podiatric Medical Association. 2011 Sep;101(5):437-46.
    8.https://geekymedics.com/ankle-brachial-pressure-index-abpi-measurement-osce-guide/#:~:text=The%20ankle%2Dbrachial%20pressure%20index,and%20the%20posterior%20tibial%20artery
    9.https://cdn.intechopen.com/pdfs/72330.pdf

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