Current Concepts In Treating Diabetic Foot Wounds
When You Should Make A Vascular Referral
• In the presence of circulatory impairment, refer the patient for vascular reconstruction. Vascular bypass, especially by the in situ technique for distal occlusions, has been the gold standard. Although graft patency rates are comparable in diabetic and non-diabetic patients, unfortunately the perioperaive mortality rate is significantly higher in the diabetic group.17
Angioplasty, including infrapopliteal angioplasty, turns out to be feasible in many diabetic patients and may indeed be the best primary choice.18 Even angioplasty achieved by subintimal dissection has been effective in certain circumstances.19
Other Options For Difficult Cases
In extremely difficult cases, consider less commonly used treatment options. One study advocates surgical decompression of peripheral nerves to restore sensation and relieve pain.20 Athermic laser radiation had a beneficial effect in one study.21
Hyperbaric oxygen therapy (HBO) may be useful for ischemic wounds in which revascularization is not possible or has been unsuccessful. Be aware that the efficacy of HBO correlates best with transcutaneous oxygen tension (TcPO2) measured in the HBO chamber rather than the usual practice of determining eligibility by measuring TcPO2 augmentation outside the chamber.22
Determining The Prognosis
Healing time correlates with the size, depth and duration of the initial wound. Wound etiology also provides a valuable predictor of wound healing. Neuropathic ulcers without vascular compromise tend to heal in significantly less time (77 days) than those associated with vascular insufficiency (130 days).23 While infection clearly requires control, in one study at least, the presence of osteomyelitis did not impede wound healing time.24 Patients with impaired renal function are particularly prone to nonhealing and limb loss.25
Amputation is most likely to be required in patients who have other remote diabetic complications such as retinopathy and nephropathy, and those with a low ABI. The latter may respond to vascular reconstruction. Unfortunately, limb salvage after vascular bypass does not necessarily translate into improved ambulation and function.26
Diabetic screening and protection programs may reduce the risk of amputation. Interestingly, the evidence is conflicting regarding the efficacy of patient education. One study suggests the benefit of patient education is short-lived (six months) while another study suggests that education has no beneficial effect.27
Insurance may cover prophylactic therapeutic footwear such as extra width and extra length therapeutic shoes with cork, prefabricated inserts or viscoelastic insole. However, there is some question as to the efficacy of widespread dispensing of therapeutic footwear to diabetic patients.28
Active and passive range of motion therapy reduce peak plantar pressures. Therefore, this therapy, theoretically, may help ameliorate the occurrence of foot ulceration.29
Researchers have found that noninvasive surveillance of autologous vascular bypass grafts improves long-term patency rates by identifying potentially failing grafts to allow early repair.30
In summary, diabetic foot ulcers confer a high cost upon society and onerous morbidity upon patients. Focusing on comprehensive multidisciplinary management and prevention is essential in order to help reduce risks and ensure better outcomes.
Dr. Stillman (top right) is the Medical Director of the Wound Healing Center and a member of the Board of Trustees of Northwest Medical Center in Margate, Florida. He has published over 100 research papers and textbook chapters, and has authored or edited a half-dozen surgical textbooks.
Dr. Steinberg (bottom right) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.