Examining The Evidence For Preventing Diabetic Foot Ulcers
Q: What does not work for foot ulcer prevention in patients with diabetes?
A: Dr. Suzuki does not like “white 100 percent cotton socks” that DPMs commonly recommend for patients with diabetes, although he does note that the white color identifies bleeding and drainage. He suggests using moisture-wicking material (synthetic blend or specific wool material such as “cool max” or “smart wool”) and sheer-force reducing multilayer socks with no seam, which should prevent blisters that lead to foot ulcers. Dr. Suzuki also notes the “X-Static” silver antimicrobial socks. He says the silver fiber in these socks decreases the skin flora and goes to the wound immediately when the skin is damaged.
Failing to prevent diabetic ulceration usually results from a delay in diagnosing an underlying risk factor, according to Dr. Zgonis. He says factors that may help prevent the healing of a recalcitrant wound include underlying infection, tissue hypoxia, biomechanical abnormalities and systemic factors.2
Q: What evidence do we have about diabetic shoes and insoles in the prevention role?
A: “The idea of therapeutic diabetic shoes being the answer of DFU prevention is a misconception practiced by many practitioners,” argues Dr. Zgonis. “There is no consistent supporting evidence suggesting that therapeutic shoes and inserts dispensed freely to patients with diabetes mellitus will prevent skin breakdown.”
Dr. Zgonis notes that researchers have shown that thorough foot inspections and proper foot care by healthcare professionals are more effective than therapeutic footwear.21 However, he says in patients with previous foot amputations or severe structural deformities, therapeutic footwear has shown promising results.22 Although some studies do support that inappropriate footwear is a precipitating factor for ulcerations in high-risk patients, Dr. Zgonis emphasizes that the evidence supporting ulcer prevention with therapeutic shoes and insoles in all patients with diabetes is inconsistent.21,22
“This does not imply that therapeutic footwear and orthotic management is not beneficial,” maintains Dr. Zgonis. “It simply implies that it needs to be individualized and overseen by a healthcare professional who is knowledgeable in the diabetic foot.”
Dr. Mowen is likewise skeptical of the evidence on diabetic shoes since amputation rates continue to rise.
Dr. Bevilacqua is an attending surgeon at the Foot and Ankle Clinics at Broadlawns Medical Center in Des Moines, Iowa.
Dr. Habershaw is an Assistant Professor of Surgery at Boston University School of Medicine, and is the Chief of Podiatry at Boston Medical Center.
Dr. Mowen runs a lower extremity neuropathy clinic in Ventnor, NJ. He is board certified in podiatric orthopedics and primary podiatric medicine. He is an Associate Member of the Academy of Ambulatory Foot Surgeons, and is a Member of the Fellowship of Peripheral Nerve Surgeons.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at Cedars-Sinai Medical Towers in Los Angeles. He is a consultant, researcher and lecturer on wound care and limb salvage in the U.S. and in Japan. The author can be contacted via e-mail at firstname.lastname@example.org.
Dr. Zgonis is an Assistant Professor in the Department of Orthopaedics/Podiatry Division and the Director of the Reconstructive Foot and Ankle Fellowship at the University of Texas Health Science Center at San Antonio. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is the Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio. Dr. Karlock is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.