Preventing Amputation In Patients With Diabetes

Lee C. Rogers, DPM

One must concentrate on measures to reduce pressure or trauma, or use devices that can provide early warning of trauma/inflammation. While physicians commonly prescribe extra-depth shoes, there is disagreement on how effective they are at preventing ulceration.
Uccioli, et al., found a 53 percent reduction in re-ulceration rates with the use of custom extra-depth shoes in high-risk patients who already had a history of ulceration.9 There have been three published randomized, controlled trials showing that home temperature monitoring reduces ulceration rates in high-risk patients.10-12 One could also consider prophylactic surgery to reduce peak plantar pressures and prevent future ulceration.13,14

Essential Pointers On Managing Diabetic Foot Ulceration

Once a diabetic foot ulceration has occurred, it is important to determine the etiology. One should initially consider the “VIPs” (vascular, infection and pressure). Increased plantar pressure is a common reason for non-healing of ulcerations.15 Podiatrists must examine the ankle and the first metatarsophalangeal joint for limited joint mobility.16 Plantar forefoot ulcers occur (or fail to heal in a timely fashion) in the presence of equinus. A percutaneous tendo-Achilles lengthening can reduce plantar forefoot pressures and speed the healing of ulcers.17 Likewise, plantar hallux ulcers are usually a result of loss of protective sensation combined with hallux limitus. A Keller arthroplasty can be a curative procedure for these wounds.18
Debridement is key in the management of diabetic foot wounds as it removes fibrotic/necrotic tissue and reduces the bioburden. Serial debridements are often necessary to maintain this positive effect.
In an oral abstract at the most recent American Podiatric Medical Association (APMA) annual meeting, Armstrong showed that diabetic foot wounds that were debrided every study visit over 12 weeks had a 5.3 times greater chance of healing than those debrided less often.19 Clinicians can accomplish debridement by a number of mechanisms including scalpel, hydrosurgery (Versajet, Smith and Nephew) or maggot debridement therapy (Monarch Labs, Irvine, Ca.). See “A Guide To Modalities For Facilitating Debridement And Granulation Tissue” below. Most wounds will heal expeditiously if one manages the VIPs. If an ulcer fails to heal by 50 percent (length multiplied by width) in four weeks, it has a 91 percent chance of not healing in 12 weeks.20 In these cases, one should prescribe more advanced treatments.
A good granular wound base is required before one can close the wound. Negative pressure wound therapy (NPWT) can help accelerate granulation tissue formation and wound bed preparation.21 Marrow-derived stem cells from a bone marrow aspirate have also shown promise in speeding the preparation of the wound bed for an allogenic or autogenic graft.22 Dermagraft (Advanced Biohealing) offers cryopreserved neonatal fibroblasts on a bioabsorbable mesh and researchers have shown that this modality speeds ulcer healing.23 Other skin substitutes and bioengineered tissues can be of benefit. The key is knowing when to use each modality.
After a wound has become granular and level with the surrounding tissue, attaining wound closure as soon as possible will limit the risk of infection.

Emphasizing The Importance Of Screening For Vascular Disease

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