Preparing to Repair Diabetic Foot Ulcers

In my practice, and throughout continued consultation with clinicians in wound healing, I’ve noted that the primary topic of conversation is advanced therapy. However, it is vital to note that one can’t properly get to that step without fully preparing the wound to repair itself. As a result, I set a goal to teach residents and other physicians to take on evidence-based steps for every patient with a wound. This is what I call the Prepare to Repair^™ paradigm.

Based on my experience, these steps do not always have to commence in a specific order, except the final step. Essentially, these are all things that warrant evaluation and management to, in my observation, move the wound through a healing trajectory that will lead the wound to accept a more advanced tissue product or skin graft.

Biofilm, chronic infection management and assessment. Chronic wounds often have significant bioburden contained within.¹ Approximately 80% of chronic infections are due to bacterial biofilm.² There are 1 billion bacteria per square centimeter on one’s body.³ So, this necessitates attention from day 1 of any chronic wound. Biofilm is a key component that may keep a wound stuck in the inflammatory phase of healing, and antibiotics may not resolve it.² Debridement is a primary way to remove biofilm, but it is also important to protect that debridement, as biofilm can reform in minutes and mature in hours.⁴

Offloading. Especially in the diabetic foot, offloading is key. When you look at total contact casting it has about an 89% healing rate in the literature.⁵ Yet, as a whole, it is not used enough, I find. I realize there are instances where it isn’t possible, but generally, this is a proven option that I strive to use as much as possible. There are other devices available when total contact casting is not desired, but offloading must take place. Managing friction, pressure, and shear is vital to wound healing. In my practice, I have used total contact casting even for dorsal foot ulcers or ankle wounds, to immobilize the joint.

Vascular assessment. Every step of the way, wound healing requires oxygen.⁶ This requires proper circulation and perfusion. We know diabetes and vascular disease go hand-in-hand, yet I still see so many patients with long-term, chronic diabetic ulcers that have never had an arterial or venous study performed. In addition to those with diabetes, other risk factors and comorbid conditions can play a role.⁷

Inflammation management. This ties into the biofilm, bioburden, and chronicity of a wound, but at the same time, we want to mitigate inflammation, specifically the matrix metalloproteinases (MMPs) and their destructive capabilities. I personally often utilize collagen for this purpose, as it can bind the MMPs and sacrifice itself to them, but it also has a positive role in cellular migration.⁸

Moisture balance. Since 1958, we have learned not to leave wounds open to the air, after one of the first blister studies took place.⁹ This began to show us that moisture balance is critical. The human body is mostly water, and cell migration requires water. However, we also don’t want wounds to become soaking wet. We’ve all seen those macerated, infected, wet wounds that will not heal. I find it is a very fine balance that we as clinicians must strike to facilitate that cell migration.

Exudate management. So, what should clinicians put on a wound to absorb drainage? Wound drainage is full of inflammatory mediators,¹⁰ and allowing that to sit on a wound can contribute to maceration and redness, and eventually even infection. I find dressing choices, when necessary, should wick that moisture away from the skin and lock it into the bandage.

Edema control. It is important to address pathologic edema, regardless of the etiology, in wound healing, as part of this Prepare to Repair construct. One also needs to get to the bottom of the root cause of the edema, whether arterial, venous, or more central in nature.

Debridement and wound preparation. Debridement is essential, and allows removal of biofilm, senescent cells, and devitalized tissue.¹¹ These all pose impediments to wound healing and create a nidus for infection. Debridement is a simple, straightforward way to prepare a wound to repair. Looking at the quality of the wound edges is also key. Sharp debridement is the primary mechanism for this but alternative types exist as well, including autolytic, mechanical, and others.¹¹

Imaging. What do you lose by obtaining an X-ray? I feel it’s very important, no matter the location. Important findings to assess for include gas in the tissue, pathologic fracture, and osteolysis or other signs of bone infection. From a lower extremity perspective, you can also assess certain structural components like bony prominences, accessory bones, foot type, and more. Magnetic resonance imaging (MRI) and white blood cell scans can also be of value in the right situations. It is important to get some type of imaging to gain insight into what’s going on.

Medication. Many medications can play a role in chronicity or impeding wound healing. Corticosteroids, anti-rejection medications, non-steroidal anti-inflammatory drugs (NSAIDs) and others can interfere,¹² as clinicians may see patients with organ transplants, etc. Immune-modulating medications are important, because the immune system is necessary for proper pathogen reduction and healing. Anticoagulants may have an impact, as bleeding can be accelerated, and clotting delayed.¹³ I encourage all of us to think about the different medications on a patient’s list, specifically the influence and risks that they may pose.

Nutrition. We all know about the role of nutrition in wound healing. Specifically, it is worth noting that there is a connection between vitamin D, diabetes, and one’s immune system.¹⁴ Vitamin A is also critical for healing, especially for those who need chronic steroids.¹⁵ I also examine vitamin C and protein supplementation, pending the patient’s needs. Many patients would benefit from consulting with a dietician, I find, and in my experience, insurances often allow for multiple visits a year.

Labs. Laboratory examination is critical, as I find that many patients haven’t undergone these tests at the proper intervals. I prefer to see a hemoglobin A1c, complete blood count, hemoglobin and hematocrit, creatinine, and vitamin D, at minimum. I will also order folate and vitamin B12 levels when indicated.

Biopsy. In my observation, this is an underutilized tool, for which we should have a low index of suspicion to use. We can gain much information, and can easily be fooled when we don’t utilize it. Chronicity, clinical suspicion, and lack of response to treatment are all among the reasons to choose a biopsy in your care plan.

Surgery. Sometimes surgical incision and drainage is necessary, or other surgical interventions that require hospitalization. But in other instances, an in-office tenotomy may help rebalance a digit, or outpatient bunion correction may improve friction and shear. Achilles tendon lengthening may be indicated in some situations. Surgery, when indicated, may mitigate risks and enhance wound healing, and this is something I have seen in my practice.

Evaluation after 4 weeks. When one does not see at least 50% healing within 4 weeks of treatment, there needs to be close examination of the next steps, as this is a milestone applied widely across wound healing.¹⁵ This is often a good time, I find, to move into using advanced therapies when indicated, like skin grafts, cellular and tissue-based products, topical oxygen therapy or hyperbaric oxygen therapy. In my experience, these advanced therapies work best when you have already “prepared to repair.”

Final Thoughts

Over years of practice, participation in research, and educating colleagues, I feel it is vital to cover these basic concepts, because they apply each and every time we encounter a wound. This process involves time—time in evaluation, in treatment, in educating patients and families. But it is critical to invest that time. My hope is that this Prepare to Repair paradigm is easy to follow, and covers all the bases clinicians need to treat patients with wounds more effectively.

Dr. Regulski is the medical director of the Wound Care Institute of Ocean County, New Jersey.

Editor’s Note: This article appears in the May 2023 issue of Podiatry Today.

Click here to download a PDF of this article.

References

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