Pearls for Best Practice in Treating DFUs
In one day in the United States, there are approximately 5,000 new diagnoses of diabetes, $670 million spent on diabetes, 200 limbs amputated due to diabetes, and 200 lives lost due to diabetes.1 Amputation is 15 times more likely in people with diabetes, and 50% of amputees will have a contralateral amputation within 3–5 years.2 The 3-year mortality rate is 20–50%. Ulceration usually precedes an amputation. Given these dire statistics, our presentation at SAWC Virtual focused on best practices for treating diabetic foot ulcers (DFU).
The holistic approach to treating DFUs includes optimal diabetes control, effective local wound care, infection control, offloading (pressure relief), and assurance of adequate blood flow (flow to the foot).
The first four weeks tell the story of DFU healing. If the wound percentage area reduction is greater than 50 percent in four weeks, the wound has a 58% chance of healing in 12 weeks.3 If the wound percentage area reduction is less than 50 percent in four weeks, the wound has a 9% chance of healing in 12 weeks.
Interventions for the DFU include the following:
- Debridement. Sharp debridement removes slough, necrotic tissue and surrounding callus
- Dressings. Types of dressings include alginates, hydrocolloids, foams, hydrogels, silver and silicone.
- Offloading. Debridement, dressings or moist wound healing, and offloading are the “holy trinity” of diabetic foot ulcer care.
- Negative pressure wound therapy (NPWT). This can reduce wound size.
- Placental-derived products. These include placenta-based extracellular matrix (extracellular matrices), placenta-based dermal substitutes, human placental membranes, and umbilical cords.
- Growth factors, platelet-related products, autologous platelet gels, and bioengineered skin products.
Practical Guidelines for Offloading
The first pearl was to not guess. Use an established guideline for making all your decisions. The International Working Group on the Diabetic Foot (IWGDF) releases guidelines for offloading the diabetic foot every several years. The 2019 recommendations include:4
In a person with neuropathic plantar forefoot or midfoot ulcer, use a non-removable knee-high offloading device such as the total contact cast (TCC) or non-removable knee-high walker with an appropriate foot-device interface as the first choice of offloading treatment to promote healing of the ulcer dependent on the resources available, technician skills, patient preferences, and extent of foot deformity present.4
When a non-removable knee-high offloading device is contraindicated or not tolerated, consider using a removable knee-high device with expanded education to encourage the patient to consistently wear the device.4
When a knee-high offloading device won’t work, use an ankle-high offloading device as the third choice may succeed if the patient is diligent in following the protocol.4
Never use conventional or standard therapeutic footwear as offloading treatment to promote healing of the ulcer, and actively discourage patients from doing so, unless none of the above-mentioned offloading devices are available.4 If you have to use a shoe-based or removable offloading device one pearl to consider is using a non-removable dressing such as felted foam or the “football” dressing in combination with the device.
Surgical options such as Achilles tendon lengthening, metatarsal head resection(s), joint arthroplasty, or digital tenotomy can be considered as adjuncts to promote healing of many ulcers if non-surgical offloading treatment fails.4
Regardless of your choice, getting patients to use non-removable offloading devices can be a challenge. Clinicians however suffer from the same reluctance. One study found most clinicians don’t use the TCC due to a perception that it may cause secondary ulcers and they don’t want to be liable.5 Complications do range from 11–30% but generally in high-risk patients.6 Ninety-four percent of the complications were minor and did not cause the therapy to be discontinued.
One additional pearl to improve your offloading outcomes is to learn the technique for TCC application and start to use it. It is simply not that hard.
To access the SAWC Virtual session “Pearls for Best Practice in Treating DFUs,” click here.
Barbara Aung, DPM, CWS, FAPWc, is the President of Aung Foot Health Clinic in Tucson, AZ.
James McGuire, DPM, PT, LPed, FAPWHc, is an Associate Professor in the Department of Medicine at Temple University School of Podiatric Medicine in Philadelphia.
References
1. CDC. National Diabetes Statistics Report Estimates of Diabetes and Its Burden in the United States, 2014. American Diabetes Association. Diabetes Care. 2013;36:1033-1045.
2. Bild DE, Selby JV, Sinnock P, et al. Lower-extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care. 1989;12(1):24-31.
3. Sheehan P, Jones P, Caselli A, et al. Percent change of wound area in diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week trial. Diabetes Care. 2003;26(6):1879-1882.
4. International Working Group on the Diabetic Foot. Offloading guideline. Available at https://iwgdfguidelines.org/offloading-guideline/ .
5. Wu SC, Jensen JL, Weber AK, et al. Use of pressure offloading devices in in diabetic foot ulcers: Do we practice what we preach? Diabetes Care. 2008;31(11):2118-2119.
6. Wukich DK, Motko J. Safety of total contact casting in high-risk patients with neuropathic foot ulcers. Foot Ankle Int. 2004; 25(8):556–60.
