best practices for the management of foot ulcers in people...

Best Practices for the Management of FootUlcers in People with Diabetes

C M E1 AMA PRACategory 1 CreditTM

ANCC3.0 Contact Hours

Kevin Y. Woo, PhD, RN & Assistant Professor & School of Nursing Queen’s University & Kingston, Ontario, Canada & WoundCare Consultant &West Park Health Centre & Toronto, Ontario, Canada &Web Clinical Editor & Advances in Skin &Wound Care

Mariam Botros, DCh & Chiropodist & Women’s College Hospital & Toronto, Ontario, Canada

Janet Kuhnke, RN, MSc ET & PhD Student & University of Ottawa & Ottawa, Ontario, Canada

Robyn Evans, MD, MSc & Director of Wound Clinic & Women’s College Hospital & Toronto, Ontario, Canada

Afsaneh Alavi, MD & Lecturer & Toronto Dermatology Clinic & Toronto, Ontario, Canada

All faculty, staff, and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, orfinancial interests in, any commercial companies pertaining to this educational activity.

To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly.

This continuing educational activity will expire for physicians on November 30, 2014.

PURPOSE:

To enhance the learner’s competence with information about best practices in management of foot ulcers in people

with diabetes.

TARGET AUDIENCE:

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES:

After participating in this educational activity, the participant should be better able to:

1. Identify assessment parameters to discern causes and risk factors for foot ulcers.

2. Apply evidence-based practices to case scenarios for the prevention and management of diabetic foot ulcers.

NOVEMBER 2013

ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 11 512 WWW.WOUNDCAREJOURNAL.COM

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

http://WWW.WOUNDCAREJOURNAL.COM

ABSTRACT

The care of persons with diabetic foot ulcers requires asystematic approach following the wound bed preparationparadigm and the existing best practice recommendations. Thepurpose of this article is to summarize key evidence andrecommendations regarding prevention and management ofdiabetic foot ulcers that can be translated into practice.KEYWORDS: diabetic foot ulcer, evidence-based practice

ADV SKIN WOUND CARE 2013;26:512-24, quiz 525-6.

Diabetes is one of the leading chronic diseases that has

become an epidemic worldwide.1 According to the Inter-

nationalDiabetes Federation, the global number of people

with diabetes will increase from 246 million or 5.9% in 2007 to

380millionor 7.1%by2025.1Ofpersonswithdiabetes (PWDs), 2%

to 3%will develop a foot ulcer annually, whereas the lifetime risk of

developing a foot ulcer is as high as 25%, primarily because of

neuropathy and potential coexisting vascular disease.2 Following

patients with diabetes and neuropathy for 1 year, it was estimated

that 7.2% of this population would develop their first foot ulcer.3

More than 80% of all nontraumatic amputations in diabetes are

preceded by foot ulcers that should be considered as one of the

prognostic indicators for advanced diabetes.4 In most countries,

the healthcare system costs of diabetic foot ulcers are exorbitant

and include a high likelihood of hospitalizations. In the United

States, the care of diabetes-related foot ulcers constitutes 25% to

50% of the total costs associated with diabetic care.1 Despite

these staggering statistics, foot ulcers and related adverse sequelae

in PWDs are deemed highly preventable.5

For optimal patient outcomes, the care of people with diabetic

foot ulcers requires a systematic approach following the wound

bed preparation paradigm and the existing best practice rec-

ommendations.6–9 Integral to the recommended best practices is

the primary emphasis on addressing patient concerns and the

causative factors prior to instituting local wound care. Foot ulcers

are often precipitated by neuropathy and complicated by vas-

cular insufficiency that necessitates thorough evaluation and

specific intervention to promote healing. Local wound care of

wounds with healing potential usually involves 3 core compo-

nents:Debridement of nonviable tissue, Infection management,

and Moisture balance (DIM).10 By applying the principles to

optimal wound healing, it has been demonstrated that 50%

surface area reduction at week 4 is predictive of complete wound

closure at week 12.11 If the wound is not healing at the expected

rate, advanced therapies may be considered. If the wound cause

cannot be corrected, compromisinghealingpotential, localwound

care should focus onmaintenance to prevent secondary infection

and further deterioration.10 This article summarizes key evidence

and recommendations regarding theprevention andmanagement

of diabetic foot ulcers that clinicians can translate into practice.

RECOMMENDATIONS FOR THEPREVENTION AND MANAGEMENT OFDIABETIC FOOT ULCERS

1. Evaluate diabetes management and conduct a systematic

assessment of the PWD including A1c, blood pressure,

cholesterol, diet, exercise, and smoking history.

Inadequate management of diabetes can put individuals at

risk for a number of serious complications including foot ul-

ceration. Hyperglycemia triggers a constellation of metabolic

events leading to excessive production of advanced glycation

end-products and overproduction of oxygen free radicals that

can delay healing of foot ulcers12 (Figure 1).

Recognizing the multifaceted nature of diabetes management

and risk factors for foot ulcers,12 several salient factors should

always be part of a careful patient history, and their associated

risks for foot ulceration are summarized in Table 1. Practitioners

may consider close monitoring, early referral to specialists, and

intensive treatment based on the risk profile.

2. Conduct a lower-leg and foot assessment to differentiate

neuropathic, neuroischemic, and ischemic diseases (ulcers).

A thorough foot examination should be conducted at least

on an annual basis to identify risk factors that can lead to foot

ulcers in order to institute early intervention. Only half of the

individuals with diabetes, however, receive routine foot exam-

inations by their healthcare providers.13 To help identify the key

and relevant risk factors, Inlow et al14 developed a 60-second

diabetic foot screening tool that allows clinicians to quickly assess

for skin, nail, foot deformity, footwear, temperature (hot and

cold), range ofmotion, loss of sensation, pedal pulses, dependent

rubor, and erythema. The key elements and supporting evidence

are summarized in Table 2. The interrater reliability of Inlow’s

60-second foot screening tool has been supported by high

intraclass correlation coefficients ranged from0.83 to 0.93.15 There

is a need to explore if the PWD understands the implications of

various risk factors and the importance of self-care practices in

diabetic foot ulcer prevention.

Neuropathic FootDiabetic neuropathy is present in almost 60%of diabetic patients

with foot ulcers5; associated nerve dysfunctionmay be described

as sensory, autonomic, ormotor. Sensory neuropathy removes the

protective sensation rendering the individual to be less aware of

potential or actual trauma to his or her skin. To screen for indi-

vidualswith sensoryneuropathy, the 5.07 (10 g) Semmes-Weinstein

monofilament test is recommended. Individuals with significant

ADVANCES IN SKIN & WOUND CARE & NOVEMBER 2013513WWW.WOUNDCAREJOURNAL.COM



sensory impairment (4 of the 10 points in Figure 2) are likely to

develop foot ulcers (odds ratio [OR], 5.4; 2.6–11.6).16

Autonomic neuropathy is associated with decreased produc-

tion of sweat and components of the natural moisturizing factor

leaving the skin dry that leads to disruption of the epidermal

barrier.17 The skin should be inspected for dryness, especially

the presence of fissures or cracks that may become a portal of

entry for bacteria. Areas with blisters, cuts, scratches, redness, or

hemorrhage are indicative of local damage from local trauma,

friction, or shear commonly caused by walking barefoot and

poorly fitting footwear. Callus formation is a reaction to in-

creased local pressure and heralds impending skin breakdown

and ulceration (relative risk [RR], 11.0).18 By recognizing early

signs of injury from pressure and friction, prompt interventions

can be instituted to prevent actual ulceration. Fungal infection is

not uncommon inPWDs. Themost occlusive areas are the fourth

and fifth toe web spaces allowing excessive moisture accumu-

lation that promotes fungal proliferation as evident by skin mac-

eration in the area. A plethora of antifungal agents are available

for local or systemic management.

Motor neuropathy interferes with the normal signaling to

the lumbrical and interosseus muscles, leading to atrophy and

wasting of the muscles, foot deformity, upper displacement of

fat pads, and altered foot biomechanics.19 Common foot defor-

mities including foot drop, equinous deformity, hammertoes, and

prominent plantar metatarsal heads12 create areas that sustain

high impact and pressure and are prone to ulcer formation (es-

pecially with ill-fitting and poorly designed footwear).

Ischemic footDiabetes is associated with a 2- to 3-fold increased risk of ac-

celerated atherosclerosis.20 Poor arterial blood supply compro-

mises not only the delivery of oxygen and nutrients to the skin

but also the availability of white blood cells to defend the host

against bacterial invasion if the skin is broken down. The sever-

ity of macrovascular and microvascular disease may hinge upon

the duration and degree of diabetes, severity of dyslipidemia,

obesity, hypertension, smoking, and family history of athero-

sclerosis and anatomical location (proximal versus distal). Over

time, chronic hemodynamic and metabolic damages to the

Figure 1.

PATHOPHYSIOLOGY OF DIABETIC FOOT AND ULCERATION




endothelium result in functional and structural changes. The typical

changes may involve thickening of the basement membrane and

sclerosis of capillary walls.20 Common tests for vascular assess-

ment are summarized in Table 3. Although measuring ankle-

brachial pressure index (divide ankle systolic blood pressure by

brachial systolic blood pressure obtained by a handheld Doppler)

andpalpation for pedal pulses are considered themost convenient

noninvasive diagnostic method for detecting peripheral vascular

disease (PVD), false elevation is not uncommon in people with

diabetes due to noncompressible arteries associated with ad-

vanced atherosclerosis and vascular calcification. To improve the

accuracy, the Wound, Ostomy and Continence Nurses Society’s

Wound Committee has published a quick clinical guide for the

performance of ankle-brachial pressure index.

In general, an ankle-brachial pressure index of less than 0.5

indicates significant PVD (Table 3).

The loss of triphasic waveform, as indicated by pulsed wave

Doppler, indicates stiff atherosclerotic vessels, providing further

validation for the presence of arterial disease. A full segmental

arterial Doppler examination should be obtained to provide ac-

curate assessment of lower-extremity arterial disease (82% sensi-

tivity and 92% specificity).21

Vascular tests should be considered in consultation with the

clinical team and patient and in conjunction with the clinical

signs of arterial disease. According to a systematic review,22 the

complaint of claudication increases the likelihood of PVD (like-

lihood ratio [LR], 3.30; 95% confidence interval [CI], 2.30–4.80).

Physical findings of atrophic skin, cool skin, blue/purple skin, or

absence of lower limb hair (LR, 1.50; 95% CI, 1.20–1.70) and

clinical assessment of capillary refill time (LR, 1.90; 95% CI,

1.20–3.20) are considered to be valuable for identifying advanced

PVD. Individuals with ischemic foot would warrant a thorough

assessment by a vascular specialist to determine themost appro-

priate interventionsbasedon the location, the involvedangiosomes,

and the extent of arterial compromise.23

Neuroischemic footClinicians should recognize that neuropathy and PVDs often

coexist, which was previously discussed.

3. Optimize plantar pressure redistribution to prevent

and treat diabetic foot ulcers.

In general, plantar pressure redistribution should be consid-

ered for all individualswith neurotrophic foot ulcers (Table 4).Most

experts advocate the pneumatic walker (made nonremovable

with flexible cohesive bandage or casting material to increase ad-

herence) or the total contact cast (TCC) for forefoot ulcers.24 The

TCC is an effective pressure redistribution measure but contra-

indicated in thepresenceof ischemia or deep infectionor if trained

Table 1.

DIABETIC FOOT ULCERS AND ASSOCIATED RISK FACTORS

Risk Factors Recommendations Evidence for Increased Risk of Foot Ulcers

A: HbA1c Target for diabetes in control is 7.0% and should

be checked every 3 mo

Elevated HbA1c (HR, 1.1; 95% CI, 1.06–1.15)

predicts foot ulcer12

B: Blood pressure Target for blood pressure control is <130 mm Hg

systolic and 80 mm Hg diastolic

Increased pulse pressure had a 2.39-fold (95%

CI, 1.14–5.02) risk of foot ulcers13

C: CholesterolVcreatinine Reducecholesterol levels: LDL-C<2.0mmol/L, TC:

HDL-C <4.0, lower triglycerides to <1.7 mmol/L,

and raise HDL cholesterol to > 1.0 mmol/L

Maintain creatinine <110 IU

Screening for proteinuria albumin creatinine ratio

Foot ulcers are related to high creatinine RR,

1.16 (1.04–1.29)14 and nephropathy (repeated

evidence of proteinuria or dialysis) (RR, 2.23; CI,

1.33–3.75)15

D: Diet and weight Calculate BMI (kg/m2), which should be within

reference range of 18.5–24.9. Measure waist

circumference taking into account ethnicity and

gender (men = 40 in; women = 35 in)

Patients with BMI 40–44.9 were 25% more likely

(OR, 1.25; 95% CI, 1–1.56), and patients with

BMI 45 were 85%more likely (OR, 1.85; 95% CI,

1.46–2.34) to develop foot ulcers after 1 y16

E: Exercise Recommend regular exercise (aerobic,

resistance, or both) of >150 min per week,

associated with improved glycemic control

Exercise is linked to an absolute HbA1c

reduction of 0.89% (95% CI, 1.26%–0.51%)17

F: Smoking Promote smoking cessation as 1 cigarette will

decrease local circulation 30% for 1 h

Smoking increases risk of foot ulcers (OR, 2.1;

P <.0000)18

Abbreviations: CI, confidence interval; BMI, body mass index; HDL-C, high-density lipoprotein cholesterol; HR, hazard ratio; LDL-C, low-density lipoprotein cholesterol; OR, odds ratio;

RR, relative risk; TC, total cholesterol.

Modified from BWoo 2010. Recommendations according to the Canadian Diabetic Association: http://guidelines.diabetes.ca.



http://guidelines.diabetes.ca


professionals are not available to apply and manage the TCC.

Deep-toed shoes and orthotics aremore appropriate for mainte-

nance after healing to prevent recurrence. Individuals with ulcers

that are located in the heel area could benefit from modified

shoes (pneumatic walkers and contact casts will actually increase

local pressure). All persons with neurotrophic foot ulcers should

see a foot specialist with appropriate training (eg, podiatrist, chi-

ropodist, pedorthist, occupational therapist, physiotherapist, foot

care nurse, or physician). Reevaluation, including further edu-

cation and rationale for the devices, should occur at regular inter-

vals (2–6 weeks with an active ulcer, 6–12 weeks with deformity

or previous ulcer, 6–12 months with neuropathy alone). Despite

best practice recommendations, clinicians need to consider the

patient’s financial and vocational demands, as well as his/her

mobility to individualize a realistic and achievable plan of care.25

4. Address the individual’s concerns and modify a plan of

care to promote self-care and treatment adherence.

The paradigm that shifts the focus to self-management and pa-

tient engagement is the cornerstone of chronic disease manage-

ment. Self-management support is ‘‘the systematic provision of

education and supportive interventions, by healthcare staff (and

others), to increase patients’ skills and confidence in managing

their health problems, including regular assessment of progress

and problems, goal setting, and problem-solving support.’’26

Without appropriate interventions to support self-management,

studies27,28 document that less than one-third of patients with

Table 2.

FEATURES FOR LOCAL FOOT EXAMINATION

Assessment Parameters RecommendationsSpecific Indicators and RiskAssociated with Diabetic Foot Ulceration

Inspect

Skin Inspect the foot for dry skin, cracks, fissures

(scaling or moccasin changes that may be

indicative of tinea)

Check for callus or hyperkeratosis

Dry nonsweating feet (OR, 1.72; P < .02)20

Tinea pedis (HR, 0.73; 0.54–.98)12

Neuropathy (RR, 4.98; 1.556–15.953)21

Hyperkeratosis (OR, 2.3; 1.3–3.9)20

Nails Identify nail problems (ingrown,

onychomycosis)

Onychomycosis (HR, 1.58; 1.16–2.16)12

Deformity Examine foot deformity and prior amputation Foot deformity (RR, 1.57; 1.22–2.02)22

Charcot deformity (RR, 3.5; 1.2–9.9)14

Prior amputation (HR, 2.57; 1.60–4.12)11,12

Hammer/claw toes (HR, 1.40; 1.03–1.90; P = .03)23

Footwear Evaluate footwear and socks

Palpate

Temperature Evaluate temperature differences (either

colder or warmer)

Temperature difference that was 4.8 times greater at

the site of ulceration24

Palpate Palpate for pedal pulses: both dorsalis pedis

and posterior tibialis (ankle-brachial pressure

index (ABI) should be obtained in patients

with diabetes due to calcification of vessels)

PVD (OR, 10.1)25

Absent dorsal pedal artery (OR, 3.65; P < .0004)

ABI dorsal pedal artery <0.9 (OR, 3.00; P < .00)18

Manipulate

Sensationand reflexes Conduct monofilament testing Monofilament insensitivity (OR, 2.03; 1.50–2.76)12

Abnormal ankle reflexes (RR, 1.55; 1.01–2.36)9

Range of motion Assess for hallux limitus and hallux rigidus Presence of hallux rigidus (OR, 3.3; P < .03)22

Abbreviations: HR, hazard ratio; OR, odds ratio; PVD, peripheral vascular disease; RR, relative risk

Figure 2.

10 SITES FOR MONOFILAMENT TESTING




diabetes and active ulcers were actually wearing downloading

devices during activities on a regular basis. Chin et al29 identified

a number of action cues from family, friends, and healthcare

professionals thatmay enhance daily foot examination by people

with diabetes. Valk et al28 identified 9 randomized controlled

trials (RCTs) that evaluated patient education to prevent diabetic

foot ulceration. The evidence is weak, with only 1 study of high-

risk individuals with diabetes that reported a reduction in ulcer

incidence (Peto OR, 0.28; 95% CI, 0.13–0.59) and reduced am-

putation rate (Peto OR, 0.32; 95% CI, 0.14–0.71) 1 year after

intensive educational interventions. Ismail et al30 identified 25

trials that utilized various psychological interventions (eg, prob-

lem solving, contract setting, goal setting, self-monitoring of

behaviors) to improve diabetic self-management. Patients al-

located to psychological therapies demonstrated improvement

in A1c (12 trials, standardized effect size = -0.32; -0.57 to -0.07)

and reduction of psychological distress including depression and

anxiety (5 trials, -0.5; -0.95 to -0.20).

Individuals livingwith foot ulcers experience poor quality of life

because of limited mobility, social isolation, disruption to work

and leisure activities, sleep disturbance, depression, and pain.31,32

According to a systematic review,33 the prevalence of depression

is3 timeshigher in type1diabetes (12%[range, 5.8%–43.3%]vs3.2%

[range, 2.7%–11.4%]) and 2 times higher prevalence of depression

in peoplewith type 2 diabetes (19.1% [range, 6.5%–33%] vs 10.7%

[range, 3.8%–19.4%]) than in those without diabetes. The impact

of depression and related distress on individuals with diabetes

cannot be underestimated.

In a 5-year follow-up study of a cohort of PWDs, Winkley

et al34 explored the association between depressive disorders

andmortality. Matched with age and gender, participants with a

documented history of depression were associated with 2-fold

increased risk inmortality (hazard ratio, 2.09; 95%CI, 1.34–3.25)

compared with those without depression. Healing of diabetic

foot ulcers can be predicted by depression.35

Similarly, PWDs who report pain most or all of the time had

statistically and clinically significantly poorer health-relatedquality

of life than those who did not report pain.36 However, pain in

diabetes is often underestimated and undertreated.37

5. Optimize local wound environment for healing through

debridement, infection control (bacterial burden control),

and moisture balance (DIM).

Table 3.

COMMON VASCULAR ASSESSMENT TECHNIQUES AND PARAMETERS

Test (Reference Values) Evidence Comments

Palpable pedal pulse

(80 mm Hg)

& Absent or reduced pedal pulses increases the likelihood

of PVD (LR, 4.70; 95% CI, 2.20–9.90)31

& PPP compared with color duplex imaging PWD with

PVD (sensitivity = 81%, specificity = 56%, PPV = 42%)32

& Absence of foot pulses Risk of new DFU (RR, <4.72;

3.28–6.78)15

& Palpable pulses can be misleading

because of noncompressible blood

vessels associated with advanced

atherosclerosis

Ankle-brachial pressure

index (ABI) (>0.5 and <1.2)

& Outside reference range, PVD identified (sensitivity =

90%; specificity = 95%)33

& ABPI compared with color duplex imaging PWD with

PVD (sensitivity = 53%; specificity = 95%; PPV = 80%)32

& False elevation in patients with

calcified vessels32

& The accuracy of ABI-toe brachial index

is poor if ABI 1.334

& Risk of ulceration if ABI dorsal pedal

artery <0.9 (OR, 3.00; P < .0000)18

Transcutaneous oxygen

tension (>30 mm Hg)

& Below-the-knee values of <30 mm Hg predict the need

for above-the-ankle amputation in diabetic patients

(sensitivity = 78.6%; specificity = 83%)35

& >30 mm Hg predicts healing of DFU (sensitivity = 15%;

specificity = 97%; PPV = 79%; NPV = 94%)36

& Expensive equipment and labor

intensive

& 15 mm Hg higher dorsal foot

transcutaneous Po2 0.8 (0.7–0.9)14

Toe pressure

(>55 mm Hg)

& >55 mm Hg has the ability to predict healing of arterial

ulcers (sensitivity = 75%; specificity = 86%)37

& >55 mm Hg compared with color duplex imaging in

diagnosed PVD in PWD (sensitivity = 100%; specificity =

61%; PPV = 48%)32

& Large toe isof a small caliberwithout a fully

developed adventitial layer to allow

circumferential calcium deposits

& Cannot be calibrated if there is previous

toe amputation

Abbreviations: CI, confidence interval; LR, likelihood ratio; NPV, negative predictive value; OR, odds ratio; PPP, palpable pedal pulses; PPV, positive predictive value; PVD, peripheral

vascular disease; PWD, persons with diabetes.




Table 4.

COMMON PLANTAR PRESSURE REDISTRIBUTION DEVICES

Device Advantages Disadvantages Evidence

TCC

Cost: ++++

& Offloads forefoot and midfoot

& Protection from trauma

& Immobilization of skin edges

& Reduction of edema

& Reduction of pressure over

the ulcers

& Forced adherence

& Contraindicated in infected

and ischemic wounds

& May cause new pressure

areas in the cast

& Requires skilled technician

& Does not reduce heel pressure

significantly

& May cause back pain

RCT: healing of DFU

compared with RCW and

half shoe in 12 wk; OR, 5.4;

1.1–26.139

RCW (eg, air cast,

walker, pneumatic

walker)

Cost: +++

& Easy to apply and fit, reusable

& Allows easy access to an ulcer

for evaluation

& Can be used on infected/

ischemic wounds

& The ankle is fixed at 90

degrees, and the sole has

a rocker

& Offloads forefoot and midfoot

& Can be made nonremovable

by applying flexible cohesive

bandage or zinc oxide paste

bandage around it (instant TCC

or iTCC)

& Potential adherence issue

& Should not be used on heel

wounds

& High cost

& May cause and aggravate

back pain

RCT: higher number of DFU

healed at week 12 in the iTCC

group than the RCW group

(OR, 1.8; 1.1–2.9)38

RCT: no difference in

complications with an RRR of

41% and ARR of 27% (P =.09)

between the TCC and iTCC40

Half shoes

Cost: ++

& Reduce forefoot pressure by

eliminating propulsive gait

& Inexpensive

& Reduce metatarsal phalangeal

(first metatarsal-phalangeal

area) pressure by 65%41

& Requires balance and

stability to use the device

& Can increase heel pressure

Case-control study: in the

half-shoe cases vs controls,

median overall healing time

was 70 vs 118 d, the median

difference being 48 (95%

confidence interval [CI], 5 to

82 d) (not statistically

significant)42

Felt padding

Cost: +

& Can be incorporated into all of

the devices to reduce further

pressure

& Reduce MTPI (first

metatarsal-phalangeal area)

pressure by 48%41

& Increase shear at the

wound edges

Comparative study: felted

foam was more effective than

postoperative and canvas

shoes in reducing periulcer

pressure43

Ankle foot orthosis

Cost: ++++

& Correct foot drop

& Correct pressure from

chronic Charcot deformity

& Costly

& May cause secondary

ulceration especially under

1st IPJ

No data available

Off-the-shelf

orthopedic shoes and

orthotics

Cost: +++

& Extra depth to fit customized

insoles and toe deformities

& Can be relatively aesthetically

pleasing

& Preventive care

& Can be incorporated into

shoes and removable cast

& Costly

& Accumulate up to 900%

more pressure in the forefoot

compared to TCC45

RCT: cork inserts compared

for controls, RR, 0.88 (95%

CI, 0.51–1.52). Prefabricated

inserts compared for controls,

reulcerations was RR 0.85

(95% CI, 0.48–1.48).46

continues




DebridementNonviable tissue including eschar or soft slough promotes bac-

teria growth and creates a proinflammatory environment that

inhibits healing.38 However, not all wounds need and benefit

from debridement. The decision to perform debridement should

take into consideration whether complete wound closure is re-

alistic and achievable. For wounds with the ability to heal, sur-

gical debridement of callus and abnormal surface granulation

with a curette, scissors, or scalpel blade has been considered to

be the most effective way to destroy the biofilm structure and

reduce the number of senescent cells that impede healing.39 In a

143-patient study by Saap and Falanga,40 wound closure of

diabetic foot ulcers was predicted by whether the ulcers were

adequately debrided (OR, 2.4; 95% CI, 1.0–5.6). Removal of hy-

perkeratosis and callus has been shown to reduce the risk of

diabetic foot ulcers by lowering overall peak plantar pressure by

29%.41 Edwards and Stapley42 reviewed RCTs pertaining to

debridement of diabetic foot ulcers. Combining results from

3 RCTs suggests hydrogels are superior to gauze or standard

ulcer care to assist tissue autolytic debridement and healing in

diabetic foot ulcers (RR, 1.84; 95% CI, 1.3–2.61). For wounds

that do not have the potential for healing, debridement is con-

traindicated.Without adequate blood supply and immunedefense,

debridement can increase the risk of infection (especially when

moisture is donated into the wound) and create a larger and

deeper wound that does not heal. It is recommended that non-

healable wounds be kept dry and only loose-hanging slough be

removed under judicious consideration (Figure 3).

InfectionIndividuals with diabetes are susceptible to wound infection

as a result of immunodeficiency, neuropathy, and arteriopathy.

Mowat et al43 documented an in vitro leukocyte chemotaxis

defect in PWDs. Phagocytosis and bactericidal capacity were

significantly reduced in thepresenceofhyperglycemia.Galkowska

et al44 compared ulcer margin of foot biopsies in PWDs (n = 12)

to normal controls (n = 5) and found no increased ratio of theCD4

andCD8 T lymphocytes indicating a relative lymphocyte response

defect. Loots et al45 examined the cellular infiltrate patterns of

punch biopsies from acute and chronic wounds including PWDs

and foot ulcers. The CD4/CD8 ratio in all chronic wounds was

significantly lower (P < .0027) compared with acute wounds. In

light of the ubiquitous presence of microbes, proposed clinical

presentations (Table 5) may help to distinguish whether sig-

nificant bacterial damage occurs in the upper superficial or ex-

tends to the lower deep compartments.46 Early assessment and

prompt treatment may help to prevent untoward outcomes.

Increased surface bacterial burdenmay be treated with topical

antimicrobials, whereas systemic treatment is required for lower

compartment involvement (Figure 4). There is no one individ-

ual sign or symptom that will accurately confirm the diagnosis

of wound infection, but a combination of 2 or more indicators

& Custom-made orthotics can

reduce submetatarsal plantar

pressure up to 56%44

RCT: At 1 y, foot ulcer

reoccurrence was lower in

orthopedic shoes than control

(P = .009)47

Non–weight-bearing

crutches, walkers,

wheelchairs

Cost: variable

& Complete pressure offloading & Patient becomes sedentary

& Use requires upper body

strength

& May cause shoulder

dislocation with crutches

& May increase pressure to the

unaffected limb

& Limit activities of daily living

& Difficulty with crutches with

loss of proprioception

No data available

Cost: + low, ++ moderate, +++ high, ++++ substantially high.

Abbreviations: ARR, absolute risk reduction; DFU, diabetic foot ulcer; IPJ, interphalangeal joint; iTCC, irremovable total contact cast; NS, nonsignificant; OR, odds ratio; RCT,

randomized controlled trial; RCW, removable cast walker; RR, risks ratio; RRR, relative risk reduction; TCC, total contact cast.

Table 4.

COMMON PLANTAR PRESSURE REDISTRIBUTION DEVICES, CONTINUED

Device Advantages Disadvantages Evidence




should be sought for the diagnosis in each level (Table 5).46,47

Wounds that probe to bone (OR, 6.7; 95% CI, 2.3–19.9) exist for

more than 30 days (OR, 4.7; 95% CI, 1.6–13.4), recur (OR, 2.4;

95%CI, 1.3–4.5), and relate to trauma (OR, 2.4; 95%CI, 1.1–5.0)

and PVD (OR, 1.9; 95% CI, 1.0–3.6) are independent risk fac-

tors for foot infection.48 Furthermore, osteomyelitis should be

suspected if ulcers probe to bone (sensitivity = 38%–87%,

specificity = 85%–91%; positive predictive value = 53%–89%;

negative predictive value = 56%–98%).49–51 Although magnetic

resonance imaging ismore sensitive and specific for the diagnosis

of osteomyelitis, changes in radiographic appearance over a

2-week interval are considered as a viable alternative.47 Eleva-

tions in erythrocyte sedimentation rate andC-reactive protein, in

the absence of other inflammatory conditions, are both valuable

diagnostic indicators to validate the diagnosis of osteomyeli-

tis.47,52 To manage damage associated with increased bacterial bur-

den in theupperor superficial compartment, anarray of antibacterial

dressings (cadexomer iodine,53 silver dressings54) or topical anti-

microbial agents (silver sulfadiazine, mupirocin, fusidic acid, or

polysporin-gramicidin cream) have been used. There was no

evidence that any particular topical agent was associated with

better clinical outcomes compared with another.55,56 When

individuals exhibit signs associated with deep and surrounding

wound infection, systemic antimicrobial therapies should be con-

sidered (Figure 4). Although most infections are caused by gram-

positive cocci, broad-spectrumantibiotic therapymaybeneeded for

long-standing and refractory ulcers.47 Systematic reviews of trials to

evaluate the effectiveness of antimicrobial treatment for diabetic

Figure 3.

LOCAL WOUND CARE FOR HEALABLE AND NONHEALABLE WOUNDS




foot ulcers fail to support the superiority of any intravenous or oral

antibiotic regimen over any other.57 When wound healing is not a

realistic goal, use of topical antiseptic agents that are often consid-

ered to be cytotoxic may be appropriate (Figure 4).

MoistureMoisture balance is a critical element during the entire healing

process. Although a desiccated wound environment can slow

keratinocyte migration, too muchmoisture can cause damage to

the surrounding skin and promote bacteria growth.47A variety of

dressings have been developed to maintain moisture balance.

For instance, foam dressings wick up and lock in a large volume

of exudate. Alginate and hydrofibers are also capable of handling

copious exudate, while the gelling effect of these materials will

keep the wound base moist without maceration. Hydrogels and

occlusive dressings are usually indicated for dry wounds.

Despite the availability of different types of dressings, previous

systematic reviews58–61 of RCTs have failed to reveal the benefit

of one dressing class over another in various chronic wound

types. Furthermore, there was no significant difference between

modern advanced moisture-controlling dressings and daily ap-

plication of normal saline gauze in healing outcomes. However,

saline gauze usually requires frequent dressing changes to main-

tainmoisture balance, increasing the likelihoodof pain (compared

with foam dressings [RR, 0.27; 95% CI, 0.10-0.69]) and discom-

fort (weighted mean difference [WMD] = 1.5; 95% CI, 0.63-2.37)

as well as higher nursing costs (WMD= -30.5; 95%CI, -37.71 to

-23.29, favoring foam dressings).58

6. Consider the use of biological agents and adjunctive

therapies for stalled wounds despite optimal treatment and

potential for healing.

Neuropathy reduces growth factor production and leukocyte

activities that are crucial to wound healing.5 Advance therapies

(such as biological agents, skin substitutes, hyperbaric oxygen

therapy, and negative-pressure wound therapy) may have a role

in chronic wounds but only after debridement, infection, and

Table 5.

UPPER AND LOWER WOUND INFECTION CHECKLIST

Clinical Evaluation of Wound Infection Definition

UPPER Signs and symptoms related to critical colonization due to infection damage in the upper wound

compartment

UVunhealthy tissue Presence of >50% of debris, red friable tissue, or abnormal discoloration of granulation tissue

PVpain Sudden emergence of increase in pain

PV poor healing Changes in wound size of <10% in last 7 d

EVexudate Moderate to heavy amount of exudate

RVreek Presence of foul odor

LOWER Signs and symptoms of wound infection related to bacterial damage in the lower or deeper

wound compartment

LVlarger in size Increase in wound size or new areas of satellite breakdown

OVosseous tissue Wound that probes to bone

WVwarmth Increased periwound temperature of more than 2- F compared with temperature in proximal area

EVedema Mild to moderate edema

RVredness Redness of >2 cm beyond wound margin

B Woo KY, 2011.

Figure 4.

ALGORITHMFORAPPROPRIATEUSEOFTOPICALANDSYSTEMIC

ANTIMICROBIAL AGENTSBASEDON HEALINGPOTENTIAL




moisture balance are addressed.62 Clinicians ask if there is suf-

ficient evidence to support advanced therapies. Analysis of

pooled data from 3 RCTs of 140 people with a diabetic foot ulcer

demonstrated an increase in the rate of ulcer healing (RR, 5.20;

95%CI, 1.25–21.66; P = .02) in favor of hyperbaric oxygen therapy

at 6 weeks, but long-term benefits remained unequivocal. There

was no difference in major amputation rate according to results

from 5 trials with 312 participants (RR, 0.36; 95% CI, 0.11–1.18).63

Negative-pressure wound therapy has been widely used. In a

recent review of 7 RCTs involving 580 patients with diabetic foot

ulcers, 5 studies documented acceleratedwoundhealingwith the

treatment of negative-pressure wound therapy.64

7. Establish and empower an interprofessional team to

improve care of PWDs and foot ulcers

The optimal care of individualswith chronic leg and foot ulcers

is complex and time-consuming and requires the support of an

interprofessional team. Management of these ulcers involves a

detailed examination and discussion with patients to adequately

address their concerns. The management of a chronic wound

may be further complicated by the fragmentation of communi-

cation and services between acute, chronic, and home care.65

An interprofessional team approach that draws on the re-

quired expertise from a number of healthcare professionals,

including diabetic education, medicine, nursing, infection con-

trol, chiropody, rehabilitation, andnutrition, is required to address

the complexity of diabetic foot ulcer care.66 A patient education

sample handout is illustrated in Table 6.

SummaryPeople with diabetes are at risk for foot problems, including skin

ulcerations. This article highlighted the need to complete a com-

prehensive and holistic assessment to include laboratory evalu-

ation, physical examination, lifestyle modifications, and patients’

perception and readiness to participate in self-management of the

disease. Lower leg and foot assessment should be part of routine

practice at each patient encounter to identify risks and needs for

early intervention. Although debridement, infection manage-

ment, and moisture balance are the key elements to optimize

local wound environment for healing, clinicians must consider all

available options to redistribute plantar pressure. The care of an

active foot ulcer would necessitate involvement of an inter-

professional team and ongoing psychosocial support.

Table 6.

PATIENT HANDOUTYou need to ensure that your feet last a lifetime. The care of your feet can be summarized with the 12 words beginning

with the letter ‘‘S’’ in the chart below. You can prevent foot complications: Act to protect your own feet.

Things to Consider Take Action

Sugar & Take care of your diabetes; check your blood glucose regularly and have your doctor check your

long-term glucose control with a test called the hemoglobin A1c every 3 months.

Smoking & Stop smoking. Every cigarette will decrease the circulation in your legs by 30% for an hour.

Sores (blisters, cuts,

open skin)

& Check for sores on your feet every day. The skin breaks down because of a loss of protective sensation

and the silent trauma of rubbing or increased pressure points during walking. Seek help!

Scale and callus & Check for scale and callus on your feet every day. Scale because of dry skin or a fungus infection and

callus because of too much local pressure. Seek help!

See the bottom of your

feet daily

&Make sure you can see and check the bottom of your feet. You may want to have someone else to help

check your feet if your vision is poor.

Socks & Socks should have no seams and should not bunch up in the shoes creating new areas of increased

pressure. Wear socks at night if your feet are cold.

Shoes & Wear proper-fitting deep-toed shoes with orthotics. Avoid pointed toes and sandals. Have your shoes

fitted at the end of the day by a professional shoe fitter. You will often choose shoes that are too tight.

Steps: & Wear your shoes all the time with each step, inside and outside of your home (including going to the

bathroom at night). Do not walk barefoot or in socks or with slippers that have no support.

Shower and wash & Shower and wash your feet every day.

Soaks & Never soak your feet!

Safe nail care & Cut nails straight across and see your foot care specialist.

Skin care & Avoid adhesive tape and chemical treatments, such as wart removers. Use moisturizers to keep your

skin soft. Do not put oil or cream between the toes.




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of, and risk factors for, new diabetic foot ulceration in a community-based patient-cohort.

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This article focuses on the current state of care recommenda-

tions for persons living with diabetic foot ulcers. These include

the following:

& Perform a comprehensive clinical assessment that includes

A1c, blood pressure, cholesterol, diet, exercise, and smoking

history.

& Conduct a lower-leg and foot assessment to differentiate

neuropathic from neuroischemic diseases (ulcers).

&Optimize plantar pressure redistribution to prevent and

treat diabetic foot ulcers.

& Address the individual’s concerns and modify plan of care

to promote self-care and treatment adherence.

&Optimize local wound environment for healing through

debridement, infection control (bacterial burden control),

and moisture balance (DIM).

& Consider the use of biological agents and adjunctive ther-

apies for stalled wounds despite optimal treatment and po-

tential for healing.

& Establish and empower an interprofessional team to im-

prove the care of persons with diabetes and foot ulcers.

PRACTICE PEARLS




43. Mowat A, Baum J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes

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diabetic wounds on the lower extremity (non–insulin-dependent diabetes mellitus) show

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assess bacterial burden. Ostomy Wound Manage 2009;55(8):40-48.47. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical

practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis

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with diabetes. Diabetes Care 2006;29:1288-93.49. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to the bone in infected pedal

ulcers. a clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995;273:721-3.50. Lavery LA, Armstrong DG, Peters EJ, Lipsky BA. Probe to the bone test for diagnosing

diabetic foot osteomyelitis: reliable or relic? Diabetes Care 2007;30:270-4.51. Shone A, Burnside J, Chipchase S, Game F, Jeffcoate W. Probing the validity of the

Probe-to-the-Bone Test in the diagnosis of osteomyelitis of the foot in diabetes. Diabetes

Care 2006;29:945.52. Kaleta JL, Fleischli JW, Reilly CH. The diagnosis of osteomyelitis in diabetes using erythrocyte

sedimentation rate: a pilot study. J Am Podiatr Med Assoc 2001;91:445-50.

53. Apelqvist J, Ragnarson Tennvall G. Cavity foot ulcers in diabetic patients: a comparative

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clinical trial. Acta Derm Venereol 1996;76:231-5.

54. Woo K, Ayello E, Sibbald RG. Bacteriology, inflammation and healing: a study of nanocrystalline

silver dressings in chronic venous leg ulcers. Surg Tech Int. In press

55. Peters EJ, Lipsky BA, Berendt AR, et al. A systematic review of the effectiveness of

interventions in the management of infection in the diabetic foot. Diabetes Metab Res

Rev 2012;28 Suppl 1:142-62.56. Hinchliffe RJ, Valk GD, Apelqvist J, et al. A systematic review of the effectiveness of

interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes

Metab Res Rev 2008;24 Suppl 1:S119-137.57. Peters EJ, Lipsky BA, Berendt AR, et al. A systematic review of the effectiveness of

interventions in the management of infection in the diabetic foot. Diabetes Metab Res Rev

2012;28 Suppl 1:142-62.58. Vermeulen H, Ubbink D, Goossens A, de Vos R, Legemate D. Dressings and topical agents

for surgical wounds healing by secondary intention. Cochrane Database Syst Rev 2004;(2):

CD003554.59. Dumville JC, O’Meara S, Deshpande S, Speak K. Alginate dressings for healing diabetic

foot ulcers. Cochrane Database Syst Rev 2012;(2):CD009110.60. Dumville JC, Deshpande S, O’Meara S, Speak K. Hydrocolloid dressings for healing diabetic

foot ulcers. Cochrane Database Syst Rev 2012;(2):CD009099.61. Game FL, Hinchliffe RJ, Apelqvist J, et al. A systematic review of interventions to enhance the

healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2012;28 Suppl 1:119-41.62. Woo K, Ayello EA, Sibbald RG. The edge effect: current therapeutic options to advance

the wound edge. Adv Skin Wound Care 2007;20:99-117.63. Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen

therapy for chronic wounds. Cochrane Database Syst Rev 2012;(4):CD004123.64. Xie X, McGregor M, Dendukuri N. The clinical effectiveness of negative pressure wound

therapy: a systematic review. J Wound Care. 2010;19:490-5.

65. Robert Wood Johnson Foundation. Chronic care: making the case for ongoing care. Princeton,

NJ: Robert Wood Johnson Foundation; 2010.

66. Woo K, Alavi A, Botros M, et al. A transprofessional comprehensive assessment model for

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s34-s47.

For more than 106 additional continuing education articles related to skin and wound care topics, go to NursingCenter.com/CE.

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