Ulcer

Wound Management in Diabetic Foot Ulcers (DFU)

It has been suggested that up to 85% of amputations can be avoided when an effective care plan is adopted. Unfortunately, insufficient training, suboptimal assessment and treatment methods, failure to refer patients appropriately and poor access to specialist footcare teams hinder the prospects of achieving optimal outcomes.
Successful diagnosis and treatment of patients with DFUs involves a holistic approach that includes:

Introduction to Diabetic Foot Ulcers

DFUs are complex, chronic wounds, which have a major long-term impact on the morbidity, mortality and quality of patients’ lives. Individuals who develop a DFU are at greater risk of premature death, myocardial infarction and fatal stroke than those without a history of DFU. Unlike other chronic wounds, the development and progression of a DFU is often complicated by wide-ranging diabetic changes, such as neuropathy and vascular disease. These, along with the altered neutrophil function, diminished tissue perfusion and defective protein synthesis that frequently accompany diabetes, present practitioners with specific and unique management challenges.

Causes of Diabetic Foot Ulcer

In most patients, peripheral neuropathy and peripheral arterial disease (PAD) (or both) play a central role and DFUs are therefore commonly classified as (Table 1):

Neuropathic DFU

Ischaemic DFU

Neuroischaemic DFU

The principle aim of DFU management is wound closure, specifically at an early stage to allow prompt healing. The essential components of management are:​

1) Peripheral Neuropathy

Peripheral neuropathy may predispose the foot to ulceration through its effects on the sensory, motor and autonomic nerves. Patients with a loss of sensation will have decreased awareness of pain and other symptoms of ulceration and infection.

2) Peripheral Arterial Disease (PAD)

People with diabetes are twice as likely to have PAD as those without diabetes. It is also a key risk factor for lower extremity amputation. Even in the absence of a poor arterial supply, microangiopathy contributes to poor ulcer healing in neuroischaemic DFUs. ​

DFUs usually result from two or more risk factors occurring together. Intrinsic elements such as neuropathy, PAD and foot deformity (e.g, from neuropathic structural changes), accompanied by an external trauma such as poorly fitting footwear or an injury to the foot can, over time, lead to a DFU.
Feature
Neuropathic
Ischaemic
Neuroischaemic
Sensation
Sensory loss
Painful
Degree of sensory loss
Callus/necrosis
Callus present and often thick
Necrosis common
Minimal callus, prone to necrosis
Wound bed
Pink and granulating surrounded by callus
Pale and sloughy with poor granulation
Poor granulation
Foot temperature and pulses
Warm with bounding pulses
Cool with absent pulses
Cool with absent pulses
Other
Dry skin and fissuring
Delayed healing
High risk of infection
Typical Location
Weight-bearing areas of the foot, such as metatarsal heads, the heel and over the dorsum of clawed toes
Tips of toes, nail edges and between the toes and lateral borders of the foot
Margins of the foot and toes
Prevalence (based on)
35%
5%
50%

Source:
International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, 2013.

Management of Diabetic Foot Ulcers

1) Treating the underlying disease processes;

2) Ensuring adequate blood supply

A patient with acute limb ischaemia is a clinical emergency and may be at great risk if not managed in a timely and effective way. Aside from critical limb ischaemia, decreased perfusion or impaired circulation may be an indicator for revascularisation in order to achieve and maintain healing and to avoid or delay a future amputation.

3) Local wound care, including infection control

The European Wound Management Association (EWMA) states that the emphasis in wound care for DFUs should be on radical and repeated debridement, frequent inspection and bacterial control and careful moisture balance to prevent maceration.

Neuropathic
Ulcer

Pre debridement

Post debridement

Pre debridement

Pre debridement

*It is important to debride a wound and refer patients to a specialist for choosing the correct method of debridement. Inadequate wound management can cause rapid deterioration with potentially devastating consequences.

4) Pressure offloading

In patients with peripheral neuropathy, it is important to offload at-risk areas of the foot in order to redistribute pressures evenly. Inadequate offloading leads to tissue damage and ulceration.

No Amputation

According to the IDF guideline, amputation should not be considered unless a detailed vascular assessment has been performed by vascular staff.
Amputation may be indicated in the following circumstances:

Diabetic Ulcer before and after treatment with NaTH Plus

DAY 0

DAY 30

DAY 60

DAY 90

Sacral pressure sore before and after treatment with NaTH Plus

DAY 0

DAY 3