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It's Not What You Put On, but What You Take Off: Techniques for Debriding and Off-Loading the Diabetic Foot Wound

The central tenet of any treatment plan addressing neuropathic diabetic foot wounds is the appropriate debridement of nonviable tissue coupled with adequate pressure relief (off-loading). Although numerous advances have been made in the treatment of diabetic foot wounds, including bioengineered tissues, autologous and exogenous cytokine delivery systems, and potentially effective topical antimicrobial modalities, none will succeed without addressing effective debridement and off-loading.

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 Diabetic foot wounds kill millions, but high-tech solutions and teamwork are making a difference

It has long been said in wound care that “it’s not what one puts on a wound that heals it, but what one takes off.” That maxim is absolutely true in the diabetic foot. Protection of the wound is key.

The gold standard for protecting the wound has been, believe it or not, to put the patient into a special cast. This device works so well because it protects the foot in a process known as offloading, or taking the burden off the foot. By its design, this cast is not easy to remove. While this has been my personal favorite device to heal these foot wounds, patients don’t like it and most doctors don’t, either. In fact, fewer than 2% of centers in the country use this as their primary means of offloading. Reasons for this include fear of putting an open wound into a cast (even though the data largely refute this), the time required to apply and remove it and patients being miserable in a hot and heavy device.

Articles of Interest

Diabetic Foot Ulcers: Do You Know Best Practices?

Many DFUs will need debridement prior to topical wound treatment application. Clinicians can usually accomplish this by conservative sharp debridement. For more severe needs, surgical debridement may be required. Other debridement methods may include autolytic, enzymatic, maggot, and hydrotherapy.

Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews

There is currently no robust evidence for differences between wound dressings for any outcome in foot ulcers in people with diabetes (treated in any setting). Practitioners may want to consider the unit cost of dressings, their management properties and patient preference when choosing dressings.

EM@3AM: Diabetic Foot Ulcer

If the patient looks well and has an ulcer, consider osteomyelitis, which can be acute (more common in pediatric patients with hematogenous spread versus chronic (more common in adults). Examination of the ulcer should include location, size, depth, notation of specific tissue involvement, and the extent of infection if it is present. It is important to note if the ulcer extends to the bone (probe-to-bone test with sterile instrument). ESR > 60 approaches 70% sensitivity for osteomyelitis, while CRP > 3.2 demonstrates a sensitivity of 85%. Wound cultures are not helpful in the ED.

Choice of wound care in diabetic foot ulcer: A practical approach

There are various topical regimes available, but the choice depends only on the treating physicians, podiatrist, or clinical care nurse. While selecting wound care materials one should bear in mind the properties of the ideal wound care dressing which should maintain a moist wound healing environment, absorb exudates, control infection/odor and be effective in treating diabetic foot wounds. In addition to these wound care techniques, antibiotic therapy and offloading plays a very important role.

Debridement of Diabetic Foot Ulcers

Understanding the complicating factors that delay wound healing at the mechanistic level of healing, including at the biochemical, cellular, and tissue level warrants the need to remove devitalized tissue from a DFU at the clinical level. Debridement helps limit the growth of pathologic organisms and tempers the inflammatory response that stagnates the DFU in the inflammatory phase of healing. Debridement effectively returns the wound to the initial acute wound phase of healing, or the hemostasis/coagulation phase of healing.

Diabetic Foot Ulcer: Treatment and Prevention

Estimates are that by 2030 there will be 550 million individuals with diabetes in the world. Because almost a quarter of all people with diabetes will develop a foot ulcer at some point, health care workers need to know the best practices for diabetic foot ulcer prevention and treatment.

Diabetic foot ulcers heal quickly with nitric oxide technology

Around the world, 425 million people live with diabetes and upwards of 15 percent develop foot ulcers, which increases their risk of death 2.5 times. A new nitric oxide-releasing technology has the potential to cut down the healing time of diabetic foot ulcers from 120 days to 21 days.

How Anthony Nolan is helping to transform the treatment of diabetic foot ulcers

For now, VascVersa is going through the process to get ANGICYTE ready and approved for clinical use for diabetic foot ulcers. As part of this, they are developing methods which will allow the team to scale-up the manufacturing of their product, in partnership with the Scottish National Blood Transfusion Service.

Hyperbaric Oxygen Therapy as a Diabetic Foot Ulcer Treatment

HBOT can also improve one's response to antibiotics, generate new capillaries, and stimulate the release of the body's natural stem cells, all of which can help to reduce recovery time. HBOT can decrease pain levels, improve your quality of life, and make the management of these non-healing wounds easier.

Maggots are making a comeback in modern medicine

The larvae of the greenbottle blowfly (Lucilia sericata) feast on the bacteria and dead tissue in chronic wounds, cleaning out the wound and giving it more of a chance to heal. This is an ancient therapy, used since Biblical times, but fell out of favour with the invention of antibiotics. However, the rise of drug-resistant bacteria, combined with skyrocketing rates of chronic wounds from diabetes, has led to a resurgence of interest in using creepy-crawlies as treatment, usually referred to these days as maggot debridement therapy or larval therapy.

Management of Diabetic Foot Ulcers

The management of diabetic foot ulcers remains a major therapeutic challenge which implies an urgent need to review strategies and treatments in order to achieve the goals and reduce the burden of care in an efficient and cost-effective way. Questions remain as to which types of intervention, technology, and dressing are suitable to promote healing, and whether all therapies are necessary and cost-effective as adjunctive therapies.

Offloading Diabetic Foot Ulcers

We develop foot ulcers due to pressure and shear forces. If I was to prescribe you a two month vacation to the moon where there is less gravity, then you will heal your foot ulcer, but that would be financially impractical. What we can do instead is put the pressure onto other parts of the foot, and that will then offload the foot ulcer. There are several devices we can use to do this, but the MOST EFFECTIVE device is one that you cannot take off. No matter how disciplined we are, wearing these things can be annoying and inconvenient, so if it is easy to remove, it will be removed. Then we would have to remember to put it back on every time we plan to take a step. A device that you cannot remove means you don’t have to think about it anymore, you only have to put up with it.

Prevention of Diabetic Foot Ulcer

Diabetic foot ulcer (DFU) is not only a patient problem but also a major health care concern throughout the world. Diabetic foot ulcer is one of the common and serious complications in diabetic patients. Treatment of infection in diabetic ulcer is difficult and expensive.

Update on management of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control.

Resources

5 Strategies for Managing Diabetic Foot Ulcers

While diabetic foot ulcer treatments and therapeutic strategies differ, here we look at five clinically-supported strategies to help manage and actively treat diabetic foot ulcers and improve patient outcomes and comfort.

Dressing Types

Only four dressings or skin substitutes are FDA approved for diabetic foot ulcers and are noted under each one. They are Apligraf and Dermagraft and Oasis and MatriStem.