best practice guidelines: wound management in diabetic foot ulcers

DFU WOUNDMANAGEMENTRecommendations from the IWGDF 26 on theuse of offloading interventions in treating uncomplicatedneuropathic foot ulcers are: Pressure relief should always be part of thetreatment plan for an existing ulcer TCCs and non-removable walkers are thepreferred interventions Forefoot offloading shoes or cast shoesmay be used when above ankle devices arecontraindicated Conventional or standard therapeutic footwearshould not be used 101 .However, in many countries, recommendeddevices are not available and all that can be offeredis cushioning constructed from items fromlocal shops (eg, kitchen sponges, upholsteryfoams etc). In many regions of the world, walkingbarefoot or with poorly protective sandals isnormal. Replacing these by advising shoe wearmay be culturally unacceptable or create otherfoot problems 105 . The use of trainers or sportsshoes is recommended by some clinicians,which may provide another option to custombuiltfootwear where this is not accessible 106 .Patients should also be advised to limit standingand walking and to rest with the foot elevated 7 .The introduction of medical insurance schemesthat do not pay for preventative care has beena significant factor in lack of care in patientswith diabetes in recent years. These schemesalso limit what equipment can be offered to apatient.The hallmark of an appropriately offloadedwound is a noticeable lack of undermining atthe wound’s edge at follow up 74 .Amputation and post-amputationcareLower-extremity amputation often results in disability and a loss of independence;amputation is often more costly than limb salvage 25According to the IDF guideline, amputationshould not be considered unless a detailedvascular assessment has been performed byvascular staff 27 .Amputation may be indicated in the followingcircumstances 27 : Ischaemic rest pain that cannot be managedby analgesia or revascularisation A life-threatening foot infection that cannotbe managed by other measures A non-healing ulcer that is accompanied bya higher burden of disease than would resultfrom amputation. In some cases, for example,complications in a diabetic foot renderit functionally useless and a well performedamputation is a better alternative for thepatient.Around half of patients who undergo an amputationwill develop a further DFU on the contralaterallimb within 18 months of amputation. Thethree–year mortality rate after a first amputationis 20–50% 107 . In a six-year follow-up study,almost 50% of patients developed critical limbischaemia in the contralateral limb, but theseverity of the DFU and amputation level wassignificantly lower than in the unilateral limb. Thismay have been due to prompt intervention madepossible by increased patient awareness 108 .Patients at high risk for ulceration (such aspatients who have undergone an amputation fora DFU) should be reviewed 1–3 monthly by a footprotection team 1 . At each review patients' feetshould be inspected and the need for vascularassessment reviewed. Provision should be madefor intensified footcare education, specialist footwearand insoles, and skin and nail care. Specialarrangements should be made for people withdisabilities or immobility 1 . The Scottish IntercollegiateGuidelines Network (SIGN) recommendsspecialist diabetes podiatrist input for patientswith a history of amputation and ulceration 37 .Although amputation incidence may notreflect the quality of local healthcare delivery,there is a need for more consistent deliveryof diabetes care 70 , with the involvement of anMDFT and patient education.318 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS