2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S144
32). In addition, an acute Charcot foot may be associated
with erythema and swelling, with overall clinical characteristics
very similar to cellulitis (33,34).
MANAGEMENT
Appropriate management can prevent or heal diabetic foot
ulcers, thereby greatly reducing the amputation rate
(6,9,10,25,26,35,36). All people with diabetes should be
instructed on proper foot care (including smoking cessation
strategies) (Appendix 5), should strive to reach recommended
glycemic targets, and should receive early referrals to a
healthcare professional trained in foot care management if
problems occur (37).
Management of foot ulceration requires an interdisciplinary
approach (38) that addresses glycemic control, infection,
lower-extremity vascular status and local wound care (39).
Essentials of good wound care involve provision of an optimal
wound environment, off-loading of the ulcer site, and, in
nonischemic wounds, regular debridement of nonviable tissue.
In general, wound dressings that maintain a moist wound
environment should be selected (40) (Appendix 6).
Expeditious debridement may be performed with sharp instruments
or biologically with medical-grade maggots (41,42).
Pressure offloading may be achieved with temporary
footwear until the ulcer heals and the character of the foot
stabilizes. Removable and irremovable cast-walkers and
total-contact casting have demonstrated proven efficacy as
pressure-reducing devices in plantar-surface ulcers (43-
45). Although very effective in healing noninfected, nonischemic
plantar-surface neuropathic ulcers, total-contact
casting requires careful individual selection and personnel
trained specifically in its application due to its potential for
complications (46).
Infections that complicate diabetic foot ulcers occur frequently
and may be imminently limb threatening (47). Surface
cultures (as opposed to cultures of deeper tissues) of ulcers in
people with diabetes have produced inconsistent results in
determining the bacterial pathogens involved (48-50). Initial
antibiotic therapy is typically empiric and broad spectrum,
with subsequent antibiotics tailored to results from appropriate
cultures. Studies to date do not clearly identify a particular
antibiotic agent that is more efficacious in reducing amputation,
accelerating ulcer healing or resolving infection (51).
Uncontrolled diabetes can result in immunopathy with a
blunted cellular response to infection. Up to 50% of patients
with diabetes who have a significant limb infection may not
have systemic signs of fever or leukocytosis at presentation
(52). Deep infections require prompt surgical debridement in
addition to appropriate antibiotic therapy (53).
In medically suitable individuals with peripheral arterial disease,
distal limb revascularization has proven benefit in longterm
limb salvage (54).Where bony foot deformities prevent
fitting of appropriate footwear and/or offloading of pressurerelated
ulcers, consultation from a surgeon skilled in foot sur-
gery may be considered to address the deformity (55-57).
Hyperbaric oxygen therapy may be useful as an adjunct to
systemic antibiotics in individuals with deep, long-standing,
nonhealing foot infections, provided there is an adequate
perfused capillary bed in the wound area (i.e. by measuring
tcPO2 response to 100% oxygen challenge). Few studies support
its use in treating uncomplicated neuropathic or
ischemic diabetic foot ulcers. There are no evidence-based
criteria to select people for hyperbaric oxygen therapy and
to predict their response (58).
RECOMMENDATIONS
1. In people with diabetes, foot examinations by both the
individual and healthcare providers should be an integral
component of diabetes management to decrease the
risk of foot lesions and amputations [Grade B, Level 2
(26,37)], and should be performed at least annually and
at more frequent intervals in those at high risk [Grade D,
Consensus].Assessment by healthcare providers should
include structural abnormalities (e.g. range of motion
of ankles and toe joints, callus pattern, bony deformities,
skin temperatures), evaluation for neuropathy and
peripheral arterial disease, ulcerations and evidence
of infection [Grade D, Level 4 (9,50)].
2. People at high risk of foot ulceration and amputation
should receive foot care education (including counselling
to avoid foot trauma), professionally fitted footwear,
smoking cessation strategies and early referrals to a
healthcare professional trained in foot care management
if problems occur [Grade B, Level 2 (37)].
3. Individuals who develop a foot ulcer should be managed
by a multidisciplinary healthcare team with expertise
in the management of foot ulcers to prevent recurrent
foot ulcers and amputation [Grade C, Level 3 (38)].
4.Any infection in a diabetic foot must be treated
aggressively [Grade D, Level 4 (53)].
OTHER RELEVANT GUIDELINES
Targets for Glycemic Control, p. S29
Neuropathy, p. S140
RELEVANT APPENDICES
Appendix 5: Diabetes and Foot Care: A Patient’s Checklist
Appendix 6: Diabetic Foot Ulcers: Essentials of Management
REFERENCES
1. American Diabetes Association: clinical practice recommendations
2004. Diabetes Care. 2004;27(suppl 1):S63-64.
2. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and
amputations in diabetes. In: Diabetes in America. 2nd ed. Bethesda,
MD: National Diabetes Data Group, National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases;
1995:409-428.
3. Eastman RC. Neuropathy in diabetes. In: Diabetes in America.