Elsevier

The Lancet

Volume 366, Issue 9498, 12–18 November 2005, Pages 1725-1735
The Lancet

Review
Treatment for diabetic foot ulcers

https://doi.org/10.1016/S0140-6736(05)67699-4Get rights and content

Summary

People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures reveal the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and should aim to cure the infection, not to heal the wound. Alleviation of the mechanical load on ulcers (off-loading) should always be a part of treatment. Neuropathic ulcers typically heal in 6 weeks with total contact casting, because it effectively relieves pressure at the ulcer site and enforces patient compliance. The success of other approaches to off-loading similarly depends on the patients' adherence to the effectiveness of pressure relief. Surgery to heal ulcers and prevent recurrence can include tenotomy, tendon lengthening, reconstruction, or removal of bony prominences. However, these procedures may result in secondary ulceration and other complications. Ulcer recurrence rates are high, but appropriate education for patients, the provision of posthealing footwear, and regular foot care can reduce rates of re-ulceration.

Section snippets

Cause

Assessment of the cause of an ulcer helps clinicians in determining the most appropriate treatment. Many clinicians classify foot ulcers in people with diabetes as neuropathic, ischaemic, or neuroischaemic, depending on the relative contributions of the late diabetic complications of peripheral neuropathy and arterial disease to the ulcer's cause.9 Motor10 and autonomic11 deficits could also contribute to the risk of ulceration. Neuropathic ulcers, the most common type, result from

Classification

Several foot-ulcer classification schemes have been proposed, but none is universally accepted. The six-grade Wagner-Meggitt classification, which has been used for decades,18 classifies wounds by the depth of ulceration and extent of gangrene. The University of Texas system18 grades wound by depth and then stages them by the presence or absence of infection and ischaemia, but it does not include measures of neuropathy or ulcer area. The S(AD) SAD classification19 grades five categories (size

Perfusion

Nearly all patients with lower-limb ulcers can benefit from evidence-based therapy aimed at reducing the risk of atherosclerotic vascular disease.22, 23 This treatment includes help on smoking cessation,24, 25 diet improvement, and medication prescription when needed to reach target concentrations of total and LDL cholesterol;26, 27 potential antiplatelet drug treatment;28 and the achieving of optimum blood pressure29, 30 and glycaemic control.31 Medical and surgical specialists should work

Extent and depth

Serial measurement of the wound area can help measure the rate of healing, and therefore the efficacy of treatment.106 Wound areas can be directly measured in several ways, for example, by tracings inked on clear acetate, calibrated digital photographs (figure 1), or direct measurement of maximum length and width, among other techniques. Wound volume is difficult to measure, but ultrasonography could prove useful.107 The criterion most accepted for healing studies is complete closure or

Infection

Not all diabetic foot wounds become infected, but when infection does take place, the patient's limb, and sometimes life, can be at risk. All open wounds are colonised with microorganisms, and even virulent pathogens (eg, Staphylococcus aureus) can sometimes be colonisers or contaminants. Because of this, infection cannot usually be defined microbiologically.111, 112 The generally accepted clinical definition of infection is the presence of purulent secretions or at least two signs or symptoms

Wound treatments

Another Review109 in this issue looks at the biology of wound healing and novel therapies. New treatments for diabetic foot ulcers continue to be introduced,162 yet few are subjected to controlled or comparative studies of their efficacy.135, 163 Recent developments include the use of bone-marrow-derived stem cells,164 negative pressure dressings,165, 166 bioengineered skin equivalents,167 and growth-factor therapy.168 Hyperbaric oxygen treatment seems to reduce the risk of major amputation,

Mechanical load relief

Patients should be counselled never to walk in the same shoes that could have contributed to a foot ulcer.175, 176 Pressure relief on ulcers, commonly referred to as off-loading, should always be a part of the treatment plan. The most compelling evidence that off-loading accelerates ulcer healing comes from studies using a total contact cast for healing non-infected neuropathic ulcers.177, 178 Neuropathic ulcers that have resisted healing for many months or years typically heal in about 6 weeks

Surgery to heal foot ulcers

Surgical interventions can both help heal foot ulcers and prevent their recurrence,207, 208 but few randomised controlled studies have compared surgical with non-surgical treatments. Complications of surgery in diabetic patients59 include ulcers at other sites,209 infection,208 and Charcot foot.210 Percutaneous lengthening of the Achilles tendon temporarily reduces pressure under the metatarsal heads,211, 212 but carries an additional risk of secondary heel ulcers resulting from an altered gait.

Prevention of ulcer recurrence

Prevention of ulcer recurrence is a major clinical challenge,219 as shown by recurrence rates ranging from 28% at 12 months220 to 100% at 40 months.221 After complete healing, patients should slowly change to full activity and weightbearing, using appropriate therapeutic footwear with custom insoles that have been prepared in advance.175 Rigid rocker shoes effectively reduce forefoot plantar pressure. Several221, 222 but not all223 studies of therapeutic shoes have shown them to reduce ulcer

Cost-benefit analysis

The treatment cost of diabetic foot ulcers must be seen in the context of amputation prevention.4, 227 Also, a healed ulcer greatly improves the low quality of life caused by a foot ulcer, whereas failure to heal reduces the quality of life for both patients and their caregivers.228, 229 Utility values have been developed230 to calculate quality-adjusted life years (QALY) that might result from differential ulcer treatment. Markov models have predicted a cost per QALY gained of less than

Conclusions

We have described the components of assessment and treatment that can help ensure successful and rapid healing of foot ulcers in diabetic patients. These approaches should be used whenever feasible to reduce the high morbidity and risk of serious complications resulting from foot ulcers. There is still much room for improvement in both the types of techniques used and in the assurance that clinicians provide the highest current standard of care.8 Multidisciplinary specialty foot clinics, which

Search strategy and selection criteria

In the preparation of this review, we used search strings that included: “diabetic foot” in combination with “ulcers”, “healing”, “infection”, “surgery”, “biomechanics”, and “cost” in a PubMed search, emphasising papers (in any language) published since 1995. We also searched for references in other databases, including EMBASE and the Cochrane Library. Because there were only a few comparative randomised controlled trials on this topic, we selected articles for reference based on an

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