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Keywords:

  • diabetic foot;
  • wound healing;
  • organisation of care;
  • patient-centred care;
  • care pathway;
  • wound care products

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References

The decision-making process involved in the management of diabetic foot wounds is complex but hinges on certain simple principles. The first is to agree the actual aim of management with the patient or their representative – and healing of an open wound may be only a part of this. The agreed plan should be discussed and reviewed if the wound is unresponsive to intervention. Management depends otherwise on regular debridement and cleansing, treatment of any infection, consideration of revascularisation and protection of the wound by dressings and off-loading. The evidence to justify the use of advanced wound care therapies is not strong, and outcome depends more on the organisation of the wound care process than on the choice of a particular wound care product. The introduction of an expert multidisciplinary team has been shown to lead to a very significant reduction in the incidence of major amputation and it is likely that it is the availability or otherwise of prompt expert advice which is the principal explanation of the major variations that are known to exist in the incidence of amputation even within single countries. Copyright © 2012 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References

Leaving aside disorders of the foot in which there is no open wound or ulcer, such as limb-threatening peripheral arterial disease (PAD) or an acute Charcot foot, the aim of management is to promote healing of open wounds. An open wound is associated with a reduced quality of life, as well as the ever-present risk of secondary infection. Moreover, wound healing may take many months, and in some people, it is never achieved. It is for this reason that the first step in any algorithm of wound care must be to determine the clinical priority – not just for the wound but for the person whose foot is affected [1].

Determining the management priority for the person with an ulcerated foot

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References

The real aim is to achieve the best possible outcome for the patient – in terms of function and well-being and while this usually means achieving wound closure in the shortest possible time, it is not always the case. There are some for whom early major amputation is the best option and it has been shown that it may be possible to predict those who will adapt best to a prosthesis; these are generally those who are younger and more active prior to the onset of limb-threatening disease [2]. In those who are less ambulant, or may even be bed-bound, a decision has to be made as to whether the loss of the limb will adversely affect life, or improve it.

Involvement of the patient and their carers in the decision-making process

It is obvious that discussions relating to limb-loss have to be made together with the full participation of the patient, whenever possible, as well as with families or their other carers. In the same way, patients and their carers should be involved in decision-making even for wounds which are not immediately limb-threatening. They need to be aware of the relative likelihood of healing and the treatment options available.

Wound management

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References

Hospital admission may be judged necessary because of (1) the condition of the wound, (2) the condition of the patient and (3) social or other factors. Whether or not admission is being considered, the following should steps should be taken.

Phase 1 – assessment
  1. Document the history of the patient – including social, medical, other treatments.
  2. Document the history of the wound – including cause, duration and evolution.
  3. Determine the relative contribution of different causative factors – including infection, PAD, neuropathy, deformity.
  4. Debride and cleanse the wound.
  5. Take samples for microbiology (tissue biopsy or wound aspirate; not surface swabs) if infection is suspected.
  6. Agree management plan with patient/carer
  7. Start antibiotic treatment if clinical signs of infection are present.
  8. Consider the need for vascular imaging prior to potential revascularisation.
  9. Protect the wound with (1) dressings and (2) off-loading/protective footwear.
  10. Make arrangements for early review.
  11. Make sure that the patient knows what to do if the wound gives rise to concern prior to the planned review.

Attempts should also be made to improve the quality of glycaemic control. There is currently little direct evidence that wound healing is enhanced by improving control but it is likely that it is.

Phase 2 – review
  1. Review of response to interventions: document ulcer status
  2. If the aim of treatment (healing or containment) is being achieved,
    1. Confirm treatment aims.
    2. Continue to involve patient/carer in decision-making.
    3. Continue current treatment.
  3. If the aim of treatment is not being achieved,
    1. Consider the reasons: see Table 1.
    2. Discuss the situation with patient/carer and agree new management plan.
  4. Make arrangements for early review.
  5. Make sure that the patient knows what to do if the wound gives rise to concern prior to the planned review.
Table 1. Barriers to achieving ulcer healing
  1. PAD, peripheral arterial disease.

1 Severity of untreatable underlying disease
2 Unrecognised underlying factors are the following:
(a) Significant PAD
(b) Unrecognised bone infection
(c) Continued trauma to the regenerating tissue: inadequate off-loading
(d) Non-compliance/non-adherence
Non-compliance/non-adherence

There is a widespread tendency among health care professionals to regard non-compliance (now referred to with clinically meaningless pedantry as ‘non-adherence’) as being an aspect of patient failure. In practice, non-compliance is really an aspect of normal human behaviour: people will often not do what is asked of them, even when they know that it would be in their best interests. It is for this reason that it is necessary that the patient's views are included in the formulation of any management plan.

Agreement that wound healing is not the primary objective

With successive visits and despite all attempts to provide optimal treatment, the wound may fail to heal and may even deteriorate. The management plan then becomes focussed on two broad options. The first is to continue with current therapy on the understanding that it is better to remain with a non-healing wound but to retain the leg, than it is to amputate – provided it is agreed that this is in the best interests of the patient and/or is his/her wish. The second option is to amputate and this will usually mean a major amputation – at or about the knee. Amputation should not, however, be regarded as an admission of failure but rather as a therapeutic option which all agree offers the best option for the future well-being of the patient.

Phase 3 – the future

The 12-month mortality of all people who present with a new ulcer has been reported to be 18% [1], and this population faces an overall reduction of life expectancy of 14 years when compared with an age-matched and gender-matched population [3]. Mortality at 5 years in industrialised nations is the same as that of carcinoma of the colon at 50% [4]. Of those who survive, 40% have been reported to have a new or recurrent ulcer by 12 months [5].

It follows that ulcer healing should not be regarded as the end of the episode. Every effort should be made to reduce cardiovascular mortality, which is the most likely cause of death [6]. Every effort should also be made to reduce the chance of new ulcer onset by providing, if possible, expert podiatric supervision and continued education and provision of appropriate footwear as highlighted in the recently updated National Minimum Skills Framework in UK [7].

Advanced wound care products

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References

When managing a wound that does not respond well to the only available intervention(s), both patient and professional may be tempted to try new (and usually expensive) therapies of unproven benefit. This applies to dressing products in particular. The lack of strong evidence to justify the use of any advanced wound care product is summarised elsewhere in this issue [8]. Moreover, data on cost-effectiveness of any advanced therapy which are derived in a health service which is primarily funded by insurance reimbursement, cannot be taken to necessarily apply in a service which is funded by central government. The structure of the wound care process is a much greater determinant of outcome of a diabetic foot wound than the choice of any wound care product.

Making a difference to wound healing across the population

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References

The algorithm described previously applies to the management of a person who presents to a specialist centre with an established wound. If, however, the remit is extended to management of the individual from the time of presentation to the management of the entire local population, then different items must be considered.

Provision of an expert multidisciplinary service

The first of these is the establishment of a specialist multidisciplinary service. Although there are no data to demonstrate the impact of any intervention on the development of new ulcers, it has been clearly shown that the creation of a multidisciplinary service can lead to a rapid [9] and sustained [10] 70–80% decrease in the incidence of major amputation in people who present with active disease. Given that the structure of care can have such an impact on the outcome of established disease, even in a population which will usually be suffering with other chronic complications of diabetes (such as PAD and neuropathy), it is very likely that it is difference in the structure of care which underlies the considerable variation in the incidence of major amputation which has been reported from USA and UK [11-13].

Need for prompt referral for expert assessment

The second is that non-specialists must be made aware of the existence of the service and need for early expert assessment of all newly occurring, or deteriorating, disease. Two studies have shown (albeit only in neuropathic ulcers) that there is a direct correlation between ulcer duration at the time of first expert assessment and the time of subsequent healing [14, 15].

Patient empowerment

The third is that it is essential that each person with diabetes – and especially those who are at increased risk because of neuropathy, PAD, chronic kidney disease and previous foot problems – are also aware of the need for prompt expert assessment and that they know how to gain access to it.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Determining the management priority for the person with an ulcerated foot
  5. Wound management
  6. Advanced wound care products
  7. Making a difference to wound healing across the population
  8. Conflict of Interest
  9. References