Diabetic Foot Ulcer A Stepwise Approach

Some Scary Number

1. 425 million adults ages ranging between 20 to 79 have diabetes worldwide. By 2045, the number will be 629 million.
2. Diabetes is responsible for at least $727 billion or 12 percent of total United States healthcare spending in 2017.
3. Around 15% of those with diabetes will develop a foot ulcer.

Three Different Types of Ulcerations

1. Neuropathic: The patient has a loss of protective sensation but no underlying arterial disease lost sensation. These make up to 35% of diabetic foot ulcers.
2. Neuroischemic: Both LOPS and Arterial disease are present. This compromises up to 50% of diabetic foot ulcers.
3. Ischemic: Ischemia is present, but sensation is not lost yet.

What is required to heal ulcerations?

1. Remove the cause of the wound
2. Create and maintain a moist wound environment
3. Remove any necrotic tissue and  serial debridement
4. Effectively manage the bioburden
5. Adequate tissue perfusion
6. Healthy patient nutrition
7. Comprehensive approach

Removing the cause of ulceration: Diabetic ulcers can be caused by increased pressure, friction in shoe gear, Decreased blood flow/Arterial disease, Kidney disease, and loss of sensation to the foot. Of the 4 listed the pressure and blood flow can be changed. This can be done by “off-loading” the ulcer and by having a consultation with a vascular surgeon to improve the blood flow to the foot. Once the ulceration has healed it is important to prevent them by getting diabetic shoes with insoles. These help to redistribute pressure from high-pressure areas. 

Creating and maintaining a moist wound environment: Having a moist wound environment is essential for wound healing. But care must be taken as overly moist environments can have the opposite effect. Moist environments can be maintained by various types of dressings, each dependent on the quality of the wound. 

Removing necrotic tissue: It is imperative to wound healing. Necrotic tissue delays wound healing and provides an environment for bacteria. With serial debridement necrotic and fibrotic tissue is removed and a granular base is allowed to form. One must be careful because debridement of arterial ulceration will lead to even bigger ulceration since the body doesn’t have adequate blood flow to heal the wound. 

Managing the Bioburden: Most wounds will have bacteria on them. It is important to manage when one notices an infection process starting. Putting the patient on antibiotics based on deep cultures is key in an infected wound and preventing antibiotic resistance.

Adequate tissue perfusion: Nothing can heal without blood flow. Wounds with blow flow under a certain level will not heal. Revascularization is extremely important in limb salvage. Recent improvements in surgical technique now allow even the smaller vessels to the foot to be opened up. 

Healthy Patient Nutrition: While blood flow is imperative to wound healing. Without nutrition to supply the building block. Usually, albumin in a blood test will indicate the patient’s nutritional status

Comprehensive approach: It is vital that the podiatrist work in conjunction with the primary care, endocrinologist, vascular surgeon, and Physical therapy for the best care with diabetic patients. This prevents ulcerations from happening in the first place and helps with healing and recovery.

Upcoming Therapies in Chronic Diabetic Foot Ulcers

There has been great innovation and advances in wound care. Chronic wounds can get stalled in the inflammatory phase. Prolonged inflammatory phase can cause wound healing to stall. There are many products on the market that help accelerate wound healing. The ones showing the most promise are amniotic products. The Amnion is the thin innermost portion of the placements. The amnio is composed of 5 layers containing different types of cells proteins and collagen types. Also, there is an increased amount of growth factors, signaling molecules, and cytokines (which are important factors in controlling the inflammatory response). 

Research studies show the importance of amniotic derived tissues. These products also contain stem cells and extracellular matrix further increasing wound closure. At our practice, we use Amniotic products both injectable and layer form for helping with stubborn ulcers that have stalled.