Evidence-Based Protocol for Diabetic Foot Ulcers

Department of Surgery, Wound Healing Program, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 07/2006; 117(7 Suppl):193S-209S; discussion 210S-211S. DOI: 10.1097/01.prs.0000225459.93750.29
Source: PubMed


Diabetic foot ulcers are the single biggest risk factor for nontraumatic foot amputations in persons with diabetes. Foot ulcers occur in 12 to 25 percent of persons with diabetes and precede 84 percent of all nontraumatic amputations in this growing population. Because of the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Strict adherence to evidence-based protocols as described herein will prevent the majority of these amputations.
The collective experience of treating patients with neuropathic diabetic foot ulcers in four major diabetic foot programs in the United States and Europe was analyzed.
The following protocol was developed for patients with diabetic foot ulcers: (1) establishment of good communication among the patient, the wound healing team, and the primary medical doctor; (2) comprehensive, protocol-driven care of the entire patient, including hemoglobin A1c, microalbuminuria, and cholesterol as well as early treatment of retinopathy, nephropathy, and cardiac disease; (3) weekly objective measurement of the wound with digital photography, planimetry, and documentation of the wound-healing process using the Wound Electronic Medical Record, if available; (4) objective evaluation of blood flow in the lower extremities (e.g., noninvasive flow studies); (5) débridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8) maintenance of a moist wound bed; (9) use of growth factor and/or cellular therapy if the wound is not healing after 3 weeks with this protocol; and (10) consideration of the use of vacuum-assisted therapy in complex wounds.
In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensures rapid healing, minimizes morbidity and mortality rates, and eliminates toe and limb amputations in the absence of ischemia and osteomyelitis.

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    • "Impaired wound healing is a major clinical problem in patients with diabetes and is a major cause of the amputation of lower limbs (Reiber et al, 1995). Current therapies have a limited success rate and fall short in addressing the microvascular pathology present in diabetes (Brem, 2006). Poor healing of diabetic wounds is characterized also by impaired angiogenesis and vasculogenesis. "
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    ABSTRACT: The seeds of Garcinia kola are used in ethnopharmacological practice to cure cough, catarrh, wounds and sores. In this study, the seeds were extracted with 80% methanol and distilled water after de-fatting with n-hexane. The ethyl acetate fraction of the methanol extract yielded 2.4% w/w abundance. Repeated fractionation of the ethyl acetate fraction yielded a major fraction identified as Kolaviron and a second pure compound identified as Garcinia hydroxybiflavanonol, (GB1). The ethyl acetate fraction containing GB1 showed significant wound healing properties. The influence of GB1 on wound healing in diabetes was studied using the excision wound and dead wound space experimental models in STZ-induced diabetic rats. Topical application of GB1 caused a significant (p<0.05) concentration-dependent reduction in wound diameter and epithelialization period of excision wounds. On day 18, GB1 topically treated rats showed 87.82% and 94.08% wound contraction in 15%- and 30%-ointments respectively compared to Neomycin-bacitracin powder (CicatrinR) (15%- ointment) treated rats (92.75%). The WC50 values showed that GB1 (30%) produced a better wound closure rate (8.8 days) than neomycin-bacitracin powder (9.1 days). In the dead space wound model, oral administration of GB1 caused a significant (p<0.05) and dose-related increase in the weight of granuloma tissue with highest dose producing 101.32±6.78 (74.71%) protection while ASA produced (110.48±5.53) 90.28% as compared to the negative control 57.81±7.73. Also, an increase was observed in the hydroxyproline content which was dose-dependent. GB1 also significantly lowered malondialdehyde levels when compared with negative control. These effects of GB1 may find a beneficial application in therapies of variousdiabetic patients especially in wound healing.
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    • "The mechanism of diabetic neuropathy may be associated with a decrease in myelinated fiber density, as hyperglycemia induces microvascular complications and loss or degeneration of nerve fibers. Peripheral arterial disease is a risk factor associated with diabetes foot complications, along with neuropathy, foot deformity, and infection [5,7]. DFP can be prevented via early screening and prompt treatment of peripheral neuropathy and vasculopathy [8]. "
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    ABSTRACT: Preventing diabetic foot problems (DFP) and their associated consequences is a critical in rural regions. The objective is to present an association of non-invasive DFP assessment tools and physiological indicators for early detection among rural cases of diabetes in Taiwan. Secondary data analysis of 387 participants previously diagnosed with type 2 diabetes was used. The Michigan Neuropathy Screening Instrument (MNSI), Ankle Brachial Index (ABI), optimal scaling combination (OSC) of MNSI, and age were used to examine peripheral neurovascular function. The King's College classification (KC) and Texas risk classification (TRC) were used to understand diabetic foot complications. The findings indicated that MNSI was negatively correlated with ABI, but positively with diabetes duration, age, KC, TRC, fasting blood glucose, low density of lipoprotein cholesterol, body mass index and waist circumference. The area under the receiver operating characteristic curves for assessing the risk of ABI based on OSC was larger than for MNSI, KC, and TRC. It is shown that using OSC, MNSI, and ABI as community screening tools is useful in detecting early neurovasculopathy. In addition, where an ABI machine is unavailable, primary healthcare providers that perform MNSI or OSC may be cost-effective. The study was approved by the institutional review board of the ethical committee (No 98-2224-B).
    BMC Public Health 06/2013; 13(1):612. DOI:10.1186/1471-2458-13-612 · 2.26 Impact Factor
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    • "Foot ulcers and their related further disabling complications are the most common difficulties of diabetes mellitus.[12] This leads to nonhealing chronic wounds and treatment difficulties, and are significant risk factors for amputations.[3–5] "
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    ABSTRACT: Vacuum-assisted closure (VAC) is a new method in wound care which speeds wound healing by causing vacuum, improving tissue perfusion and suctioning the exudates. This study aims to evaluate its efficacy in the treatment of diabetic foot ulcers. Thirteen patients with diabetic foot ulcers were enrolled in the moist dressing group, and 10 patients in the VAC group. The site, size and depth of the wound were inspected and recorded before and every three days during the study period. Patient satisfaction and formation of granulation tissue were also assessed. Improvement of the wound in the form of reducing the diameter and depth and increasing proliferation of granulation tissue was significant in most of the patients of the VAC group after two weeks. Satisfaction of patients in the VAC group was evaluated as excellent as no amputation was done in this group. Wagner score was reduced in both the study groups, although this decrement was not significant in the moist dressing group. VAC appears to be as safe as and more efficacious than moist dressing for the treatment of diabetic foot ulcers.
    Journal of Cutaneous and Aesthetic Surgery 03/2013; 6(1):17-20. DOI:10.4103/0974-2077.110091
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