Diabetes mellitus continues to grow in global prevalence and to consume an increasing amount of health care resources. One of the key areas of morbidity associated with diabetes is the diabetic foot.
In February 2016, the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine came out with the guidelines on management of diabetic foot.
Following are its major recommendations:-
Prevention of Diabetic Foot Ulcers (DFUs)
1. The committee recommends that patients with diabetes undergo annual interval foot inspections by physicians (MD, DO, DPM) or advanced practice providers with training in foot care (Grade 1C).
2. The committee recommends that foot examination include testing for peripheral neuropathy using the Semmes-Weinstein test (Grade 1B).
3. The committee recommends education of the patients and their families about preventive foot care (Grade 1C).
4a. The committee suggests against the routine use of specialized therapeutic footwear in average-risk diabetic patients (Grade 2C).
4b. The committee recommends using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation (Grade 1B).
5. The committee suggests adequate glycemic control (hemoglobin A1c <7% with strategies to minimize hypoglycemia) to reduce the incidence of DFUs and infections, with subsequent risk of amputation (Grade 2B).
6. The committee recommends against prophylactic arterial revascularization to prevent DFU (Grade 1C).
1. In patients with plantar DFU, the committee recommends offloading with a total contact cast (TCC) or irremovable fixed ankle walking boot (Grade 1B).
2. In patients with DFU requiring frequent dressing changes, the committee suggests off-loading using a removable cast walker as an alternative to TCC and irremovable fixed ankle walking boot (Grade 2C). The committee suggests against using postoperative shoes or standard or customary footwear for off-loading plantar DFUs (Grade 2C).
3. In patients with nonplantar wounds, the committee recommends using any modality that relieves pressure at the site of the ulcer, such as a surgical sandal or heel relief shoe (Grade 1C).
4. In high-risk patients with healed DFU (including those with a prior history of DFU, partial foot amputation, or Charcot foot), the committee recommends wearing specific therapeutic footwear with pressure-relieving insoles to aid in prevention of new or recurrent foot ulcers (Grade 1C).
Diagnosis of Diabetic Foot Osteomyelitis (DFO)
1. In patients with a diabetic foot infection (DFI) with an open wound, the committee suggests doing a probe to bone (PTB) test to aid in diagnosis (Grade 2C).
2. In all patients presenting with a new DFI, the committee suggests that serial plain radiographs of the affected foot be obtained to identify bone abnormalities (deformity, destruction) as well as soft tissue gas and radiopaque foreign bodies (Grade 2C).
3. For those patients who require additional (i.e., more sensitive or specific) imaging, particularly when soft tissue abscess is suspected or the diagnosis of osteomyelitis remains uncertain, the committee recommends using magnetic resonance imaging (MRI) as the study of choice. MRI is a valuable tool for diagnosis of osteomyelitis if the PTB test is inconclusive or if the plain film is not useful (Grade 1B).
4. In patients with suspected DFO for whom MRI is contraindicated or unavailable, the committee suggests a leukocyte or antigranulocyte scan, preferably combined with a bone scan as the best alternative (Grade 2B).
5. In patients at high risk for DFO, the committee recommends that the diagnosis is most definitively established by the combined findings on bone culture and histology (Grade 1C). When bone is débrided to treat osteomyelitis, the committee recommends sending a sample for culture and histology (Grade 1C).
6. For patients not undergoing bone débridement, the committee suggests that clinicians consider obtaining a diagnostic bone biopsy when faced with diagnostic uncertainty, inadequate culture information, or failure of response to empirical treatment (Grade 2C).
Wound Care for DFUs
1. The committee recommends frequent evaluation at 1- to 4-week intervals with measurements of diabetic foot wounds to monitor reduction of wound size and healing progress (Grade 1C).
1.1. The committee recommends evaluation for infection on initial presentation of all diabetic foot wounds, with initial sharp débridement of all infected diabetic ulcers, and urgent surgical intervention for foot infections involving abscess, gas, or necrotizing fasciitis (Grade 1B).
1.2. The committee suggests that treatment of DFIs should follow the most current guidelines published by the Infectious Diseases Society of America (IDSA) (Ungraded).
2. The committee recommends use of dressing products that maintain a moist wound bed, control exudate, and avoid maceration of surrounding intact skin for diabetic foot wounds (Grade 1B).
3. The committee recommends sharp débridement of all devitalized tissue and surrounding callus material from DFUs at 1- to 4-week intervals (Grade 1B).
4. Considering lack of evidence for superiority of any given débridement technique, the committee suggests initial sharp débridement with subsequent choice of débridement method based on clinical context, availability of expertise and supplies, patient tolerance and preference, and cost-effectiveness (Grade 2C).
5. For DFUs that fail to demonstrate improvement (>50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, the committee recommends adjunctive wound therapy options. These include negative pressure therapy, biologics (platelet-derived growth factor [PDGF], living cellular therapy, extracellular matrix products, amnionic membrane products), and hyperbaric oxygen therapy. Choice of adjuvant therapy is based on clinical findings, availability of therapy, and cost-effectiveness; there is no recommendation on ordering of therapy choice. Re-evaluation of vascular status, infection control, and off-loading is recommended to ensure optimization before initiation of adjunctive wound therapy (Grade 1B).
6. The committee suggests the use of negative pressure wound therapy for chronic diabetic foot wounds that do not demonstrate expected healing progression with standard or advanced wound dressings after 4 to 8 weeks of therapy (Grade 2B).
7. The committee suggests consideration of the use of PDGF (becaplermin) for the treatment of DFUs that are recalcitrant to standard therapy (Grade 2B).
8. The committee suggests consideration of living cellular therapy using a bilayered keratinocyte/fibroblast construct or a fibroblast-seeded matrix for treatment of DFUs when recalcitrant to standard therapy (Grade 2B).
9. The committee suggests consideration of the use of extracellular matrix products employing acellular human dermis or porcine small intestinal submucosal tissue as an adjunctive therapy for DFUs when recalcitrant to standard therapy (Grade 2C).
10. In patients with DFU who have adequate perfusion that fails to respond to 4 to 6 weeks of conservative management, the committee suggests hyperbaric oxygen therapy (Grade 2B).
Peripheral Arterial Disease (PAD) and the DFU
1.1. The committee suggests that patients with diabetes have ankle-brachial index (ABI) measurements performed when they reach 50 years of age (Grade 2C).
1.2. The committee suggests that patients with diabetes who have a prior history of DFU, prior abnormal vascular examination, prior intervention for peripheral vascular disease, or known atherosclerotic cardiovascular disease (e.g., coronary, cerebral, or renal) have an annual vascular examination of the lower extremities and feet including ABI and toe pressures (Grade 2C).
2. The committee recommends that patients with DFU have pedal perfusion assessed by ABI, ankle and pedal Doppler arterial waveforms, and either toe systolic pressure or transcutaneous oxygen pressure (TcPO2) annually (Grade 1B).
3. In patients with DFU who have PAD, the committee recommends revascularization by either surgical bypass or endovascular therapy (Grade 1B).
To read the full guidelines click on the following link