Management

1. General measures

Criteria have been determined for risk stratification of the diabetic foot, as shown on the following table1 (NICE):

Proper education of patients on appropriate foot care and the need for early medical visit are the most important parameters here. The multidisciplinary approach is the optimal one concerning health professionals managing diabetic foot. Besides that, efficient – optimal glycaemic control is important, and assists wound healing in many ways. Smoking cessation should also be addressed, as well as other cardiovascular risk factors that should be treated accordingly (eg hypertension, dyslipidaemia). Regular foot care, under special guidance is very important and should include careful debridement of the ulcer and surrounding tissues (eg calluses). Initially, this may need to be directed by frequent medical appointments

2. Therapy of “Diabetic Foot” ulcers

This depends on the severity of each of the main underlying causes for every single diabetic: Ischemia or neuropathy. It also underlines the need for individualized management of ulcers.

Treatment of the ischemic ulcer

Diabetes harms circulation, especially micro-circulation. Actions against cardiovascular risk factors are of paramount importance: Smoking cessation, pharmacological treatment of hypertension and dyslipidaemia, and anti-platelet drugs should be initially considered. The need for revascularization either with open surgery or percutaneous angioplasty should be considered early. It should also be considered that, multi-level, distal and calcified vascular disease seen in diabetics can be hardly treated with angioplasty

* HBOT stimulates angiogenesis (new vessel formation) and creates conditions of efficient micro-circulation. It also ensures sufficient oxygenation to support wound healing (collagen formation, fibroblast proliferation, enhancement of osteoblast and osteoclast activity).

Treatment of infected ulcers

Cleansing the wound and proper but gentle debridement are crucial. Initial antibiotic regimen selection is made empirically and later modified if needed, judging by response and culture results. Severe infections may require intravenous antibiotics. Duration of antibiosis may vary and severe soft tissue infections may require 2 – 3 weeks of antibiosis. Infection of the bone requires more extended treatment. Antibiotics should be used wisely in order to avoid unnecessary side-effects and the development of resistance to antibiotics

Identification and treatment of underlying osteomyelitis is essential, as antibiotic treatment must be prolonged for at least 4 – 6 weeks. Moreover, appropriate regimens should be selected, capable of penetrating into bone. Although not preferable, surgical treatment may be required when infection extensively involves bony structures and threatens the limb.

* HBOT enhances white blood cells’ bacteria-killing activity, has bactericidal and bacteriostatic properties, and acts synergistically with antibiotics. Historically, an early successful use of HBOT was against severe necrotizing soft-tissue infections (not necessarily in diabetics).

3. Offloading

This aims to uniform distribution of load, in order to relieve pressure from the wound. Various modalities have been used and several devices have been developed. Total Contact Casting has been tested widely, and other devices are in use. Compliance for each one of them usually has a cost against quality of life and mobility for the patient. Easy wound inspection and dressing are also important.

4. Other measures

Use of custom footwear

Prescription shoes may be needed, especially when foot deformities exist. Patients at low risk may benefit from well fitting, good quality shoes while taking precautions.

Prophylactic foot surgery

Selective, non-vascular surgery is used to relieve pain, reduce the risk of ulceration, heal an open wound and control severe limb and/or life threatening infection

Trials studying the use of Hyperbaric Oxygen Therap

• Addition of HBOT to the classic management of diabetic ulcer, has been shown to improve rates of infection control and results in negative cultures, when compared to classic treatment alone
• Published results have shown that addition of HBOT to the treatment of patients with diabetic gangrene, led to significant healing rates compared to patients without HBOT (16 of 18 in the HBOT group, compared to 1 of 10). In another, more carefully designed trial, diabetic ulcer patients were treated by a Surgeon with thorough debridement and vascular surgery where needed . Addition of HBOT had the following effects: Enhanced angiogenesis with significant increase of tissue Oxygen measured at the end of HBOT sessions, and significant reduction of amputations needed for definite treatment (1 of 3 patients needed amputation in the non-HBOT group, 1 of 12 in the HBOT group)
• Concerning cost-effectiveness of HBO Therapy: Results of HBOT in efficient treatment of diabetic – chronic ulcers, combined with reduction of amputations and costs for dressings lead to cost reduction greater than the actual cost of HBOT. Total care cost reduction up to 20% has been reported when HBOT is added, as well as reduced morbidity. Furthermore, there is sufficient reduction of social and psychological burden that cannot be measured, for each one amputation avoided.