A Physician's Guide to Problem Wound Management

A Physician’s Guide To Problem Wound Management

VOL. 3 Diabetic Foot Ulcers There are some 18.5 million people who have been diagnosed with diabetes in the United States, with another 800,000 new cases diagnosed annually. Approximately 15% of these diabetic patients develop foot ulcers every year. Since lower extremity amputations in persons with diabetes occur at a rate of 4.8 per 1000, there are approximately 60,000 diabetic patients receiving amputations annually. In 1999, the estimated cost of treating a newly diagnosed diabetic foot ulcer was $28,000, while the cost for an initial amputation was $45,000. To reduce both the morbidity and the cost of amputation, Healthy People 2010 set a goal of reducing the rate of amputations in diabetic patients to below 1.8 per 1,000. In support of this goal, the American Diabetes Association has reported that the management of diabetic foot ulcers requires a multidisciplinary approach. A comprehensive, aggressive multidisciplinary approach is proven to heal diabetic foot ulcers quickly, thereby reducing the incidence of amputations and recurrent ulcerations, and thus substantially reducing the cost burden to those individuals with diabetes and to their families.

Appropriate Diabetic foot ulcers are often associated with poor outcomes, including infections Treatments and higher amputation rates. Unfortunately, despite much effort, the incidence of lower extremity amputation continues to rise and following amputation the five year mortality Options is significant. It is essential that these patients receive appropriate care early, thereby reducing the risk of amputation and preventing recurrent ulceration. The American Diabetes Associations (ADA) 1999 Consensus Development Conference on Diabetic Foot Wound Care states that treatment modalities must include the following six approaches: off-loading, debridement, dressing selection, management of infection, vascular reconstruction, and, if needed, amputation.

One, three and five year mortality following amputation in Diabetics The ADA also reported that a Amputation results in significant mortality for Diabetic Patients6 major contributor to sub-optimal chronic wound care is a fragmented delivery system. A Comprehensive A comprehensive approach to healing in these patients includes attention to all of Approach To the following essential components: Wounds I glycemic control I ensuring adequate blood flow

I nutritional support I debridement/surgery as needed

I off-loading I appropriate topical wound care

I treatment of infection, if present I patient education

An aggressive and coordinated team approach can save limbs, improve function, and enhance quality of life. Coordination of the care provided by the patient’s primary care physician and appropriate specialists is also a key component of successful wound healing in this group of patients.

Advanced Many different treatment options, utilizing the most advanced wound care modalities, are Technologies available to concurrently supplement usual wound care. These treatment options have been shown, in appropriate patients, to significantly improve rates of wound healing and to prevent amputation.

I Hyperbaric Oxygen Therapy: A Cochrane Review released in 2005 supported a ninety-five percent reduction in major amputations when adjunctive HBOT was used to treat chronic diabetic foot ulcers.

I Bio-engineered Skin Equivalents: Engineered skin products advance wound healing by using living cells to promote healing.

I Regenerative Tissue Matrix: Supports cell repopulation with stem cells by providing a framework for tissue regeneration.

I Growth Factors: Recombinant human platelet-derived growth factor promotes wound healing by stimulating cell migration to the ulcer site.

I Negative Pressure Wound Therapy: Removes excess fluid and infectious material while promoting granulation tissue formation, reducing the time to complete healing.

I Total Contact Casting: The gold standard treatment for off-loading non-infected diabetic foot ulcers.

References 1) American Diabetes Association: Position Statement: Standards of medical care in diabetes. Diabetes Care 2005; 28 (1): S4-S36. 2) Cavanagh PR, Buse JB, Frykberg RG, et al: Consensus development conference on diabetic foot wound care. Diabetes Care 1999; 22(8): 1354-1360. 3) Kranke P, Bennett M, Roeckl-Wiedmann L, et al: Hyperbaric oxygen therapy for chronic wounds (Cochrane Review). The Cochrane Library 2005, Issue 1. 4) Lnlow S, Orsted H, Sibbald RG, et al: Best practices for the prevention, diagnosis, and treatment of diabetic foot ulcers. Ostomy Wound Management 2000; 46 (11): 55-68. 5) Cianci P: Advances in the treatment of the diabetic foot: is there a role for adjunctive hyperbaric oxygen therapy? Wound Repair and Regeneration 2004; 12: 2-10. 6) One, three and five year mortality following amputation in Diabetics: Amputation results in significant mortality for Diabetic Patients Larsson J, Agadh CD, Apelqvist J, Stenström A: Long term prognosis after healed amputation in patients with diabetes. Clin Orthop 350:149-157, 1998.