Unresolved issues in the management of ulcers of the foot in diabetes

Management of diabetic foot ulcers presents a major clinical challenge. The response to treatment is often poor and the outcome disappointing, while the costs are high for both healthcare providers and the patient. In such circumstances, it is essential that management should be based on firm evidence and follow consensus. In the case of the diabetic foot, however, clinical practice can vary widely. It is for these reasons that the International Working Group on the Diabetic Foot has published guidelines for adoption worldwide. The Group has now also completed a series of non‐systematic and systematic reviews on the subjects of soft tissue infection, osteomyelitis, offloading and other interventions designed to promote ulcer healing. The current article collates the results of this work in order to demonstrate the extent and quality of the evidence which is available in these areas. In general, the available scientific evidence is thin, leaving many issues unresolved. Although the complex nature of diabetic foot disease presents particular difficulties in the design of robust clinical trials, and the absence of published evidence to support the use of an intervention does not always mean that the intervention is ineffective, there is a clear need for more research in the area. Evidence from sound clinical studies is urgently needed to guide consensus and to underpin clinical practice. It is only in this way that patients suffering with these frequently neglected complications of diabetes can be offered the best hope for a favourable outcome, at the least cost.     

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention.

AIM: To evaluate the role of preventative strategies in reducing foot ulcers in patients with Type 2 diabetes mellitus, both in the general population and those identified to be at a raised risk. METHOD: A systematic review of interventions to prevent diabetic foot ulcers. RESULTS: Available studies are generally unsatisfactory in their ability to answer the important questions relating to prevention. However, where people with diabetes receive well-organized and regular care with rapid referral to appropriate specialist multidisciplinary teams when problems (or their precursors) occur, ulcer morbidity can be substantially reduced. CONCLUSION: Foot ulcers are common in people with diabetes and are costly in terms of both patient morbidity and the use of healthcare resources. Although it is nearly a decade since the St Vincent Declaration called for a marked reduction in morbidity to be achieved through better patient management, available evidence suggests that the process of care in Britain is still very variable in quality. Foot care for people with diabetes must be organized to provide monitoring, education and referral in a manner acceptable to patients and realistic for local healthcare providers.     

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. II: treatment.

AIM: To assess the value of treatments for foot ulcers in patients with Type 2 diabetes mellitus. METHODS: A systematic review of interventions to treat diabetic foot ulcers. RESULTS: The evidence base for treating infections and dressing wounds is poor. A number of new and potentially promising treatments are being developed but currently available studies are often small, inadequately powered and use different methods and outcomes. CONCLUSIONS: Given the prevalence, morbidity and healthcare costs of diabetic foot disease, it is surprising that available trials provide inadequate evidence to improve upon current empirically based treatment approaches. Substantial effort and resources should be deployed in order to investigate both new and existing treatments in a co-ordinated, systematic and consistent manner, so that a proper evidence base can be established for this important disease area.     

Systematic review of methods to diagnose infection in foot ulcers in diabetes.

AIM: To undertake a systematic review of the diagnostic performance of clinical examination, sample acquisition and sample analysis in infected foot ulcers in diabetes. METHODS: Nineteen electronic databases plus other sources were searched. To be included, studies had to fulfil the following criteria: (i) compare a method of clinical assessment, sample collection or sample analysis with a reference standard; (ii) recruit diabetic individuals with foot ulcers; (ii) present 2 x 2 diagnostic data. Studies were critically appraised using a 12-item checklist. RESULTS: Three eligible studies were identified, one each on clinical examination, sample collection and sample analysis. For all three, study groups were heterogeneous with respect to wound type and a small proportion of participants had foot ulcers due to diabetes. No studies identified an optimum reference standard. Other methodological problems included non-blind interpretation of tests and the time lag between index and reference tests. Individual signs or symptoms of infection did not prove to be useful tests when assessed against punch biopsy as the reference standard. The wound swab did not perform well when assessed against tissue biopsy. Semiquantitative analysis of wound swab might be a useful alternative to quantitative analysis. The limitations of these findings and their impact on recommendations from relevant clinical guidelines are discussed. CONCLUSION: Given the importance of this topic, it is surprising that only three eligible studies were identified. It was not possible to describe the optimal methods of diagnosing infection in diabetic patients with foot ulceration from the evidence identified in this systematic review.     

老年糖尿病足坏疽患者的临床特征及其危险因素分析

目的了解老年人糖尿病足坏疽（ＤＦ）的临床特征及其危险因素。方法对２２１例老年和１６３例老年前期ＤＦ的患病率、各种诱因的百分比、ＤＦ和非ＤＦ患者胫后感觉神经传导速度、双下肢动脉管径和血流量等检测结果进行分析。结果（１）老年和老年前期ＤＦ患者的患病率（４９．５％和２７．４％）明显高于青中年组（１１．０％）;自发性溃疡、水疱破裂、穿鞋不当摩擦伤为ＤＦ的常见诱因;湿性坏疽为ＤＦ的主要类型。（２）老年和老年前期ＤＦ患者因周围神经病变致传导速度检测不能引出波形者分别占９２％和８２％、周围血管病变致动脉狭窄和闭塞者分别占９２％和７８％,显著高于非ＤＦ组。结论老年人糖尿病易合并ＤＦ;周围神经病变和周围血管病变在ＤＦ的发生和发展中起重要作用。     

老年糖尿病足坏疽患者的临床特征及其危险因素分析

目的 了解老年人糖尿病足坏疽（DF）的临床特征及其危险因素。 方法 对221例老年和163例老年前期DF的患病率、各种诱因的百分比、DF和非DF患者胫后感觉神经传导速度、双下肢动脉管径和血流量等检测结果进行分析。 结果 （1）老年和老年前期DF患者的患病率（49.5%和27.4%）明显高于青中年组（11.0%）;自发性溃疡、水疱破裂、穿鞋不当摩擦伤为DF的常见诱因;湿性坏疽为DF的主要类型。（2）老年和老年前期DF患者因周围神经病变致传导速度检测不能引出波形者分别占92%和82%、周围血管病变致动脉狭窄和闭塞者分别占92%和78%,显著高于非DF组。 结论 老年人糖尿病易合并DF;周围神经病变和周围血管病变在DF的发生和发展中起重要作用。     

Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series

Aims The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin‐resistant Staphylococcus aureus (MRSA) with cases caused by methicillin‐sensitive Staphylococcus aureus (MSSA). Methods We abstracted data of a series of 185 consecutive patients with diabetes and foot osteomyelitis undergoing surgery within the first 12 h after admission at a single hospital. Bone infection was confirmed by histopathological studies. Only cases where Staphylococcus aureus was isolated from bone specimens were included in this analysis. We analysed several variables between the two groups: MRSA vs. MSSA. Results MRSA bone infection was associated with higher body temperature (P = 0.02) and white blood cell count (P = 0.02) than MSSA. Patients with MRSA infections underwent a greater number of surgical procedures (P = 0.03). Limb salvage was achieved in 93.6% of the patients, with no statistically significant difference in limb salvage rates between MRSA and MSSA‐related osteomyelitis. Conclusions From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis.     

Retrospective data for diabetic foot complications: only the tip of the iceberg?

Admission rates for diabetes-related foot complications to an Australian hospital were assessed by comparing the frequently used method of retrospectively identifying patients according to International Classification of Diseases (ICD) codes with that of prospectively identifying patients at the time of admission. The aim was to determine the true admission rate of diabetes-related foot complications and to assess the ability of ICD discharge codes to accurately represent the clinical severity of each identified admission. The retrospective study of ICD codes identified approximately one-third of the patients admitted during the prospective studies. Furthermore, ICD codes allocated in the prospective studies failed to accurately represent the clinical condition in 61% of cases and the corresponding Weighted Inlier Equivalent Separations weighting resulted in a $215,000/year deficit for admissions to a single hospital.