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Abstract
Periprosthetic joint infection (PJI) has moved into the first place as the cause of failure following total knee arthroplasty (TKA). Recent studies have shown that PJI results in higher mortality in patients than many cancers. The economic burden of treating PJI is likely to exceed $1 billion this year in the US. Thus, it is paramount that all efforts are invested to prevent this dreaded complication after total joint arthroplasty (TJA). This article summarizes some of the most effective and proven strategies for prevention of PJI. It is hoped that the article will be of benefit to the readers of the journal.
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Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes 2015; 6:37-53. [PMID: 25685277 PMCID: PMC4317316 DOI: 10.4239/wjd.v6.i1.37] [Citation(s) in RCA: 288] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/22/2014] [Accepted: 12/17/2014] [Indexed: 02/05/2023] Open
Abstract
Diabetic foot ulcer (DFU) is the most costly and devastating complication of diabetes mellitus, which affect 15% of diabetic patients during their lifetime. Based on National Institute for Health and Clinical Excellence strategies, early effective management of DFU can reduce the severity of complications such as preventable amputations and possible mortality, and also can improve overall quality of life. The management of DFU should be optimized by using a multidisciplinary team, due to a holistic approach to wound management is required. Based on studies, blood sugar control, wound debridement, advanced dressings and offloading modalities should always be a part of DFU management. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management in some cases. Also, hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bio-engineered skin and growth factors could be used as adjunct therapies for rapid healing of DFU. So, it’s suggested that with appropriate patient education encourages them to regular foot care in order to prevent DFU and its complications.
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Conner-Kerr T. The Topical Evolution: Free Ions, Orthomolecular Agents, Phytochemicals, and Insect-Produced Substances. Adv Wound Care (New Rochelle) 2014; 3:530-536. [PMID: 25126473 PMCID: PMC4121108 DOI: 10.1089/wound.2014.0563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 06/10/2014] [Indexed: 11/12/2022] Open
Abstract
Significance: A variety of topical antiseptic substances have been used historically to treat open wounds with suspected tissue infection or that are slow to heal. However, the effectiveness of these substances in treating infected or recalcitrant wounds remains controversial. Recent Advances: Newly formulated topical antiseptics delivered through differing dressing technologies, such as ionic substances, hold the potential to limit the development of and treat antibiotic-resistant microbes in open wounds. Other topically delivered substances, such as insect-derived substances, orthomolecular agents, and phytochemicals, also present opportunities to optimize wound healing by decreasing tissue bioburden and facilitating the wound healing process. Critical Issues: Limited systemic perfusion of open wounds in individuals with certain diagnoses, such as peripheral arterial disease or necrotizing infection and the increasing number of antibiotic-resistant wound pathogens, suggests a continued role for topically applied antiseptic agents. Likewise, the failure of wounds to heal when treated with standard of care therapy opens the door to innovative treatment approaches that include the natural substances described in this article. Future Directions: Evidence for the use of select topical antiseptic agents from each of the aforementioned categories will be discussed in this article. Additional well-controlled clinical studies are needed to provide definitive recommendations for many of these topical agents.
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Affiliation(s)
- Teresa Conner-Kerr
- College of Health Sciences & Professions, University of North Georgia, Dahlonega, Georgia
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Ghanem E, Heppert V, Spangehl M, Abraham J, Azzam K, Barnes L, Burgo FJ, Ebeid W, Goyal N, Guerra E, Hitt K, Kallel S, Klein G, Kosashvili Y, Levine B, Matsen L, Morris MJ, Purtill JJ, Ranawat C, Sharkey PF, Sierra R, Stefansdottir A. Wound management. J Orthop Res 2014; 32 Suppl 1:S108-19. [PMID: 24464883 DOI: 10.1002/jor.22554] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Pinheiro LDS, Borges EL, Donoso MTV. Uso de hidrocolóide e alginato de cálcio no tratamento de lesões cutâneas. Rev Bras Enferm 2013; 66:760-70. [DOI: 10.1590/s0034-71672013000500018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 08/27/2013] [Indexed: 11/22/2022] Open
Abstract
Hidrocolóide e alginato de cálcio são utilizados no tratamento de lesões cutâneas e muitos profissionais da saúde desconhecem as evidências que sustentam sua indicação na cicatrização. Objetivou-se nesse estudo identificar evidências da ação da placa de hidrocolóide e alginato de cálcio no tratamento de lesão cutânea. Utilizou-se o método de revisão integrativa da literatura. Fizeram parte da amostra 12 estudos com nível de evidências I, II, III e IV, formados por pacientes com lesão cutânea tratada durante qualquer período de tempo com hidrocolóide placa ou alginato de cálcio. Os desfechos avaliados foram redução da área, cicatrização da lesão, taxa de cicatrização, tempo e infecção. Os resultados permitiram estabelecer três recomendações para o uso de hidrocolóide e nenhuma para uso de alginato de cálcio no tratamento de lesão crônica.
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Chitosan-hyaluronic acid/nano silver composite sponges for drug resistant bacteria infected diabetic wounds. Int J Biol Macromol 2013; 62:310-20. [PMID: 24060281 DOI: 10.1016/j.ijbiomac.2013.09.011] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 08/22/2013] [Accepted: 09/15/2013] [Indexed: 02/07/2023]
Abstract
The aim of this work was to develop an antimicrobial sponge composed of chitosan, hyaluronic acid (HA) and nano silver (nAg) as a wound dressing for diabetic foot ulcers (DFU) infected with drug resistant bacteria. nAg (5-20 nm) was prepared and characterized. The nanocomposite sponges were prepared by homogenous mixing of chitosan, HA and nAg followed by freeze drying to obtain a flexible and porous structure. The prepared sponges were characterized using SEM and FT-IR. The porosity, swelling, biodegradation and haemostatic potential of the sponges were also studied. Antibacterial activity of the prepared sponges was analysed using Escherichia coli, Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and Klebsiella pneumonia. Chitosan-HA/nAg composite sponges showed potent antimicrobial property against the tested organisms. Sponges containing higher nAg (0.005%, 0.01% and 0.02%) concentrations showed antibacterial activity against MRSA. Cytotoxicity and cell attachment studies were done using human dermal fibroblast cells. The nanocomposite sponges showed a nAg concentration dependent toxicity towards fibroblast cells. Our results suggest that this nanocomposite sponges could be used as a potential material for wound dressing for DFU infected with antibiotic resistant bacteria if the optimal concentration of nAg exhibiting antibacterial action with least toxicity towards mammalian cells is identified.
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Abstract
Chronic DFUs are a growing global health concern due to the implied high rates of morbidity and mortality. Standard-of-care modalities sometimes are not sufficient for some recalcitrant ulcers. The use of adjuvant topical therapies including advanced dressings and biologic therapies should be considered in patients whose DFU did not reduce in size after receiving standard care for a period of 4 weeks. These advanced treatments must be used in combination with standard care measures, including debridement, moist wound healing, offloading, and infection control.
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Affiliation(s)
- Nicholas A Richmond
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Wound dressings are regarded as important components of ulcer treatment, with clinicians and patients having many different types to choose from including hydrocolloid dressings. There is a range of different hydrocolloids available including fibrous-hydrocolloid and hydrocolloid (matrix) dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of hydrocolloid wound dressings with no dressing or alternative dressings on the healing of foot ulcers in people with diabetes. SEARCH METHODS For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrocolloid with alternative wound treatments in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies (535 participants) in the review: these compared hydrocolloids with basic wound contact dressings, foam dressings, alginate dressings and a topical treatment. Meta-analysis of two studies indicated no statistically significant difference in ulcer healing between fibrous-hydrocolloids and basic wound contact dressings: risk ratio 1.01 (95% CI 0.74 to 1.38). One of these studies found that a basic wound contact dressing was more cost-effective than a fibrous-hydrocolloid dressing. One study compared a hydrocolloid-matrix dressing with a foam dressing and found no statistically significant difference in the number of ulcers healed. There was no statistically significant difference in healing between an antimicrobial (silver) fibrous-hydrocolloid dressing and standard alginate dressing; an antimicrobial dressing (iodine-impregnated) and a standard fibrous hydrocolloid dressing or a standard fibrous hydrocolloid dressing and a topical cream containing plant extracts. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that any type of hydrocolloid wound dressing is more effective in healing diabetic foot ulcers than other types of dressing or a topical cream containing plant extracts. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- University of ManchesterDepartment of Nursing, Midwifery and Social WorkManchesterUKM13 9PL
| | - Sohan Deshpande
- Kleijnen Systematic ReviewsUnit 6, Escrick Business ParkRiccall Road, EscrickYorkUKYO19 6FD
| | - Susan O'Meara
- University of LeedsSchool of HealthcareRoom LG.12, Baines WingLeedsUKLS2 9JT
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including hydrogel dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To assess the effects of hydrogel wound dressings compared with alternative dressings or none on the healing of foot ulcers in people with diabetes. SEARCH METHODS For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrogel with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies (446 participants) in this review. Meta analysis of three studies comparing hydrogel dressings with basic wound contract dressings found significantly greater healing with hydrogel: risk ratio (RR) 1.80, 95% confidence interval (CI) 1.27 to 2.56. The three pooled studies had different follow-up times (12 weeks, 16 weeks and 20 weeks) and also evaluated ulcers of different severities (grade 3 and 4; grade 2 and grade unspecified). One study compared a hydrogel dressing with larval therapy and found no statistically significant difference in the number of ulcers healed and another found no statistically significant difference in healing between hydrogel and platelet-derived growth factor. There was also no statistically significant difference in number of healed ulcers between two different brands of hydrogel dressing. All included studies were small and at unclear risk of bias and there was some clinical heterogeneity with studies including different ulcer grades. No included studies compared hydrogel with other advanced wound dressings. AUTHORS' CONCLUSIONS There is some evidence to suggest that hydrogel dressings are more effective in healing (lower grade) diabetic foot ulcers than basic wound contact dressings however this finding is uncertain due to risk of bias in the original studies. There is currently no research evidence to suggest that hydrogel is more effective than larval therapy or platelet-derived growth factors in healing diabetic foot ulcers, nor that one brand of hydrogel is more effective than another in ulcer healing. No RCTs comparing hydrogel dressings with other advanced dressing types were found.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing, Midwifery and Social Work, University of Manchester, Manchester,
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Abstract
BACKGROUND Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of alginate wound dressings with no wound dressing or alternative dressings on the healing of foot ulcers in people with diabetes mellitus. SEARCH METHODS For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of alginate dressings with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (375 participants) in this review; these compared alginate dressings with basic wound contact dressings, foam dressings and a silver-containing, fibrous-hydrocolloid dressing. Meta analysis of two studies found no statistically significant difference between alginate dressings and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI 0.66 to 1.80). Pooled data from two studies comparing alginate dressings with foam dressings found no statistically significant difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08). There was no statistically significant difference in the number of diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid dressing was compared with a standard alginate dressing (RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up times (six to 12 weeks), and small sample sizes. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES The review aimed to evaluate the effects of foam wound dressings on the healing of foot ulcers in people with diabetes. SEARCH METHODS For this first update we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL in April 2013. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects on ulcer healing of one or more foam wound dressings in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (157 participants) in this review. Meta analysis of two studies indicated that foam dressings do not promote the healing of diabetic foot ulcers compared with basic wound contact dressings (RR 2.03, 95%CI 0.91 to 4.55). Pooled data from two studies comparing foam and alginate dressing found no statistically significant difference in ulcer healing (RR 1.50, 95% CI 0.92 to 2.44). There was no statistically significant difference in the number of diabetic foot ulcers healed when foam dressings were compared with hydrocolloid (matrix) dressings. All included studies were small and/or had limited follow-up times. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that foam wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however all trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing,Midwifery and Social Work, University of Manchester, Manchester,UK.
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Gottrup F, Apelqvist J, Bjarnsholt T, Cooper R, Moore Z, Peters E, Probst S. EWMA Document: Antimicrobials and Non-healing Wounds: Evidence, controversies and suggestions. J Wound Care 2013; 22:S1-89. [DOI: 10.12968/jowc.2013.22.sup5.s1] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- F Gottrup
- Professor of Surgery, Bispebjerg University Hospital, Copenhagen, Denmark
| | - J Apelqvist
- Senior Consultant, Associate Professor, Skåne University Hospital, Malmö, Sweden
| | - T Bjarnsholt
- Associate Professor, University of Copenhagen and Copenhagen University Hospital, Copenhagen, Denmark
| | - R Cooper
- Professor of Microbiology, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - Z Moore
- Lecturer in Wound Healing & Tissue Repair, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - E.J.G. Peters
- Internist- Infectious Diseases Specialist, VU University Medical Center, Amsterdam, the Netherlands
| | - S Probst
- Lecturer, Zurich University of Applied Sciences, Winterthur, Switzerland
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Kim PJ, Steinberg JS. Wound care: biofilm and its impact on the latest treatment modalities for ulcerations of the diabetic foot. Semin Vasc Surg 2012; 25:70-4. [PMID: 22817855 DOI: 10.1053/j.semvascsurg.2012.04.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Biofilm is an increasingly important topic of discussion in the care of the chronic diabetic foot wound. Treatment modalities have focused on biofilm reduction or eradication through debridement techniques, topical therapies, negative pressure therapy, and ultrasound. In addition, advanced wound healing modalities, such as bioengineered alternative tissues, require optimal wound bed preparation with specific consideration of biofilm reduction before their application. Although fundamental principles of diabetic wound care still apply, critical thought must be given to biofilm before implementing a treatment plan for the closure of these complex wounds.
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Affiliation(s)
- Paul J Kim
- Center for Wound Healing and Hyperbaric Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, USA.
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Schwartz JA, Lantis JC, Gendics C, Fuller AM, Payne W, Ochs D. A prospective, non comparative, multicenter study to investigate the effect of cadexomer iodine on bioburden load and other wound characteristics in diabetic foot ulcers. Int Wound J 2012; 10:193-9. [PMID: 23136838 DOI: 10.1111/j.1742-481x.2012.01109.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Few studies regarding wound treatment with topical antimicrobials evaluate change in the bacterial bioburden of the wound with treatment. This study sought out to determine the in vivo effect of cadexomer iodine antibacterial dressing on diabetic foot ulcers (DFUs) that were infected or achieved a critical level of colonisation, looking specifically at wound progression in relation to bioburden. Fifteen patients corresponding to 16 total DFUs met criteria of displaying clinical signs of infection or critical colonisation and were suitable for a topical antibacterial dressing. They underwent weekly treatment for 6 weeks. Cultures were taken at week 0, 3 and 6 as appropriate. At week 6 median log10 bacterial count reduction of 1.0 was observed from baseline (p = 0·025). At week 3- a median log10 bacterial count reduction of 0.3 was observed from baseline (p = 0·049). Over the study period there was a 53.6% median reduction of the wound surface area. There were no patients that completely healed their ulcer over the 6 week study period. There was a statistically significant median reduction in the bacterial load over the 6 week period (p = 0·025) as well as 3 weeks (p = 0·049). This was accompanied by a median reduction of 53.6% in ulcer surface area and 50% in ulcer depth from baseline to final.
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Affiliation(s)
- Jamie A Schwartz
- Division of Vascular Clinical Research, Department of Surgery, St. Luke’s-Roosevelt Hospital Center, Columbia University, New York, NY, USA.
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Abstract
Diabetic foot infections (DFIs) are a commonly encountered medical problem. They are associated with an increased frequency and length of hospitalization and risk for lower-extremity amputation. Furthermore, they have substantial economic consequences. Patients with diabetes mellitus are particularly susceptible to foot infections because of neuropathy, vascular insufficiency, and diminished neutrophil function. The approach to managing DFIs starts with determining if an infection exists. If an infection exists, then the type, severity, extent of infection, and risk factors for resistant organisms should be determined through history, physical examination, and additional laboratory and radiological testing. Optimal management requires surgical debridement, pressure offloading, effective antibiotic therapy, wound care and moisture, maintaining good vascular supply, and correction of metabolic abnormalities, such as hyperglycemia, through a multidisciplinary team. Empiric antibiotics for DFIs vary based on the severity of the infection, but must include anti-staphylococcal coverage.
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Affiliation(s)
- Mazen S Bader
- McMaster University, Faculty of Health Sciences, Division of Infectious Diseases, Hamilton, Ontario, Canada.
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Dumville JC, Soares MO, O'Meara S, Cullum N. Systematic review and mixed treatment comparison: dressings to heal diabetic foot ulcers. Diabetologia 2012; 55:1902-10. [PMID: 22544222 PMCID: PMC3369130 DOI: 10.1007/s00125-012-2558-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 03/19/2012] [Indexed: 11/27/2022]
Abstract
AIMS/HYPOTHESIS Foot ulcers in people with diabetes are a common and serious global health issue. Dressings form a key part of ulcer treatment. Existing systematic reviews are limited by the lack of head-to-head comparisons of alternative dressings in a field where there are several different dressing options. We aimed to determine the relative effects of alternative wound dressings on the healing of diabetic foot ulcers. METHODS This study was a systematic review involving Bayesian mixed treatment comparison. We included randomised controlled trials evaluating the effects on diabetic foot ulcer healing of one or more wound dressings. There were no restrictions based on language or publication status. RESULTS Fifteen eligible studies, evaluating nine dressing types, were included. Ten direct treatment comparisons were made. Whilst there was increased healing associated with hydrogel and foam dressings compared with basic wound contact materials, these findings were based on data from small studies at unclear or high risk of bias. The mixed treatment comparison suggested that hydrocolloid-matrix dressings were associated with higher odds of ulcer healing than all other dressing types; there was a high degree of uncertainty around these estimates, which were deemed to be of very low quality. CONCLUSIONS/INTERPRETATION These findings summarise all available trial evidence regarding the use of dressings to heal diabetic foot ulcers. More expensive dressings may offer no advantages in terms of healing than cheaper basic dressings. In addition, evidence pointing to a difference in favour of 'advanced' dressing types over basic wound contact materials is of low or very low quality.
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Affiliation(s)
- J C Dumville
- Department of Health Sciences, University of York, Area 2, Seebohm Rowntree Building, York YO10 5DD, UK.
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71
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Balingit PP, Armstrong DG, Reyzelman AM, Bolton L, Verco SJ, Rodgers KE, Nigh KA, diZerega GS. NorLeu3-A(1-7) stimulation of diabetic foot ulcer healing: results of a randomized, parallel-group, double-blind, placebo-controlled phase 2 clinical trial. Wound Repair Regen 2012; 20:482-90. [PMID: 22672145 DOI: 10.1111/j.1524-475x.2012.00804.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 02/27/2012] [Indexed: 11/29/2022]
Abstract
This randomized, double-blind, placebo-controlled Phase 2 clinical trial explored NorLeu(3)-A(1-7) (DSC127) safety and healing efficacy in diabetic foot ulcers. Patients with chronic, noninfected, neuropathic, or neuroischemic plantar Wagner Grade 1 or 2 foot ulcers (n = 172) were screened for nonhealing. Subjects were randomized to receive 4 weeks' once-daily topical treatment with 0.03% DSC127 (n = 26), 0.01% DSC127 (n = 27), or Placebo (n = 24), followed by 20 weeks' standard of care. DSC127 was assessed for safety (including laboratory values and adverse events), primary efficacy (% ulcers completely epithelialized at Week 12), and durability of effect. Baseline, demography, and safety parameters were compared between intent-to-treat groups and were comparable. Dose-response curves for DSC127 effect on % area reduction from baseline at Week 12 (40% placebo; 67% 0.01% DSC127; 80% 0.03% DSC127) and 24 (23% placebo; 53% 0.01% DSC127; 95% 0.03% DSC127) followed a log-linear pattern for both intent-to-treat and per-protocol populations. Covariate analysis compared reduction in ulcer area, depth, and volume from baseline; reductions in the 0.03% DSC127 group were greater at Weeks 12 and 24. Placebo-treated ulcers healed in a median 22 weeks vs. 8.5 weeks for 0.03%DSC127 (p = 0.04). This study provides preliminary evidence that DSC127 is safe and effective in accelerating the healing of diabetic foot ulcers.
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Affiliation(s)
- Peter P Balingit
- Olive View-UCLA Medical Center, University of California, Los Angeles, Sylmar, California, USA
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72
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Doerler M, Reich-Schupke S, Altmeyer P, Stücker M. Impact on wound healing and efficacy of various leg ulcer debridement techniques. J Dtsch Dermatol Ges 2012; 10:624-32. [DOI: 10.1111/j.1610-0387.2012.07952.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Wound dressings are regarded as important components of ulcer treatment, with clinicians and patients having many different types to choose from including hydrocolloid dressings. There is a range of different hydrocolloids available including fibrous-hydrocolloid and hydrocolloid (matrix) dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of hydrocolloid wound dressings with no dressing or alternative dressings on the healing of foot ulcers in people with diabetes. SEARCH METHODS We searched The Cochrane Wounds Group Specialised Register (searched 4 January 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (1950 to December Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to 2011 Week 52); and EBSCO CINAHL (1982 to 30 December 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrocolloid with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included four studies (511 participants) in the review: these compared hydrocolloids with basic wound contact dressings, foam dressings and alginate dressings. Meta-analysis of two studies indicated no statistically significant difference in ulcer healing between fibrous-hydrocolloids and basic wound contact dressings: risk ratio 1.01 (95% CI 0.74 to 1.38). One of these studies found that a basic wound contact dressing was more cost-effective than a fibrous-hydrocolloid dressing. One study compared a hydrocolloid-matrix dressing with a foam dressing and found no statistically significant difference in the number of ulcers healed. There was no statistically significant difference in healing between an antimicrobial (silver) fibrous-hydrocolloid dressing and standard alginate dressing; or an antimicrobial dressing (iodine-impregnated) and a standard fibrous hydrocolloid dressing. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that any type of hydrocolloid wound dressing is more effective in healing diabetic foot ulcers than other types of dressing. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK.
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Abstract
BACKGROUND Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of alginate wound dressings with no wound dressing or alternative dressings on the healing of foot ulcers in people with diabetes mellitus. SEARCH METHODS We searched The Cochrane Wounds Group Specialised Register (searched 4 January 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (1950 to December Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to 2011 Week 52); and EBSCO CINAHL (1982 to 30 December 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of alginate dressings with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (375 participants) in this review; these compared alginate dressings with basic wound contact dressings, foam dressings and a silver-containing, fibrous-hydrocolloid dressing. Meta analysis of two studies found no statistically significant difference between alginate dressings and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI 0.66 to 1.80). Pooled data from two studies comparing alginate dressings with foam dressings found no statistically significant difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08). There was no statistically significant difference in the number of diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid dressing was compared with a standard alginate dressing (RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up times (six to 12 weeks), and small sample sizes. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK.
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Gottrup F, Apelqvist J. Present and new techniques and devices in the treatment of DFU: a critical review of evidence. Diabetes Metab Res Rev 2012; 28 Suppl 1:64-71. [PMID: 22271726 DOI: 10.1002/dmrr.2242] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Management of foot ulcer in individuals with diabetes remains a major therapeutic challenge throughout the world. We performed a critical review of evidence of present and new techniques and devices in the treatment of diabetic foot ulcer. The golden standard for optimal evidence in the Cochrane system is level I - randomized controlled trials, and meta-analyses of several randomized controlled trials. Available evidence on different types of wound debridement; use of antimicrobials; use of dressings in wounds; topical negative pressure, hyperbaric oxygen treatment; electrical, electromagnetic, laser, shockwave, and ultrasound therapies; growth and cell biology factors; cell products and tissue engineering; bioengineered skin and skin grafts; and adjuvant therapies were evaluated. The results of this review show that there is limited evidence on the highest level to justify a change in routine clinical practice. There is a paucity of high-quality evidence, because the studies are often based on inadequate sample size, short follow-up, nonrandom allocation to treatment arms, nonblinded assessment of outcomes, poor description of control, and concurrent intervention. The heterogeneity of the population (of both people and ulcers), with multiple factors contributing to both ulcer onset and failure to heal, makes the trial design difficult in this field. Another fundamental reason for the lack of evidence is the general use of the outcome measure 'complete healing'. In conclusion, when the results of this updated review are taken together with those of the earlier reports, they provide limited evidence to justify a change in routine clinical practice. For this reason, there is an urgent need to increase the quality of clinical studies. A re-evaluation of which type of research is acceptable for producing evidence in the wound area may be important in the future.
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Affiliation(s)
- Finn Gottrup
- Department of Dermatology, D42, Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen NV, Denmark.
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Game FL, Hinchliffe RJ, Apelqvist J, Armstrong DG, Bakker K, Hartemann A, Löndahl M, Price PE, Jeffcoate WJ. A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2012; 28 Suppl 1:119-41. [PMID: 22271737 DOI: 10.1002/dmrr.2246] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The outcome of management of diabetic foot ulcers is poor, and there is continuing uncertainty concerning optimal approaches to management. It was for these reasons that in 2006 the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing undertook a systematic review of the evidence to inform protocols for routine care and to highlight areas which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between December 2006 and June 2010. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae and hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; hyperbaric oxygen therapy (HBOT); compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound; other systemic therapies which did not fit in the above categories. Heterogeneity of studies prevented pooled analysis of results. Of the 1322 papers identified, 43 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic review, but the conclusion is similar: that with the exception of HBOT and, possibly, negative pressure wound therapy, there is little published evidence to justify the use of newer therapies. This echoes the conclusion of a recent Cochrane review and the systematic review undertaken by the National Institute for Health and Clinical Excellence Guidelines Committee in the UK. Analysis of evidence presents considerable difficulties in this field particularly as controlled studies are few and the majority are of poor methodological quality.
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Affiliation(s)
- F L Game
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK.
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78
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES The review aimed to evaluate the effects of foam wound dressings on the healing of foot ulcers in people with diabetes. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (searched 10 June 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); Ovid MEDLINE (1950 to June Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 8 June, 2011); Ovid EMBASE (1980 to 2011 Week 22); EBSCO CINAHL (1982 to 3 June 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects on ulcer healing of one or more foam wound dressings in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (157 participants) in this review. Meta analysis of two studies indicated that foam dressings do not promote the healing of diabetic foot ulcers compared with basic wound contact dressings (RR 2.03, 95%CI 0.91 to 4.55). Pooled data from two studies comparing foam and alginate dressing found no statistically significant difference in ulcer healing (RR 1.50, 95% CI 0.92 to 2.44). There was no statistically significant difference in the number of diabetic foot ulcers healed when foam dressings were compared with hydrocolloid (matrix) dressings. All included studies were small and/or had limited follow-up times. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that foam wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however all trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK, YO10 5DD
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including hydrogel dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To assess the effects of hydrogel wound dressings compared with alternative dressings or none on the healing of foot ulcers in people with diabetes. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (searched 10 June 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); Ovid MEDLINE (1950 to June Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, June 8, 2011); Ovid EMBASE (1980 to 2011 Week 22) and EBSCO CINAHL (1982 to 3 June 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrogel with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies (446 participants) in this review. Meta analysis of three studies comparing hydrogel dressings with basic wound contract dressings found significantly greater healing with hydrogel: risk ratio (RR) 1.80, 95% confidence interval (CI) 1.27 to 2.56. The three pooled studies had different follow-up times (12 weeks, 16 weeks and 20 weeks) and also evaluated ulcers of different severities (grade 3 and 4; grade 2 and grade unspecified). One study compared a hydrogel dressing with larval therapy and found no statistically significant difference in the number of ulcers healed and another found no statistically significant difference in healing between hydrogel and platelet-derived growth factor. There was also no statistically significant difference in number of healed ulcers between two different brands of hydrogel dressing. All included studies were small and at unclear risk of bias and there was some clinical heterogeneity with studies including different ulcer grades. No included studies compared hydrogel with other advanced wound dressings. AUTHORS' CONCLUSIONS There is some evidence to suggest that hydrogel dressings are more effective in healing (lower grade) diabetic foot ulcers than basic wound contact dressings however this finding is uncertain due to risk of bias in the original studies. There is currently no research evidence to suggest that hydrogel is more effective than larval therapy or platelet-derived growth factors in healing diabetic foot ulcers, nor that one brand of hydrogel is more effective than another in ulcer healing. No RCTs comparing hydrogel dressings with other advanced dressing types were found.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK, YO10 5DD
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80
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Toy LW, Macera L. Evidence-based review of silver dressing use on chronic wounds. ACTA ACUST UNITED AC 2011; 23:183-92. [DOI: 10.1111/j.1745-7599.2011.00600.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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81
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Fontenoy C, Kamel S. Silver in the medical devices/equipments: Marketing or real clinical interest? ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.phhp.2010.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Blome-Eberwein S, Johnson R, Miller S, Caruso D, Jordan M, Milner S, Tredget E, Sittig K, Smith L. Hydrofiber dressing with silver for the management of split-thickness donor sites: A randomized evaluation of two protocols of care. Burns 2010; 36:665-72. [DOI: 10.1016/j.burns.2009.06.193] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 06/01/2009] [Accepted: 06/02/2009] [Indexed: 10/20/2022]
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Carter MJ, Tingley-Kelley K, Warriner RA. Silver treatments and silver-impregnated dressings for the healing of leg wounds and ulcers: a systematic review and meta-analysis. J Am Acad Dermatol 2010; 63:668-79. [PMID: 20471135 DOI: 10.1016/j.jaad.2009.09.007] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 07/23/2009] [Accepted: 09/09/2009] [Indexed: 01/11/2023]
Abstract
Previous systematic reviews of silver-impregnated dressings have been contradictory regarding the healing of leg wounds/ulcers. Our systematic review was restricted to randomized controlled trials. Cochrane Library, Scopus, and MEDLINE databases were searched using the term "silver" in combination with "wound" or "ulcer" (and plural versions) without date/language restriction. Study quality was assessed and meta-analysis conducted for complete wound healing, wound size reduction, and healing rates. Overall study quality was fair with most studies having some bias. Evidence for wound healing using individual studies was poor. Meta-analyses found strong evidence for wound healing based on wound size reduction but no evidence based on complete wound-healing or healing rates. Although our results provide some evidence that silver-impregnated dressings improve the short-term healing of wounds and ulcers, long-term effects remain unclear. Clinical trial data with longer follow-up times are needed to address these issues.
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84
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Abstract
BACKGROUND Silver-containing treatments are popular and used in wound treatments to combat a broad spectrum of pathogens, but evidence of their effectiveness in preventing wound infection or promoting healing is lacking. OBJECTIVES To establish the effects of silver-containing wound dressings and topical agents in preventing wound infection and healing of wounds. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (6 May 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) (2009 Issue 2); Ovid MEDLINE (1950 to April Week 4 2009); Ovid EMBASE (1980 to 2009 Week 18); EBSCO CINAHL (1982 to April Week 4 2009) and Digital Dissertations (to May 2009) for relevant trials. We contacted manufacturers and distributors. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing silver-containing wound dressings and topical agents with silver-containing and non silver-containing comparators on uninfected wounds. DATA COLLECTION AND ANALYSIS Two authors independently selected trials, assessed risk of bias, and extracted data. MAIN RESULTS We identified 26 RCTs (2066 patients). Heterogeneity of treatments and outcomes precluded meta-analysis. We grouped results according to wound type, and silver preparation.BurnsThirteen trials compared topical silver (in a variety of formulations - including silver sulphadiazine (SSD) cream) with non-silver dressings. One trial showed fewer infections with silver nitrate when compared with a non-silver dressing, but three trials showed significantly more infection with SSD than with the non-silver dressing.Six trials compared SSD cream with silver-containing dressings. One showed significantly fewer infections with the silver-containing dressing (Hydron AgSD) compared with SSD, the remaining five found no evidence of a difference.One trial compared two silver-containing dressings, and showed a significantly lower infection rate with silver-coated gauze (Acticoat(R)) than with silver nitrate gauze.Other woundsSix trials compared SSD/silver-containing dressings with non-silver dressings (nine dressings in total). Most comparisons (seven) found no significant differences in infection rates; one trial in a variety of wounds exhibited significantly fewer infections with SSD/hydrocolloid, but another, in acute wounds, found significantly more infections with SSD. Only one comparison showed a significant reduction in healing time associated with a silver-containing hydrofibre dressing in diabetic foot ulcers. AUTHORS' CONCLUSIONS There is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection; some poor quality evidence for SSD suggests the opposite.
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Affiliation(s)
- Marja N Storm-Versloot
- Department of Surgery, Academic Medical Centre at the University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ
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85
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Abstract
BACKGROUND Foot ulceration is thought to affect 15% of people with diabetes at some time in their lives. Debridement is widely regarded as an effective intervention to speed up ulcer healing. The most effective method is unclear. OBJECTIVES To assess the effects of debridement interventions on the healing of diabetic foot ulcers. SEARCH STRATEGY For this third update we searched the Cochrane Wounds Group Specialised Register (June 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2009, Issue 2; Ovid MEDLINE - 1950 to June Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 25 and Ovid CINAHL - 1982 to June Week 3 2009. SELECTION CRITERIA Randomised controlled trials (RCTs) evaluating any method of debriding diabetic foot ulcers and measuring complete healing or rate of healing. There was no restriction on articles/trials based on language or publication status. DATA COLLECTION AND ANALYSIS Data extraction and assessment of study quality were undertaken by one review author and checked by an Editor of the Wounds Group. MAIN RESULTS Six RCTs of debridement were identified: four assessed hydrogels, with an additional study evaluating larval therapy against hydrogel and one evaluated surgical debridement. Pooling the three RCTs which compared hydrogel with gauze or standard care suggested that hydrogels are significantly more effective in healing diabetic foot ulcers (Relative Risk 1.84, 95% Confidence Interval (CI)1.3 to 2.61). Surgical debridement showed no significant benefit over standard treatment. One small trial suggested that larvae resulted in a more than 50% reduction in wound area compared with hydrogel. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in diabetic foot ulcers. AUTHORS' CONCLUSIONS There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
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Affiliation(s)
- Jude Edwards
- Trafford CollegeDepartment of Health and Social CareManchester RoadWest TimperleyAltrinchamCheshireUKWA14 5PQ
| | - Sally Stapley
- Teesside UniversitySchool of Health and Social CareC1.10, Constantine BuildingMiddlesbroughTees ValleyUKTS1 3BA
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Kasseroller RG, Brenner E. A prospective randomised study of alginate-drenched low stretch bandages as an alternative to conventional lymphologic compression bandaging. Support Care Cancer 2009; 18:343-50. [DOI: 10.1007/s00520-009-0658-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 05/13/2009] [Indexed: 12/01/2022]
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87
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Lo SF, Chang CJ, Hu WY, Hayter M, Chang YT. The effectiveness of silver-releasing dressings in the management of non-healing chronic wounds: a meta-analysis. J Clin Nurs 2009; 18:716-28. [DOI: 10.1111/j.1365-2702.2008.02534.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Meuleneire F. An observational study of the use of a soft silicone silver dressing on a variety of wound types. J Wound Care 2008; 17:535-9. [DOI: 10.12968/jowc.2008.17.12.31767] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jeffcoate WJ, Lipsky BA, Berendt AR, Cavanagh PR, Bus SA, Peters EJG, van Houtum WH, Valk GD, Bakker K. Unresolved issues in the management of ulcers of the foot in diabetes. Diabet Med 2008; 25:1380-9. [PMID: 19046235 DOI: 10.1111/j.1464-5491.2008.02573.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- W J Jeffcoate
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK.
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90
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White R, McIntosh C. Topical therapies for diabetic foot ulcers: standard treatments. J Wound Care 2008; 17:426, 428-32. [DOI: 10.12968/jowc.2008.17.10.31305] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - C. McIntosh
- Department of Podiatry, National University of Ireland, Galway, Ireland
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91
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Lo SF, Hayter M, Chang CJ, Hu WY, Lee LL. A systematic review of silver-releasing dressings in the management of infected chronic wounds. J Clin Nurs 2008; 17:1973-85. [DOI: 10.1111/j.1365-2702.2007.02264.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Eneroth M, van Houtum WH. The value of debridement and Vacuum-Assisted Closure (V.A.C.) Therapy in diabetic foot ulcers. Diabetes Metab Res Rev 2008; 24 Suppl 1:S76-80. [PMID: 18393328 DOI: 10.1002/dmrr.852] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Treatment of diabetic foot ulcers includes a number of different regimes such as glycaemic control, re-vascularization, surgical, local wound treatment, offloading and other non-surgical treatments. Although considered the standard of care, the scientific evidence behind the various debridements used is scarce. This presentation will focus on debridement and V.A.C. Therapy, two treatments widely used in patients with diabetes and foot ulcers. METHODS A review of existing literature on these treatments in diabetic foot ulcers, with focus on description of the various types of debridements used, the principles behind negative pressure wound therapy (NPWT) using the V.A.C. Therapy system and level of evidence. RESULTS Five randomized controlled trials (RCT) of debridement were identified; three assessed the effectiveness of a hydrogel as a debridement method, one evaluated surgical debridement and one evaluated larval therapy. Pooling the three hydrogel RCTs suggested that hydrogels are significantly more effective than gauze or standard care in healing diabetic foot ulcers. Surgical debridement and larval therapy showed no significant benefit. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in RCTs of people with diabetes. More than 300 articles have been published on negative pressure wound therapy, including several small RCTs and a larger multi-centre RCT of diabetic foot ulcers. Negative pressure wound therapy seems to be a safe and effective treatment for complex diabetic foot wounds, and could lead to a higher proportion of healed wounds, faster healing rates, and potentially fewer re-amputations than standard care. CONCLUSIONS Although debridement of the ulcer is considered a prerequisite for healing of diabetic foot ulcers, the grade of evidence is quite low. This may be due to a lack of studies rather than lack of effect. Negative pressure wound therapy seems to be safe and effective in the treatment of some diabetic foot ulcers, although there is still only one well-performed trial that evaluates the effect.
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Affiliation(s)
- Magnus Eneroth
- Department of Orthopaedics, Malmö University Hospital, 205 02 Malmö, Sweden.
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Cutting K, White R, Edmonds M. The safety and efficacy of dressings with silver - addressing clinical concerns. Int Wound J 2007; 4:177-84. [PMID: 17651232 PMCID: PMC7951405 DOI: 10.1111/j.1742-481x.2007.00338.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
With the increasing use of silver as a topical application in wound care, concerns focussing on its role are bound to arise. These concerns, which centre on issues such as resistance and toxicity, clinical efficacy and cost-effectiveness, need to be addressed and openly discussed so that they are viewed from a rational perspective. While clinical efficacy and safety, along with cost-benefit, are of obvious interest, the origin of some of these concerns is a matter of debate. The silver-containing dressing segment of the medical device market is of huge commercial importance, and, consequently, marketing and promotional issues occasionally obscure the evidence that clinicians need to have in order that they may provide appropriate treatment for their patients. The impact of silver application on the wound bioburden needs to be examined carefully to heighten our awareness of any deleterious effects on the healing process, without inducing any unfounded anxieties.
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Affiliation(s)
- Keith Cutting
- Faculty of Society & Health, Buckinghamshire Chilterns University College, Chalfont St. Giles, HP8 4AD, UK.
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94
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Bell A, Hart J. Evaluation of two absorbent silver dressings in a porcine partial-thickness excisional wound model. J Wound Care 2007; 16:445-8, 450-3. [DOI: 10.12968/jowc.2007.16.10.27911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- A Bell
- Institute for Molecular and Cellular Biology, University of Leeds, West Yorkshire, LS2 9JT, UK
| | - J Hart
- Cica Biomedical Ltd, PO Box 146, Knaresborough, North Yorkshire HG5 9WB, UK
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Abstract
BACKGROUND Foot ulceration affects 15-20% of people with diabetes. It is a major precursor to amputation in this patient group, and early and appropriate treatment provides the greatest opportunity for healing. The use of silver for its antimicrobial properties has re-emerged, and modern wound dressings that release a sustained amount of free silver ions, are now widely used in wound management. OBJECTIVES To evaluate the effects of silver-containing dressings and topical agents on infection rates and healing of diabetes related foot ulcers. SEARCH STRATEGY Searches were made of the Cochrane Wounds Group Specialised Register (August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3 2005) MEDLINE (1966 to October week 2 2004), EMBASE (1980 to October week 2 2004) and CINAHL (1982 to October week 2 2004). The Journal of Wound Care (Volume 12/13 Issues 1-10) was hand-searched. Manufacturers, researchers and local and international wound groups were contacted in order to identify unpublished trials. Web sites for wound groups and World Wide Wounds (www.worldwidewounds.com) were searched. SELECTION CRITERIA Randomised controlled trials and non-randomised controlled clinical trials were considered for inclusion. Studies were included if they involved participants with Type 1 or Type 2 diabetes and related foot ulcers, met the requirements for randomisation, allocation and concealment where appropriate, and compared the intervention with a placebo or a sham dressing, an alternative non silver based dressing or no dressing, and reported outcomes that represent healing rate or infection. DATA COLLECTION AND ANALYSIS Two authors independently evaluated the papers identified by the search strategy against the inclusion criteria but identified no trials eligible for inclusion in the review. It was not possible to perform planned subgroup and sensitivity analysis in the absence of data. In future, if eligible trials become available, a random effects model will be applied for meta-analysis in the presence of statistical heterogeneity (estimated using the I(2) statistic). Dichotomous outcomes will be reported as risk ratios with 95% confidence intervals (CI), and continuous outcomes as weighted mean differences (WMD) with 95% CI. Statistical significance will be set at P value < 0.05 for all outcomes and the magnitude of the effect will be estimated by calculating the number needed to treat (NNT) with 95% CI. MAIN RESULTS No studies were identified that met with the inclusion criteria AUTHORS' CONCLUSIONS Despite the widespread use of dressings and topical agents containing silver for the treatment of diabetic foot ulcers, no randomised trials or controlled clinical trials exist that evaluate their clinical effectiveness. Trials are needed to determine clinical and cost-effectiveness and long term outcomes including adverse events.
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Affiliation(s)
- S M Bergin
- Royal Melbourne Hospital, Departments of Diabetes & Clinical Epidemiology, Monash Institute of Health Services Research, Monash University, Grattan St, Parkville, Melbourne, Australia, 3050.
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96
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Abstract
BACKGROUND Foot ulceration is thought to affect 15% of people with diabetes at some time in their lives. OBJECTIVES The aim of this review is to assess the evidence for the effectiveness of debridement as a treatment for diabetic foot ulcers. SEARCH STRATEGY Searches of electronic databases, hand searching journals, bibliographies and identification of unpublished work by written communication with recognised experts in the diabetic foot. SELECTION CRITERIA Randomised controlled trials evaluating a method of debridement in the treatment of diabetic foot ulcers. The outcome had to include either complete healing or rate of healing. There was no restriction on articles/trials based on language or publication status. DATA COLLECTION AND ANALYSIS Data extraction and assessment of study quality were undertaken by one reviewer and checked by an Editor of the Wounds Group. MAIN RESULTS 5 RCTs of debridement were identified; 3 RCTs assessed the effectiveness of a hydrogel as a debridement method, 1 RCT evaluated surgical debridement and 1 RCT evaluated larval therapy. Pooling the 3 hydrogel RCTs suggested that hydrogels are significantly more effective than gauze or standard care in healing diabetic foot ulcers (absolute risk difference 0.23; 95% CI: 0.10,0.36). Surgical debridement and larval therapy showed no significant benefit in these small trials. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in RCTs of people with diabetes. REVIEWER'S CONCLUSIONS There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
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Affiliation(s)
- J Smith
- Department of Podiatry, Selby & York NHS Primary Care Trust, Diabetes Centre, York District Hospital, Wigginton Road, York, North Yorkshire, YO31 7HE, UK.
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