Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: A systematic review

BACKGROUND

It is critical that interventions used to enhance the healing of chronic foot ulcers in diabetes are backed by high-quality evidence and cost-effectiveness. In previous years, the systematic review accompanying guidelines published by the International Working Group of the Diabetic Foot performed 4-yearly updates of previous searches, including trials of prospective, cross-sectional and case-control design.

AIMS

Due to a need to re-evaluate older studies against newer standards of reporting and assessment of risk of bias, we performed a whole new search from conception, but limiting studies to randomised control trials only.

MATERIALS AND METHODS

For this systematic review, we searched PubMed, Scopus and Web of Science databases for published studies on randomised control trials of interventions to enhance healing of diabetes-related foot ulcers. We only included trials comparing interventions to standard of care. Two independent reviewers selected articles for inclusion and assessed relevant outcomes as well as methodological quality.

RESULTS

The literature search identified 22,250 articles, of which 262 were selected for full text review across 10 categories of interventions. Overall, the certainty of evidence for a majority of wound healing interventions was low or very low, with moderate evidence existing for two interventions (sucrose-octasulfate and leucocyte, platelet and fibrin patch) and low quality evidence for a further four (hyperbaric oxygen, topical oxygen, placental derived products and negative pressure wound therapy). The majority of interventions had insufficient evidence.

CONCLUSION

Overall, the evidence to support any other intervention to enhance wound healing is lacking and further high-quality randomised control trials are encouraged.

Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)

AIMS

Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes-related foot ulcer. However, the rising incidence and costs of diabetes-related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes-related foot ulcers are supported by high-quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold-standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

MATERIALS AND METHODS

We followed the GRADE approach by devising clinical questions and important outcomes in the Patient-Intervention-Control-Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders.

RESULTS

From the results of the systematic review and evidence-to-decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post-operative wounds, the use of placental-derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions.

CONCLUSIONS

These wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.

Screening for the loss of protective sensation in people without a history of diabetic foot ulceration: validation of two simple tests in India

The ability of the Ipswich touch test (IpTT) and Vibratip^TM to detect loss of protective sensation (LOPS) was tested against a neurothesiometer in an outpatient diabetic population without a history for ulceration. Our results support the use of the IpTT as a screening tool for LOPS, but not of Vibratip^TM.

The Medial Column Fusion Bolt

Category:

Diabetes

Introduction/Purpose:

Charcot neuroarthropathy (CN) of the foot can cause severe bone and joint destruction. The aim of reconstruction is to correct the deformity and achieve bone fusion, in order to provide a plantigrade foot to ambulate with using accommodative footwear. Column beaming using the Medial Column Fusion Bolt (MCB) is a new technique described to stabilize - medial and/or lateral columns. We performed a meta-analysis to assess the outcome of the use of column beaming in treatment of CN.

Methods:

We performed a search of the English literature for the following search terms: ‘Charcot’, ‘arthropathy’, ‘column bolt’, ‘superconstruct’, ‘intramedullary’, ‘beaming’, ‘rodding’, ‘midfoot fusion’, ‘midfoot arthrodesis and ‘fusion bolt’. We included all the studies published until 2015. Only 10 studies met the inclusion criteria, and were identified for evaluation.

Results:

There were a total of 197 feet in 191 patients 47; average age 58.1 years (29-81 years). Diabetes mellitus was the most common cause of CN (81.8%). The average follow-up duration post-operatively was approximately 30 months (range 3-137 months). Several classification systems were used to grade deformity, implants were commonly combined with other fixation based on the location and severity of the deformity, presence or absence of ulcers and surgeon’s preference. All studies reported improvement in correction of deformities both clinically & radiologically with an associated-loss of correction over the follow-up period. Overall, we observed 49.8% of patients experienced a complication, including screw breakage or migration (33), infection (42), wound dehiscence (20) and peri-prosthetic fractures (4). Resulting in revision and lower than expected fusion rates and recurrent ulceration.

Conclusion:

The MCB provides excellent correction of deformity, with high-failure-rate. This is especially true if a single-rod is used, as it may not provide enough stability to achieve osseous-fusion, due its inability to provide enough compression, reduce shear stress at bone interfaces when used in isolation. Thus additional-implants in neutralising rotational-instability to achieve a stable ‘‘superconstruct’’ may-avoid implant-failure, recurrent-deformity & high-complication-rates. Further assessment & stratification of CN deformity and implant use must be ascertained prior to definitive conclusions being reached regarding the use of the MCB. Whilst there is significant heterogeneity, current evidence suggests surgeons should use this device with caution.