Current Concepts Review: Diabetic Foot Ulcers

Diabetic foot ulcers can be associated with severe morbidity. The goals of treatment are to heal the ulcer, prevent secondary infection, prevent recurrence, and avoid amputation. In the future, providing patients with access to a multidisciplinary foot care team may be able to decrease the rate of major amputations.39 Meanwhile, clinical evidence that broadens our understanding of this complex medical issue supports the following summary points: • The healing rate of a diabetic foot ulcer is an important predictor of eventual wound closure.Wounds that do not reduce in size by 50% at 4 weeks are less likely to heal than wounds which have a greater reduction in area. • Advanced imaging is not routinely indicated in patients with a healthy appearing DFU that is demonstrating progressive signs of healing. However, if osteomyelitis is suspected, nuclear imaging offers sensitivity but not specificity. In one study, MRI was shown to be superior than technetium and white blood cell scans in detecting osteomyelitis. • Off loading of diabetic plantar neuropathic ulcers is an important and effective treatment modality to assist in healing of DFU. However, the clinician must be vigilant for complications associated with this technique. Additionally, an irremovable boot walker is equally effective in patients with minimal deformity and plantar ulcers. • Achilles tendon lengthening performed in conjunction with the use of a walking boot or TCC is effective in healing DFU and reducing recurrence rates. • Certain bio-engineered advanced wound healing modalities are more effective than standard moist wound care in healing diabetic foot ulcers. • Negative pressure wound therapy is more effective than standard moist wound care in healing diabetic foot ulcers. • Surgery may be required to treat recalcitrant DFU. These procedures include exostectomy, arthrodesis, osteotomy, tendon release, hammertoe correction and hallux rigidus correction. However, the body of evidence is not easily interpretable to an individual case of a recalcitrant DFU and is therefore insufficient to make a specific recommendation for the use of any of these methods. • The evidence to support the use of hyperbaric oxygen, electrical stimulation and ultrasound in the treatment of DFU is insufficient at this time, although hyperbaric oxygen appears to reduce the incidence of major amputations. Copyright © 2010 by the American Orthopaedic Foot & Ankle Society.