Consensus development conference on diabetic foot wound care

Advances in Wound Care,  Sep 1999  

• E-mail
• Print
• Link

SPECIAL REPORT

7-8 April 1999, Boston, MA

AMONG PEOPLE WITH DIABETES, 15% WILL experience a foot ulcer in their lifetime; foot ulcers are a major predictor of future lower-extremity amputation in patients with diabetes. Indeed, about 1424% of people with a foot ulcer will require an amputation. It is therefore not surprising that diabetes is the leading cause of nontraumatic lower-extremity amputations in the U.S. Despite much effort directed towards amputation prevention in the last decade, the incidence of lower-extremity amputation in people with diabetes continues to rise. Thus, appropriate techniques for wound care that can reduce amputation rates are an essential prevention strategy.

The most common location for foot ulcers is the plantar surface of the forefoot. These ulcers are often caused by repetitive mechanical stress that is not recognized by the patient because of peripheral neuropathy and loss of protective sensation. In addition, the presence of peripheral vascular disease and infection can lead to poor healing of foot wounds and to the development of gangrene.

Despite substantial morbidity resulting from foot wounds in people with diabetes, there are no widely accepted evidence-based guidelines for assessing and treating foot ulcers and preventing their recurrence. Opinion, rather than scientific evidence, is the basis for many existing treatments. In addition, some therapies with proven effectiveness are not widely available. Also, as new therapies are being developed, there is no general agreement on how they should be evaluated. Finally, economic forces in the U.S. are moving the health care system toward becoming more cost-effective; this highlights the priority for identifying the most cost-effective methods for treating and preventing foot wounds.

The American Diabetes Association recently published a technical review and position statement on preventive foot care for people with diabetes (1,2). These papers did not, however, address treatment of the ulcerated foot. To provide guidance to clinicians who manage foot wounds in people with diabetes, the Association convened a Consensus Development Conference on Diabetic Foot Wound Care on April 7-8, 1999. A multidisciplinary 8-member panel heard presentations from 25 experts, complemented by audience contributions, on the economics of wound care, the biology of wound healing, and the classification, assessment, treatment, and prevention of recurrence of foot wounds. After extensive discussion with the speakers and the audience, the panel developed a consensus position on the following questions:

1. What is the value of treating a diabetic foot wound?

2. What is the biology of wound healing?

3. How should diabetic foot wounds be assessed and classified?

4. What are the appropriate treatments for foot wounds?

5. How should new treatments be evaluated?

6. How can recurrent foot wounds be prevented?

QUESTION 1: What is the value of treating a diabetic foot wound?

The term "diabetic foot wound" refers to a variety of pathological conditions. Ulcers, the most frequent and characteristic type of lesions, are defined as any break in the cutaneous barrier, but they usually extend through the full thickness of the dermis (3). Certain infections of the foot, e.g., cellulitis or osteomyletis, can occur without a break in the skin. A wound may be acute or chronic; the latter could be defined as a wound that is not continuously progressing toward healing. Any wound that remains unhealed after 4 weeks is cause for concern as it is associated with worse outcomes, including amputation.

The perceived value of treating foot ulcers varies from the point of view of the patient, the provider, the health care system, the payor, or the purchaser. Foot wounds in diabetic patients should be treated for several reasons. To improve function and quality of life. Healing of foot wounds improves the appearance of the foot and may allow the patient to return to ambulation in appropriate footwear. Patients who have an altered gait or who have modified their usual activities because of a foot wound should benefit from treatment. Improving function and return to wellbeing are important goals of therapy. A healed wound relieves the patient of the burden of changing dressings and taking or applying medications, and it allows him or her to better negotiate activities of daily living. A more functional patient is also less of a burden to his/her family, other helpers, and the health care system. To control infection. Infected wounds are often minimally symptomatic, displaying only drainage, odor, or mild discomfort. They may, however, progress to involve deeper soft tissues or bone. Infected wounds can be limb-threatening or even life-threatening. The goal of treatment should be to prevent wounds from becoming infected. Treating infections promotes resistant bacteria and burdens the patient with antibiotics that can cause allergic reactions, troublesome or disabling side effects, and superinfections. This further compromises the patient's health and negatively impacts providers and the health care system. To maintain health status. Diabetic foot infections can impose an increased metabolic demand on the patient by worsening the patient's glycemic control, renal and cardiac function, nutritional balance, or other metabolic parameters. By impairing mobility, foot wounds often lead to general deconditioning and psychosocial dysfunction.