Friday, December 26, 2014

Offloading foot ulcers essential for wound healing

Offloading is essential to diabetic foot ulcer healing, according to new podiatry consensus guidelines.
The new guidance, published in the November/December 2014 issue of the Journal of the American Podiatric Association, was written by a nine-member panel of podiatrists, surgeons, and other experts in diabetic foot care.

The group reviewed the literature using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to make eight evidence-based recommendations about management of diabetic foot ulcers, with an emphasis on the use of offloading.

The guidance also makes clear that total contact casting — not shoe gear or removable casts — is the optimal offloading method.

Offloading of diabetic foot ulcers is critical to healing but often neglected in primary and even specialty care, lead author Dr Robert J Snyder (Barry University School of Podiatric Medicine, Miami, Florida) told Medscape Medical News.

"Predominantly, diabetic foot ulcers occur on the bottom of the foot, under the metatarsal head or in the heel. It's very, very important that those areas be offloaded. Unfortunately, there are large numbers of physicians, both generalists and specialists, who don't really offload to the extent that they should, or in fact, in some cases don't offload or take pressure off these wounds at all."

Dr Jan Ulbrecht (Mount Nittany Medical Center, State College, Pennsylvania) agreed. "Adequate offloading absolutely has to be at the core of care of every single foot ulcer," he told Medscape Medical News.
Dr Ulbrecht praised the consensus statement. "They did a pretty good job of reviewing what's known and making recommendations based on where maybe the evidence is incomplete but is the best we've got. I basically agree with everything they say."

Total Contact Casts Are "Gold Standard"
Based on the GRADE review of 66 papers, the panel made the following eight consensus statements.
1) Vascular management, infection management and prevention, and pressure relief are essential to diabetic foot ulcer healing (evidence quality high/recommendation strong). Often denoted in the wound-care literature as VIP, this is the overall aggressive approach the panel deems necessary for diabetic foot ulcer healing.

Vascular assessment requires a combination of physical examination and laboratory tests. Blood-pressure indices such as the ankle-brachial index have poor reliability in patients with diabetes, so should not be used as the only assessment, according to the guidelines.

For infection diagnosis and treatment, the panel endorses the clinical-practice guidelines of the Infectious Diseases Society of America (Clin Infect Dis. 2012;54:e132-e173).

The third VIP component, pressure relief, is addressed throughout the rest of the guidelines.

Source: Medscape Medical News

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