Dr. Frykberg is podiatry chief and residency director and Dr. Banks is a research fellow, both at the Phoenix VA Health Care System in Arizona. Dr. Frykberg is a professor of practice at the University of Arizona College of Medicine in Phoenix. Dr. Banks is a professor at Grand Canyon University in Phoenix.
Author disclosures Dr. Frykberg has received research support from Osiris Therapeutics, Advanced BioHealing, AOTI, KCI, Smith & Nephew, Tissue Regenix, and ACell. All other authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Table 3 lists most of the wound care technologies commonly used in current clinical practice. Although randomized controlled trials have been published supporting the use of most of these modalities, a lack of strong data proving efficacy for use of such treatment options remains.
Treatment of any underlying ischemia is critical in achieving a successful outcome. Vascular surgical consultation should be obtained on presentation of an ischemic wound and in cases where ulcers show no sign of progress despite appropriate management.4,13 Revascularization is commonly performed in patients with critical limb ischemia and DFUs but is also performed in patients with less severe arteriopathy. The goal is to restore a palpable pulse on the affected foot.65 The postrevascularization ulcer-healing rate ranges from 46% to 91% at 1 year and seems to be improved in those patients with distal arterial reconstruction and restoration of pulsatile flow.66
Endovascular approaches are becoming increasingly common in patients whose arterial disease is more limited or morbidity is a significant concern.67,68 Studies report that the exact role of isolated endovascular procedures is still to be determined, although such interventions are frequently performed in concert with angiography preceding vascular reconstructive procedures.69,70 However, in many such studies, healing was often a secondary criterion, and there was no description of the initial wound or its management.71
Challenges
Within the VA setting there is a wide range of patient comorbidities that frequently present clinicians with unique challenges. Often these patients are older with many social and mental health conditions, including self-abuse, drug-abuse, nonadherence, psychological issues and lack of financial and/or educational resources or support. Many of these patients have comorbidities associated with diabetes that can delay healing of their ulcerations.
Systemwide VA mandates have implemented multidisciplinary foot care teams. The teams identify veterans at risk for lower limb complications; provide preventive care; track high-risk foot care across the continuum of outpatient, inpatient, and rehabilitative care; and provide education, orthoses, and social support.72,73 In the late 1990s, the VHA implemented a national program of foot risk screening and referral, conducted largely in primary care.29 By 1998 as determined from medical record reviews, 95% of veterans had a visual examination, 84% had palpation of pulses, and 78% had undergone a sensory examination. In addition, about 83% of patients had a monofilament examination, and 85% of individuals with risk factors were referred to foot specialists in 2004.72,74 Veterans at higher risk for lower extremity complications routinely receive subsequent preventive foot care, such as education or prescription of therapeutic shoes in the VHA.
Tseng and colleagues evaluated risk-adjusted trends in amputations among veterans with diabetes during a 5-year period and reported a decrease in amputation rates observed for all types of lower extremity amputations (LEA) and among all racial groups.74 Implementation of such universal programs for foot screening, tracked through performance measures, may have contributed to a decrease in LEAs and improved outcomes in the VA patient population.
A healthy, intact diabetic foot is best maintained by a consistent and recurrent preventive treatment strategy. Prevention of ulcer recurrence remains to be a major clinical challenge. Andrews and colleagues demonstrated that recurrence rates range from 28% at 12 months to 100% at 40 months.75 They report that the highest incidence of reulceration is in the site of a previous ulceration, noting that a newly healed ulcer is covered with fragile skin and after complete healing, there is an area of higher density tissue (scar). Shearing between the different tissue densities often contributes to new ulcers.
After the ulcer heals, the patient and their caregivers must incorporate preventative measures in care plans to reduce the risk of wound reoccurrence. A study reported by Barshes and colleagues demonstrated that a majority of people with diabetes do not receive guideline-recommended foot care, including regular foot examinations.76 Identifying the patients with diabetes at risk for ulceration requires foot examination,including the vascular and neurologic systems, skin conditions, and foot structure.77 Among the complications of diabetes, lower limb amputation is considered to be preventable.78,79 Because there is a great beneficial effect of patient education on reducing LEAs, a flexible schedule for diabetes education, that offers education at any time for the maximum convenience of patients rather than focusing on health care provider’s convenience is critical.79,80 Conservative management of foot problems also has reduced the risk of amputation by simple procedures, such as appropriate foot wear, cleanliness, aggressive surgical debridement, and evidence-based ulcer management.34 This is best accomplished through a multidisciplinary approach involving a team of specialists and personnel who provide a coordinated process of care, including a patient motivated to ensure its success.6
