Diabetic Foot Ulcers - Literature review Example

Literature Review/ Rear foot/ forefoot ulceration diabetic patient Introduction Diabetic foot ulcers are poor healing and a burden to the patient that has them. There at this point does not seem to be a gold standard for prevention or treatment. Conservative treatment consists of such things as wound debridement, pressure relief and wound dressings. There does not seem to be any specific wound dressing recommended. There is also prevention to consider with the fact being, of course, that it is better to try to prevent the problem than to treat it. This paper will review the literature in an effort to understand what might be done to prevent these ulcers from occurring and what is being studied for treatment once they have formed. Background Diabetic foot ulcers have a great impact on patients as well as the healthcare system. They heal slowly, need very intensive care and often end up with infection and sometimes gangrene, which will lead to long term in-hospital treatment as well as the possibility of amputation. The average cost of healing a single ulcer is $8,000, that of an infected ulcer, $17,000, and that of a major amputation is $45,000. More than 80,000 amputations are performed each year in diabetic patients in the United States alone (Kruse & Edelman, 2006).The diabetic foot ulcer can seem benign appearing to be a callus or skin defect. This reassures the patient and the ulcer gets out of hand quickly. Many patients have a tremendous change in their quality of life due to the ulcers themselves or the amputations that may follow. There is a great loss of mobility and the possibility of loss of work and a major reduction in social activities. If an amputation occurs the prognosis for lifestyle is even worse. AIM The aim of this literature review is to find some of the best practice that is being used today to prevent as well as treat these slow healing diabetic foot ulcers. Review Strategy/ Inclusion and Exclusion This literature review will eliminate articles that are not peer reviewed and those about wounds other than diabetic wounds. Included in the review will be studies and literature from journals that are peer reviewed and published in scholarly journals. The review strategy used will be to enter a multiple key word search in ebsco host and Ovid, as well as medline. Included in the multiple key word searches will be diabetic ulcer, forefoot, rearfoot, offloading, hydrocolloids, and other words suggested in the review. Those articles found will be categorized in background, information about the diabetic ulcer, prevention methods, and then treatment methods. Those articles found not to be peer reviewed will be eliminated. Literature Review Schaper, Prompers, and Huijberts, (2007) provide the reader with a good background understanding of the diabetic foot ulcer, general methods of diagnosis and treatment. Covered in this article are epidemiology and costs as well as general pathways to ulceration and amputation. Distal sensori-motor polyneuropathy and altered biomechanics as well as the major and minor injuries that occur every day that the diabetic with neuropathy may not notice causing the beginning of an ulcer. The article continues with an excellent review of peripheral vascular disease and diagnosis as well as medical and surgical treatment of vascular disease. This article is further supported with data such as the fact that diabetic neuropathy affects 60-70% of people who have diabetes. This often leads to the diabetic foot ulcer. This study discusses the physiologic, structural and functional changes associated with diabetic neuropathy and foot ulcers. Prevention strategies are discussed including foot assessment, education and specialist referrals. Semmes-Weinstein monofilaments use are supported in this article as are the use of therapeutic footwear. (Zangaro, & Hull, 2009) for prevention. Prevention is the key to good health for these diabetic patients but complications are generally secondary to diabetes (Boulton, Meneses, & Ennis, 2000, pg 7) and diabetic foot ulcers can be devastating to the patient and the continually overwhelmed healthcare system. There are according to Boulton, (2000) ways to prevent these ulcers from occurring. The principles of off loading and optimal wound care are well used to heal an ulcer within 12 weeks or even prevent some of them from occurring at all. Boulton tells us that screening and prevention are extremely important to prevent an end stage ulcer from occurring and that most of these ulcers occur when the patient does not even realize it is happening. Elevated plantar dynamic pressures as well as callus formation are included as reasons for ulcer formation. Callus exacerbates already high planter pressures. Boulton (2000, pg 11) goes on to talk about the effects of vascularity and neuropathy. The article goes on to say that any wound on a diabetics foot needs pressure off loaded and that a large wound is a small wound in which the pressure was not relieved. Supporting this concept, Mueller, Zou, Bohnert et.al. (2008, pg.1375), state that plantar skin breakdown in the diabetic is often due to unnoticed plantar stresses during walking. They performed a study, the purpose of which was to determine the differences in stress variables (peak plantar pressure, peak pressure gradient, peak maximal subsurface shear stress, and depth of peak maximal subsurface shear stress) between the forefoot and the rear foot (Zou, 2008). Twenty four subjects were used during this study, 12 with diabetes and 12 without diabetes. Plantar pressures were measured, using a pressure platform. Stress variables were measured during at the forefoot and rear foot in all subjects tested. The results showed that ass stress variables were higher in the forefoot (127% to 871%) than in the rear foot. Stresses were also higher in the diabetic foot than the non diabetic foot. The conclusions determined by this study are that the highest stress on the foot is where the ulcers are most likely to appear and that where peak plantar pressure is, is also where the offloading needs to occur. This study needs to be carried farther to allow for testing of offloading techniques in the relief of that pressure. Walking patterns were studied by Kwon, & Mueller (2001) in an effort to further determine how to reduce forefoot plantar pressures in people with diabetic neuropathies. The concern here is that patients with these issues often do not sense an injurious sequence when it occurs therefore prevention of the sequence is important. Their study also confirms that diabetics have abnormally high plantar pressures. Boulton’s research is used in the discussion to support this study. Decreasing high plantar foot pressures during walking is critical in these patients. This can be improved by decreasing force or by spreading the force over a larger area. They studied several different ways in managing to reduce or spread out pressures. One of those was casting. Casting showed a reduction in pressures (see appendix A) Walking patterns have also been noted to reduce plantar pressures. Several authors have noted that a short shuffling gate is better for area weight bearing than a regular walk pattern. (Appen. A). There were several other gaits that were studied but study results were not proven for the others. It should be noted at this time that rocker bottom shoes are often recommended for diabetics but when studied by the University of East Caroline studied this; they found that unless balance studies are done on diabetics first, they should not be prescribed (Foster, 2007) The Ransart boot can be used as an offloading device and its effects were studied by Dumont, Lepeut, and Tsirtsikolou, et.al. (2009 pg. 48). This was an observational study. In a patient that had more than one ulcer, one was chosen as the as the index ulcer for the study. Time to healing and incidence of amputation were compared during this study. Conclusions were that there was a shorter time to healing and this was a removable devise that was studied. It was noted that the study is really inconclusive without doing a randomized trial on more patients. The positive thing about this boot is that it is removable and not permanent. The football is an intuitive dressing that is used to offload neuropathic plantar forefoot ulcerations. It is used in response to a need for a dressing that can interrupt the causal pathway of trauma in the healing of diabetic foot ulcers (Rader & Barry, 2008). This dressing was developed by the authors and has been reported in more than one study. When studied it had a mean healing time consistent with that of the total contact cast which has been documented as the gold standard. Effective offloading of the existing wound allows for healing of that wound. The average is four to six weeks of healing (Rader & Barry, 2008). Both follow up studies showed the same results. The cost of this dressing is quite inexpensive and is receiving good study reviews for being effective. Once the diabetic ulcer occurs, there are many possibilities for attempting to heal it. Sequential treatment with calcium alginate dressings and hydrocolloid dressings has been studied. The efficacy of this kind of dressing was compared in an open, randomized multicenter parallel group trial. 110 patients were included in the study. The comparative strategy was to apply hydrocolloid dressings for 8 weeks and the comparing study was to apply calcium alginate dressings for the first 4 weeks and hydrocolloid dressings for the next 4 weeks. Ulcer surface areas were measured weekly. The results showed that 57 and 53 patients were randomly allocated to sequential and control strategies respectively. Baseline patient characteristics and ulcer features at the inclusion were similar in the two groups. In grade III or IV ulcers, treatment using first calcium alginate and then hydrocolloid dressings promotes faster healing than the hydrocolloid treatment alone (Bellmen, Meaume, Rabus, et.al. 2002). In much the same way, Edmonds (2009, pg. 12) studied the use of Apiligraf in the treatment of these ulcers. Efficacy was assessed by time to complete wound healing and the incidence of complete wound closure. Two treatment groups after being screened received standard care based on international treatment guidelines which was sharp debridement, saline moistened dressings and non weight bearing regimen. The others used the Apiligraf treatment. The median time to healing was 84 days in the apiligraf group whereas no median time to healing could be determined for the standard therapy group because less than 50% achieved complete wound closure. The study was then halted prematurely because of the lack of healing of the standard therapy group. Even though the study was ended prematurely, the Apiligraf had shown good results toward healing and should be studied again (Edmonds, 2009). Sustained silver-releasing dressings have been used for some time. The results that are produced have only recently been looked at under study parameters. This study looked at sustained silver releasing foam dressings, Contreet Foam, in the treatment of diabetic foot ulcers. The study involved patients that were stage I or II by Wagner’s classification which were followed for 6 weeks. For one week they used Biatain dressings and 4 weeks treatment with Contreet Foam non-adhesive dressing, and then a one week follow-up with Biatain. Four ulcers out of 27 during the 4 week treatment with Contreet and 56% of the ulcers reduced in size. There was good exudate management with this product as well as being easy to use. The conclusion of the study was that Contreet Foam is safe and effectively supports healing and good wound progress when it is used to treat diabetic ulcers (Rayman, Baker, Jurgeviciene, et.al. 2005). Tissue repair is a major part of healing the diabetic ulcer. Thrombin and thrombin peptides play a role in that tissue repair. The efficacy and safety of thrombin peptides in diabetic ulcer treatment was studied by File, Mader, Stone et.al. (2007, pg.23). There used 60 randomized subjects under double blind placebo controlled clinical trial circumstances. Chrysalin in saline or saline alone were applied topically twice a week. The results of this study showed 75% better healing than the placebo treatment. It also decreased the mean time toward 100% closing by 40%. There were no adverse effects noted during the study and the final conclusion was that Chrysalin is safe and effective in the treatment of diabetic ulcers. In some areas where healthcare is difficult to get to and diabetic ulcers still abound the VAC is being used more and more often. It has recently been shown to be very effective in healing of these ulcers and can be used remotely (Tan, Rajanayagam & Schwarz, 2007). There is also the use of Filgrastim which is somewhat cost effective for hospitals that need to have costs reduced and rural areas such as those that may use the VAC. Patients who are treated with Filgrastim according to the study done by Edmonds, Gouch, Solovera et.al. (2009, pg 278), was quicker than without. It shows the mean cost savings of treating ulcers to be 36% less. The conclusion was that the overall benefit of using the drug reduced the cost of the drug. They felt that a randomized clinical trial needs to be done to follow up on this study. Limitations of the Review There were many areas where the studies provided were old and there were not replacement studies. There are also many suggestions at the conclusion of the studies for further study but further study could not be found. Conclusion In conclusion, there are many treatments presently available for preventing and treating diabetic foot ulcers. It starts with regular check ups and teaching the patient how to adequately care for their feet, continues with offloading and other prevention. Many people get ulcers even when they have done all the right things and that means treatment and there are many types of treatment at present and many being studied as healthcare has realized the long term costs of inappropriate or ineffective treatment. References Belmin, J. Meaume, S., Rabus, M. 2002. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing. JAGS. 50. 269-274. Boulton, A., Meneses, P., Ennis, W. 2000. Diabetic foot ulcers: A framework for prevention and care. Wound Repair and Regeneration. 7(7). 7-16. Dumont, I., Lepeut, M., Tsirtsikolou, D. 2009. A proof of concept study of the effectiveness of a removable device for offloading in patients with neuropathic ulceration of the foot: the ransart boot. Diabetic Medicine.26(8).778-782. Edmonds, M. 2009. Apligraf in the treatment of neuropathic diabetic foot ulcers. The International Journal of Lower Extremity Wounds. 8(1). 11-18. Edmonds, M. Gough, A., Solovera, J. 2009. Filgrastim in the treatment of infected diabetic foot ulcers. Clinical Pharmacoeconomics. 17(4). 275-286. Fife, C., Mader, J., Stone, J. 2007. Thrombin peptide Chrysalin stimulates healing of diabetic foot ulcers in a placebo-controlled phase I/II study. Wound Repair and Regeneration. 15. 23-34. Foster, J. 2007. Offloading shoe sole designs could impair patients’ balance. Biomechanics Magazine. 14(4). 13-14. Kruse, I., Edelman, S. 2008. Evaluation and treatment of diabetic foot ulcers. Clinical Diabetes. 24(2). 91-93. Kwon, O., Mueller, M. 2001. Walking patterns used to reduce forefoot plantar pressures in people with diabetic neuropathies. Physical Therapy81 (2). 828-835.. Muleller, M., Zou, D., Bohnert, K., et.al. 2008. Plantar stresses on the neuropathic foot during barefoot walking. Physical Therapy. 88(11). 1375. Rader, A., Barry, T., 2008. The football: an intuitive dressing for offloading neuropathic plantar forefoot ulcerations. Int. Wound Journal. 5(69). 72-78. Rayman, G., Rayman, A., Jureviciene, N. 2005. Sustained silver-releasing dressing in the treatment of diabetic foot ulcers. 14(2). 109-114. Schaper, N., Prompers, L. & Huijberts, M. 2007. Treatment of diabetic foot ulcers. Immunology, Endocrinology, Metabolism. 7 95-104. Tan, D., Rajanayagam, J., Schwarz, F. 2007. Treatment of long-stand poor-healing diabetic foot ulcers with topical negative pressure in the Torres Strait. 15. 275-276. Zangaro, G., & Hull, M. 2009. Diabetic neuropathy; pathophysiology and prevention of foot ulcers. Clinical Nurse Specialist. 13(2). 57-68. Appendix A Treatment Reduction in pressure Where Casting 32% Under great toe 63% Under fourth metatarsal 69% Under first metatarsal 45% Under the heal Protective footwear Reduce 50% of all ulcers when worn 60% of the day. Ulcer reoccurrence rate was 26% as compared to 83% in people who did not wear protective shoes. Shuffling Gate 57.8% First and second metatarsal 63.2% Hallux (Kwon, Mueller 2001). Read More