Diabetes-related foot ulceration (DFU) causes a significant burden on patients with diabetes and healthcare systems globally and in Australia. This health complication is a major cause of morbidity and mortality. Statistics show that DFUs account for nearly two-thirds of all non-traumatic amputations performed globally and approximately twenty-five per cent of all hospital stays for patients with diabetes. Moreover, World Health Organization (WHO) claims that diabetic foot ulcers are responsible for five per cent of mortality within the first year and forty-two per cent within the five years. These statistics demonstrate the need for prompt and effective interventions to improve wound healing among clients with DFU. Although healthcare organizations have adopted standard practices in DFU management, such as wound offloading, vascular assessment, and surgical debridement, there is still significant room for improvement in related outcomes. This assessment will evaluate and apply level one and two evidence to recommend the most effective wound care interventions in improving wound healing among clients with diabetic foot ulcers.
Diabetes foot ulcers profoundly impact the quality of life among healthcare consumers in a community. These ulcers may cause significant pain, discomfort, and reduced mobility, mainly when pressure is applied to the affected area. The pain and discomfort associated with DFU may force patients to adjust their gait or limit their mobility to avoid worsening the ulcer (Ling et al., 2020). According to Crocker et al. (2021), the reduction in mobility substantially affects the client’s daily activities, including performing simple tasks and walking, leading to decreased overall functional ability. Overall, physical impacts stemming from diabetes foot ulcers underscore the critical need for intervention and timely management.
DFU provides an entry for bacteria, leading to infections that may aggravate the pain and discomfort. Untreated infection caused by DFU can lead to life-threatening complications such as bone infection, abscess formation, and cellulitis (Crocker et al., 2021). The DFU location may also impact physical functioning. For instance, if the ulcer is in a weight-bearing area like the sole, an individual may be unable to walk and perform daily activities. The economic implications of DFUs also affect the quality of life among healthcare consumers. Coffey et al. (2019) claim that DFUs lead to significant economic burdens due to increased healthcare costs associated with medications, specialized wound care services, and hospitalizations. Individuals with DFU experience reduced productivity and earning potential, thus, worsening financial burdens on individuals and their families (Jodheea et al., 2022). In general, the life-threatening complications and economic burden of diabetic foot ulcers diminish healthcare consumers and their families’ quality of life.
Additionally, DFUs contribute to emotional distress and psychological burdens. In research by Crocker et al. (2021), individuals with DFUs are more susceptible to anxiety, depression, and social isolation than those without these ulcers. Frequent medical visits, dressing changes, and offloading devices disrupt individuals’ routines and require significant time and resource investments (Ling et al., 2020). Consequently, this ongoing wound care and prolonged healing can lead to frustration, emotional stress and feelings of being a burden to others (Jodheea-Jutton et al., 2022). Health consumers with diabetes foot ulcers tend to avoid social gatherings or recreational activities due to fear of complications, mobility problems and pain, leading to decreased social support, limited engagement and a diminishing sense of overall well-being (Crocker et al., 2021). Based on this evidence, patients in the community who have DFU require comprehensive care to address the ulcers’ psychosocial impact.
Table of Included Studies
|author||year||Study design||population||Intervention type(s)||Comparator intervention (if applicable)||Outcome(s)|
|Collings et al.||2021||Study review and meta-analysis of multiple databases for published and unpublished studies reporting offloading footwear and insoles for people with diabetic neuropathy and nonulcerated feet.||People with diabetic peripheral neuropathy||offloading||Vascular assessment and optimization||metatarsal additions, apertures and arch profiles are effective in reducing plantar pressure in this population|
|Flores-Escobar et al.||2022||Systematic Review and Meta-Analysis systematic review of literature from PubMed and Web of Science||Patients with DFU||debridement||Placebo||debridement showed higher healing rates, a greater percentage of wound area reduction, and similar healing times when compared with the placebo|
|Pérez-Panero et al.||2019||Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and a quality assessment by the Appraisal of Guidelines for Research and Evaluation (AGREE II)||Patients with DFU||debridement||Negative Pressure Wound Therapy (NPWT)||The highly recommended intervention for DFU management is debridement|
|Racaru et al.||2022||A systematic scoping review was conducted by searching Medline, CINAHL, PubMed, EMBASE, and EMCARE databases.||Patients with peripheral sensory neuropathy or active foot ulceration and foot offloading prescription||offloading||Not applicable||Psychosocial factors are the most common influencers of adherence|
|Suglo et al.||2022||A systematic review based on PRISMA, and Synthesis Without Meta-analysis (SWiM) guidelines||persons with diabetes, with or at risk of foot ulcers and their caregivers||Offloading/debridement||Infection control||Engaging caregivers and the person with diabetes in education about foot checks and wound care improved wound healing.|
Synthesis of the Evidence
Different literature suggests different interventions to improve wound healing among clients with diabetic foot ulcers. However, the literature review found that most scholarly resources suggested offloading and debridement as the most effective interventions for managing DFU.
Offloading helps relieve pressure on the ulcer site, which promotes wound healing. Racaru et al. (2022) claim that this intervention redistributes the weight, reduces the ulcer’s mechanical stress, and allows improved flow and oxygenation to the site. Suglo et al. (2022) add that offloading devices like specialized footwear provide a physical barrier that protects the ulcer from additional trauma and friction, allowing the body’s natural healing mechanisms to focus on repairing the existing ulcer. As a result, the intervention promotes faster healing. This DFU management technique minimizes shear forces—which can break down the wound bed—by stabilizing the foot and reducing movement (Suglo et al., 2022).
Healthcare professionals should allow patients with DFUs to actively participate in selecting and fitting offloading devices to increase their compliance with the prescribed treatment plan. According to Suglo et al. (2022), patient compliance and adherence to offloading protocols ensure a consistent reduction of pressure on diabetic foot ulcers, which promotes healing and prevents complications. Racaru et al. (2022) state that offloading is most successful when implemented as part of a multidisciplinary approach to diabetic foot care. Effective collaboration among healthcare professionals such as podiatrists, wound care specialists, and diabetes educators ensures a comprehensive assessment of the ulcer, proper offloading device selection, and a continuum of care (Collings et al., 2021).
Debridement is an essential intervention in managing diabetic foot ulcers (DFUs). Flores-Escobar et al. (2022) claim that this intervention involves the removal of debris, non-viable tissue and bacteria from the ulcer wound bed to promote healing and prevent infections. Perez-Panero et al. (2019) concur with Flores-Escobar et al. (2022) by stating that non-viable tissue slows the healing process by hindering new tissue growth and promoting bacterial growth. Collings et al. (2021) posit that eliminating these tissues facilitates the formation of healthy granulation tissue and promotes the regeneration of new, healthy cells. Debridement allows better penetration and effectiveness of topical agents like antimicrobial dressings (Flores-Escobar et al., 2022). This intervention facilitates advanced wound therapies essential such as negative pressure wound therapy and skin substitutes.
Debridement helps reduce the bacterial load within the wound by removing biofilm, a complex matrix of bacteria, extracellular polymeric substances, and debris (Collings et al., 2020). This measure creates a less favourable environment for bacterial growth and infection, facilitating healing. Suglo et al. (2022) explain that debridement promotes wound healing mechanisms. The process triggers an inflammatory response that activates growth factors and cytokines, which play a crucial role in angiogenesis, collagen synthesis, and re-epithelialization. Removing debris and non-viable tissues enhances nutrient supply and oxygenation, creating an environment favouring tissue regeneration and cellular proliferation (Perez-Panero et al., 2019). Debridement can also help identify any underlying structures or signs of infection that may require additional interventions or specialist referrals (Flores-Escobar et al., 2022).
Based on the findings presented in this research, different stakeholders have a vital role in ensuring the proposed interventions’ success. Regarding the offloading technique, healthcare professionals should educate patients, caregivers, and fellow healthcare providers about the crucial role of offloading in managing DFUs by highlighting how it helps relieve pressure, promotes wound healing, and minimizes shear forces. These professionals should actively involve patients with DFUs in selecting and fitting offloading devices to increase patient compliance and adherence to the prescribed treatment plan. Concerning the debridement intervention, healthcare organizations should develop clear protocols and guidelines for debridement in managing DFUs, while considering the patient’s overall health and medical. During the debridement process, nurses and other medical care providers should remain vigilant for signs of infection, underlying structures involvement, or complications that may require additional interventions or specialist referrals. Promptly address these issues to optimize healing outcomes.
Effective wound care interventions are crucial for improving wound healing among clients with diabetic foot ulcers (DFUs). Offloading and debridement are the most effective interventions in managing DFUs. Offloading helps relieve pressure, promote wound healing, and minimize shear forces, while debridement removes non-viable tissue and bacteria, facilitating healthy tissue formation and reducing infection risks. Healthcare professionals should involve patients in selecting and fitting offloading devices and develop clear protocols for debridement, considering individual patient factors. Implementing these interventions will help healthcare organizations enhance wound healing outcomes, reduce complications, and improve individuals’ overall quality of life with DFUs. Prompt identification and management of complications during debridement are crucial for optimal healing outcomes.
Coffey, L., Mahon, C., & Gallagher, P. (2019). Perceptions and experiences of diabetic foot ulceration and foot care in people with diabetes: a qualitative meta‐synthesis. International wound journal, 16(1), 183–210. https://doi.org/10.1111/iwj.13010
Collings, R., Freeman, J., Latour, J. M., & Paton, J. (2021). Footwear and insole design features for offloading the diabetic at risk foot—a systematic review and meta‐analyses. Endocrinology, diabetes & metabolism, 4(1), e00132. https://doi.org/10.1002/edm2.132
Crocker, R. M., Palmer, K. N., Marrero, D. G., & Tan, T. W. (2021). Patient perspectives on the physical, psychosocial, and financial impacts of diabetic foot ulceration and amputation. Journal of Diabetes and its Complications, 35(8), 107960. https://doi.org/10.1016/j.jdiacomp.2021.107960
Flores-Escobar, S., Álvaro-Afonso, F. J., García-Álvarez, Y., López-Moral, M., Lázaro-Martínez, J. L., & García-Morales, E. (2022). Ultrasound-Assisted Wound (UAW) Debridement in the Treatment of Diabetic Foot Ulcer: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 11(7), 1911. https://doi.org/10.3390/jcm11071911
Jodheea-Jutton, A., Hindocha, S., & Bhaw-Luximon, A. (2022). Health economics of diabetic foot ulcer and recent trends to accelerate treatment. The Foot, 101909. https://doi.org/10.1016/j.foot.2022.101909
Ling, E., Lepow, B., Zhou, H., Enriquez, A., Mullen, A., & Najafi, B. (2020). The impact of diabetic foot ulcers and unilateral offloading footwear on gait in people with diabetes. Clinical Biomechanics, 73, 157–161. https://doi.org/10.1016/j.clinbiomech.2020.01.014
Pérez-Panero, A. J., Ruiz-Muñoz, M., Cuesta-Vargas, A. I., & Gónzalez-Sánchez, M. (2019). Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines: A systematic review. Medicine, 98(35), e16877. https://doi.org/10.1097/MD.0000000000016877
Racaru, S., Saghdaoui, L. B., Choudhury, J. R., Wells, M., & Davies, A. H. (2022). Offloading treatment in people with diabetic foot disease: A systematic scoping review on adherence to foot offloading. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 102493.
Suglo, J. N., Winkley, K., & Sturt, J. (2022). Prevention and Management of Diabetes-Related Foot Ulcers through Informal Caregiver Involvement: A Systematic Review. Journal of diabetes research, 2022.https://doi.org/10.1155/2022/9007813