Diabetic Foot Ulcers

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By Temple University School of Podiatric Medicine Journal Review Club

A diabetic foot ulcer (DFU) is a wound that has a higher risk of becoming chronic, leading to amputation and, in some cases, even death. Currently, the Wagner and Texas classification are used worldwide to assess the extent of diabetic foot lesion. The authors of this article believe that there is a lack of wound treatment principles based on both classification systems. In the article, they have summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification system. The STAGE principle refers to surgical intervention during wound treatment of a DFU. With a focus on the anatomical layers of the wound, the management of blood supply, layer by layer incision to the infected area, maintenance of adequate wound drainage, and step by step treatment of the wound. STAGE is the management of an ulcer through its anatomical layers. Skeleton, Tendon, Angiogenesis, Granulation, and Epithelialization.

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Chronic wounds of the lower extremities impose an increasing burden on health care providers and systems, and they can have a devastating impact on patients and their families. These wounds include diabetic ulcers, venous ulcers, arterial ulcers, and pressure injuries. The estimated socioeconomic cost of chronic wounds is 2% to 4% of the health budget in Western countries. Moreover, patient mortality in individuals with chronic wounds has been estimated at 28% over a two-year period, significantly higher than the 4% mortality rate reported for 75 to 79 year-olds without chronic wounds.

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Chronic and non-healing wounds are those that do not progress through the healing process in a timely or predicted manner. They are a global problem and are becoming harder to treat. Medicare estimates that over 8 million Americans have chronic wounds that cost the national health care system between $18.1 and $96.8 billion dollars annually.

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By Temple University School of Podiatric Medicine Journal Review Club

Hard-to-heal wounds, such as diabetic foot ulcers, pressure injuries, and venous leg ulcers, comprise a significant portion of health care visits, and these wounds place a physical and economic burden on many patients. These hard-to-heal wounds are defined as wounds with stagnant or delayed stages of healing that fail to resolve within eight weeks. Finding ways to accelerate this healing process is of great importance because it can reduce the physical and economic burden on patients, as well as decreasing costs for health care facilities. Matrix metalloproteinases (MMPs) are endopeptidases, which are involved in many healing processes, including the cell signaling processes, migration processes, angiogenesis, and the degradation of extracellular proteins. These mechanisms are necessary for the wound healing process by breaking down damaged tissue. In the late stages of healing, when breaking down of tissue is no longer necessary, tissue inhibitors of metalloproteinases down-regulate MMPs. In hard-to-heal wounds, this process is thrown off balance, with delays in the subsequent stages of healing. In an attempt to restore this balance, MMPs have been investigated for their role in wound healing through MMP-inhibiting wound dressings. There have been a number of consequential reviews done using current market wound dressings, such as oxidized regenerated cellulose/collagen and Technology Lipido-Colloid with nano-oligosaccharide factor (TLC-NOSF).

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Holly Hovan MSN, RN-BC, APRN, CWOCN-AP

Diabetes is extremely prevalent in the United States. The Centers for Disease Control and Prevention (CDC) report that over 10% of the US population has this chronic disease, and 26.8% of older adults (65 and over) are impacted by diabetes, both diagnosed and undiagnosed.

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Holly Hovan MSN, APRN, RN-BC, CWOCN-AP

Identifying wound etiology before initiating topical treatment is important. Additionally, correctly documenting wound etiology is significant in health care settings for many reasons. Accurate documentation and appropriate topical treatment are two critical components of a strong wound treatment plan and program. Bedside staff members should be comfortable with describing wounds, tissue types, and differentiating wound etiologies. Training should be provided by the certified wound care clinician, along with follow-up (chart reviews and documentation checks, one-on-one education as needed, and routine competency or education days). Additionally, the wound care clinician should be able to develop an appropriate treatment plan based on wound etiology, by involving additional disciplines as needed to best treat the whole patient.

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By Temple University School of Podiatric Medicine Journal Review Club

Chronic diabetic foot ulcers affect approximately 13% of the United States population. Chronic diabetic foot ulcers, or DFU, are defined by the authors as, “nonhealing ulcers of the foot lasting more than 3 months’ duration in patients with diabetes”. It is critical to treat DFUs effectively and timely, as ulcers may progress to the point of requiring an amputation. Patients suffering from a DFU may have an amputation rate of 21.5% to 28.4%.

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By the WoundSource Editors

Collateral circulation: A collateral blood vessel circuit that may be adapted or remodeled to minimize the use of occluded arteries. Collateralization may offset some of the physiological signs of peripheral artery disease, such as maintaining a normal capillary refill.

Critical limb ischemia: A severe form of peripheral arterial disease in which a severe blockage of the arteries of the lower extremities reduces blood flow. It is a chronic condition that is often characterized by wounds of the lower extremity.

Dependent rubor: A light red to dusky-red coloration that is visible when the leg is in a dependent position (such as hanging off the edge of a table) but not when it is elevated above the heart. The presence of dependent rubor is often an indicator of underlying peripheral arterial disease. When the leg is raised above the level of the heart, its color will normalize.

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By the WoundSource Editors

Lower extremity wounds such as diabetic foot ulcers (DFUs), venous ulcers, and arterial ulcers have been linked to poor patient outcomes, such as patient mortality and recurrence of the wound. Although precise recurrence rates can be difficult to determine and can vary across different patient populations, we do know that the recurrence rates of lower extremity wounds are quite high.

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By the WoundSource Editors

Wounds of the lower extremity, such as chronic venous leg ulcers and diabetic foot ulcers, often have a severe impact on patients' quality of life. Symptoms may range from mild to debilitating, depending on the location of the injury and its severity. These types of wounds also affect a tremendous number of people because lower extremity wounds are estimated to occur in up to 13% of the United States population. The estimated annual cost of treating lower extremity wounds is at least $20 billion in the United States.