About 80 percent of diabetes-related lower-limb amputations are preceded by a foot ulcer. This progression from foot ulcer to amputation lends itself to several possible steps where intervention based on evidence-based guidelines may prevent major amputation. Considering the disease burden and the existing variations in care that make decisions challenging for patients and clinicians, the Society for Vascular Surgery (SVS) collaborated with the American Podiatric Medical Association (APMA) and the Society for Vascular Medicine (SVM) to improve the care of patients with diabetes-related foot conditions and to provide an evidence-based, multidisciplinary management approach.
The guidelines are the result of a three-year-long project involving a committee of vascular surgeons, podiatrists, and physicians with expertise in vascular and internal medicine. The committee was assisted by a guideline methodologist, a librarian, and a team of investigators with expertise in conducting systematic reviews and meta-analysis. The clinical guidelines were published in the February issue of the Journal of Vascular Surgery. These recommendations are meant to pertain to all individuals with diabetes, regardless of etiology.
The committee made specific practice recommendations using the Grades of Recommendation Assessment, Development, and Evaluation system. The best available evidence was used, and patients’ values and preferences and the clinical context were considered to develop these guidelines. The committee included preventive recommendations, such as those for adequate glycemic control, periodic foot inspections, and patient and family education, as well as evidence to support the recommendations. Specific areas of focus include prevention of diabetes-related foot ulceration, off-loading, diagnosis of osteomyelitis, wound care, and peripheral arterial disease.
The committee recommends using custom therapeutic footwear in patients with diabetes who are at high risk for amputations, including those with significant neuropathy, foot deformities, or previous amputations. In patients with plantar diabetic foot ulcers (DFUs), off-loading with a total contact cast or irremovable fixed ankle walking boot is recommended. In patients with a new DFU, it is recommended that they undergo probe-to-bone test and plain films to be followed by an MRI if a soft tissue abscess or osteomyelitis is suspected. Recommendations on comprehensive wound care and various debridement methods are also included. For DFUs that fail to improve (>50 percent wound area reduction) after a minimum of four weeks of standard wound therapy, adjunctive wound therapy options are recommended. In patients with DFUs who have peripheral arterial disease, revascularization by either surgical bypass or endovascular therapy is recommended.
The committee acknowledged that these guidelines do not cover all the aspects of diabetes-related foot issues, and said that as future evidence accumulates, it plans to update these recommendations.