Recurrence rates in DFU are more likely in patients with significant peripheral vascular disease, poor glycemic control and with significant bony deformities or gait abnormalities. For patients, once admitted to a multidisciplinary wound clinic, socio-economic deprivation alone does not account for a poor wound healing outcome or for increased recurrence of DFU’s (Hicks et al., 2018). However, of the 80% of DFU which are considered healable, the most common reason, resulting in recurrence, is from nonadherence to wearing the recommended offloading device and to performing the recommended daily foot care routine (Dubský et al., 2013). The term, nonadherence however, should be re-examined in the context of the patient’s perspective. A better terminology might be to address the barriers to care that a PWD with a DFU, experiences during their wound healing journey. Although offloading devices are to be worn constantly whenever weight-bearing, consider these scenarios which are a small sample of the difficulties our PWD may experience:
- Taking the time to apply a device in the middle of the night in a rush to toilet may not be feasible
- These devices are best used on dry pavement and are treacherous on icy sidewalks. Some of our patients live in rural areas where mud, dust and water are a concern.
- In some climates, heat and humidity make wearing these devices uncomfortable and encourage periwound maceration
- Driving may be prohibitive
- PWD and limited vision will need to ask another person to do the daily foot routine
- Significant flexibility is required to view the bottom of your foot or to apply socks which are a requirement to wear in devices
Newer technologies are also employed to help overcome these barriers to care, including ‘smart’ insoles, alert the wearer to pressure peaks . Infrared thermometry can be used for early detection of inflammation and also provides an early warning sign with patient self-monitoring of repetitive trauma. For acute Charcot arthropathy, there may be an 8-15 degrees Fahrenheit temperature difference than the mirror image on the other foot.
Temperature normalization may allow gradual re-ambulation with plantar pressure redistribution devices (Armstrong et. Al 1997, 2002). .
Devising appropriate care plans must always take into consideration the needs of the patient and their circle of care. Understanding the patient perspective and developing ways to circumvent barriers are needed to help clinicians in this work (Armstrong et al., 2017). It is important to understand the social determinants of health in the context of health inequity. Patients may have a history of poor experiences in the health care system. Lived experiences of historical trauma, racism and discrimination may affect communication and adherence to treatment regimes. Adopting a critical theoretical lens may contribute to better outcomes. Critical health literacy aims to empower patients to understand structural inequities of power and oppression and gain a greater control over their health (Matthews, 2014).
Local Wound Care
Wounds should be cleansed with sterile water, normal saline or other low-toxicity antiseptic solutions (Sibbald et al., 2021). Ensure that all cleansing fluid is removed following irrigation. This is especially important when the base of the wound is not visible. Wounds should be assessed and classified as healable, maintenance and non-healing to direct the treatment regime.
Debride Healable Wounds When Appropriate
Using the DIME (devitalized tissues, infection/inflammation, moisture balance and edges preparation) framework, diabetic foot wounds often accumulate hyperkeratosis (callus) around the wound margins requiring debridement (Snyder et al., 2016). Debridement enables the clinician to fully assess wound depth, removes necrotic (dead) tissue which can lead to infection, reduces peak plantar pressures, disturbs biofilm and allows for the collection of culture specimens (Botros et al., 2019). Healable diabetic foot wounds are commonly debrided by sharp surgical debridement using a scalpel or curette (Botros et al., 2019; Sibbald et al, 2021). Most healable diabetic foot ulcers require serial debridement at each clinical visit to remove the callous that forms around the wound edges (Alavi A, et al, 2014). Without ongoing removal of callous, pressure is increased at the wound edges and delays wound healing. Specialized training is required for sharp surgical debridement. Consider conservative surgical debridement for maintenance or non-healable wounds to remove devitalized tissue (Sibbald et al, 2021). Other methods of debridement include autolytic, mechanical, enzymatic and biological.
The selection of each wound dressing should address the features of each diabetic foot ulcer and patient centered concerns. Keep it simple. Moist, interactive dressings can be used on healable wounds (Sibbald et al, 2021). However, exercise caution in the use of moist interactive dressings in healable diabetic foot wounds as these wounds often tend to have an excess of moisture in the authors’ experience. Maintenance and hon-healable wounds benefit from moisture management and antiseptic dressings (Sibbald et al, 2021). Be aware of the bulk of dressings. Ensure dressings are not too bulky and fit into offloading devices to avoid negative effects (Hilton et al., 2004).
Basic dressings are good options to begin with in the treatment of diabetic foot ulcers due to the high frequency of dressing changes and associated costs. Although the selection of dressing is important, proper offloading is key. It is more important what is taken off pressure-wise than put on.