MHP

Wundmanagement 1/2018

Current issue

  • Real-world management of patients with diabetic foot syndrome and peripheral artery disease
  • Biofilms and debridement in case of diabetic foot ulcers
  • Below-the-knee revascularizations for the treatment of critical limb ischemia

Overview

Real-world management of patients with diabetic foot syndrome and peripheral artery disease

N. Malyar

WundManagement 2018; 12 (1): 11–16.

KEYWORDS: Diabetes mellitus, diabetic foot syndrome, peripheral artery disease, claudication, critical limb ischemia, endovascular/ surgical revascularization, amputation

The prevalence of diabetes mellitus (DM) and its associated complications such as peripheral artery disease (PAD) and diabetic foot syndrome (DFS) are increasing worldwide. Particularly patients with DFS have a reduced quality of life, are exhibited to high rates of ischemic limb amputations and high death rates. Despite all the measures initiated by health care systems and providers (such as awareness campaigns, preventive measures, establishing specialized foot centers, increased and sophisticated revascularization procedures etc.) in the last decades the prognosis of DFS patients is still poor. Patients with PAD and DM have frequently diabetic senso-motoric polyneuropathy, thereby masking early ischemic symptoms such claudication and rest pain. Approximately 30–50% of patients with diabetic foot lesions exhibit at first presentation advanced stages of PAD, such as ulcers and gangrenes. As the pathophysiology of DFS is multifactorial the therapeutic management also necessitates a multidisciplinary approach. An optimal blood glucose control, effective treatment of all underlying cardiovascular risk factors and other comorbidities, a state-of-theart wound care, immediate treatment of infections and edema and biomechanical offloading are mandatory, since they all are important determinants of the wound healing, of limb amputation and of overall survival of patients with DFS. Particularly revascularization is the key element decisively affecting the prognosis of patients with diabetes and limb ischemia. Nevertheless, diagnosis and treatment of relevant ischemia is one of the most neglected aspects of the therapeutic management of patients with PAD and DM. Patients’ education, a regular screening of the patients at-risk, a multidisciplinary therapeutic approach and an early revascularization in case of ischemia are key elements for amelioration of the persistently poor outcome in this high-risk subset of patients.

Overview

Biofilms and debridement in case of diabetic foot ulcers

A. Elend, C. Hoppe, M. Augustin

WundManagement 2018; 12 (1): 17–20.

KEYWORDS:  Diabetic foot ulcers, Biofilm, Wound bed preparation, Débridement

The biofilm on wounds is a community of different bacteria, fungi and algae. The development of biofilms initially begins completely harmless. Individual cells of micro-organisms attach themselves to surfaces and multiply in the humid environment. These micro-organisms are able to produce a layer of mucus through self-produced polysaccharides. This mucus matrix penetrates and surrounds the micro-organisms. A biofilm colony is created. These colonies are immune to the body's own attempts to clean the wound. Furthermore, the mucus matrix, protect the biofilm, against antimicrobial substances and antibiotics. The healing of the wound stagnates and the risk of infection increases. If the biofilm remains untreated, it can spread freely in the wound. If there is a suspicion of biofilm in a wound or the presence of biofilm on the wound is even secured, the therapeutic approach of a biofilm-based wound treatment should follow. This includes, among other things, a regular débridement of the wound, a cleaning of the wound bed by removing non-avital tissues (fibrin, biofilm, and necrosis) to the intact anatomical structures, without injuring the existing granulation tissue. The débridement can be performed in a variety of ways. The mechanical débridement (compresses, cleaning pads) is probably the most commonly performed procedure, but also autolytic (Hydrogel, Hydrogeldressing), surgical (scalpel, Curette), bio surgical (Maggot therapy), enzymatic and Ultrasonic assisted (UAW) procedures are suitable for wound bed cleaning.

Overview

Below-the-knee revascularizations for the treatment of critical limb ischemia

C.-A. Behrendt, W. P. Tigges, H. C. Rieß, H. Diener, E. S. Debus

WundManagement 2018; 12 (1): 21–26.

KEYWORDS: Critical Limb Ischemia (CLI), Diabetic Foot Syndrome (DFS), Peripheral Arterial Disease (PAD), Below-the-knee, Bypass, Amputations

Several complementary open-surgical and endovascular approaches exist to treat below-the-knee lesions in patients with critical limb ischemia. Due to a lack of evidence, several practical guideline recommendations are limited to expert consensus. Evidence-based tools like the WIfI-Score from the Society for Vascular Surgery (SVS) are available to estimate the amputation risk or possible benefit of revascularization in patients with critical limb ischemia and diabetic foot syndrome.