Wound bed preparation for chronic diabetic foot ulcers

Abstract

The escalating incidence of diabetic mellitus has given rise to the increasing problems of chronic diabetic ulcers that confront the practice of medicine. Peripheral vascular disease, neuropathy, and infection contribute to the multifactorial pathogenesis of diabetic ulcers. Approaches to the management of diabetic ulcers should start with an assessment and optimization of the patient's general conditions, followed by considerations of the local and regional factors. This paper aims to address the management strategies for wound bed preparation in chronic diabetic foot ulcers and also emphasizes the importance of preventive measures and future directions. The "TIME" framework in wound bed preparation encompasses tissue management, inflammation and infection control, moisture balance, and epithelial (edge) advancement. Tissue management aims to remove the necrotic tissue burden via various methods of debridement. Infection and inflammation control restores bacterial balance with the reduction of bacterial biofilms. Achieving a moist wound healing environment without excessive wound moisture or dryness will result in moisture balance. Epithelial advancement is promoted via removing the physical and biochemical barriers for migration of epithelium from wound edges. These systematic and holistic approaches will potentiate the healing abilities of the chronic diabetic ulcers, including those that are recalcitrant.

Figure 1

(a) A 51-year-old lady with underlying long-standing diabetes mellitus presented with large diabetic foot ulcer over her right foot dorsum, exposing extensor tendons and covered with slough tissue. (b) Regular dressings with chlorhexidine and serial bedside sharp debridement were performed to control local infection while optimizing her general and local conditions including blood sugar level. (c) Negative pressure wound therapy was applied for several cycles for wound bed pressure to achieve a vascularized wound bed covered healthy granulation tissue with advancing epithelialization. (d) The ulcer was successfully resurfaced with split skin graft and healed well without complication.