Debridement of diabetic foot ulcers.

NewsBot · Jan 22, 2010

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Debridement of diabetic foot ulcers.
Edwards J, Stapley S.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD003556.

BACKGROUND: Foot ulceration is thought to affect 15% of people with diabetes at some time in their lives. Debridement is widely regarded as an effective intervention to speed up ulcer healing. The most effective method is unclear.

OBJECTIVES: To assess the effects of debridement interventions on the healing of diabetic foot ulcers.

SEARCH STRATEGY: For this third update we searched the Cochrane Wounds Group Specialised Register (June 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2009, Issue 2; Ovid MEDLINE - 1950 to June Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 25 and Ovid CINAHL - 1982 to June Week 3 2009.

SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating any method of debriding diabetic foot ulcers and measuring complete healing or rate of healing. There was no restriction on articles/trials based on language or publication status.

DATA COLLECTION AND ANALYSIS: Data extraction and assessment of study quality were undertaken by one review author and checked by an Editor of the Wounds Group.

MAIN RESULTS: Six RCTs of debridement were identified: four assessed hydrogels, with an additional study evaluating larval therapy against hydrogel and one evaluated surgical debridement. Pooling the three RCTs which compared hydrogel with gauze or standard care suggested that hydrogels are significantly more effective in healing diabetic foot ulcers (Relative Risk 1.84, 95% Confidence Interval (CI)1.3 to 2.61). Surgical debridement showed no significant benefit over standard treatment. One small trial suggested that larvae resulted in a more than 50% reduction in wound area compared with hydrogel. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in diabetic foot ulcers.

AUTHORS' CONCLUSIONS: There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
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Admin2 · Jan 22, 2010

Related threads:
Other Cochrane reviews.
Extent/depth of ulcer debridement
Principles of Wound Debridement
Hydrosurgery device in surgical debridement of wounds

NewsBot · Jan 27, 2016

A systematic review and meta-analysis of debridement methods for chronic diabetic foot ulcers
Tarig Elraiyah, MBBS, Juan Pablo Domecq, MD, Gabriela Prutsky, MD, Apostolos Tsapas, MD, PhD, Mohammed Nabhan, MD, Robert G. Frykberg, DPM, MPH, Rim Hasan, MD, Belal Firwana, MD, Larry J. Prokop, MLS, Mohammad Hassan Murad, MD, MPH
Journal of Vascular Surgery; February 2016 Volume 63, Issue 2, Supplement, Pages 37S–45S.e2

Background
Several methods of d?bridement of diabetic foot ulcers are currently used. The relative efficacy of these methods is not well established.

Methods
This systematic review and meta-analysis was conducted to find the best available evidence for the effect of d?bridement on diabetic foot wound outcomes. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus through October 2011 for randomized controlled studies (RCTs) and observational comparative studies.

Results
We identified 11 RCTs and three nonrandomized studies reporting on 800 patients. The risk of bias was moderate overall. Meta-analysis of three RCTs showed that autolytic d?bridement significantly increased the healing rate (relative risk [RR], 1.89; 95% confidence interval [CI] 1.35-2.64). Meta-analysis of four studies (one RCT) showed that larval d?bridement reduced amputation (RR, 0.43; 95% CI, 0.21-0.88) but did not increase complete healing (RR, 1.27; 95% CI, 0.84-1.91). Surgical d?bridement was associated with shorter healing time compared with conventional wound care (one RCT). Insufficient evidence was found for comparisons between autolytic and larval d?bridement (one RCT), between ultrasound-guided and surgical d?bridement, and between hydrosurgical and surgical d?bridement.

Conclusions
The available literature supports the efficacy of several d?bridement methods, including surgical, autolytic, and larval d?bridement. Comparative effectiveness evidence between these methods and supportive evidence for other methods is of low quality due to methodologic limitations and imprecision. Hence, the choice of d?bridement method at the present time should be based on the available expertise, patient preferences, the clinical context and cost.
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NewsBot · Sep 28, 2018

A Systematic Review to Compare the Effect of Low-frequency Ultrasonic Versus Nonsurgical Sharp Debridement on the Healing Rate of Chronic Diabetes-related Foot Ulcers.
Michailidis L, Bergin SM, Haines TP, Williams CM.
Ostomy Wound Manage. 2018 Sep;64(9):39-46.

Abstract
Management of diabetes-related foot ulcers often involves debridement of devitalized tissue, but evidence regarding the most effective debridement method is limited.

PURPOSE:
A systematic review was conducted to determine the effectiveness of nonsurgical sharp debridement (NSSD) versus low-frequency ultrasonic debridement (LFUD) for diabetes-related foot ulceration in adults.

METHOD:
Published studies (earliest date available to April 2017) comparing healing outcomes of LFUD- and NSSD-treated foot ulcers in adults were considered. The quality of publications that met inclusion criteria were assessed using the PEDro scale, and a meta-analysis was undertaken to compare percentage healed and percentage of ulcer size reduction.

RESULTS:
Of the 259 publications identified, 4 met the inclusion criteria but 2 of the 4 did not contain sufficient patient outcomes details for meta-analysis, leaving a sample size of 173 patients. Outcome data for the 2 studies included percentage of ulcers healed between the 2 debridement methods. This difference was not significant (RR = 0.92; 95% CI = 0.76-1.11). The risk of bias for both studies was low.

CONCLUSION:
No difference in healing outcomes between NSSD and LFUD debridement of diabetic foot ulcers was found. Well-designed, controlled clinical studies are needed to address the current paucity of studies examining the efficacy and comparative effectiveness of debridement methods.
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NewsBot · Oct 20, 2018

Healing rates in diabetes-related foot ulcers using low frequency ultrasonic debridement versus non-surgical sharps debridement: a randomised controlled trial.
Michailidis L et al
BMC Res Notes. 2018 Oct 16;11(1):732. doi: 10.1186/s13104-018-3841-4.

OBJECTIVE:
Current clinical practice varies around debridement techniques used to promote healing of diabetes-related foot ulcers. This randomised controlled study will compare healing rates for diabetes-related foot ulcers treated with low frequency ultrasonic debridement versus non-surgical sharps debridement. Individuals with diabetes-related foot ulcers being managed by podiatry at a metropolitan hospital were screened against study criteria. Eligible participants were randomly allocated to either the non-surgical sharps debridement group or the low frequency ultrasonic debridement group and received weekly treatment for 6 months. Participants also completed a quality of life measure and visual analogue pain scale.

RESULTS:
This trial was ended early due to recruitment issues. Ten participants with 14 ulcers participated. Results were analysed using a survival analysis approach. Ulcers treated with non-surgical sharps debridement healed more quickly (61.6 days ± 24.4) compared with low frequency ultrasonic debridement (117.6 days ± 40.3). In both groups, quality of life was observed to improve as ulcers healed and pain levels reduced as ulcers improved. Observations from this study found faster healing using non-surgical sharps debridement. However, these results are unable to be generalised due to the small sample size.
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NewsBot · Oct 21, 2021

Frequency of sharp wound debridement in the management of diabetes-related foot ulcers: exploring current practice
Vanessa L Nube, Jennifer A Alison & Stephen M Twigg
Journal of Foot and Ankle Research volume 14, Article number: 52 (2021)

Background
Conservative sharp wound debridement (CSWD) is fundamental to wound bed preparation. Evidence-based practice guidelines strongly recommend frequent CSWD of diabetes-related foot ulcers (DFU) based on expert opinion and observational studies which suggest that more frequent debridement is associated with better healing outcomes.

Aim
To document current practice with regards to CSWD of DFU and whether this is performed at every visit, how often and what factors determine debridement frequency.

Method
Survey data were collected and managed using REDCap electronic data tools, a secure, web-based application. The survey was distributed through podiatry managers and relevant clinical networks between October 2017 and February 2018.

Results
One hundred clinicians opened the survey and seventy-five surveys were completed by n = 53 NSW Health (Australia) employed podiatrists (representing 41% of all NSW Health podiatrists), 11 privately practicing podiatrists, and 11 nurses. Most (n = 47) worked in metropolitan areas versus regional/remote (n = 28). CSWD was the most frequently used debridement method, performed at every visit by most (84%) of podiatrists. Callus, slough and infection presence were the top 3 most important determinants of frequency, with staff time (a limiting factor) ranking 4th. Regional/remote podiatrists practiced less frequent debridement compared with those in metropolitan areas (debridement every 2 weeks or less = 71% regional podiatrists versus 45% metropolitan podiatrists) (p = 0.024).

Conclusion and clinical implications
CSWD was the predominant form of debridement used with debridement occurring at every treatment visit for most of the clinicians surveyed. Debridement frequency was determined by clinical wound indications and staffing resources, with regional/remote podiatrists providing debridement less often than their metropolitan colleagues.
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NewsBot · Apr 12, 2022

Ultrasound-Assisted Wound (UAW) Debridement in the Treatment of Diabetic Foot Ulcer: A Systematic Review and Meta-Analysis
Sebastián Flores-Escobar et al
J Clin Med. 2022 Mar 30;11(7):1911

A systematic review and meta-analysis were carried out to investigate the effect of ultrasound-assisted wound (UAW) debridement in patients with diabetic foot ulcers (DFUs). All selected studies were evaluated using the Cochrane risk of bias tool to assess the risk of bias for randomized controlled trials. PubMed and Web of Science were searched in October 2021 to find randomized clinical trials (RCT) assessing the effect of UAW debridement on DFUs. RevMan v5.4. was used to analyze the data with the Mantel-Haenszel method for dichotomous outcomes. A total of 8 RCT met our inclusion criteria, with 263 participants. Concerning the healing rate comparing UAW versus the control group, a meta-analysis estimated the pooled OR at 2.22 (95% CI 0.96-5.11, p = 0.06), favoring UAW debridement, with low heterogeneity (x2 = 7.47, df = 5, p = 0.19, I2 = 33%). Time to healing was similar in both groups: UAW group (14.25 ± 10.10 weeks) versus the control group (13.38 ± 1.99 weeks, p = 0.87). Wound area reduction was greater in the UAW debridement group (74.58% ± 19.21%) than in the control group (56.86% ± 25.09%), although no significant differences were observed between them (p = 0.24). UAW debridement showed higher healing rates, a greater percentage of wound area reduction, and similar healing times when compared with placebo (sham device) and standard of care in patients with DFUs, although no statistically significant differences were observed between groups.
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NewsBot · Jun 20, 2022

Debridement of diabetic foot ulcers: public health and clinical implications - a systematic review, meta-analysis, and meta-regression
David Dayya et al
BMJ Surg Interv Health Technol. 2022 May 30;4(1):e000081

Background: Diabetic foot ulceration (DFU) has devastating complications and a lifetime occurrence of 15%-34%. Debridement of DFU is regarded as an intervention that accelerates ulcer healing and may reduce complications including amputations, infections, and poor quality of life (QoL), which have serious public health and clinical implications. A systematic review (SR) of SRs and of randomized controlled trials (RCTs) with meta-analyses (MAs) on debridement of DFU that synthesizes all human experimental evidence is warranted.

Objectives: Are debridement methods in DFU beneficial over other forms and standard gauze dressings (control condition) in these outcomes?

Study eligibility criteria: All SRs/MAs/RCTs comparing debridement methods for DFU with alternative methods of debridement and with control.

Data sources: Cochrane Wounds Group Specialized Register, Cochrane Central Register of Controlled Trials (Cochrane Library), Ovid MEDLINE, PubMed, EMBASE, EBSCO, CINAHL, and Web of Science.

Participants and interventions: Adults with type 1/2 diabetes with DFU and any debridement method compared with alternative debridement methods or control.

Main outcomes: Amputation rates, wound infections, QoL, proportion of ulcers healed, time to complete healing, ulcer recurrence, and treatment cost.

Study selection and analysis: Data extraction/synthesis by two independent reviewers pooled using a random-effects model with sensitivity analysis.

Results: 10 SRs were retrieved and reported qualitatively. Six SRs included MAs. This SR included 30 studies, with 2654 participants, using 19 debridement combinations. The debridement methods were compared with findings pooled into MAs. Meta-regression (MR) did not identify significant predictors/moderators of outcomes.

Limitations: The studies may have been under-powered. The inclusion/exclusion criteria varied and the increased risk of bias contributed to low-quality evidence.

Discussion/conclusion: Weak evidence exists that debridement methods are superior to other forms of debridement or control in DFU.

Implications: Researchers should follow standardized reporting guidelines (Consolidated Standards of Reporting Trials). Clinicians/investigators could use the findings from this SR/MA/MR in guiding patient-individualized decision making and designing future RCTs.
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NewsBot · Sep 1, 2022

A new precise way to guide the debridement process of diabetic foot ulcer using indocyanine green fluorescence molecular imaging
ChengFang et al
Photodiagnosis and Photodynamic Therapy; 28 August 2022, 103095

Highlights
•Indocyanine green binds to lipoproteins to target necrotic tissue
•Abundant tissue fluid on the wound surface of patients can increase the effect of fluorescence molecular imaging
•Fluorescence molecular imaging can guide the debridement of necrotic tissue in real time, with the characteristics of precision and safety
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Objective
: The purpose of this study was to estimate the value of a novel imaging technique in necrotic tissue debridement of diabetic foot ulcers (DFU), using near-infrared (NIR) fluorescence molecular imaging (FMI) of indocyanine green (ICG).

Methods
: The patients with DFU were included and divided into a FMI navigation debridement group and a traditional group. The FMI of the wounds and the debridement effect of each group was analyzed, including debridement frequency, length of hospital stay, and the histological examination of removed tissue.

Result
: A total of 40 patients with DFU (23 cases in the FMI group and 17 cases in the traditional group) were included in this study. The positive rate of wound fluorescence in the FMI group was 96%, and no patients had related side effects. The pathological examination confirmed that the tissue emitting NIR fluorescence was totally necrotic tissue. In addition, the debridement frequency in the FMI group is less than that in the traditional group, but there is no difference in the length of hospital stay between the two groups.

Conclusion
: ICG FMI technique can accurately illuminated necrotic tissue, with high sensitivity, easy operation and good safety, which would be a new way to precisly guide the process of debridement in clinical.
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NewsBot · Jul 25, 2023

Diabetic foot ulcers: weekly versus second-weekly conservative sharp wound debridement
Vanessa L Nube, Jennifer A Alison, Stephen M Twigg
Journal of Wound CareVol. 32, No. 6:10 Jun 2023

Diabetic foot ulcers (DFU) are a serious and costly long-term complication of diabetes, and are one of the most prevalent hard-to-heal (chronic) wound types. Conservative sharp wound debridement (CSWD) is a mainstay of care. It is performed regularly until healing is achieved (when there is adequate blood flow for healing) to support endogenous healing and improve the efficacy of advanced healing therapies. CSWD is supported by evidence-based treatment guidelines, despite a lack of prospective studies. The first prospective randomised study to compare different frequencies of CSWD—the Diabetes Debridement Study (DDS)—showed no difference in healing outcomes at 12 weeks between those ulcers debrided weekly and those debrided every second week. A DFU may require more or less frequent debridement according to individual wound characteristics; however, the new data from DDS can inform clinical decisions and service provision. The implications of weekly versus second-weekly debridement are discussed.
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NewsBot · Feb 19, 2024

Comparison of healing effectiveness of different debridement approaches for diabetic foot ulcers: a network meta-analysis of randomized controlled trials
Peng Ning et al
Front Public Health. 2023 Dec 11:11:1271706

Objectives: The choice of the debridement method is very important for the healing of diabetic foot ulcers (DFUs), but the relative effectiveness of different debridement methods in the healing of DFUs remains unclear. This study conducted a network meta-analysis of the relative healing effectiveness of different debridement methods in patients with DFUs.

Methods: We performed a literature search in PubMed, Embase, and Cochrane Library from database inception up to 30 June 2023 for screening randomized controlled trials on the healing effectiveness of debridement in DFUs. Outcome measures included ulcer healing rate and ulcer area reduction rate. The Cochrane Risk Bias Tool, version 2.0, was used to assess the risk of bias in the included trials. R software was used for performing statistical analysis and GraphPad Prism was used for image plotting.

Results: A total of 19 randomized controlled trials were included, and 900 patients with DFUs were assessed in this analysis. The proteolytic fraction from the latex of Vasconcellea cundinamarcensis (P1G10) in enzymatic debridement showed the best ulcer healing rate (SURCA = 0.919) when compared with the standard of care (SOC) group, with a mean difference (MD) and 95% confidence interval (CI) of 1.40 (0.57, 2.36). Kiwifruit extract demonstrated the best effect on the ulcer area reduction rate (SURCA = 0.931), when compared with that in the SOC group, with an MD and 95% CI of 0.47 (0.27, 0.66).

Conclusion: Enzymatic debridement was superior to other debridement methods in terms of ulcer healing rate and ulcer area reduction rate in patients with DFUs. However, as the quality of the included trials is low, enzymatic debridement can be used as a candidate debridement method in addition to sharp-based debridement in clinical practice.
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NewsBot · Mar 6, 2024

Diabetic Foot Ulcers: A Review of Debridement Techniques
Brianna C Sa et al
Surg Technol Int. 2024 Feb 15:44

Diabetic foot ulcers (DFUs) are a prevalent complication of diabetes mellitus (DM) and lead to significant morbidity and mortality. Patients with DM have a lifetime risk of DFUs as high as 34%. The pathogenesis of DFUs is multifactorial, and the most common underlying causes are poor glycemic control, peripheral neuropathy, peripheral vascular disease, foot deformity, and poor foot care. Diabetic lower-extremity complications are also a significant burden in terms of healthcare costs. In the United States alone, the direct cost of diabetic foot care has been estimated to be $8,659 per patient, with total annual medical costs for managing diabetic foot disease ranging from $9 to $13 billion. Given the risk of amputation and poor wound healing, the fast, accurate diagnosis and treatment of DFUs are critical. Measures to prevent DFUs include glycemic control and annual foot inspections. For patients with DFUs, off-loading and local wound care are critical for wound healing. Debridement is the standard of care for DFU wounds, and several techniques exist. In this review, we discuss the current practices of diabetic wound care, different methods of debridement and their practical use in DFUs, and novel debridement approaches with the potential for improving wound-healing outcomes.
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