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Debridement Procedures for Managing Diabetic Foot Ulcers: A Review of Clinical Effectiveness, Cost-effectiveness, and Guidelines

Published on: September 15, 2014
Project Number: RC0579-002
Product Line: Rapid Response
Research Type: Devices and Systems
Report Type: Summary with Critical Appraisal
Result type: Report

Report in Brief

Context
The rising prevalence of diabetes and its associated complications represent a global public health care problem and financial burden. The estimated prevalence of diabetes in Canada is 6.8% — roughly 2.4 million Canadians — and it is increasing, with a 280% increase from 1998. Diabetic foot ulcers (DFUs) are the most common chronic complication, affecting 4% to 10% of patients with diabetes. DFUs can become infected and lead to osteomyelitis (bone infection), cellulitis (skin infection), and even amputation, resulting in significant morbidity, mortality, and costs to the health care system.

Technology
Debridement — the removal of dead, damaged, infected, or callused tissue — is a common treatment for DFUs. Because callused tissue may eventually lead to the formation of DFUs, callus debridement is used as a preventive measure as well. Debridement methods can be autolytic (hydrogels, hydrocolloids, and transparent films), biological (maggots), mechanical (irrigation), enzymatic, or surgical.

Issue
A review of the comparative clinical effectiveness and cost-effectiveness of various debridement procedures for the treatment of DFUs, of the clinical effectiveness of callus debridement for the prevention and treatment of DFUs, and of the evidence-based guidelines will help to inform decisions about foot care in these patients.

Methods
A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results
The literature search identified 132 citations, with 7 additional articles identified from other sources. Of these, 12 articles met the criteria for inclusion in this review: 1 systematic review, 1 meta-analysis, 2 randomized controlled trials, 1 randomized controlled trial with a cost-effectiveness analysis, and 7 guidelines.

Key Messages

  • Of the available debridement techniques, hydrogels and enzyme preparations appear to be more effective than no debridement for the treatment of DFUs (based on limited evidence).
  • Clostridial collagenase ointment (an enzymatic method) appears to be more cost-effective than saline moist gauze for the debridement of DFUs (based on limited evidence).
  • No evidence was found on the effectiveness of callus debridement for the prevention and treatment of DFUs.
  • The guidelines are inconsistent with one another with respect to their recommendations for the debridement of DFUs.

Question

  1. What is the comparative clinical effectiveness of wound debridement procedures for the treatment of diabetic foot ulcers?
  2. What is the clinical effectiveness of surgical callus debridement for the prevention and treatment of diabetic foot ulcers?
  3. What is the cost-effectiveness of wound debridement for the treatment of diabetic foot ulcers?
  4. What are the evidence-based guidelines regarding wound debridement for the treatment of diabetic foot ulcers?

Key Message

This report identified evidence that autolytic (hydrogel) and enzymatic debridement (clostridial collagenase ointment) are more clinically effective wound debridement procedures for the treatment of diabetic foot ulcers than standard wound care. This is supported by RCTs with important limitations including a moderate to high risk of bias. No clinical effectiveness evidence was found for callus debridement for the prevention and treatment of diabetic ulcers. The cost-effectiveness data identified suggests that clostridial collagenase ointment is more cost-effective than saline moist gauze for the debridement of diabetic foot ulcers, however the cost-effectiveness analysis has some important limitations. No clear consensus was present in the identified guidelines regarding diabetic foot ulcer debridement. Three different guidelines contained recommendations for selecting autolytic debridement in the treatment of diabetic foot ulcers. Recommendations for selecting surgical, mechanical, larvae, conservative sharp wound debridement, and enzymatic debridement techniques were also identified. Two guidelines also recommended callus debridement for treatment and prevention of DFU without recommending a specific debridement technique.

Tags

debridement, diabetic foot, wounds and injuries, diabetes, surgery