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or 2) may be as high as 25 percent [ 1-3 ]. Diabetic foot ulcers are a major cause of
morbidity and mortality, accounting for approximately two-thirds of all nontraumatic
amputations performed in the United States [ 4,5 ]. This observation illustrates the
importance of prompt treatment of foot ulcers in patients with diabetes. The
management of diabetic foot lesions is provided here. Evaluation and prevention of
foot ulcers and the treatment of diabetes-related foot infections (cellulitis and
osteomyelitis) are discussed separately. (See "Evaluation of the diabetic
foot" and "Clinical manifestations, diagnosis, and management of diabetic infections of
the lower extremities" .)
El riesgo de por vida de una úlcera en el pie para pacientes con diabetes (tipo 1 o 2) puede ser tan alto como el
25 por ciento [1-3]. Las úlceras del pie diabético son una causa importante de morbilidad y mortalidad, ya que
representan aproximadamente dos tercios de todas las amputaciones no traumáticas realizadas en los Estados
Unidos [4,5]. Esta observación ilustra la importancia del tratamiento rápido de las úlceras del pie en pacientes
con diabetes. El manejo de las lesiones del pie diabético se proporciona aquí. La evaluación y prevención de
las úlceras del pie y el tratamiento de las infecciones del pie relacionadas con la diabetes (celulitis y
osteomielitis) se tratan por separado.
The Wagner classification is based upon clinical evaluation (depth of ulcer and
presence of necrosis) alone and does not account for the vascular status of the foot. A
modified system that is frequently used by orthopedic surgeons individually scores the
components of wound depth and ischemia [ 7 ]. Other ulcer classification systems have
also been published [ 8-11 ]. The International Working Group on the Diabetic Foot
proposed classifying all ulcers according to the following categories: perfusion, extent,
depth, infection, and sensation (PEDIS) [ 12 ]. The PEDIS system is primarily used for
research purposes.
The usual approach to the management of lesions of each Wagner grade is given
below, followed by a discussion of some newer approaches.
LESIONES DE GRADO 1 Y 2: se considera que los componentes importantes de la terapia para las úlceras de
grado 1 y 2 pies [9,13,14 ]. Hay datos limitados que evalúan la eficacia de este enfoque estándar, en particular
los beneficios del desbridamiento y el cuidado local de heridas. En un metanálisis de los grupos de control de
10 ensayos (622 pacientes) que evaluaron el tratamiento estándar (desbridamiento y cuidado de heridas locales)
versus varios tratamientos nuevos, el 24 y el 31 por ciento de las úlceras se curaron después de 12 y 20 semanas,
respectivamente, de tratamiento estándar [ 15 ].
En la práctica clínica, las mediciones del tamaño de la úlcera de un paciente se deben tomar en cada visita al
consultorio para que se puedan realizar comparaciones y documentar el progreso. El área de superficie de una
úlcera del pie diabético sano debe disminuir de tamaño a una tasa de aproximadamente el uno por ciento por
día. Las úlceras que no mejoran deben evaluarse para detectar una infección tisular u osteomielitis en curso que
requiera antibióticos, flujo vascular insuficiente o, lo que es más frecuente, la necesidad de una descarga más
eficaz. (Consulte 'Evaluación de la enfermedad de la arteria periférica' a continuación y 'Evaluación de la
osteomielitis' a continuación.)
Sharp debridement involves the use of a scalpel or scissors to remove necrotic tissue
[ 17 ]. It is the most widely used method except in certain settings, such as highly
vascular ulcers or when there is significant vascular compromise such that concerns
exist as to the patient's ability to heal any new wounds created by sharp debridement.
In such settings, enzymatic debridement (topical application of proteolytic enzymes
such as collagenase) may be preferable [ 8 ]. Autolytic debridement, using a
semiocclusive or occlusive (hydrogel) dressing to cover a wound so that necrotic tissue
is digested by enzymes normally present in wound tissue, may be a good option in
patients with painful ulcers.
In a systematic review of six small randomized trials, hydrogels were significantly more
effective than wet to moist saline or dry gauze in healing foot ulcers in diabetic
patients [ 18 ]. However, a hydrogel combined with good wound care (defined as sharp
debridement, saline dressings, pressure relief, and control of infection) was not
significantly better than good wound care alone. Larval therapy (a form of biological
debridement) showed no significant benefit in small studies. Overall, the review was
limited by the small number of trials and poor methodological quality.
Thus, there are few data to guide choice of debridement. When surgeons with
expertise in sharp debridement are available, we prefer this method. As an alternative,
we suggest application of a hydrogel since limited data support its efficacy in
promoting ulcer healing. For patients with evidence of arterial insufficiency, we suggest
referral to a vascular specialist.
Método de desbridamiento: el desbridamiento del tejido necrótico es importante para la curación de úlceras
[16], aunque existen pocos ensayos que comparen los diferentes métodos de desbridamiento (agudo,
enzimático, autolítico, mecánico y biológico). Los tipos de desbridamiento se revisan por separado. (Ver "El
tratamiento de las úlceras por presión", en la sección 'El desbridamiento').
desbridamiento cortante implica el uso de un bisturí o unas tijeras para eliminar el tejido necrótico [17]. Es el
método más utilizado, excepto en ciertos entornos, como úlceras altamente vasculares o cuando existe un
compromiso vascular importante, de modo que existen preocupaciones en cuanto a la capacidad del paciente
para curar cualquier nueva herida creada por un desbridamiento agudo. En tales entornos, el desbridamiento
enzimático (aplicación tópica de enzimas proteolíticas como la colagenasa) puede ser preferible [8]. El
desbridamiento autolítico, que utiliza un apósito semioclusivo u oclusivo (hidrogel) para cubrir una herida de
modo que el tejido necrótico sea digerido por las enzimas normalmente presentes en el tejido de la herida, puede
ser una buena opción en pacientes con úlceras dolorosas.
En una revisión sistemática de seis ensayos aleatorios pequeños, los hidrogeles fueron significativamente más
efectivos que la solución salina húmeda a húmeda o una gasa seca en la curación de las úlceras del pie en
pacientes diabéticos [18]. Sin embargo, un hidrogel combinado con un buen cuidado de la herida (definido
como desbridamiento agudo, apósitos salinos, alivio de la presión y control de la infección) no fue
significativamente mejor que el buen cuidado de la herida solo. la terapia de larvas (una forma de
desbridamiento biológico) no mostró beneficios significativos en pequeños estudios. En general, la revisión
estuvo limitada por el pequeño número de ensayos y la calidad metodológica deficiente.
Por lo tanto, hay pocos datos para guiar la elección de desbridamiento. Cuando hay cirujanos con experiencia
en desbridamiento agudo, preferimos este método. Como alternativa, se sugiere la aplicación de un hidrogel
dado que los datos limitados apoyan su eficacia en la promoción de la cicatrización de la úlcera. Para los
pacientes con evidencia de insuficiencia arterial, sugerimos la derivación a un especialista vascular.
Some dressings simply provide protection, whereas others promote wound hydration
or prevent excessive moisture. Wet-to-dry saline dressings are frequently used, but
some ulcers may require a moister environment. In addition, wet-to-dry dressings will
remove both nonviable and viable tissues. Thus, caution is required to avoid damaging
healthy tissue.
Some dressings are impregnated with antimicrobial agents to prevent infection and
enhance ulcer healing. However, there are no clinical trial data to support their
effectiveness [ 22 ]. (See "Treatment of pressure ulcers", section on 'Dressing
choices' .)
Cuidado local de las heridas: después del desbridamiento, las úlceras deben mantenerse limpias y húmedas,
pero sin exceso de líquidos. La humedad acelera la cicatrización de los tejidos. Los apósitos deben seleccionarse
en función de las características de la herida, como la extensión del exudado, la desecación o el tejido necrótico.
Algunos apósitos simplemente brindan protección, mientras que otros promueven la hidratación de la herida o
evitan la humedad excesiva. Los apósitos de solución salina húmeda a seca se usan con frecuencia, pero algunas
úlceras pueden requerir un ambiente más húmedo. Además, los apósitos húmedos a secos eliminarán los tejidos
viables y no viables. Por lo tanto, se requiere precaución para evitar dañar el tejido sano.
Algunos apósitos están impregnados de agentes antimicrobianos para prevenir infecciones y mejorar la curación
de las úlceras. Sin embargo, no hay datos de ensayos clínicos que respalden su efectividad [22]. (Consulte
"Tratamiento de las úlceras por presión", sección "Selección de apósitos".)
Descarga mecánica: los dispositivos de descarga, que incluyen moldes de contacto total, andadores de yeso,
modificaciones del calzado y otros dispositivos para ayudar a la ambulación, están disponibles para reducir o
eliminar la presión en la región de la úlcera, lo cual es importante para la curación. La evidencia respalda el
uso de moldes de contacto total y andadores no removibles para aliviar la presión asociada con la curación de
la úlcera diabética [23]. Una revisión de la base de datos Cochrane 2000 actualizada en 2013 evaluó 14
ensayos que compararon varias formas de tratamientos para aliviar la presión (no removibles, removibles) y
apósitos [24,25]. En cinco ensayos, la probabilidad de curación de la herida fue significativamente mejor a las
12 semanas para los moldes no removibles y que alivian la presión en comparación con los dispositivos o
apósitos removibles (riesgo relativo [RR] 1.17, IC del 95% 1.01-1.36). En un ensayo, no se encontraron
diferencias significativas entre los diferentes tipos de tratamientos no removibles para aliviar la presión [26].
Total contact cast — A total contact cast is a padded fiberglass shell designed to
take pressure off the heel or elsewhere on the foot by averaging the pressure across
the sole of the foot (ie, eliminates high and low pressure regions by providing contact
at all points) or to generally un-weight the entire foot through a total contact fit at the
calf. The most aggressive unloading is achieved by making the patient non-weight-
bearing. Disadvantages of total contact casting include expertise needed in applying
the cast, inability to inspect the wound frequently, inconvenience in activities of daily
living (eg, bathing), and the risk of developing a secondary ulcer in an ill-fitting cast
(particularly in patients with neuropathy) [ 9 ]. Frequent cast changes may be needed
to avoid complications.
Based upon randomized trials, total contact casting enhances diabetic ulcer healing
and is the standard for relieving pressure from the forefoot [ 24-32 ]. As an example,
in a trial of off-loading modalities in 63 diabetic patients with superficial, noninfected,
nonischemic plantar ulcers, the proportion of ulcers that were healed at 12 weeks was
significantly higher in those randomly assigned to a total contact cast compared with a
half-shoe or removable cast walker (90 versus 58 and 65 percent, respectively) [ 29 ].
Patients with a total contact cast also had faster wound healing. Another small trial
found that a casting combined with Achilles tendon lengthening resulted in significantly
fewer ulcer recurrences at seven months (15 verus 59 percent) and two years (38
versus 81 percent) compared with the casting alone [ 33 ].
Total contact casts should not be used in patients with infected wounds, osteomyelitis,
peripheral ischemia, bilateral ulceration, lower extremity amputation or heel ulceration
[ 34 ].
Total de fundición de contacto: una funda de contacto total es una cubierta de fibra de
vidrio acolchada diseñada para quitar la presión del talón o de cualquier otra parte del pie
promediando la presión en la planta del pie (es decir, elimina las regiones de alta y baja
presión proporcionando contacto en todos los puntos) ) o en general, sin peso de todo el
pie a través de un ajuste de contacto total en la pantorrilla. La descarga más agresiva se
logra haciendo que el paciente no soporte peso. Las desventajas de la fundición por
contacto total incluyen la experiencia necesaria para aplicar el yeso, la incapacidad para
inspeccionar la herida con frecuencia, las molestias en las actividades de la vida diaria
(por ejemplo, bañarse) y el riesgo de desarrollar una úlcera secundaria en un yeso mal
ajustado (especialmente en pacientes). con neuropatía) [9]. Se pueden necesitar cambios
frecuentes en el yeso para evitar complicaciones. Sobre la base de ensayos aleatorios, el
contacto total mejora la cicatrización de la úlcera diabética y es el estándar para aliviar la
presión del antepié [24-32]. Como ejemplo, en un ensayo de modalidades de descarga en
63 pacientes diabéticos con úlceras plantares superficiales, no infectadas y no
isquémicas, la proporción de úlceras que se curaron a las 12 semanas fue
significativamente mayor en las personas asignadas aleatoriamente a un yeso de contacto
total en comparación con una caminador de medio zapato o desmontable (90 contra 58 y
65 por ciento, respectivamente) [29]. Los pacientes con un yeso de contacto total también
tuvieron una cicatrización más rápida de la herida. Otro ensayo pequeño encontró que un
lanzamiento combinado con el alargamiento del tendón de Aquiles dio lugar a un número
significativamente menor de recurrencias de úlceras a los siete meses (15 verus 59 por
ciento) y dos años (38 versus 81 por ciento) en comparación con el lanzamiento solo [33].
El total de moldes de contacto no debe utilizarse en pacientes con heridas infectadas,
osteomielitis, isquemia periférica, ulceración bilateral, amputación de extremidades
inferiores o ulceración del talón [34].
Cast walkers — An alternative to total contact casting is a prefabricated brace called
a cast walker that is designed to maintain a total contact fit (figure 1 ). Several cast
walkers (non-removable, removable) are commercially available and provide capability
to off-load the foot similar to contact casts. Cast walkers also appear to facilitate
wound healing, but a significant disadvantage is poor patient compliance if the cast
walker is removed [ 35 ].
Cast walkers appear to have a similar ability to off-load the foot compared with total
contact casting.
One study compared plantar foot pressure metrics in a standard shoe, total
contact cast and prefabricated pneumatic walking brace [ 36 ]. Five plantar foot
sensors were placed at the first, third, and fifth metatarsal heads, fifth
metatarsal base, and mid-plantar heel of 10 healthy male subjects who walked
at a constant speed over a distance of 280 meters. Peak pressures were
significantly reduced in the pneumatic walking brace compared with the
standard shoe for all sensor locations to an equal or greater degree compared
with the total contact cast in all sensor locations.
Another study measured foot pressures using an in-shoe pressure
measurement system (Novel Pedar®) in 18 healthy subjects while wearing a
cast walker or total contact cast [ 37 ]. Peak foot pressures using the cast
walker were significantly reduced in the forefoot (12 versus 18 N/cm 2 ) and
foot as a whole (14 versus 19 N/cm 2 ) compared with a fiberglass total contact
cast, but no differences were found for the heel or midfoot.
These studies suggest these prefabricated products are at least as good as total
contact casting for off-loading the foot and equalizing foot pressures when the foot
anatomy is normal, but data are not available demonstrating these effects for patients
with diabetic foot deformities.
Cast walkers have been used for the treatment of neuropathic plantar ulcers but these
devices, thus far, have not been found to be superior to total contact casting in
randomized trials. In one trial, the rate of ulcer healing was significantly higher in
those randomly assigned to total contact casting compared with a half-shoe or
removable cast walker [ 29 ]. Another trial that randomly assigned 48 patients to total
contact casting or a removable cast walker (ie, Stabil-D®), found no difference in the
number of days to achieve healing (35 versus 39 days) [ 38 ].
Wedge shoes (eg, Darco International), also called half shoes, are available as a
forefoot wedge and heel wedge shoes to off-load the forefoot and heel, respectively
( figure 3 ). These shoes may be useful under certain circumstances. For example,
plantar heel ulcers are particularly difficult to heel because of an inability to adequately
off-load this region; the heel wedge shoe can be useful to achieve this goal.
The disadvantage of wedge shoes is that most patients, especially elderly patients or
those with proprioception abnormalities may not be able to maintain their balance, and
some patients find walking in them difficult, if not impossible.
Knee walkers — Knee walkers are ambulatory assist devices that may be indicated
for anyone with a lower extremity issue where weight bearing needs to be avoided
( figure 4 ). These devices are becoming more popular in the treatment of diabetic
ulcer as a means to off-load the foot. There are no trials evaluating the effectiveness of
these devices in healing diabetic foot ulcers.
Summary — Debridement, good local wound care, and relief of pressure on the ulcer
are believed to be important components of therapy for grade 1 and 2 foot ulcers [ 9 ].
This treatment program does not require hospitalization. Close monitoring is required,
and hospitalization for bed rest and intravenous antibiotic therapy is advisable if the
ulcer does not improve. (See "Clinical manifestations, diagnosis, and management of
diabetic infections of the lower extremities" .)
Se cree que el desbridamiento, el buen cuidado local de las heridas y el alivio de la presión sobre la úlcera son
componentes importantes de la terapia para las úlceras de grado 1 y 2 pies [9]. Este programa de tratamiento
no requiere hospitalización. Se requiere una estrecha vigilancia y es recomendable la hospitalización para el
reposo en cama y la terapia con antibióticos por vía intravenosa si la úlcera no mejora. (Consulte
"Manifestaciones clínicas, diagnóstico y tratamiento de las infecciones diabéticas de las extremidades
inferiores".)
Antes de decidir sobre el manejo adecuado de las úlceras profundas, es importante evaluar la presencia de una
enfermedad vascular periférica sustancial o afectación ósea. Una breve reseña se encuentra aquí. Estos temas
se discuten en detalle por separado. (Consulte "Evaluación del pie diabético", sección "Signos físicos de la
enfermedad arterial periférica" y "Evaluación del pie diabético", sección "Signos de infección".
The ankle-brachial index is a measurement of the ratio of blood pressure at the ankle
to that in the brachial artery that correlates with the presence and severity of arterial
occlusive disease [ 42 ]. In patients with diabetes, the blood vessels may be
incompressible and ankle-brachial index values misleading. Segmental volume
plethysmography and toe-brachial index values are more reliable for determining the
severity of disease. The noninvasive diagnosis of lower extremity peripheral artery
disease is reviewed in detail elsewhere. (See "Noninvasive diagnosis of arterial
disease" .)
Evalúe la osteomielitis: es probable que se presente osteomielitis si se puede ver hueso en el piso de una úlcera
profunda, o si se puede detectar fácilmente al sondear la úlcera con una sonda de acero inoxidable roma y estéril.
Otros signos que sugieren una osteomielitis son un tamaño de úlcera mayor de 2 x 2 cm y una elevación de otra
manera inexplicable en la tasa de sedimentación del eritrocito. (Consulte "Manifestaciones clínicas, diagnóstico
y tratamiento de las infecciones diabéticas de las extremidades inferiores", sección "Diagnóstico de
osteomielitis subyacente").
Surgical removal of infected bone may be necessary if the ulcer is not healing. A short
period of hospitalization, with surgical debridement, including culture of material
obtained from deep in the ulcer and bone biopsy, is often helpful in choosing antibiotic
therapy [ 47 ]. Parenteral antibiotic therapy based upon the culture results has
traditionally been given for four to six weeks in patients with osteomyelitis. The
optimal regimen and when to transition to oral therapy are dependent upon the clinical
features of each case. (See "Clinical manifestations, diagnosis, and management of
diabetic infections of the lower extremities", section on 'Antimicrobial therapy' .)
GRADE 4 AND 5 LESIONS — Patients with these more advanced lesions require
urgent hospital admission and surgical consultation, and amputation may sometimes
be required. (See "Clinical manifestations, diagnosis, and management of diabetic
infections of the lower extremities" .)
LESIONES DE GRADO 4 Y 5: los pacientes con estas lesiones más avanzadas requieren hospitalización
urgente y consulta quirúrgica, y en ocasiones puede ser necesaria la amputación. (Consulte "Manifestaciones
clínicas, diagnóstico y tratamiento de las infecciones diabéticas de las extremidades inferiores".)
Randomized trials have found that NPWT reduces time to closure of diabetic foot
ulcers, and wounds following diabetic foot surgery [ 52-57 ]. In this patient population,
NPWT also decreases length of hospitalization, complication rates, and cost [ 58-60 ].
One multicenter trial randomized 342 patients with diabetic foot ulcers (stage 2
or 3 Wagner ulcers, and adequate vascular perfusion) to negative pressure
wound therapy or moist wound therapy (ie, hydrogel, alginate) [ 53 ]. All ulcers
were debrided (as needed) within two days of randomization, and the majority
of the patients also received off-loading therapy. The primary endpoint was
wound closure. A significantly greater percentage of patients treated with
negative pressure wound therapy achieved wound closure within the 16 week
timeframe of the study compared with alternative medical therapy (43 versus
29 percent). The negative pressure wound therapy group also demonstrated
significantly fewer amputations compared with the alternate medical therapy
group (4 versus 10 percent).
Another multicenter trial followed 162 diabetic patients for 16 weeks following
partial foot amputation [ 52 ]. The percentage of patients with healed wounds
(56 versus 39 percent) and time to complete closure (42 versus 84 days) were
significantly improved in patients randomized to vacuum-assisted wound
closure group compared with the control group.
Skin substitutes — Human skin equivalents have been studied in diabetic patients
with noninfected, nonischemic chronic plantar ulcers [ 50,61-64 ]. In one study of 208
patients, weekly application of the cultured skin equivalent (Graftskin) for four weeks
improved the healing rate compared with usual care (complete wound healing in 56
and 38 percent of patients, respectively) [ 61 ]. Bioengineered skin substitutes
(Dermagraft, Apligraf) are also available for the treatment of nonhealing diabetic foot
ulcers [ 62,63 ].
A pooled analysis found significantly improved wound healing (OR 9.99, 95% CI 3.97-
25.1), and decreased risk of amputation (OR 0.24, 95% CI 0.14-0.43) [ 68-71 ]. A
later metaanalysis found similar results [ 72 ]. As an example of these effects, in one
of the larger trials that included 70 patients with severely ischemic foot ulcers (Wagner
grades 3 and 4), the amputation rate was 9 percent in the treatment group and 33
percent in the control [ 73 ]. In another trial that included 94 patients, a significantly
increased incidence of complete healing (Wagner 2 though 4 ulcers) was achieved in
the hyperbaric oxygen therapy group (52 versus 29 percent) compared with a placebo
group [ 80 ].
Therapies that combine hyperbaric oxygen therapy with known mediators of wound
healing may augment the effects of hyperbaric oxygen. Activation and mobilization of
endothelial progenitor cells (EPCs) are impaired in patients with diabetes. These cells
are known to play an important role in wound healing by participating in the formation
of new blood vessels in areas of hypoxia [ 83-86 ]. Hyperoxia effectively improves EPC
mobilization, but does not specifically target to a specific site which may, in part,
explain the nonuniform improvement in diabetic foot wounds with hyperbaric oxygen
therapy alone [87 ]. However, in a murine model of diabetes, coadministration of the
chemokine stromal cell-derived factor-1 alpha (SDF-1 alpha) resulted in homing of
activated EPCs into the wound site [ 88 ]. These data suggest that combining
hyperbaric oxygen therapy with administration of SDF-1 alpha may be synergistic.
Other combination therapies (eg, fibroblast growth factor) are also being studied
[ 89,90 ].
Other agents — Small trials have shown some promise for other topical agents. In a
randomized study, application of .05 percent tretinoin solution for 10 minutes a day
followed by iodine gel for four weeks resulted in complete resolution of 46 percent of
the ulcers in the treatment group (n = 13) compared with 18 percent in the control
group (n = 11) [ 91 ]. In addition, electrical stimulation near the ulcer may also help
slowly healing ulcers [ 92,93 ].
Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on “patient info” and the
keyword(s) of interest.)