Sharp debridement in the management of diabetes-related foot ulcers: outcomes of a randomised study of debridement frequency, current practice of debridement and implications for frequency of treatment.

Abstract

Diabetes related foot ulcers (DFU) are a leading cause of hospital admission and lower extremity amputations. DFU are optimally managed by an interdisciplinary team including podiatrists. Sharp debridement (SD) of DFU is standard care based on observational data that more frequent SD is positively associated with healing. There are no prospective studies assessing frequency of SD. Available literature relating to SD was explored in this thesis and three studies conducted; a clinician survey to determine what is current practice, a randomised trial to determine whether SD performed weekly vs second weekly results in a higher proportion of DFU healed, and a survey exploring patients’ experiences. Clinician survey respondents (n=75), mostly podiatrists, reported weekly and second weekly SD regimens were usual practice and publicly funded podiatrists debride at every visit. Those in rural/regional areas, SD DFU less often and clinicians rely on clinical features to inform SD frequency. The randomised trial recruited 122 participants from seven centres. DFU stratified by Centre and size, were randomised to weekly or second weekly SD. All received weekly standard care. Healing outcome at 12 weeks was objectively based on digital images (n=78) assessed by wound experts blinded to group allocation with 53% of weekly and 52% of second weekly debrided DFU healed (mean difference 1.8%, 95% CI -16.3 to 20). Clinician reported healing outcomes were similar. The patient survey included (n=60) participants from three clinics. Participants expressed satisfaction with SD, half reported mobility restricted their capacity to attend, and the majority used a car to travel to the appointments with family support often being required. The aetiology of DFU is multifactorial and many factors impact healing outcomes. In the context of standard care, second weekly SD has similar outcomes to weekly, with the potential to reduce the burden of care for patients and their families.