The most effective way to debride diabetic foot ulcers is not clear. This Cochrane review looked at, and pooled, the latest evidence for different interventions to promote wound healing
Author Lei Cheng is a postgraduate student, School of Nursing, Fudan University, Shanghai, China, and a member of the Cochrane Nursing Care Field (CNCF)
What is the best available evidence on the effects of debridement interventions on the healing of diabetic foot ulcers?
Fifteen per cent of people with diabetes are affected by foot ulceration at some time.
Debridement is an intervention intended to speed up ulcer healing. It involves the removal of devitalised, contaminated or foreign material from the wound, until surrounding healthy tissue is exposed.
Effective management of the diabetic foot is generally regarded as requiring a multidisciplinary input and good communication between primary and secondary care providers.
However, the most effective method of debridement is still unclear.
This review identified six randomised controlled trials with 488 participants that compared any method of debridement with no debridement, or an alternative method of debridement.
Debridement was defined as “the removal of necrotic tissue from the wound, by either mechanical or non-mechanical debridement”.
Participants were patients with type 1 or 2 diabetes, who had an active foot ulcer of neuropathic, neuroischaemic or ischaemic aetiology. Primary outcomes included the time to complete healing, the proportion of people whose ulcers healed completely in the trial period, and rate of reduction in wound size expressed in absolute or relative terms.
As adequate methodological reporting was absent in all six trials, all were deemed to be at a high risk of bias.
Of the six RCTs, four assessed hydrogels, one investigated larval therapy against hydrogel, and one evaluated surgical debridement. Meta analysis was undertaken where possible.
Summary of key evidence
Three RCTs compared hydrogel with gauze or standard care. Pooled results indicated that hydrogels were significantly more effective in healing diabetic foot ulcers than gauze or standard care. (Relative risk = 1.84, 95% confidence interval [CI]: 1.3 to 2.61).
In one study (n=42), surgical debridement (surgical excision, eventual debridement or removal of bone segments underlying the lesion and surgical closure) was compared to conventional management (pressure relief and regular dressings). Surgical debridement showed no significant benefit over standard treatment.
One study (n=140), published in abstract form only, suggested that larvae resulted in a more than 50% reduction in wound area compared with hydrogel. However, this data was an interim result and reported at 10 days.
Another study (n=74) also reported in abstract form compared a hydrogel containing carboxymethylcellulose and calcium alginate (Purilon Gel) with another hydrogel, which contained modified carmellose polymer and propylene glycol (Intrasite Gel) on wound healing and mean change of wound area. However, data was inadequate so conclusions could not be drawn.
Best practice recommendations
The evidence, which was poor in quality, suggests that hydrogel results in better healing of diabetic foot ulcers than gauze dressings or standard wound care. However, it is not clear whether this effect is due to debridement.
Evidence from a single study (in abstract form) suggests that larval therapy may achieve a greater reduction in wound area than hydrogel, but this was only an interim analysis of early results and therefore must be viewed with caution.
The full review report, including references, can be accessed at click here
Edwards J, Stapley S (2010) Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews; Issue 1, Art No: CD003556. DOI: 10.1002/14651858.CD003556.pub2