Management of Diabetic Foot Ulcers

Diagnosis and Assessment

Evaluate peripheral circulation using ankle-brachial index (ABI), toe pressure, and transcutaneous oxygen pressure (TcPO₂) to assess severity of ischemia, with values <0.5, <30 mmHg, and <25 mmHg indicating severe ischemia, critical ischemia, and poor healing potential, respectively, as recommended by the American Diabetes Association 1
Perform vascular imaging, including color Doppler ultrasound, computed tomography angiography, magnetic resonance angiography, or intra-arterial digital subtraction angiography, to evaluate the entire lower extremity arterial circulation, with detailed visualization of below-the-knee and pedal arteries 1, 2
Indicators for peripheral arterial disease (PAD) assessment include:
| Indicator | Threshold | | --- | --- | | Absent pedal pulses | - | | ABI | <0.9 | | TBI | <0.7 | | Toe pressure | <30 mmHg | | Transcutaneous oxygen pressure (TcPO2) | <25 mmHg | 1, 3, 4

Start empiric antibiotic therapy immediately for diabetic foot ulcers with signs of infection, targeting Staphylococcus aureus and streptococci for superficial infections, and using broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria for deep or severe infections, as recommended by the Infectious Diseases Society of America 5, 6
Obtain wound cultures before starting antibiotics if possible, and adjust antibiotic therapy based on culture results and clinical response 6
For infected arterial ulcers, cleanse and carefully debride necrotic tissue, start empiric antibiotics targeting common pathogens, and consider urgent surgical drainage for deep infections, with the goal of complete wound healing 3, 7

Perform urgent revascularization for diabetic foot ulcers with severe ischemia, indicated by toe pressure <30 mmHg, TcPO₂ <25 mmHg, ankle pressure <50 mmHg or ABI <0.5, or ulcers showing no healing within 6 weeks despite optimal management, as recommended by the American College of Cardiology 1
The goal of revascularization is to restore direct blood flow to at least one foot artery, preferably the one supplying the area of the ulcer, and options include endovascular techniques and bypass surgery 1, 2
Aim to achieve minimum perfusion parameters (skin perfusion pressure ≥40 mmHg, toe pressure ≥30 mmHg, or TcPO2 ≥25 mmHg) after revascularization 3, 1

Provide appropriate dressings to maintain a moist wound environment, ensure proper offloading to reduce pressure on the affected area, and consider negative pressure wound therapy for post-operative wounds, as recommended by the Wound, Ostomy and Continence Nurses Society 7
Never soak an arterial ulcer as this can lead to maceration and worsening of the wound, and avoid debridement in purely ischemic ulcers without infection until revascularization has been performed 7
For purely ischemic ulcers without infection, provide protective covering to maintain a moist wound environment, and consider offloading to reduce mechanical stress on the wound 8, 1
Advanced therapies such as negative pressure wound therapy (NPWT) and hyperbaric oxygen therapy may be considered for non-healing wounds, with dressings selected based on exudate control, patient comfort, and cost 9, 10

With successful revascularization, healing rates of >60% can be achieved at 12 months, and "time is tissue" in infected ischemic diabetic foot ulcers, with treatment recommended within 24 hours 2
Without revascularization, limb loss occurs in approximately 19% of cases within 6 months and 23% within 12 months, emphasizing the importance of prompt treatment 2

Aggressive cardiovascular risk reduction is essential, including smoking cessation, treatment of hypertension, lipid management (statin therapy), low-dose aspirin or clopidogrel, and diabetes control (optimal blood glucose <8 mmol/L or <140 mg/dL), as recommended by the American College of Cardiology 1, 7, 9, 11, 4
Continue antiplatelet therapy unless contraindicated, to reduce the risk of graft occlusion and improve long-term patency, as suggested by the American College of Cardiology 9, 12
Instruct patients to limit standing and walking, and use crutches if necessary to reduce mechanical stress on the wound, and provide verbal and written instructions on self-surveillance for recurrent problems, and educate on proper foot care and signs of infection or ischemia, as recommended by the American College of Cardiology 3, 4

An interdisciplinary care team, including vascular specialists, interventional specialists, podiatrists, wound care specialists, endocrinologists, and physical therapists, should be involved in the management of patients with vascular calcification, as outlined by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines and the European Society of Cardiology (ESC) guidelines 11, 13, 14, 9, 15
Coordinate care among clinicians to improve management of PAD and comorbid conditions, with early recognition of chronic limb-threatening ischemia (CLTI) and referral to a vascular team for limb salvage, as suggested by the European Society of Cardiology (ESC) guidelines 9, 15
Perform duplex ultrasound surveillance at 1, 3, 6, and 12 months post-repair, and regular ABI measurements to monitor perfusion, and physical examination with pulse checks at each follow-up visit, as recommended by the American College of Cardiology 4, 12