Technological developments in the assessment and management of diabetic foot ulcers

Abstract

There are more than 4,400 amputations every year in Australia because of diabetes. In 2005, more than 1000 people with diabetes died as a direct result of foot ulcers and lower limb wounds which accounts for 8% of all diabetes related deaths. The rates of diabetes-related amputations have increased by over 30% between 1998 and 2011 which reflects a concerning trend. In 2019, the International Working Group (IWGDF) on the Diabetic Foot released guidelines focused on the main facets of diabetic foot management: offloading, infection control, wound healing interventions and peripheral artery disease. Complex diabetic foot wounds and chronic wounds are at very high risk of limb loss due as they are difficult to heal and are at higher risk of infection. However, there remains limited options for treatment of these wounds. When diabetic foot ulcers develop in patients with peripheral arterial disease it often results in chronic, non-healing ulcers exacerbated by ischaemia with lack of oxygen and nutrition to facilitate tissue repair. The advancements in endovascular technology for treatment of peripheral arterial disease have been rapid, but the nomenclature and classification systems have remained antiquated and risk inappropriate treatment. All diabetic foot wounds need to be monitored closely as rapid infection and deterioration may occur without early intervention but improvements in the accessibility and accuracy of measurement tools needs to be developed. This thesis is aimed at developing new technologies to prevent diabetic foot wound deterioration for limb salvage and reducing mortality. The aims of this research are: 1. To evaluate the efficacy of using BTM in the reconstruction of complex diabetic foot wounds. 2. To use the NDKare phone application to assess its accuracy and practicality for diabetic foot ulcer wound size assessment 3. To critically evaluate the historical classification and management of chronic limb ischaemia and critical limb ischaemia with the development of the latest GVG guidelines Research from this thesis has evaluated a new dermal template (biodegradable temporising template – BTM) which demonstrated in our prospective cohort study that all the patients with complex, chronic diabetic foot wounds were able to heal with BTM. Whilst it is difficult to extrapolate given the small number of patients within the study, the results were suggestive of potentially a relatively low infection and re-ulceration rate. The NDKare phone application was able to accurately measure wound size in 2-dimensions and it was a practical new technology to use in the clinical setting as users with different smartphones were able to obtain similar results. Evaluation of the history of the classification and nomenclature of chronic limb ischaemia and critical limb ischaemia will contribute to increased awareness of the the significance and need for the development of the Global Vascular Guidelines and the Global Limb Anatomic Staging System.