Management of Diabetic Foot

Publication Date: February 1, 2016
Last Updated: March 21, 2022

Prevention

Prevention of Diabetic Foot Ulceration

We recommend that patients with diabetes undergo annual interval foot inspections by physicians (MD, DO, DPM) or advanced practice providers with training in foot care. ( S , C )
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We recommend that foot examination include testing for peripheral neuropathy using the Semmes-Weinstein test. ( S , B )
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We recommend education of the patients and their families about preventive foot care. ( S , C )
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Therapeutic Footwear:

We suggest against the routine use of specialized therapeutic footwear in average-risk diabetic patients. ( W , C )
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We recommend using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation. ( S , B )
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We suggest adequate glycemic control (hemoglobin A1c <7% with strategies to minimize hypoglycemia) to reduce the incidence of diabetic foot ulcers (DFUs) and infections, with subsequent risk of amputation. ( W , B )
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We recommend against prophylactic arterial revascularization to prevent DFU. ( S , C )
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Assessment

Diagnosis of Diabetic Foot Osteomyelitis (DFO)

In patients with a diabetic foot infection (DFI) with an open wound, we suggest doing a probe to bone (PTB) test to aid in diagnosis. ( W , C )
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In all patients presenting with a new DFI, we suggest that serial plain radiographs of the affected foot be obtained to identify bone abnormalities (deformity, destruction) as well as soft tissue gas and radiopaque foreign bodies. ( W , C )
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For those patients who require additional (ie, more sensitive or specific) imaging, particularly when soft tissue abscess is suspected or the diagnosis of osteomyelitis remains uncertain, we recommend using magnetic resonance imaging (MRI) as the study of choice. ( S , B )
MRI is a valuable tool for diagnosis of osteomyelitis if the PTB test is inconclusive or if the plain film is not useful.
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In patients with suspected DFO for whom MRI is contraindicated or unavailable, we suggest a leukocyte or antigranulocyte scan, preferably combined with a bone scan as the best alternative. ( W , B )
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In patients at high risk for DFO, we recommend that the diagnosis is most definitively established by the combined findings on bone culture and histology. ( S , C )
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When bone is débrided to treat osteomyelitis, we recommend sending a sample for culture and histology. ( S , C )
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For patients not undergoing bone débridement, we suggest that clinicians consider obtaining a diagnostic bone biopsy when faced with diagnostic uncertainty, inadequate culture information, or failure of response to empirical treatment. ( W , C )
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Peripheral Arterial Disease (PAD) and the DFU

We suggest that patients with diabetes have ankle-brachial index (ABI) measurements performed when they reach 50 years of age. ( W , C )
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We suggest that patients with diabetes who have a prior history of DFU, prior abnormal vascular examination, prior intervention for peripheral vascular disease, or known atherosclerotic cardiovascular disease (eg, coronary, cerebral, or renal) have an annual vascular examination of the lower extremities and feet including ABI and toe pressures. ( W , C )
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We recommend that patients with DFU have pedal perfusion assessed by ABI2, ankle and pedal Doppler arterial waveforms, and either toe systolic pressure or transcutaneous oxygen pressure (TcPO) annually. ( S , B )
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In patients with DFU who have PAD, we recommend revascularization by either surgical bypass or endovascular therapy. ( S , B )
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Treatment

Off-Loading DFUs

In patients with plantar DFU, we recommend off-loading with a total contact cast (TCC) or irremovable fixed ankle walking boot. ( S , B )
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In patients with DFU requiring frequent dressing changes, we suggest off-loading using a removable cast walker as an alternative to TCC and irremovable fixed ankle walking boot. ( W , C )
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We suggest against using postoperative shoes or standard or customary footwear for off-loading plantar DFUs. ( W , C )
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In patients with nonplantar wounds, we recommend using any modality that relieves pressure at the site of the ulcer, such as a surgical sandal or heel relief shoe. ( S , C )
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In high-risk patients with healed DFU (including those with a prior history of DFU, partial foot amputation, or Charcot foot), we recommend wearing specific therapeutic footwear with pressure-relieving insoles to aid in prevention of new or recurrent foot ulcers ( S , C )
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Wound Care For DFUs

We recommend frequent evaluation at 1- to 4-week intervals with measurements of diabetic foot wounds to monitor reduction of wound size and healing progress. ( S , C )
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We recommend evaluation for infection on initial presentation of all diabetic foot wounds, with initial sharp débridement of all infected diabetic ulcers, and urgent surgical intervention for foot infections involving abscess, gas, or necrotizing fasciitis. ( S , B )
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We suggest that treatment of DFIs should follow the most current guidelines published by the Infectious Diseases Society of America (IDSA). (, U )
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We recommend use of dressing products that maintain a moist wound bed, control exudate, and avoid maceration of surrounding intact skin for diabetic foot wounds. ( S , B )
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We recommend sharp débridement of all devitalized tissue and surrounding callus material from diabetic foot ulcerations at 1- to 4-week intervals. ( S , B )
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Considering lack of evidence for superiority of any given débridement technique, we suggest initial sharp débridement with subsequent choice of débridement method based on clinical context, availability of expertise and supplies, patient tolerance and preference, and cost-effectiveness. ( W , C )
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For DFUs that fail to demonstrate improvement (>50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, we recommend adjunctive wound therapy options. ( S , B )
  • These include negative pressure therapy, biologics (platelet-derived growth factor [PDGF], living cellular therapy, extracellular matrix products, amnionic membrane products), and hyperbaric oxygen therapy.
  • Choice of adjuvant therapy is based on clinical findings, availability of therapy, and cost-effectiveness. There is no recommendation on ordering of therapy choice.
  • Re-evaluation of vascular status, infection control, and off-loading is recommended to ensure optimization before initiation of adjunctive wound therapy.
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We suggest the use of negative pressure wound therapy for chronic diabetic foot wounds that do not demonstrate expected healing progression with standard or advanced wound dressings after 4–8 weeks of therapy. ( W , B )
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We suggest consideration of the use of PDGF (becaplermin) for the treatment of DFUs that are recalcitrant to standard therapy. ( W , B )
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We suggest consideration of living cellular therapy using a bilayered keratinocyte/fibroblast construct or a fibroblast-seeded matrix for treatment of DFUs when recalcitrant to standard therapy. ( W , B )
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We suggest consideration of the use of extracellular matrix products employing acellular human dermis or porcine small intestinal submucosal tissue as an adjunctive therapy for DFUs when recalcitrant to standard therapy. ( W , C )
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In patients with DFU who have adequate perfusion that fails to respond to 4–6 weeks of conservative management, we suggest hyperbaric oxygen therapy. ( W , B )
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Recommendation Grading

Overview

Title

Management of Diabetic Foot

Authoring Organizations

American Podiatric Medical Association

Society for Vascular Surgery

Publication Month/Year

February 1, 2016

Last Updated Month/Year

October 18, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Diabetes mellitus continues to grow in global prevalence and to consume an increasing amount of health care resources. One of the key areas of morbidity associated with diabetes is the diabetic foot. To improve the care of patients with diabetic foot and to provide an evidence-based multidisciplinary management approach, the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine developed this clinical practice guideline.

Target Patient Population

Patients with diabetes

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Long term care

Intended Users

Diabetes educator, nurse, nurse practitioner, physical therapist, physician, physician assistant, podiatrist

Scope

Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D017719 - Diabetic Foot

Keywords

foot ulcer, diabetic foot ulcer, DFU, diabetic foot