Everyone knows diabetic foot wound treatment is challenging and should be undertaken with the utmost care. Even something seemingly simple as callus removal can lead to dramatic complications. The recommendations of the latest guidance on wound healing “IWGDF Guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes” are clear. Provide basic wound care for diabetic foot ulcers, this means clean, debride and take care of callus. In this guideline there is no text regarding offloading, vascular, neurological, immunological assessment etc. This does not mean it is not important, it means diabetic wound management is complex and those involved have to make sure they are competent. Do not apply any intervention lightheartedly.
In summary: Never forget to apply basic wound healing principles and know the limits of your expertise, you could very well be liable.
So far the good news.
The underpinning of the first part of this recommendation is as follows: GRADE strength of recommendation: Strong; Quality of Evidence: Low.
GRADE is used because it appears to be better suited than the normal meta-analysis which provides even more dramatic results.
This means the working group cannot find any better evidence than “LOW” for a recommendation considered cornerstone to wound healing. For some reason I think; if they cannot find it, there is a good possibility it does not exist.
So today, 2015 the only thing we know about diabetic wound care is the experts have strong feelings but lack facts. We feel we should have a clean wound and select dressings based on absorption, comfort and cost. The latest facts could be over 60 years ago when captain Bloom made some observations using cellophane.
This leads to the following conclusions:
- We know very little about interventions to enhance healing.
- There is a lack of good research leading to recommendations. (cause 1 for finding 1, above)
- Most “hot” treatment options lack underpinning because a. they may not work or b. research is not well set up. (See finding 2, above)
- Lack of relevant and underpinned findings gives way to the wildest of treatment regimens. (See finding 3, above)
- The flurry of “research” and “protocols” might mask relevant findings. Therefore:
- We need clear and well-written guidelines until we have our research in order.
- To get our research in order, we have to stop doing the same type of research over and over again. (as we did the last 50+ years)
- If I am wrong (which I hope) please explain why the guidelines are written the way they are.
Finally, it just might be a good idea to do a reproducibility test on all wound care research. Like the recently done on psychology. Findings in this guideline point towards an even higher non-reproducibility rate for wound care research compared to psychology.