Podiatric intervention in the management of a diabetic foot ulceration: a case study using total contact casting

Transcription

1 Podiatric intervention in the management of a diabetic foot ulceration: a case study using total contact casting Abstract Howard FJ, BTech Pod, PGDiplDiabetes, Diabetic Foot Module Podiatrist, Rubicon Medical Centre, Witbank Diabetic Centre Correspondence to: Fortune Howard, fortunejh@telkomsa.net Keywords: podiatric intervention, diabetic foot ulceration, total contact casting An understanding of the key elements of the cause of diabetic foot ulcerations is critical to enable comprehensive care for such patients. Identification of associated challenges is also essential in order to implement effective care. The management of diabetic foot ulcerations can be very challenging for both the health professional and the patient. Lack of resources and appropriate wound care skills may impact on the ability to achieve wound healing successfully. It is also crucial that management encompasses an interdisciplinary team to provide holistic care for the patient. This article shows that only a few members of different healthcare disciplines needed to work together to provide effective care. The reduction and redistribution of peak plantar pressures, in combination with ulcer debridement, is key to the management of diabetic foot ulcerations. Unfortunately, decisions that are taken in clinical practice vary widely as to which device to use when offering wound pressure offloading. This is despite the fact that total contact casting (TCC) is regarded as the gold standard in the offloading of noninfected neuropathic ulcerations. The consensus is that TCC is underused in the South African wound community. Other offloading devices, such as felt paddings or shoe inserts, are used primarily. This article seeks to demonstrate that in South Africa, TCC should be considered as a primary offloading device if there are no contraindications, such as impaired circulation or infections in the wound. Peer reviewed. (Submitted: Accepted: ) Medpharm 2012;5(2): Introduction Patients living with diabetes are at risk of developing various complications, of which foot ulcerations are the most common. The management of patients with diabetic foot ulcerations is perceived to be a challenging prospect by both patients, and their healthcare providers and funders. Failure to introduce an effective treatment approach may lead to suboptimal care that delays the wound healing process, increases medical costs and affects the patient s quality of life. Callus removal, ulcer debridement and equal pressure redistribution, such as using total contact casting, forms an integral part of diabetic foot ulcer management. The use of total contact casting (TCC) in the management of diabetic foot ulcerations is well documented. Numerous studies indicate its effectiveness. 1-5 However, it is still underused in the South African wound healing community. This paper presents a case study that demonstrates the successful use of TCC in a South African context. Emphasis is placed on the challenges that are encountered by the patient, and those faced by the podiatric profession when attempting to deliver optimal diabetic foot ulcer care. Quality of life of patients living with a diabetic foot ulceration Quality of life issues in patients with chronic wound care forms an essential aspect of total health care. 6 The inability to recognise and appreciate the difficulties that patients face on a daily basis, while having to endure the prospect of living with chronic diabetic foot ulcerations, may further impact on their overall condition. Clarke and Tsubane 7 outline the importance of reducing diabetic foot ulcer healing time in order to yield improved quality of life in affected patients. Quality of life assessment becomes essential when expensive and hazardous treatment options are considered in nonhealing wounds in order to facilitate healing. 8 Interdisciplinary team approach The implementation of an interdisciplinary team approach to the management of diabetic foot ulceration is still lacking, despite the vast amount of evidence that shows its efficacy. 8 Pupp and Scholl 9 advocate the importance of an aggressive team approach to patients who are at risk of developing diabetic foot ulcerations and related complications. This ensures a prompt and appropriate treatment approach. 10,11 Adoption of an effective interdisciplinary approach ensures that amputation rates are reduced, by addressing the pathophysiology and biomechanics aspects of the diabetic foot. 12 Sibbald et al 13 suggest that the interdisciplinary team should develop an individualised treatment plan to suit the patient, after having completed the wound assessment. Determining whether a wound is healable or not One of the most important aspects of successful wound healing management is to assess if a wound has the ability to heal

2 Kenshole and MacDonald 14 suggest that five factors are important in establishing the healability of a diabetic foot ulcer: Adequate tissue perfusion to the affected site The presence and management of infection Good glycaemic control, ideally with a glycated haemoglobin A 1c (HbA 1c ) below 7% Regular debridement to remove devitalised tissue and promote granulation tissue in the process Adequate pressure redistribution. Failure to achieve wound healing with these interventions should lead to the consideration of advanced therapies to further promote wound closure. 8 Plantar pressure redistribution and the use of TCC The development of neuropathic diabetic foot plantar ulcerations is mainly attributed to structural deformities. These may include foot deformities and limited joint mobility that results in increased plantar peak pressure. 15,16 Marked plantar pressure on a chronic ulcerated area in the neuropathic foot impedes healing because of constant mechanical trauma to the wound bed. 17 Most diabetic foot specialists consider the use of TCC to be the gold standard in plantar pressure redistribution of neuropathic foot ulcerations. 1-5,16-18 Armstrong et al 18 state that an abundance of studies supports the clinical efficacy of TCC, as it has been shown that appropriate use of TCC is capable of reducing up to 84-92% of plantar pressure over the ulcer site. The application of TCC involves moulding a minimally padded cast (fibreglass texture), while maintaining contact with the entire surface of the foot and lower leg. 18 Armstrong et al 18 report that most of the reductions in forefoot pressure are transmitted to the rear foot or through the walls of the TCC. This allows for even distribution of pressure on the plantar aspect of the foot during weightbearing. Peak pressure, that normally occurs in the forefoot, is reduced and distributed away from the ulcer site. This leads to effective ulcer offloading and the facilitation of healing. 1 According to Armstrong et al, 18 it may take 5-7 weeks to achieve % healing of a diabetic plantar ulcer. Importantly, the plantar pressures are reduced while the patient is able to ambulate. One of the most important aspects of TCC is that it aids patient adherence to the prescribed treatment, as the device cannot be removed by patients themselves. 2,17,18 Fitzgerald recommends proper wound debridement prior to introducing a plantar pressure redistribution mechanism, such as TCC, to ensure even wound margins. 1 It also provides an ideal wound-healing environment by creating an acute wound condition, while reducing the risk of infection. 2 The application of appropriate dressings is also essential to complement TCC in the healing of neuropathic plantar ulcers. 16 The use of TCC should be avoided when there are serious concerns of impaired circulation, severe infection or the presence of heel ulcerations. 16 Improper application may lead to secondary ulcerations or skin irritations, joint rigidity and muscle atrophy. 4 TCC application needs to be carried out by a skilled healthcare professional with adequate training to appropriately and safely apply the cast. It can be a demanding task for clinicians who practise on their own to apply the TCC without the help of an assistant. Armstrong et al 18 and Wu et al 2 recommend the use of instant total contact castong (itcc) to reduce application problems. It has also been shown to be more cost-effective compared to the nonremovable TCC. 2,18 itcc is a modification of a removable cast walker (RCW). A layer of plaster or cohesive bandage is wrapped around the RCW so that it is not easily removed by patients. 18 This ensures treatment adherence, as well as pressure offloading benefits. It can be used for infected or heel ulcerations. 18 TCC cost-effectiveness has been reported by Cavanagh and Bus, 3 who found that TCC use could reduce diabetic foot ulcer costs to half that of conventional costs. Hospital costs are almost entirely eliminated in this approach. This further reduces overall medical costs. Cavanagh and Bus 3 also found that TCC was widely underused in most clinical settings that offer diabetic foot ulcer offloading treatments in the USA. This was the case despite the fact that updated clinical recommendations were in favour of its use. Extreme caution is recommended when reducing weightbearing within the first six months post-ulcer healing, as the newly healed ulcer is at its most vulnerable during this period. 5 It is imperative that plantar pressure redistribution is continued by wearing appropriate footwear and insoles. 3 Footwear and orthotics in diabetic foot treatment Having successfully achieved wound healing, the most important management aspect is to provide the patient with appropriate footwear and accompanying shoe inserts. This will aid in evenly distributing plantar pressure and providing adequate cushioning in order to prevent recurrence ulcerations in the future. 3,15,19 Understanding the biomechanical aspect of diabetic foot ulceration enables the team to make an appropriate referral to a footwear specialist. 5,7 Attending to factors that are responsible for the development of diabetic ulcerations may result in the reduction of elevated plantar pressure, as well as reduced plantar ulcer formation risk using therapeutic footwear. 15,19 Although Bus 19 states that there is insufficient evidence from clinical studies to support the use of custom-made shoes in the treatment of the diabetic foot, there is a case to be made for footwear with rocker outsoles, which can be effective in reducing peak plantar pressure by up to 50%, compared to conventional shoes. Bus 15 further states that using custom-made insoles or inserts, rather than standard flat insoles, can effectively reduce plantar pressure in previously ulcerated sites. Case study History A 67-year-old female patient, with a 12-year type 2 diabetes history, was referred for a podiatric consultation by her general practitioner, to evaluate current footwear and explore possible plantar pressure redistribution options to treat her foot ulceration. Clinical information A neuropathic ulceration had been present for the last 10 years. There were numerous surgical and therapeutic attempts to promote healing. At her visit, she presented with a grade 2B plantar ulcer, 97

3 according to the University of Texas Classification system. The ulcer measured 52 mm x 43 mm x ±7 mm (estimated depth). It was located on the plantar aspect of the first metatarsophalangeal joint of the left foot. The ulcer was surrounded by heavy callus and fibrotic tissue (Figures 1 and 2). The wound edges were undermining, with a deep red shiny wound base. A strong malodour emanated from the wound and serous fluid strikethrough was visible on the dressings. Further assessment of the ulcer revealed no evidence of soft tissue infection or osteomyelitis, as it did not probe to bone. Plain radiographs confirmed the clinical findings of the negative test for osteomyelitis. Although a bone biopsy is considered to be the gold standard for establishing osteomyelitis, the use of the probe-to-bone test is a very effective primary clinical tool when assessing bone infection. 20 The pedal vascular status of this patient was intact with palpable pedal pulses, warm feet and no evidence of peripheral vascular disease or ischaemia. The peripheral neuropathy diagnosis was made based on negative findings following the patient s inability to perceive the 10-g monofilament and the 28-Hz tuning fork vibratory sensation at all the tested sites. 21 At the assessment interview, it was discovered that she had had multiple corrective operations to her feet. She reported that her problems started following corrective bunion surgery that required subsequent operations to promote healing. This resulted in altered bilateral structural foot shapes, with a plantar flexed first ray and minimal joint movement that was worse in the left foot. Footwear and insert assessment The patient wore prescribed therapeutic footwear, but on closer evaluation, it was found to be inadequate. Although the shoes were extra wide, they could not accommodate her visible deformities. Assessment of the inserts showed minimal evidence of adequate plantar pressure redistribution. They also did not appear to accommodate the presenting deformities and so prevented the associated lesions from healing. Lavery et al 8 identified ill-fitting shoes as one of the main causative factors in ulcer formation or reoccurrence. Previous ulcer management As part of previous treatment regimens, the patient had received regular wound treatment two to three times a week. This involved irrigation with saline and the application of conventional dressings. During this period, she had numerous surgical interventions in an attempt to aid the healing process of the foot ulcerations. The ulcerations persisted. It should be noted that, in an attempt to aid wound healing, some of the surgical procedures, such as tendon lengthening or reconstruction, could have led to secondary ulcer formations and other complications. 22 Commencement of holistic wound care In initiating an effective treatment plan, the clinical findings were discussed with the patient. The treatment plan was formulated to include skills and knowledge that could be offered to her within reasonable expectations and responsibilities that the patient was willing to accept. The treatment team comprised a general practitioner, a diabetes educator, a dietitian and a podiatrist. Although this did not constitute a traditional comprehensive diabetic foot team, there was sufficient support to implement the treatment. At that stage, surgical involvement was not deemed to be necessary. The diabetic educator and general practitioner took responsibility for ensuring improved glycaemic control. The dietitian addressed nutritional concerns about glycaemic control and optimisation of wound healing outcomes. Initial podiatric management After wound assessment, it became clear that the wound would be able to heal, provided adequate blood supply was maintained and correctable host factors, like poor nutritional status and comorbidities, were addressed. 8 The wound was regularly debrided to remove nonviable tissue using a scalpel for sharp debridement (Figure 3). 23,24 The wound was also cleansed with saline and interchangeably with a surfactant wound cleansing solution to aid Figure 1: Left neuropathic plantar ulceration (before consultation) Figure 2: State of the foot ulcer at the initial podiatric consultation 98

4 in effective wound healing. 25 Sterile gauze was used in combination with either saline or the surfactant solution to clean the wound from the centre towards the wound margins. Wound debridement and cleansing were conducted twice weekly initially, and at least once a week thereafter as the ulcer base improved. Wound dressings were selected and applied according to the state of the wound. 13 Interactive silver dressings and polyurethane foam were used in the early stages to absorb wound exudate. The bioburden was controlled by using an applicable dressing on superficial infection that occurred during the course of the treatment. The ulcer became static. During this period, a zinc-impregnated bandage system was used to try and achieve healing. All three layers of the system were used, i.e. the zinc-paste protection layer in contact with the skin, followed by the woolband to aid absorption of the exudate and the short stretch bandage as the outer layer. The system was applied from the toe to the calf area below the fibula head. Initially, felted foam padding was used to redistribute plantar pressure from the ulcer site. Felt padding was intended as a shortterm intervention and a guide to long-term orthotic management. It was discontinued following the development of an edge effect, which is a disadvantage. 18,26 Although ongoing assessment of the wound did not show any signs of osteomyelitis, antibiotic therapy was included to treat deep-tissue infection as the ulcer area exhibited deterioration, became stalled, wound size increased, there was a strong malodour and the foot and lower leg became erythematous 27 (Figures 4 and 5). Introduction and use of TCC Despite appropriate wound bed preparation measures, the wound became stalled. Further deterioration was possible. The main reason for this was ineffective plantar pressure redistribution. Various ulcer offloading approaches were attempted, such as applying cut-out felt padding, advocating bed rest and getting the patient to use crutches, walkers and a shoe cast. 16,18,23 The ulcer was treated as a maintenance ulcer as the patient was opposed to surgical intervention. No-one in the team had the necessary skills and resources to apply TCC. This was one of the reasons why the ulcer s healing was delalyed. The option to utilise TCC was discussed with the patient and the referring general practitioner. It was agreed that it was probably the most suitable option. TCC was applied using 3M Scotchcast products (Table I), following adequate wound debridement and dressing application. The patient returned for reviews to ensure that the cast facilitated healing and that it was not causing secondary complications. Upon removal of the cast at different visits, improvement was visible (Figures 6 and 7). No secondary problems were caused by the cast and the patient reported no associated discomfort, other than having to get used to it. The cast was reused and reinforced with a single layer of soft scotchcast on a weekly basis to allow for regular wound debridement and dressing changes. This treatment option continued. There was a 90% healing rate in 10 weeks (Figures 8 and 9). The slipper cast was introduced to prevent reulceration while waiting for authorisation from the medical aid scheme for custom-made shoes and orthotics. The cost implications were taken into consideration and a motivation for the planned treatment was sent to the medical aid scheme for reimbursement of services. The patient s footwear and inserts didn t provide her with the desired pressure redistribution to prevent ulcer recurrence. The ulcer recurred and TCC treatment was resumed. It waas hoped that funding would be obtained for the correct footwear, such as custommade shoes with a rocker sole and custom-made insoles to reduce forefoot plantar pressure. Discussion The treatment of nonhealing chronic wounds, including diabetic foot ulcerations, is a challenging prospect for everyone involved. Therefore, it is essential that the assessment, diagnosis and treatment plans are based on best practice wound care guidelines. 13 Our patient was failed by a healthcare system that could not help to provide essential diabetic foot management devices to keep Figure 3: Wound bed following sharp ulcer debridement using a scalpel Figure 4: Stalled foot ulcer, showing no improvement Figure 5: Further deterioration of the ulcer. This was a few weeks prior to the use of TCC. 99

5 Table I: Application of total contact casting Materials needed: Tensogrip Stokinette, gauze or woolband padding, 3M Microfoam Medical Tape, 3M Scotchcast Soft 75 mm casting tape, 3M Scotchcast Plus 100 mm casting tape, a coban or crepe bandage, and a surgical pair of scissors and gloves. An assistant to help with the application. The patient should to be placed comfortably in the prone position, with the leg flexed at the knee. A pillow must be placed under the upper leg. The patient s foot may be kept in a neutral position, with the ankle as close to 90 degrees as possible. It should be ensured that the applied dressing is intact and not easily movable. Two pieces of stokinette must be cut and measured to cover the entire lower leg, and to include an overlap, i.e. from the toes extending to the knee. The stokinette can be applied so that it extends beyond the toes. The stokinette should be pulled back to reveal the digital area. The gauze or woolband padding must be applied in and around the toes to provide a protective cover for them. The assistant should pull the stokinette over the toes and use the overlap as leverage to hold the foot in a neutral position, with the ankle at a 90-degree angle. The microfoam tape may be cut and applied to cover the maelleoli and anterior shin area for protection. While wearing gloves, the cast splint can be prepared by cutting the 3M Scotchcast Plus into a triple-layer mediolateral splint [the remainder should be used for the plantar splint, with the layers fanning out from the central point (the heel)]. The 3M Scotchcast Soft 75 mm needs to be applied from below the knee first. The lateral head of the fibula should be avoided. There must be a 50% overlap from medial to lateral, without any tension on the foot. When reaching the ankle area, go around the lateral malleolus at 45 degrees and extend to the forefoot, covering the forefoot and mid-foot area, then back to the Achilles tendon at 45 degrees. The ankle joint must be covered. The mediolateral malleoli splint should be applied using 3M Scotchcast Plus, followed by the plantar splint. Another 3M Scotchcast Soft layer should be applied, as before, to hold or finish the cast. Any excess cast material may be cut off and the dorsal digital area cut open. The coban or crepe bandage must be moistened, and applied to the cast to activate the chemical reaction to firm the cast. The patient should remain nonweightbearing for ±15-20 minutes until the cast has taken form and has become rigid and has cooled. Figure 6: Marked improvement took place following the application of TCC (week 3): Second cast (1 August 2011) use of TCC Figure 7: The ulcer size reduced steadily with continued TCC use (week 5): third cast (9 August 2011) use of TCC Figure 8: The almost completely healed foot ulcer. The patient stopped using full TCC. The patient started to use a slipper cast (17 October 2011). her plantar aspect ulcer-free. Johnson demonstrated that the diabetic foot is still neglected, even though evidence exists that foot complications that relate to diabetes continue to be one of the most common and preventable diabetic difficulties. 19 Many patients in South Africa will continue to receive suboptimal diabetic foot ulcer care, based on some of the factors outlined by Abbas and Archinbold 28 and Van Rensburg. 29 They list the following reasons for poor diabetic foot care in many African countries: Lack of awareness of foot care issues by patients and healthcare providers. Very few health professionals have an interest in the diabetic foot or are trained to provide specialist care. Limited or nonexistent podiatry services. Figure 9: Maintained improvement. The patient continued to use a slipper cast (25 October 2011). 100

6 Absence of training programmes for healthcare professionals. Lack of a team approach concept. Delays by patients in seeking timely medical care or by untrained healthcare providers in passing on referrals for specialist opinion for patients with serious complications. Quality of wound care is vastly dependent on regulatory issues and reimbursement mechanisms. 30 In part, this may explain why healthcare providers fail to offer timely optimal care when effective treatment is achievable. Diabetic foot ulcer management in South Africa continues to be affected by lack of financial resources in all sectors of care. 7 Motta 30 suggests that it is the responsibility of clinicians to provide the paying sector (medical aid schemes) with detailed clinical data; proposed management approaches, including information on new therapies and correct diagnostic and treatment coding in order to overcome reimbursement challenges. Although information regarding the patient, treatment plan, codes and costs were provided to our patient s medical aid scheme as suggested by Motta, 30 podiatric care was not fully authorised. The case manager s reply was that the patient had to be handled by her general practitioner or nurse for wound care. Podiatrists are key members of the diabetic foot interdisciplinary team and can play a vital role in adequate management of diabetic foot ulcerations. 7 This should be acknowledged. Conclusion Compared to other conventional methods, the use of TCC in offloading pressure from diabetic foot plantar ulcers has been shown to be effective in improving healing rates and reducing medical costs.it should be incorporated into an effective diabetic foot management approach, providing there are no contraindications. Podiatric involvement, as part of the interdisciplinary team in treating diabetic foot ulcerations is crucial to provide expert knowledge regarding biomechanical assessment, ulcer debridement and different pressure offloading techniques. Appropriate footwear and orthotic therapy should be introduced timely following the healing of an ulcer to prevent reulceration. References 1. Fitzgerald RH. Current concepts in offloading diabetic foot ulcers. Podiatry Today. 2009:22(9); Wu SC, Driver VR, Wrobel JS, Armstrong DG. Foot ulcers in the diabetic patient, prevention and treatment. Vasc Health Risk Manag. 2007;3(1): Cavanagh PR, Bus SA. Off-loading the diabetic foot for ulcer prevention and healing. J Am Podiatr Med Assoc. 2010;100(5): Nabuurs-Franssen MH, Sleegers R, Huijberts MSP, et al. Total contact casting of the diabetic foot in daily practice: a prospective follow up study. Diabetes Care. 2005;28(2): Sinacore DR. Total contact casting for diabetic neuropathic ulcers. Physical Therapy. 1996;76(3): Price P. Health-related quality of life. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Clarke EAM, Tsubane M. The role of the podiatrist in managing the diabetic foot ulcer ;1(1): Lavery LA, Peters EJG, Armstrong DG. What are the most effective interventions in preventing diabetic foot ulcers? Int Wound J. 2008;5 (3): Pupp GR, Scholl D. Evaluating and refining the team approach to limb salvage. Podiatry Today. 2010;23 (10): Orsted HL, Inlow S. The team approach to treating ulcers in people with diabetes. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Krasner DL, Rodeheaver GT, Sibbald RG. Inter-professional wound care. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Tudhope L. Principles of management of vascular problems in the diabetic foot. CME. 2010;28(2): Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update. Adv Skin Wound Care. 2011;24(9): Kenshole AB, Macdondald J. The role of the healthcare team in the prevention and management of diabetic foot ulcers. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Bus SA. Foot structure and footwear prescription in diabetes mellitus. Diabetes Metab Res Rev. 2008;24 Suppl 1:S90-S Caravaggi C, Faglia E, De Gigglio R, et al. Effectiveness and safety of a fiberglass offbearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers. Diabetes Care. 2000;23(12): Jeffcoate WJ, Lipsky BA, Berendtt AK, et al. Unresolved issues in the management of ulcers of the foot in diabetes. Diabet Med. 2008;25(12): Armstrong DG, Bevilacqua NJ, Wu SC. Offloading foot wounds in people with diabetes. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Johnson T. Barriers to effective management of the high risk foot in diabetes: a case report. South African Journal of Diabetes. 2010;3(3): Lipsky BA, Berendt AR, Deery G, et al. Diagnosis and treatment of diabetic foot infection. Clin Infect Dis. 2004;39(7): Rogers LC, Driver VR, Armstrong DG. Assessment of the diabetic foot. In: Krasner DL, healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Cavanagh PR, Lipsky BA, Bradbury AW, Botek G. Treatment of diabetic foot ulcers. Lancet. 2005;366(9498): Steed DL. Wounds in people with diabetes: assessment, classification, and management. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Weir D, Scarborough P, Niezgoda JA. Wound debridement. In: Krasner DL, healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, wound disinfection. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Botros M, Goettl K, Parsons L, et al. Best practice recommendations for the prevention, diagnosis and treatment of diabetic foot ulcers: update Canadian Wound Care. 2010; 8(4): Landis S, Ryan S, Woo K, Sibbald RG. Infections in chronic wounds. In: Krasner DL, healthcare professionals. 4th ed. Malvern: HMP Communications, 2007; p Abbas ZG, Archibald LK. Challenges for management of the diabetic foot in Africa: doing more with less. 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