Those of us who treat diabetic foot infections know the difficulties
involved in healing and the potential sequelae. Morbidity and mortality
in patients with foot infections are high. The cost of treatment
is also substantial, and the incidence of foot ulcers in diabetic
patients may be as high as 2% per year1. Various treatment
modalities used with varying success have been discussed in the
literature. Compliance with any treatment program is often difficult
for these patients.
The study by Armstrong and Nguyen, one of few randomized trials
of treatment alternatives, describes the use of a pneumatic compression
device to decrease foot edema and promote healing. The authors show
improved results with the use of this device, and patient compliance also
improved the results. The included patients had ulcers large enough
to require surgical incision and débridement.
The placebo and study treatment groups were similar in terms
of age, gender, ethnicity, duration of diabetes, vibratory sensation, tissue
perfusion, and wound size. Given this population of patients, the
results are impressive.
However, I would like more information about the patients. The
depth, grade, and location (some locations are more difficult to
treat) of the ulcer were not described, nor were any previous treatments.
Were patients kept non-weight-bearing? What did they wear on their
feet postoperatively?
My more practical concerns involve the logistics in use and the
cost of the pneumatic compression device. Some mention should be
made of this, if we are to be able to use it effectively in the
community. Does use of the device require home visits by a professional
to verify its appropriate use, or can patients use it independently?
Use of the total-contact cast or orthosis has often been considered
the gold standard of treatment for nonhealing ulcers in diabetic
patients2. The pneumatic compression device may supplant the total-contact
cast or at least be a useful adjunct in terms of effectiveness or
costs. Additional studies comparing the two treatment devices would
be helpful.
Author’s note: Control of edema is an important and
often overlooked aspect of the aftercare of surgical débridement
for diabetic foot infections. Better attention to edema through
whatever means the surgeon has at his or her disposal may indeed
yield more consistent results. David Armstrong, DPM