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Similarly, in a study conducted by Faglia

et al.

over a 90-day

period where the efficacy of RCW and a non-removable fibreglass

off-bearing cast (TCC) were compared in DFU healing, it was

reported that 73.9% of patients in the TCC group and 72.7% in

the RCW group achieved complete healing.


Overall, these studies

show that whether the off-loading device is removable or non-

removable, it can be used effectively to redistribute pressure on the

plantar aspect of the foot. However results are dependent on the

patient’s compliance to constantly wear removable devices.

results were observed; ulcers showed a 6-cm


reduction within

the mean ulcer surface area (MSA) versus a 1-cm


reduction in

the control group. However, it was noted that the reduction in

MSA between the study groups over the entire period was not

statistically significant. Nevertheless, wounds after debridement

alone are capable of regressing in 57% of the days between visits

because there is balance shift favouring the biofilm, even though

the rate of healing immediately after debridement is more rapid.


It has been suggested that frequent debridement of DFUs and

chronic venous leg ulcers, as part of wound treatment, may increase

wound healing rates and closure of the ulcer.


If debridement is

done in a sequential fashion, it will avoid the re-establishment

of microbial biofilm growth and tissue devitalisation, which is

responsible for delayed healing of ulcers.


Wilcox and colleagues investigated the frequency of debridement

and the time to heal for different types of ulcers, including DFUs

and chronic venous ulcers. This study noted that the median time

to heal after weekly or more frequent debridement for DFU was 21

days, compared to 64 days when debridement frequency was in the

range of every one to two weeks, and 76 days when debridement

was once every two weeks or more.


Furthermore, in a study performed by Ahmad and colleagues,

which assessed the efficacy of radical debridement and skin

grafting in treating DFUs, compared with other conservative wound

treatments (such as the use of dressings, negative-pressure wound

therapy and hyperbaric oxygen), the results showed a 100%

skin graft take in 80% of the patients on day four after surgery.

Debridement in this study was performed three times a week, every

second day, and the amount of granulation tissue was assessed

before skin grafting. The mean healing time and hospital stay was

lower in the skin-graft group compared to the control group (4.0 ±

1.5 vs 10.0 ± 1.0 weeks).


These findings suggest that aggressive

and repeated debridement definitely does increase ulcer healing

rates of chronic wounds.

Both off-loading and debridement methods are regularly

practised by podiatrists to promote the healing process of diabetic

lower-limb ulcers. Additionally, selecting the right type of wound

dressing is also important to aid the healing process, and this is

also dependant on the characteristics of the individual ulcer that is

receiving treatment.


Debridement practises offer an opportunity for additional

antibiotic interventions, applied topically and/or systemically, which

temporarily disrupt biofilm defence colonies, forcing microbes to

become more susceptible to these interventional treatments as

well as the host’s immune defenses.


A summary of these clinical

studies is presented in Table 1.

Key message:

Total-contact casting has been shown to be

effective in redistributing pressure in the plantar aspect of the

foot and so either prevents ulcers from re-occurring or promotes

healing of current DFUs.

Fig. 5.

Total contact cast.

Key message:

Mechanical or sharp debridement is one of the

essential treatment procedures in podiatry with which chronic

inflammation can be converted to acute inflammation to

promote DFU healing.

Wound debridement

In wound-healing clinics, various types of debridement techniques

can be used by podiatrists to treat DFUs, such as surgical and sharp

debridement, mechanical, autolytic and enzymatic debridement,

and larval debridement.


Debridement is the most important step

towards achieving chronic diabetic wound healing, as it transforms

chronic wounds into acute wounds.


Unlike acute wounds, chronic diabetic ulcers seldom follow

the normal pattern of repair due to various physiological factors

such as hypoxia, dysfunction in the fibroblasts and epidermal

cells, impaired angiogenesis and neovascularisation, high levels

of metalloproteases, damage from oxygen radicals and advanced

glycation end-products, which delay wound healing.


In addition,

there is also sometimes an accumulation of non-viable tissue

(calluses) and slough with excess exudate, which also encourages

bacterial colonisation (biofilm), promoting the risk of infection and

so preventing healing.


Sharp debridement (scalpel debridement) helps to break down

bacterial colonies, thus reducing the bacterial load of an ulcer even

in the absence of overt infection, and so promotes the release of

growth factors to aid the healing process.


When combined with

standard or advanced therapies that are currently used in ulcer

treatment, the net rate of healing is increased.


Williams and colleagues evaluated the effect of sharp

debridement on the progression of recalcitrant chronic venous leg

ulcers. This study concluded that sharp debridement was effective in

stimulating the healing of ulcers. It was conducted over a 12-month

period and already at four weeks post-debridement, some positive


Phototherapy is a therapeutic modality that involves the application

of laser light, at a particular wavelength and at low intensities, to

tissue to stimulate various biological processes.


Low-level laser

therapy (LLLT) is widely used to accelerate tissue repair in surgery,

dentistry, dermatology, somatology, pain management and ulcer