Volume 27 Number 3

Editors: Schaper NS (Chair), van Netten J (Secretary), Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA.

Publisher: The International Working Group on the Diabetic Foot

Year published: 2019

Reviewer: Nicholai Jakosz (Podiatrist), Royal Perth Hospital, Perth, WA

The IWGDF Guidelines on the Prevention and Management of Diabetic Foot Disease contains six chapters/guidelines highlighting the varied aspects of working with patients with diabetic foot disease (DFD). The chapters are well structured, with each guideline opening with a quick reference list of all the recommendations before going into greater detail. Throughout the guidelines, each recommendation asks a clinical-based question utilising the Patient-Intervention-Comparison-Outcome format, answering this question with a recommendation before a literature review. The use of charts are very valuable but potentially underutilised; however, the flow charts provided on infection management and offloading are very helpful when working with patients with varying degrees of DFD. The tables were utilised well, providing overviews of the different grading systems – including the peripheral arterial disease (PAD), infection and ulcer classification systems – therefore allowing for an easy comparison between grading systems and as well as being useful for different practitioners who may be unfamiliar with certain classifications.

The practical and prevention guidelines provide an in-depth look at managing patients with DFD, exploring testing, education, multidisciplinary input and wound management. The offloading guideline discusses the methods of offloading suitable for different stages of DFD, with a well-designed flow chart to direct clinical decision-making. The PAD guideline details the best available testing to determine PAD and when/what surgical intervention is needed. The infection guidelines show the best investigations and tests for determining osteomyelitis or cellulitis in a patient along with the associated antimicrobial therapy. The final guideline on wound healing interventions explores wound dressings suitable for DFD; however, it doesn’t offer an associated literature review.

In general, the literature is well referenced, primarily drawing from high quality evidence, with all literature considered to be ‘very low quality’ discarded. The guidelines mainly utilised randomised controlled trials, with cohort and case-controlled trials being the lowest quality of evidence considered. The IWDGF Guidelines offer transparency, clearly highlighting any conflicts of interest. Each guideline concludes with a future research agenda, key considerations and research priorities, allowing for an educated insight into where the research may be lacking and what is required for follow-up in future guidelines.

The guidelines would be useful to a majority of practitioners who work with patients either with or at risk of developing DFD, including podiatrists, endocrinology, infectious disease or vascular specialists, as well as nurses, diabetic educators, general practitioners and certain allied health professionals. These guidelines ideally should be utilised as an evidence-based reference for directing clinical decision-making. The guidelines are written in a way that it can be understood and applied by both beginner and advanced practitioners, with the inclusion of glossaries at the end of guidelines allowing for transparency between specialities.

Overall, the IWGDF Guidelines on the prevention of DFD is a valuable, evidence-based resource for any practitioner who regularly encounters patients with diabetes and DFD. Highlighting the different aspects of diabetic foot care in separate guidelines creates a more digestible overview in the treatment and management of DFD. The practical guidelines alone are a fantastic educational tool which ensure that patients and practitioners are aware of potential diabetic foot complications. As a podiatrist, my biggest comment about improving the guidelines would be including information on Charcot Neuroarthropathy, including one to two paragraphs on the condition’s pathophysiology and how it is recognised and managed; this would be valuable as it is often underdiagnosed. Also useful would be a proper literature review supplementing the wound healing intervention guidelines.

Author(s)

Reviewer: Nicholai Jakosz (Podiatrist),
Royal Perth Hospital, Perth, WA