Among the approaches you used in 1989, which are still used today?

The basic principles of wound healing remain very much the same: Identify and
treat infection; address vascular insufficiency; prepare the wound bed with
debridement; improve glucose control; and off-load, or protect, the wound.

In the world of infection, we have come to better understand the presence and role
of biofilmsthese are communities of bacteria that form an impermeable barrier in
the wound or on an implant. This reduces the effectiveness of antibiotics.

Techniques of revascularization have become more sophisticated, though they are

similar in concept to 25 years ago. Hyperbaric oxygen therapy has gained some
traction. We still struggle with how to effectively off-load a plantar diabetic foot
ulcer, as this relies considerably on the patient's buy-in. The total contact cast
remains one of our best tools, but it is one of the least utilized by clinicians, partly
because it is not well-accepted by patients.

Importantly, the field of wound healing has become a specialty in and of itself.
There is certification and more training available, so our practitioners are better-
versed in treatment options.

The greatest area of development has been with the techniques and products
available to enhance healing. There are many more products and techniques
available today than there were 25 years ago, partly due to the research that has
been performed in VA and elsewhere.

Overall, compared with 25 years ago, how has the outlook improved for those
with diabetes who may be at risk for amputation?

Sadly, the risk of amputation still remains high for those with poorly controlled
diabetes. Much of the damage has been done before they develop an ulcer, and
patients often delay seeking care or have difficulty fully participating in a care plan
focused on limb salvage.

One of the greatest tools for successful intervention continues to be that of the
interdisciplinary team, a model which VA embraced early on. Successful limb
salvage always starts with the interdisciplinary team, and the VA model has this as
its foundation. New areas of research can be integrated into this model. VA has a
large population of patients at risk for amputation, making it critical that we
continue to examine how we can reduce amputation rates.