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Table 4 Summary of evidence for diabetic ulcer management

From: Seeking effective interventions to treat complex wounds: an overview of systematic reviews

Outcome Intervention Systematic reviews with MA Systematic reviews without MA
High-quality* Low/moderate quality High-quality** Low/moderate quality
Wound area/size reduction (MAs: NA; non-MAs: 2) [79,88] Hyperbaric oxygen therapy (systemic + usual care) NA NA NA
Stem cell therapy NA NA NA +
Time to healing or rate of healing (MAs: NA; non-MAs: 3) Human skin equivalent NA NA NA +
Human cultured dermis NA NA NA
Laser therapy and complex intervention NA NA NA +/−
[79,88,95] Platelet derived growth factors (topical) NA NA NA +
  Pressure off-loading, felted foam NA NA NA
  Pressure off-loading, total contact or non-removable cast NA NA NA +
  Stem cell therapy NA NA NA
  Skin grafts NA NA NA
  Topical negative pressure NA NA NA
Ulcer healing (MAs: 4 [24,35,57]; non-MAs: 10 [69,70,74,79,81,86,88,93,112,122]) Chinese herbal medicine + standard therapy NA + NA NA
Granulocyte colony-stimulating factor (SC, IV) + antibiotics (oral, IV) +/− NA +/−
  Alginate, foam, hydrogel, hydrocolloid dressings NA NA NA +/−
  Alginate, hydrogel, hydrocellulose, semi-permeable membrane dressings NA NA NA
  Amoxicillin + clavulanic acid (oral), ofloxacin, imipenem/cilastatin, ampicillin/sulbactam (IV) NA NA NA +/−
  Antibiotics, choice based on bone biopsy (IV, oral) NA NA NA +/−
  Ayurvedic preparations (oral + topical) NA NA NA +/−
  Clindamycin, fluoroquinolone, rifampicin, amoxicillin/clavulanic acid (oral, topical) +/− surgical intervention NA NA NA +/−
  Compression NA NA NA +
  Cultured human dermis NA NA NA +/−
  Dressings + debridement (hydrogel) NA NA NA +
  Early surgical intervention + antibiotics NA NA NA +/−
  Electrical stimulation NA NA NA
  Endovascular or open bypass revascularization surgery of an ulcerated foot NA NA NA +/−
  Foot care clinic interventions NA NA NA +/−
  Growth factors (topical) NA NA NA
  Hydrogel, cadexomer iodine ointment, dressings, larval therapy, sugar (topical) systemic antibiotics NA NA NA +/−
  Hyperbaric oxygen therapy NA NA NA +/−
  Hyperbaric oxygen therapy (systemic + usual care) NA NA NA
  Imipenem/cilastatin, cefazolin, Ampicillin/sulbactam, Linezolid, Piperacillin/tazobactam. Amoxycillin + clavulanic acid, clindamycin hydrochloride (oral), pexiganan cream NA NA NA
  Ketanserin (oral, topical) NA NA NA +/−
  Larval therapy NA NA NA +
  Lyophilized collagen, platelets and derived products (topical) NA NA NA +
  Magnet and normothermic therapy NA NA NA
  Patient education NA NA NA +/−
  Percutaneous flexor tenotomy NA NA NA +/−
  Procaine + polyvinylpyrrolidone (IM) NA NA NA
  Resection of the complex wound NA NA NA
  Sharp debridement NA NA NA +/−
  Skin grafts NA NA NA +
  Stem cell therapy NA NA NA +
  Superoxidized water and soap, povidone iodine (topical) NA NA NA +/−
  Therapeutic footwear NA NA NA +/−
  Thrombin-induced human platelet growth factor, recombinant platelet derived growth factor, recombinant basic fibroblast growth factor,arginine-glycine-aspartic acid peptide matrix (topical) NA NA NA +/−
  Topical negative pressure NA NA NA +
  Negative pressure therapy NA NA NA +
  Total contact casting NA NA NA +/−
  Ultrasound NA NA NA
  Zinc oxide tape NA NA NA +
No healing improvement/non-healed wounds (MAs: 5) Chinese herbal medicine NA + NA NA
[22,33,35] Hyaluronic acid-based scaffold and keratinocytes NA NA NA
  Hyaluronic acid-based derivative + NA NA NA
  Low frequency low intensity noncontact ultrasound + NA NA NA
Proportion of patients with healed wounds (MAs: 18) [17-20,22,24,27,28,35,38,46,47,57-59] Alginate dressing NA NA NA
Artificial skin graft and standard care NA + NA NA
Chinese herbal medicine plus standard treatment NA + NA NA
Skin graft (Dermagraft) NA NA NA
  Fibrous-hydrocolloid (hydrofibre) dressing NA NA NA
Foam dressing NA NA NA
  Granulocyte colony-stimulating factor (SC, IV) + antibiotics (oral, IV) + + NA NA
Hyaluronic acid-based scaffold and keratinocytes NA NA NA
  Hydrogel dressing + + NA NA
Hyperbaric oxygen therapy   NA NA
  Platelet-rich plasma NA + NA NA
Skin replacement therapy (keratinocyte allograft, meshed skin autograft, split thickness autograft) NA + NA NA
  1. *At least one systematic review with meta-analysis and AMSTAR score ≥8.
  2. **At least one systematic review without meta-analysis and AMSTAR score ≥8.
  3. + Effective (statistically significant difference between interventions and comparators); – No difference (no statistically significant difference between interventions and comparators); +/− Unknown (conflicting evidence between meta-analysis or indeterminate results); NA, No studies available; MA, Meta-analysis.