The level of evidence of the publications on conservative surgery for the treatment of diabetic forefoot ulcers: A scoping review

Abstract Objective The diabetic foot disease is one of the most serious complications of diabetes causing high rates of amputations, premature deaths and healthcare cost. While standard non-surgical care is the mainstay of treatment of diabetic foot ulcers (DFU), many reports demonstrated that conservative surgery particularly in the forefoot, compared better in terms of clinical outcomes. Nevertheless, the quality of surgical articles dealing with diabetic ulcers of the forefoot is thought to be average. This paper aimed to quantify the level of evidence of the DFU surgical papers published in the literature. Literature survey PubMed was searched from inception till Feb 2020. All study designs but case reports were accepted for inclusion. Two outcomes were searched for: a) study design and b) level of evidence. The level of evidence of the studies was based on the classification developed by the Oxford Center for Evidence-based Medicine. Results In total, 90 articles were included for analysis. Only 6 studies (6.7%) had a Level 1 level of evidence. One study had a Level 2 (1.1%) and 13 studies (14.4%) a Level 3. The majority of the included studies had a Level 4 of level of evidence with 70 studies (77.8%) being case-series. Conclusion It is surprising that a disease with such enormous health-related and financial burden did not generate enough interest among surgeons to invest more into high quality research. The findings should incite surgeons to get more involved in the treatment of forefoot diabetic wound and infection. Large comparative prospective high quality trials to assess the available surgical methods are needed.