Bayesian network meta-analysis of seven debridement approaches for diabetic foot ulcers shows low certainty evidence

Despite advancements in treatment, diabetic foot ulcers (DFU) are challenging to heal, and the comparative efficacy of debridement strategies is poorly understood. This study assessed the effectiveness and ranked debridement methods for DFU based on wound size reduction (WSR). We conducted a Bayesian network meta-analysis (BNMA) of randomised trials, including individuals with diabetic foot ulcers. PubMed, Embase, Scopus, Web of Science, and Cochrane were examined till August 2025. Seven debridement approaches were compared with each other and with standard wound care (SWC); trial arms were classified by the primary debridement method, with routine wound care co-interventions permitted. We estimated mean differences with 95% credible intervals, ranked treatments using the Surface Under the Cumulative Ranking curve (SUCRA) (0%-100%; higher scores indicate a greater likelihood of best effect), and assessed risk of bias and certainty of evidence using GRADE. Twenty-two RCTs (n = 1148) were incorporated. Biological debridement showed the largest reduction in WSR (MD 29.6%, 95% CrI -4.4 to 64.1), and enzymatic debridement (MD 21.8%, -11.5 to 55.6). Sensitivity analyses supported biological debridement over surgical and SWC, and enzymatic debridement over autolytic debridement. Across all interventions, SUCRA ranked autolytic (85%) and mechanical (75%) highest, whereas the largest estimated WSR were observed with biological and enzymatic debridement. Overall, certainty of evidence was low, although a few comparisons were rated as moderate certainty. Biological and enzymatic debridement seem to be the most successful for decreasing DFU size. However, SUCRA preferred autolytic and mechanical techniques. Evidence is scarce, endorsing personalised care and comprehensive multicenter trials.