Clinical Pearls & Morning Reports
Published June 14, 2017
What are some of the recommendations for preventing the recurrence of diabetic foot ulcers?
The lifetime incidence of foot ulcers has previously been estimated to be 15 to 25% among persons with diabetes, but when additional data are considered, between 19% and 34% of persons with diabetes are likely to be affected. Read the latest Review Article on this topic.
Q. What is the risk of death in a patient with a diabetic foot ulcer?
A. The natural history of diabetes-related foot ulcers is sobering. The risk of death at 5 years for a patient with a diabetic foot ulcer is 2.5 times as high as the risk for a patient with diabetes who does not have a foot ulcer. More than half of diabetic ulcers become infected. Approximately 20% of moderate or severe diabetic foot infections lead to some level of amputation. Mortality after diabetes-related amputation exceeds 70% at 5 years for all patients with diabetes and 74% at 2 years for those receiving renal-replacement therapy.
Q. Do most diabetic foot ulcers heal?
A. With appropriate therapy — surgical débridement, off-loading of pressure, attention to infection, and if necessary, vascular reconstruction — foot ulcers heal in many patients, and the need for amputation is averted. On the basis of outcome data in specialized tertiary care hospitals in Europe, approximately 77% of diabetic foot ulcers heal within 1 year.
A: Unfortunately, even after the resolution of a foot ulcer, recurrence is common. Prevention of foot ulcer recurrence requires good diabetes control, ongoing professional foot care at intervals of 1 to 3 months, and properly fitting footwear that has a demonstrated effect on the relief of plantar pressure. If preulcerative lesions are identified in a timely manner, treating them is likely to prevent many ulcer recurrences. Biomechanical factors such as the degree of barefoot and in-shoe mechanical stress and the level of adherence to wearing prescribed footwear are also important factors in the recurrence of ulcers of the plantar foot surface, and in-shoe mechanical stress is a factor in the recurrence of nonplantar foot ulcers, mostly through ill-fitting footwear. Repetitive stress can be detected with a pressure platform and in-shoe pressure sensors. Home monitoring of foot skin temperatures, as well as appropriate foot care when the temperature difference between feet exceeds a specified threshold, can effectively reduce the incidence of recurrent plantar ulcers.
A: Patient education is considered important and can improve patients’ knowledge of diabetes-related foot problems and foot care. When given in only one or two sessions, however, patient education does not effectively prevent ulcer recurrence at 6 or 12 months. This apparent lack of efficacy provides an opportunity to strengthen clinician-to-patient educational efforts, through more continuous education or the use of specific educational techniques, but also to do more to promote and measure outcomes associated with clinician training in diabetic foot care and counseling. Adherence to treatment has now been confirmed to play an important role in the clinical outcome. The problem of nonadherence should guide clinical practice much more than is currently the case, with a focus on identifying patients who are nonadherent or are anticipated to be nonadherent and aiming to improve adherence in conjunction with providing proper evidence-based foot care. An understanding of the reasons for nonadherence and the development of ways to improve adherence are urgently needed to help clinicians in this effort.