Diabetic foot and disaster; risk factors for amputation during the Syrian crisis

BackgroundDiabetic foot patients in Syria faced many challenges and difficulties during the recent long term crisis that has prevailed since 2011. This study establishes the risk factors of diabetic foot amputation, either minor or major amputation. It also suggests facilities to improve diabetic foot care in the disaster.MethodsThis is a retrospective study that reviewed diabetic foot outpatients' charts between Jan 2012 and Dec 2017 in Diabetic Foot Clinic in Damascus Teaching Hospital, Syria. We classified the lesions according to the final outcome into: non-amputation, minor and major amputation. We predicted the independent risk factors of lower extremity amputation (LEA).ResultsA total of 2317 diabetic patients visited our clinic regularly with 2722 diabetic foot symptoms. We studied 2006 lesions belong to 1630 diabetic foot patients. They were divided into: group A (outcome without amputation, n = 1372), group B (outcome with minor amputation, n = 528) and group C (final outcome with major amputation, n = 106). Males were slightly predominant (56.73%; n = 1138), but with clearly higher risk of major amputation (6.77%; n = 77). 15.10% of patients was older than 70 years, with no significant relationship between age and amputation risk. According to Meggitt-Wagner classification system, the major amputation rate was (5.28%) in the lesions grade 1 through 5, it went up to (87.30) in isolated grade 5 lesions.The study recorded a degree of infection in (42.07%; n = 844) of the cases. The amputation rate went up in this group of patients to 38.5% and 8.44% for minor and major amputation, respectively. The presence of peripheral occlusive artery disease (PAD) doubled the minor amputation incidence one time (44.02%), and major amputation incidence five times (15.16%). The heel ulcer showed a great tendency toward the major amputation (18.80%), while the incidence rate in the DFUs spared heel was (3.36%). The war injuries of the diabetic foot was followed up in three cases that were treated conservatively and didn’t considered an independent risk factor for amputation as long as the standard care was applied.ConclusionThis article is the first one that discussed the reality of the diabetic foot care in disasters. It figures out that diabetic foot patients are obviously at higher risk of neglect during the crisis. In the absence of early detecting of wounds, deformities and PAD, DFUs likely come to the podiatrists in advanced stages. The unhealthy environment drives DFUs toward injuries, cellulites and infection. Non-Governmental Organizations (NGOs) and local institutions that work in crisis areas should pay attention for special care requirements of diabetic foot patients, for the standard care of the diabetic foot and the regular follow-up till the healing eventually.     

Patients’ clinical charecteristics and predictors for diabetic foot amputation

IntroductionMedical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients.MethodsIn this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed.ResultsOf the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p < 0,05). Amputees also exhibited significantly longer smoking histories (p < 0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p = 0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision.ConclusionThe following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4–5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.     

Amino acids and wound healing in people with limb-threatening diabetic foot ulcers

BackgroundAmino acids are associated with wound healing in traumatic wounds and burns, although their effects on healing in patients with diabetic foot ulcers (DFUs) are limited. This study aimed to evaluate and identify specific amino acids associated with healing outcomes of patients with DFUs.MethodsSixty-two out of 85 patients who completed the in-hospital treatment for limb-threatening DFUs were enrolled. All ulcers had epithelialization without clinical evidence of infection at discharge. The patients and their families were instructed on foot-care techniques and committed to regular follow-up for 1 year. Baseline characteristics, PEDIS wound classification, laboratory data and serum amino acid levels were used to analyze their predictive power.ResultsFifty-seven patients completed the study in which 38 had healed and 19 had unhealed ulcers. The unhealed group had higher incidence of coronary artery disease and larger wound size. Most patients received endovascular therapy (81.6% healed group; 78.9% unhealed group) before enrollment. Following adjustments for clinical factors, the serum levels of arginine (326.4 μmol/L vs. 245.0 μmol/L, P = 0.045), isoleucine (166.7 μmol/L vs. 130.1 μmol/L, P = 0.019), leucine (325.8 μmol/L vs. 248.9 μmol/L, P = 0.039), and threonine (186.7 μmol/L vs. 152.0 μmol/L, P = 0.019) were significantly higher in the healed group.ConclusionsThe amino acids associated with wound healing in DFUs differ from those reported for traditional traumatic wounds. These findings affirm the necessity for future large-scaled studies for the application of these amino acids in DFU healing, either as prognostic predictors or supplemented regimens.     

Nanotherapeutic approach to treat diabetic foot ulcers using tissue-engineered nanofiber skin substitutes: A review

Background and aimsDiabetes mellitus (DM) is a chronic metabolic disease associated with long-term multisystem complications, among which nonhealing diabetic foot ulcers (DFUs) are recognized as major cause of morbidity and mortality. Treating DFUs with surgical procedures such as synthetic or biological skin grafts or skin substitutes has several limitations, where none of the currently available skin substitutes is ideal.MethodsOVID/Medline and PubMed databases were searched using the Medical Subject Heading (MeSH) or Title/Abstract words (“diabetic foot ulcers”, “skin substitutes”, and “nanofibers”), to identify published research studies on DFUs and nanofibers.ResultsElectrospinning nanotechnology is being used in the biomedical field to produce polymeric nanofibers impregnated with drugs for wound healing, burns and diabetic ulcers. Those nanofibers also enable seeding of cells into them and culturing them in vitro to synthesize tissue-like structures. Knowing the advantages of generating patient-specific induced pluripotent stem cells (iPSCs) and organoids in three-dimension (3D), including skin organoids, it is worth mingling these technologies to develop tissue-engineered biological skin substitutes.ConclusionNanofiber-skin substitutes hold promise for treatment of patients suffering from DFUs and inspire novel strategies that could be applied to other organ systems as well, introducing a new era of “regenerative and personalized medicine”.     

Distal symmetrical polyneuropathy is present in all individuals with diabetes and foot ulcers - and does not associate with healing time

We estimated the occurrence of diabetic neuropathy using six different diagnostic modalities in individuals with newly diagnosed diabetic foot ulcers (DFUs) and assessed the association with DFU healing time. All individuals with DFU had distal symmetrical polyneuropathy. Presence of neuropathy did not associate with ulcer healing time (p ≥ 0.12).     

Diabetic foot in patients below 40 years of age

Data on diabetic foot ulcers (DFU) in young patients are scarce. We aimed to examine the risk factors, clinical presentation, wound characteristics, and outcome of DFU among young diabetic patients and to compare them with similar age diabetics without foot ulcer and those of older age diabetics with foot ulcers. A prospective cohort of 745 patients (834 ulcers) below 40 years of age, 7620 patients (9405 ulcers) ages 40 years and above, and 992 patients below 40 years diabetics without foot ulcers in a single multidisciplinary diabetes center were studied. Registered patients with foot ulcers in Jabir Abu Eliz Diabetes Centre (JADC) in Khartoum, Sudan from March 2001 to Dec 2011 were reviewed. Below 40 years of age constituted 8.9 % (n?=?7450) of all patients with DFU. Male-to-female ratio was 1.7:1. IDDM type was prevalent in 60.9 %. Thirty-six per cent of below 40 years had peripheral neuropathy compared to 61.6 % of older group (p?<?0.0002) and 8.7 % of below 40 without DFU (p?<?0.0002). ABI <0.9 was found in 38.7 % (n?=?288) in below 40 years with ulcers compared to 41.4 % in older patients (p?=?0.8989) and 36.3 % (n?=?360) of below 40 without DFU (p?=?0.3125). HbA1c >7 % was significantly more in diabetics below 40 years with foot ulcers compared to those without foot ulcers (83.5 vs. 75.1 %) (p?=?0.0002). In below 40 years of age, 80.1 % of ulcers healed compared to 70.6 % in older age group (p?>?0.0002). Major lower extremity amputation was performed in 4.8 % in below 40 years patients compared to 7.3 % in older group (0.0105). Young diabetics with foot ulcers had significantly longer duration of the disease, more foot deformities, and callus formation and more severe neuropathy than young diabetics without ulcers but had a lesser duration of diabetes than elderly diabetics with foot ulcers. HbA1c in young diabetics with foot ulcers was significantly higher than young diabetics without ulcers, and their foot ulcers healed better and with less major lower extremity amputation than elderly patients.     

Osteopontin levels in plasma,muscles, and bone in patient with non-healing diabetic foot ulcers: A new player in wound healing process?

Background

The present study was designed to investigate the impact of osteopontin (OPN) in different tissue (e.g., plasma, muscles and bone) on amputation rate (in-hospital and during one year follow-up) for non-healing diabetic foot ulcers (DFUs).

Association of diabetic foot ulcers with chronic vascular diabetic complications in patients with type 2 diabetes

ContextDiabetes mellitus is a common disease which is prevalent globally, presenting with chronic complications and constitutes a major risk to the patient. Diabetic foot ulcers are the single biggest risk factor for non-traumatic lower limb amputations in persons with diabetes. We aimed to screen for the chronic vascular diabetic complications in patients with diabetic foot ulcers (DFUs) and to assess the association of diabetic foot ulcers with these complications in the study group.Subjects and methodsThis cross-sectional study included 180 type 2 diabetic patients (aged 30–70 years) with diabetic foot ulcers who attended the Outpatient Clinic of Diabetes in Alexandria Main University Hospital. Full diabetic foot examination was done to all study subjects. DFUs were assessed using University of Texas Diabetic Wound Classification System. HbA1c, LDL-C, serum creatinine, and urinary albumin creatinine ratio (ACR) were measured for all study subjects. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI equation. Fundus examination was done for all study subjects.ResultsThe prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) was 86.1% and 90% respectively among the study group. 86.7% of patients had neuropathic DFUs, 11.1% of them had ischemic DFUs and 2.2% had neuro-ischemic DFUs. Regarding diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) as risk factors for developing DFU, the prevalence of both of them respectively was 82% and 20% among the study group. There was statistically significant association between both DKD, DR and peripheral neuropathy. There was also statistically significant association between both DKD, DR and peripheral arterial disease (PAD).ConclusionChronic vascular diabetic complications are common among type 2 diabetic patients with diabetic foot ulcers. There is statistically significant association between these complications and diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD).     

Outpatient clinic attendance and outcomes among patients hospitalized with diabetic foot ulcers

BackgroundThere are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs).MethodsRetrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care within 30 days of hospital discharge (“30-day post-discharge clinic attendance”). Log-binomial regression was used to estimate risk ratios (RR) and 95 % confidence intervals (CI).ResultsAmong 888 patients, 60.0 % were between 45 and 64 years old, 80.5 % were Black, and 24.1 % were uninsured. Overall, 478 (53.8 %) attended ≥1 30-day post-discharge clinic appointment. Initial hospital outcomes were associated with clinic attendance. For example, the RR of 30-day post-discharge clinic attendance was 1.39 (95%CI 1.19–1.61) among patients who underwent a major amputation compared to patients with DFUs without osteomyelitis and did not undergo an amputation during the initial hospitalization. Among 390 patients with known 12-month outcome, 71 (18.2 %) had a major amputation or died ≤12 months of hospital discharge.ConclusionWe found a low post-discharge clinic attendance and high post-discharge amputation and death rates among patients hospitalized with DFUs. Interventions to increase access to outpatient DFU care are needed and could prevent amputations.     

Prospective randomized controlled study of Hydrofiber dressing containing ionic silver or calcium alginate dressings in non-ischaemic diabetic foot ulcers.

AIMS: Diabetic foot ulcers (DFUs) are at risk of infection and impaired healing, placing patients at risk of lower extremity amputation. DFU care requires debridement and dressings. A prospective, multicentre study compared clinical efficacy and safety of AQUACEL Hydrofiber dressings containing ionic silver (AQAg) with those of Algosteril calcium alginate (CA) dressings in managing out-patients with Type 1 or 2 diabetes mellitus and non-ischaemic Wagner Grade 1 or 2 DFUs. METHODS: Patients stratified by antibiotic use on enrolment were randomly assigned to similar protocols including off-loading, AQAg (n = 67) or CA (n = 67) primary dressings and secondary foam dressings for 8 weeks or until healing. Clinical efficacy measures were healing outcomes and primarily healing speed. Adverse events were recorded. RESULTS: AQAg and CA groups were comparable at baseline. All ulcer healing outcomes improved in both groups. The mean time to healing was 53 days for AQAg ulcers and 58 days for CA ulcers (P = 0.34). AQAg-treated ulcers reduced in depth nearly twice as much as CA-treated ulcers (0.25 cm vs. 0.13 cm; P = 0.04). There was more overall ulcer improvement and less deterioration in AQAg subjects (P = 0.058), particularly in the subset initially using antibiotics (P = 0.02). Safety profiles of both groups were similar. CONCLUSION: When added to standard care with appropriate off-loading, AQAg silver dressings were associated with favourable clinical outcomes compared with CA dressings, specifically in ulcer depth reduction and in infected ulcers requiring antibiotic treatment. This study reports the first significant clinical effects of a primary wound dressing containing silver on DFU healing.     

Serum prolidase activity in diabetic foot ulcers

Impaired wound healing is an important problem in diabetes mellitus; however, its pathogenesis remains unclear. We aimed to evaluate serum prolidase activity (SPA), an important marker of collagen turnover, in subjects with and without diabetic foot ulcers as compared with healthy controls. Twenty-seven patients with diabetic foot ulcers (foot ulcer group), 27 patients without diabetic foot ulcers (diabetic control group) and 27 healthy controls were enrolled. The study groups had similar age, sex distribution and body mass index. Metabolic and inflammatory parameters as well as SPA were determined. The diabetic foot ulcer group had significantly higher SPA (both p < 0.001) when compared with the diabetic and the healthy control groups. SPA showed a positive correlation with high-sensitive C-reactive protein and a negative correlation with high-density lipoprotein cholesterol levels (r = 0.313, p = 0.021 and r = ?0.233, p = 0.036, respectively). No correlation was detected between SPA and glycaemic parameters. SPA appears to be higher in patients with diabetic foot ulcers when compared with patients without diabetic foot ulcers and healthy controls. The underlying mechanisms of elevated SPA and its clinical significance in predicting the natural course of wound healing in diabetic foot ulcers needs to be further evaluation.     

Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies

ObjectiveTo evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs).Research design and methodsMedline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. Ameta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842).ResultsOf 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses(n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes.ConclusionsOur findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.     

The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital

AimWound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70–80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU).Materials and methodsData from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula.ResultsThe study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions.ConclusionsThe results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.     

Prognostic value of the clinical examination of the diabetic foot ulcer

Objective

To determine the value of the history, physical examination, and magnetic resonance imaging (MRI) in predicting successful primary healing of a foot ulcer in a diabetic patient.

Design

Prospective cohort study.

Setting

Durham (NC) Veterans Affairs Medical Center.

Patients

Sixty-four consecutive diabetic patients with 78 dermal ulcers through the full thickness of the skin and at or distal to the malleoli of the ankle.

Measurements and main results

A structured clinical history and physical examination were performed by two examiners, a physician participating in the study and the refering physician. Fifty of these patients with 63 ulcers underwent MRI. Patients were followed prospectively for 6 months after enrollment to ascertain healing of the ulcer, amputation, and death. During the 6-month follow-up period, 8 (13%) of the patients died. Seventeen (22%) of the ulcers were amputated, 17 (22%) of the ulcers failed to heal, and 36 (47%) healed primarily. Univariate predictors of healing at 6 months included age less than 65 years, diagnosis of diabetes within the last 15 years, painless ulcer, palpable ankle pulse, anklebrachial index greater than 0.5, and the physician’s assessment of the overall likelihood of osteomyelitis. In a multivariable logistic regression model, predictors of healing included the presence of an audible pulse on Doppler examination (p=.01) and a painless ulcer (p=.04). The diagnosis of osteomyelitis on MRI did not predict healing in these patients.

Conclusions

Foot ulcers in patients with diabetes frequently have poor outcomes; fewer than half the patients in this study healed their ulcers within 6 months. The vascular components of the clinical examination are the best predictors of healing in patients with a diabetic foot ulcer.     

Negative pressure wound therapy in grade 1 and 2 diabetic foot ulcers: A randomized controlled study

Background and aimsFoot ulcers are one of the major causes of morbidity and mortality among diabetics in India. Early diagnosis and timely management is vital in preventing the progression of the disease which may require amputation. Conventional methods take a long time for healing. This study aims to compare negative pressure wound therapy (NPWT) and conventional saline dressings in diabetic foot ulcer (DFU) healing.MethodsThis prospective randomized study was conducted in 45 patients with grade 1 and 2 DFUs. 22 patients in group A received NPWT and 23 patients in group B received saline dressings. The formation of granulation tissue, reduction in ulcer size, duration of hospital stay and time for complete healing of wounds were assessed.ResultsThe formation of granulation tissue (91.14 vs 52.61%, p < 0.001) and reduction in ulcer size (40.78 vs 21.18%, p = 0.008) at 14 days was significantly more in group A. The duration of hospital stay (15.68 vs 29.00 days, p < 0.001) and time for 100% coverage of the wound with granulation tissue (14.82 ± 7.30 vs 44.57 ± 7.11 days, p < 0.001) was significantly less in group A. Complete healing of wounds at 3 months was observed in 20 patients (90.9%) in group A and 6 patients (26.1%) in group B (p = 0.006).ConclusionIn our study NPWT led to early reduction in ulcer size, more granulation tissue formation, shorter hospital stay and complete wound healing. In lower and middle income countries like India with high prevalence of DFUs, early recovery is a boon to the patients to resume their daily activities.     

Amputation and infection are the greatest fears in patients with diabetes foot complications

AimsTo determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications.Methods478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy.ResultsOf the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8–4.5), major LEA (OR 2.8, 95 % CI 1.8–4.4), minor LEA (OR 2.3, 95 % CI 1.5–3.5), blindness (OR 2.0, 95 % CI 1.3–3.2), dialysis (OR 2.0, 95 % CI 1.1–3.3), and death (OR 2.4, 95 % CI 1.4–4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation.ConclusionPatients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.     

Incidence and characteristics of diabetic foot ulcers in subjects with type 2 diabetes in Catalonian primary care centres: An observational multicentre study

AimsThe main objective was to assess the incidence of diabetic foot ulcers in type 2 diabetes individuals from primary care centres in Catalonia, Spain.MethodsProspective observational study in 36 Primary Care centres in Catalonia during February 2018 and July 2019 was conducted. We included participants with type 2 diabetes and a new foot ulcer. We estimated the annual foot ulcer incidence and described the characteristics: presence of comorbidities, clinical parameters and the characteristics of the diabetic foot ulcers (DFU) at inclusion in the study.ResultsThe incidence of a new DFU during the 12-month recruitment period was 0.42%. The mean age of the participants was 72.2 years (± 12.7), the majority of them were males (n = 178; 69.5%). Overall, 43.8% of DFUs were located on the dorsal aspect of toes or interdigital spaces. A percentage of 43.4% of the participants had ulcers of less than 1 cm2 surface. Further, 44.1% of the participants had a neuroischemic, 20.3% a neuropathic, 20.3% an ischemic ulcer. A 25.3% of ulcers with a concomitant peripheral artery disease were infected.ConclusionsAlthough the incidence found was low, our study shows the great complexity of patients with foot ulcers treated in primary care.     

Diabetic foot ulcers in a multidisciplinary setting An economic analysis of primary healing and healing with amputation

Abstract. Objectives . To perform an economic analysis of primary healing and healing with amputation in diabetic patients with foot ulcers. Design . A retrospective economic analysis based on a prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer. Setting . A multidisciplinary foot-care team. Subjects . A total of 314 consecutively presenting diabetic patients with foot ulcers. Forty patients died before healing occurred. In those patients who healed primarily (n = 197) or after amputation (n = 77), a retrospective economic analysis was performed. Interventions . All patients were treated by a multi-disciplinary foot care team consisting of diabetologist, orthopaedic surgeon, diabetes nurse, podiatrist and orthotist both as in- and out-patients. The patients were followed by the team from admittance until final outcome, i.e. primary healing or healing with amputation or death. Main outcome measures . Data from both the prospectively collected patient material and from patient records were used to estimate the cost for hospital care, antibiotics, surgery, out-patient care, staff attendance, drugs and material for ulcer dressings, and orthopaedic appliances. Results . The total costs were SEK 51000 (3000–808000) for patients with primary healing and SEK 344000 (27000–992000) for healing with amputation. Costs for in-patient care were 37% of total average costs for primary healing and 82% for patients with amputation. The costs for topical treatment of the ulcers in out-patient care were 45% of the total average cost for primary healed and 13% for patients who healed with amputation. The costs for products used for ulcer dressings were 21% of total costs for topical treatment, i.e. 9% and 3% of total average costs for primary healing and healing with amputation, respectively. Costs for visits to the foot care team, antibiotics and orthopaedic appliances were low in relation to total costs. Conclusion . Treatment of diabetic patients with foot ulcers in a multidisciplinary system was associated with relatively low costs. Healing with amputation was associated with high costs mainly due to multiple and extended hospitalization. These findings indicate the potential cost savings of preventive and multi-disciplinary foot care.