A systematic review investigating the identification,causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration

ObjectivePatients presenting with chronic limb-threatening ischemia and diabetic foot ulceration (DFU) are at high risk of major lower limb amputation. Long-standing concern exists regarding late presentation and delayed management contributing to increased amputation rates. Despite multiple guidelines existing on the management of both conditions, there is currently no accepted time frame in which to enact specialist care and treatment. This systematic review aimed to investigate potential time delays in the identification, referral, and management of both chronic limb-threatening ischemia and DFU.MethodsA systematic review conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards was performed searching MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from inception to November 14, 2018. All English-language qualitative and quantitative articles investigating or reporting the identification, causes, and outcomes of time delays within “high-income” countries (annual gross domestic product per person >$15,000) were included. Data were extracted independently by the investigators. Given the clinical crossover, both conditions were investigated together. A study protocol was designed and registered at the International Prospective Register of Systematic Reviews.ResultsA total of 4780 articles were screened, of which 32 articles, involving 71,310 patients and 1388 health care professionals, were included. Twenty-three articles focused predominantly on DFU. Considerable heterogeneity was noted, and only 12 articles were deemed of high quality. Only four articles defined a delay, but this was not consistent between studies. Median times from symptom onset to specialist health care assessment ranged from 15 to 126 days, with subsequent median times from assessment to treatment ranging from 1 to 91 days. A number of patient and health care factors were consistently reported as potentially causative, including poor symptom recognition by the patient, inaccurate health care assessment, and difficulties in accessing specialist services. Twenty articles reported outcomes of delays, namely, rates of major amputation, ulcer healing, and all-cause mortality. Although results were heterogeneous, they allude to delays being associated with detrimental outcomes for patients.ConclusionsTime delays exist in all aspects of the management pathway, which are in some cases considerable in length. The causes of these are complex but reflect poor patient health-seeking behaviors, inaccurate health care assessment, and barriers to referral and treatment within the care pathway. The adoption of standardized limits for referral and treatment times, exploration of missed opportunities for diagnosis, and investigation of novel strategies for providing specialist care are required to help reduce delays.     

周围神经松解术在降低糖尿病足部溃疡发病率中的应用

糖尿病足部溃疡的发生与下肢周围神经病变密切相关。周围神经松解术通过对病变神经的局部受压点进行松解,来治疗糖尿病周围神经病变,该手术不仅改善周围神经病变引发的症状,且极大降低了足部溃疡的发生率。本文就周围神经松解术降低糖尿病下肢周围神经病变患者足部溃疡发病率的基础和临床研究进行综述。     

The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden.Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%.Infection develops in 50%–60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers.Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.     

The Diabetic Foot in End Stage Renal Disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5–10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies—neuropathy, ischemia, and infection—are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.     

Knowledge,attitude, and practice of diabetic patients regarding foot care: Experience from a single tertiary care outpatient clinic

BackgroundFoot complications are a common problem among the diabetic population globally. Proper preventive education by health care providers should be provided to the diabetic population. This study aims to assess the knowledge, attitude, and practice of diabetic patients regarding foot care.MethodsThis study was carried out in the medicine outdoor patient department of Allied Hospital, Faisalabad. A total sample of 150 diabetic patients was taken. Sampling was done through a non-probability convenient sampling technique. The data was analyzed using SPSS version 20.ResultsThe mean age of the respondents was 52.49 ± 11.87 years. Most of the patients had moderate knowledge and also practiced a moderate level of foot care. 32.7% of the patients had good knowledge, 51.3% had moderate knowledge, and 16.0% had poor knowledge regarding foot care. 63.3% of the patients had moderate practice; 24.5%, poor practice; and 12.2%, good practice. Patients belonging to urban areas scored better on both knowledge and practice scales. A significant statistical association of education with knowledge (P = 0.012) and practice (P = 0.008) regarding foot care was found. The patients compliant with drug therapy also observed better foot care practices.ConclusionEducation had a significant role in positively influencing the behavior of the patients. There was found a gap between knowledge and practice level of patients. Hence patients should be actively engaged in their health care plan with more emphasis on changing their behavior.     

Current concepts in the surgical management of acute diabetic foot infections

Diabetic foot complications are common, costly, and difficult to treat. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common reasons that lead to ulcers, infection, and hospitalization. Individuals with diabetes presenting with foot infection require optimal medical and surgical management to accomplish limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. Multiple classification systems have been recommended to ease the understanding and the management of these infections. Multi-disciplinary approach is the mainstay for a successful management. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article is an overview in how to medically and surgically approach the diabetic foot infection with emphasis in soft tissue infection.     

Diabetic foot syndrome: Immune-inflammatory features as possible cardiovascular markers in diabetes

Diabetic foot ulcerations have been extensively reported as vascular complications of diabetes mellitus associated with a high degree of morbidity and mortality. Diabetic foot syndrome (DFS), as defined by the World Health Organization, is an “ulceration of the foot (distally from the ankle and including the ankle) associated with neuropathy and different grades of ischemia and infection”. Pathogenic events able to cause diabetic foot ulcers are multifactorial. Among the commonest causes of this pathogenic pathway it’s possible to consider peripheral neuropathy, foot deformity, abnormal foot pressures, abnormal joint mobility, trauma, peripheral artery disease. Several studies reported how diabetic patients show a higher mortality rate compared to patients without diabetes and in particular these studies under filled how cardiovascular mortality and morbidity is 2-4 times higher among patients affected by type 2 diabetes mellitus. This higher degree of cardiovascular morbidity has been explained as due to the observed higher prevalence of major cardiovascular risk factor, of asymptomatic findings of cardiovascular diseases, and of prevalence and incidence of cardiovascular and cerebrovascular events in diabetic patients with foot complications. In diabetes a fundamental pathogenic pathway of most of vascular complications has been reported as linked to a complex interplay of inflammatory, metabolic and procoagulant variables. These pathogenetic aspects have a direct interplay with an insulin resistance, subsequent obesity, diabetes, hypertension, prothrombotic state and blood lipid disorder. Involvement of inflammatory markers such as IL-6 plasma levels and resistin in diabetic subjects as reported by Tuttolomondo et al confirmed the pathogenetic issue of the a “adipo-vascular” axis that may contribute to cardiovascular risk in patients with type 2 diabetes. This “adipo-vascular axis” in patients with type 2 diabetes has been reported as characterized by lower plasma levels of adiponectin and higher plasma levels of interleukin-6 thus linking foot ulcers pathogenesis to microvascular and inflammatory events. The purpose of this review is to highlight the immune inflammatory features of DFS and its possible role as a marker of cardiovascular risk in diabetes patients and to focus the management of major complications related to diabetes such as infections and peripheral arteriopathy.     

Factors Associated with Nonunion,Delayed Union,and Malunion in Foot and Ankle Surgery in Diabetic Patients

The incidence of bone healing complications in diabetic patients is believed to be high after foot and ankle surgery. Although the association of hyperglycemia with bone healing complications has been well documented, little clinical information is available to show which diabetes-related comorbidities directly affect bone healing. Our goal was to better understand the risk factors associated with poor bone healing in the diabetic population through an exploratory, observational, retrospective, cohort study. To this end, 165 diabetic patients who had undergone arthrodesis, osteotomy, or fracture reduction were enrolled in the study to assess the risk factors associated with nonunion, delayed union, and malunion after elective and nonelective foot and/or ankle surgery. Bivariate analyses showed that a history of foot ulcer, peripheral neuropathy, and surgery duration were statistically significantly associated with bone healing complications. After adjusting for other covariates, only peripheral neuropathy, surgery duration, and hemoglobin A1c levels >7% were significantly associated statistically with bone healing complications. Of the risk factors we considered, peripheral neuropathy had the strongest association with bone healing complications.     

Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.     

Diabetic foot ulcers: A framework for prevention and care

Complications secondary to diabetes, such as diabetic foot ulcers, continue to be a major worldwide health problem. At the same time, health care systems are changing rapidly, causing concern about the quality of patient care. While the ultimate effect of current changes on health care professionals and patient outcomes remain uncertain, measures commonly used to reduce costs, e.g., disease and multi discliplinary management strategies, have been shown to help prevent the occurrence of diabetic ulcers. In addition, ultilizing a multi discliplinary approach, the principles of off-loading and optimal wound care, the vast majority of diabetic foot ulcers can be expected to heal within 12 weeks of treatment. Education of primary care providers and patients is paramount. (WOUND REP REG 1999;7:7–16)     

Diabetic foot disease:From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease(DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy(DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.     

The diabetic foot in end stage renal disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5-10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies--neuropathy, ischemia, and infection--are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.     

Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease

BackgroundLower extremity complications are a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD) and diabetes mellitus. Patient education programs may decrease the risk of diabetic foot complications.MethodsA preventive program was instituted, consisting of regular assessments by a foot care nurse with expertise in foot care and wound management and patient education about foot care practices and footwear selection. Medical records were reviewed and patients were examined. A comparison was made with data about patients from a previous study done from this institution prior to development of the foot care program.ResultsDiabetic subjects more frequently had weakness of the left tibialis anterior, left tibialis posterior, and left peroneal muscles than non-diabetic subjects. A smaller percentage of diabetic subjects had sensory neuropathy compared with the previous study from 5 years earlier, but a greater percentage of diabetic subjects had absent pedal pulses in the current study. The frequency of inadequate or poor quality footwear was less in the current study compared with the previous study.ConclusionsThe current data suggest that a foot care program consisting of nursing assessments and patient education may be associated with a decrease in frequency of neuropathy and improved footwear adequacy in diabetic patients with ESRD.     

Diabetic foot screening: why is it neglected?

Understanding reasons for the neglect of foot screening during the annual review of people with diabetes enables the development of solutions for this omission. This study explores the reasons within the context of health care delivery systems in terms of the professional, social, political and economic aspects of this screening. Information was obtained through reviewing publications on diabetic foot and health care reform. The omission of annual foot examination for people with diabetes is attributed to the nature of diabetes-related foot problems, people with diabetes, health care professionals and the current structure of health care delivery systems. Increasing the adherence to foot screening for those with diabetes requires short- and long-term strategies. Short- and long-term strategies for reminding patients and staff about foot screening are suggested.     

Vascular complications of the lower extremities in diabetic patients on peritoneal dialysis

BACKGROUND: Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development. PATIENTS: We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease. RESULTS: 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p<0.05), more often had peripheral neuropathy (p<0.002), as well as coronary artery disease (p<0.044). They had lower serum albumin (p<0.005), significantly higher serum phosphorus (p<0.047) and they received higher doses of erythropoietin (p<0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA(1c), body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca x P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p<0.0066 and p <0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all. CONCLUSION: In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patient's feet, especially in those with low serum albumin and peripheral neuropathy.     

Barriers to podiatric care among diabetic patients in the San Francisco Bay area.

This study investigates the provision of general medical and foot care, the barriers to access for foot care, and the awareness of foot risks in an urban diabetic population. A survey composed of 26 questions was mailed to 2375 diabetic patients in the San Francisco Bay area who are members of the American Diabetes Association (ADA). Three hundred ninety-two surveys were returned for a response rate of 16%. Of the 392 respondents, 7 (1.8%) indicated that they were not receiving any medial care for their diabetes, with another 15 (3.8%) receiving general medical care from an alternative health care provider. Among the respondents, 87 (22%) did not have their feet examined by any health care provider. The remainder of the patients were receiving foot care from a health care provider with 191 (48.7%) under the care of a provider other than a podiatrist. Of those not receiving any foot care, 53 (61%) reported that they did not seek any pedal care because they do not have any apparent foot or leg problems. Another 12 (13.8%) indicated that they did not know whom to see for their lower extremity problems. Lack of insurance or inability to afford medical care was the main reason that prevented 7 (8%) of the patients from receiving routine foot care. With respect to the patient's knowledge of diabetes-associated foot disorders, the majority (72%-79%) knew that poor circulation, neuropathy, ulcers, painful leg and foot conditions, infection, and amputation were associated with diabetes. From all the surveyors, 106 (27%) reported that they were not advised or educated on the potential lower extremity complications of diabetes by their health care provider. The results of this study indicate that in an urban population of diabetic patients, all of whom were members of ADA, a significant number are not adequately educated on the importance of routine foot care.     

Gait changes in persons with diabetes: Early risk marker for diabetic foot ulcer

Background Increasing prevalence of diabetic foot ulcer (DFU) and subsequent foot amputation in persons with type 2 diabetic neuropathy is a well known fact. The present study was aimed to identify the initial risk marker for DFU.Methods Dynamic plantar pressure analysis was done for persons with type 2 diabetes mellitus (T2DM) without neuropathy (D), patients with diabetic neuropathy (DN) with normal foot profile and healthy persons with normal foot profile (C).Results The data showed a significant difference in dynamic peak plantar pressure between C and DN (P = 0.035) and no significant difference between D and DN (P = 0.997). The dynamic segmental peak plantar pressure results showed significant difference only in the medial heel region (P = 0.009) among the three groups.Conclusions Gait variations and restrictions in subtalar and first metatarsophalangeal joint are found in persons with diabetic neuropathy even before the onset of foot deformity.     

Foot and ankle problems of Aboriginal and non-Aboriginal diabetic patients with end-stage renal disease

BACKGROUND: There is little information available about the profile of lower extremity morbidity in diabetic patients with end-stage renal disease (ESRD) in the Canadian Aboriginal and non-Aboriginal population. METHOD: A retrospective review of medical records in 127 diabetic patients on hemodialysis at a tertiary health care center was performed. Patient interviews and physical examinations were performed in 77 of these patients (36 Aboriginal, 41 non-Aboriginal), and followup evaluation was done in 39 patients at an average of 1 year later. RESULTS: Aboriginal patients were an average of 7 years younger than non-Aboriginal patients. Comorbidities of diabetes and ESRD were frequent. Peripheral neuropathy and inability to occlude the vessels were present in the majority of feet. Lower extremity complications were frequent, including prior foot ulcer in the majority of patients and an amputation in more than one fourth of the patients. Aboriginal patients had a significantly greater frequency of prior foot ulcer, mean number of foot ulcers per patient, amputation, prior osteomyelitis, and Charcot foot than non-Aboriginal patients. Almost all patients were at risk for future foot ulcer, but many patients did not inspect their feet daily. Home care was significantly less frequently available for Aboriginal than non-Aboriginal patients. The majority of patients had inadequate custom or prefabricated shoes and did not wear insoles on the day of examination. Aboriginal patients cited financial cost, insufficient family support, and language barriers as reasons for inadequate foot care and footwear more frequently than non-Aboriginal subjects. A significantly smaller frequency of Aboriginal patients had good knowledge of footwear or diet than non-Aboriginal patients. CONCLUSIONS: Lower extremity complications were significantly more frequent in Aboriginal than non-Aboriginal diabetic patients with ESRD. Financial cost and knowledge deficit were barriers to adequate foot care and footwear. These findings support the need for a formal foot care and footwear program for this high-risk population.