The effects of ulcer size and site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers.

AIMS: The outcome of foot ulcers is affected by wound depth, infection, ischaemia and glycaemic control. The aim of this study was to determine the effects of ulcer size, site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. METHODS: Diabetic patients with new foot ulcers presenting during a 12-month period had demographics and ulcer characteristics recorded at presentation. Ulcers were followed-up until an outcome was noted. RESULTS: One hundred and ninety-four patients (77% males) with a mean (+/- SD) age and duration of diabetes of 56.6 +/- 12.6 and 15.4 +/- 9.9 years, respectively, were included in the study. The majority of ulcers were neuropathic (67.0%) and present on the forefoot (77.8%) with a median (interquartile range) area of 1.5 (0.6-4.0) cm2. Amputations were performed for 15% of ulcers; 65% healed; 16% remained unhealed and 4% of patients died. The median (95% confidence interval) time to healing was 10 (8.8-11.6) weeks. Ulcer area at presentation was greater in the amputation group compared to healed ulcers (3.9 vs. 1.2 cm2, P < 0.0001). Ulcer area correlated with healing time (rs = 0.27, P < 0.0001) and predicted healing (P = 0.04). Patient's age, sex, duration/type of diabetes, and ulcer site had no effect on outcome. CONCLUSIONS: Ulcer area, a measure of ulcer size, predicts the outcome of foot ulcers. Its inclusion into a diabetic wound classification system will make that system a better predictor of outcome.     

Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study

Aims/hypothesis  We sought to identify factors related to short-term outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. Methods  Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1–5, below ankle) (n = 2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31. The characteristics of the remaining 2,480 patients were: 1,465 men, age 68 ± 15 years (range 18–96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. Results  The healing rate without major amputation in surviving patients was 90.6% (n = 1,867). Sixty-five per cent (n = 1,617) were healed primarily, 9% (n = 250) after minor amputation and 8% after major amputation; 17% (n = 420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to co-morbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. Conclusions/interpretation  Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.     

Diagnosis and assessment of peripheral arterial disease in the diabetic foot

Approximately half of all patients with a diabetic foot ulcer have co‐existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.     

Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer?

BACKGROUND: At the Surgical Department of Surgery of the University Hospital Würzburg microbiological examinations were performed of the ulcer grounds from patients with diabetic-neuropathic, diabetic-ischemic, venous, and arterial leg ulcers. The aim of the examination was to evaluate possible differences in the healing process of these ulcers based on the knowledge of their bacterial populations. PATIENTS AND METHODS: In a period of four months, 63 patients were consecutively examined by taking a bacteriological swab of their ulcer area. The healing process of their wounds was followed and related to the impact of bacterial colonisation and clinical signs of infection. RESULTS: 95% of the venous and arterial leg ulcers had a positive smear, whereas only 70% of diabetic ulcers were positive for bacterial growth. Bacterial population of the three ulcer entities, however did not differ significantly. 100% of the clinically infected venous and arterial ulcers but only 80% of the diabetic wounds revealed a positive smear. On the other hand, only 22% of the venous ulcers with a positive smear developed a clinical infection in contrast to 70% of the arterial and diabetic. Venous ulcers showed only in a few patients prolonged healing, even in cases of marked bacterial contamination. Despite of clinical signs of infection however, diabetic wounds sometimes did not reveal a positive wound smear (20%). All infected venous, but only 20% of the infected ischemic ulcers healed satisfactorily. Arterial wounds with no bacterial growth healed significantly better than contaminated wounds. This difference was not significant in the other entities. Radical removal of the infection by minor amputation increased the healing rate in diabetic ulcers over 80%, whereas ischemic wounds did not profit from this therapy. CONCLUSIONS: A positive bacterial wound smear is not inevitably correlated with a protracted leg ulcer healing. Nevertheless a fulminant infection often developed in diabetic ulcers despite the initial inability to demonstrate bacterial growth. In order to start antibiotic treatment as early as possible, a wound smear should be obtained routinely from patients with diabetic ulcers. In chronic venous ulcers, a routine swab does not appear to be indicated as it bears no clinical consequences. The same applies to patients with surgically fully treated peripheral arterial occlusive disease. As ischemia presents the limiting factor, antibiotic therapy in case of infection will not prevent imminent amputation.     

Frequency of risk factors for foot ulceration in individuals with chronic kidney disease

Background: Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group. Methods: One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors. Results: Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end‐stage kidney failure. Conclusion: Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end‐stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.     

Diabetic heel ulcers: a major risk factor for lower extremity amputation

Of all the ulcers seen in patients with diabetes, heel ulcers are the most serious and often lead to below-the-knee amputation. Management of heel ulcers requires a thorough knowledge of the major risk factors for ulceration in the heel area and a standardized program of local ulcer care, metabolic control, early control of infection, and improvement of blood supply to the foot. The most common risk factors for ulceration in the heel region include immobility of the lower limbs, diabetic neuropathy, structural deformity, and peripheral arterial occlusive disease. Patient education regarding foot hygiene, skin care, and proper footwear is crucial to reducing the risk of an injury that can lead to heel ulceration. A careful foot examination that tests for neuropathy and arterial insufficiency can identify patients at risk for heel ulcers and appropriately classify patients with ulcers into different grades to design proper therapeutic plans for management. Team management programs that focus on education, prevention, regular foot examinations, aggressive intervention, and proper use of therapeutic measures can significantly reduce the risk of lower-extremity amputations from heel ulcers.     

Treatment of chronic plantar ulcer of the diabetic foot using an irremovable windowed fibreglass cast boot: prospective study of 177 patients

The objective of this study was to evaluate the level of healing of chronic neuropathic plantar ulcers, using an irremovable windowed fibreglass cast boot, which is only opened after healing. A single‐centre prospective study of a cohort of 177 diabetic patients with chronic neuropathic plantar ulcers was carried out. The duration of neuropathic plantar ulcers was 604 ± 808 days, with a mean surface area of 4.6 ± 6.5 cm², a mean depth of 1.04 ± 1.08 cm and a mean volume of 5.9 ± 17.7 cm³. After a mean of 96 days of wearing a windowed fibreglass cast boot (min 9 days, max 664 days and median 68 days), the level of healing reached 83.6%, although 29 patients did not heal (16.4%). The compliance was at 95%. NPUs with bigger volumes (p = 0.037) and those located at the heels ( p = 0.004) had significantly lower healing levels. Twenty‐one patients had moderate peripheral arterial disease (12%), and 24 patients were ostectomized for underlying osteomyelitis (14%), before inclusion. Moderate peripheral arterial disease (p = 0.970) or operated osteomyelitis (p = 0.128) did not modify the level of healing significantly, which were of 81% and 70.8%, respectively. Complications include 12 ulcers due to the windowed fibreglass cast boot (i.e. 7%) and two other ulcers being moderately infected, resulting in 2% of toe amputation, but there was no major amputation or phlebitis. The treatment of old and deep NPUs of the diabetic foot by wearing a windowed fibreglass cast boot without opening the boot prior to healing offers very high ulcer recovery levels. Windowed fibreglass cast boots were changed in only 26 cases (14.6%). In addition, compliance was excellent and of the order of 95%. Furthermore, moderate peripheral arterial disease or a recent ostectomy did not affect the efficacy of windowed fibreglass cast boot. Copyright © 2015 John Wiley & Sons, Ltd.     

A case series to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis

The aim of this study was to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis (RA). Adults with RA and current foot ulceration but without diabetes were recruited. Clinical examination included assessment of RA disease activity, foot deformity, peripheral vascular disease, neuropathy and plantar pressures. Location, wound characteristics and time to healing were recorded for each ulcer. Participants completed the Health Assessment Questionnaire and Leeds Foot Impact Scale. Thirty-two cases with 52 current ulcers were recruited. Thirteen patients (41%) experienced more than one current ulcer: 5 (16%) had bilateral ulceration, 15 (47%) had previous ulceration at a current ulcer site. The majority (n = 33) of open ulcers were located over the dorsal aspect of the interphalangeal joints (n = 12), plantar aspect of the metatarsophalangeal joints (MTPJs) (n = 12) and medial aspect of first MTPJs (n = 9). In ulcerated limbs (n = 37), ankle brachial pressure index (ABPI) was <0.8 in 2 (5%); protective sensation was reduced in 25 (68%) and peak plantar pressures were >6 kg/cm² in 6 (16%). Mean ulcer size was 4.84 by 3.29 mm. Most ulcers (n = 42, 81%) were superficial; five (9.6%) were infected. Time to healing was available for 41 ulcers: mean duration was 28 weeks. Three ulcers remained open. In conclusion, foot ulceration in RA is recurrent and multiple ulcers are common. Whilst ulcers are small and shallow, time to achieve healing is slow, posing infection risk. Reduced protective sensation is common in affected patients. The prevalence of arterial disease is low but may be under estimated due to high intolerance of ABPI.     

Which diabetic patients should receive podiatry care? An objective analysis

INTRODUCTION: Diabetes is the leading cause of lower limb amputation in Australia. However, due to limited resources, it is not feasible for everyone with diabetes to access podiatry care, and some objective guidelines of who should receive podiatry is required. METHODS: A total of 250 patients with neuropathy (Biothesiometer; Biomedical Instruments, Newbury, Ohio, USA) ( > 30, age < 65)) but no active foot lesion, and 222 without neuropathy matched for age, type of diabetes, gender and duration, was followed prospectively for 2 years. Sensation was also tested using a 10 g Semmes Weinstein monofilament (Royal Prince Alfred Hospital Diabetes Centre). After the baseline examination, patients were contacted at 6 months and thereafter yearly to determine ulcer status. Incidence of foot ulceration across different risk categories was calculated using Kaplan-Meier survival curve. Log-rank test and Cox's proportional model were used to compare groups. The Number Needed to Treat (NNT) to prevent one ulcer per year was calculated using the standard formulae. RESULTS: During the follow-up period, 34 new ulcers occurred in the neuropathy group and three ulcers in the control group (chi2 (1df) = 21.3; P < 0.0001), equating to an annual incidence of 6.3% and 0.5%, respectively. Fifty-four per cent of the ulcers were due to trauma from footwear. Further stratification of the neuropathy group showed annual incidence of ulceration to be 4% for those with abnormal biothesiometer reading, but who could still feel the monofilament, 10% for those who cannot feel the monofilament and 26% for those with previous ulceration or amputation. Predictors of ulceration were past history of ulceration/amputation (chi2 = 27.8; P < 0.0001) and the presence of neuropathy (chi2 = 4.7; P = 0.03). Assuming a 55% relative risk reduction in ulceration from podiatry care (mean of estimates from 10 reports), the NNT to prevent one foot ulcer per year was: no neuropathy (vibration perception threshold (VPT) < 30)), NNT = 367; neuropathy (VPT > 30) alone, NNT = 45; +cannot feel monofilament, NNT = 18; +previous ulcer/amputation, NNT = 7. CONCLUSION: Provision of podiatry care to diabetic patients should not be only economically based, but should also be directed to those with reduced sensation, especially where there is a previous history of ulceration or amputation.     

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.     

Diabetic foot ulcers—comparison of performance of ankle-brachial index and transcutaneous partial oxygen pressure in predicting outcome

Diabetic foot ulcer (DFU) is the commonest condition for hospital admission and usually the starting point of most diabetic related lower limb amputations. Considering the significant role played by vascularity in the outcome of ulcer healing, we undertook this study to find out the comparative utility of commonly used vascular assessment methods. This study was a single center prospective non-randomized observational study, conducted for a period of 6 months, in diabetic patients presenting with foot ulcers of Wagner Grade II and III. The aim of our study was to compare the performances of ankle-brachial index (ABI) and transcutaneous partial pressure of oxygen (tcPO₂) measurement in predicting wound healing in diabetic ulcers and to define the optimal cut-off value for Indian patients. Five hundred sixty-four patients were included in this study, with the mean age of 58 years. Eighty-seven patients (15%) had peripheral arterial occlusive disease. Four hundred seventy ulcers (83%) healed with the mean healing days of 42.6 days. Age, duration of diabetes, serum creatinine level, and presence of infection were the factors with negative impact in wound healing. In our study, ABI value of 0.6 was found to have 100% sensitivity and 70% specificity, and tcPO₂ value of 22.5 was found to have 75% sensitivity and 100% specificity in predicting wound healing. Both ABI and tcPO₂ are complementary, but tcPO₂ is a better predictor for amputation while ABI is a better predictor for ulcer healing. While assessing the ischemic status of foot ulcer, the cut-off values should be higher in diabetics than non-diabetics.     

Peripheral Neuropathy as a Presenting Feature of Type 2 Diabetes: A Case-Controlled Study

The characteristics and outcome of 68 newly diagnosed Type 2 diabetic patients who presented with clinically evident peripheral neuropathy were compared with matched controls who had no neuropathy at diagnosis. All subjects (34 male) whose median age was 68 (range 47–89) yr were identified from a computerized diabetes register and presented in 1982–1990. The groups were compared at diagnosis for haemoglobin A₁, body mass index, blood pressure, smoking, and alcohol consumption, and for co-existent coronary and peripheral vascular disease. Mortality and morbidity were recorded to March 1991. Significantly more patients with neuropathy had co-existent peripheral vascular disease: 24(35%) compared to 6(9%) controls (p = 0.0021). Twenty (30%) of those with neuropathy and no controls had retinopathy at diagnosis, which was sight-threatening in 10. Seven (10%) with neuropathy but no controls presented with foot ulcers, one requiring limited amputation. Two more patients with neuropathy and one control subsequently developed foot ulcers resulting in one or more amputation in each group. Twenty-one (31%) of those with neuropathy and 14 (21%) controls died (p = 0.2109). In conclusion more diabetic patients with clinically evident peripheral neuropathy at diagnosis have peripheral vascular disease than matched patients without neuropathy. It is likely that macrovascular disease either exacerbates or causes the neuropathy in this group of patients. They are at high risk of developing foot ulceration and high priority should be given to foot care in planning their management.     

Ulcer-free survival following management of foot ulcers in diabetes.

AIMS: Measures of healing rate may not give a complete indication of the effectiveness of overall management of diabetic foot ulcers. Apart from healing and speed of healing, the outcomes of greatest importance to the patient are avoidance of any amputation and remaining free from any recurrence. We have documented the number of patients presenting with diabetic foot ulcers who become ulcer free and examined the value of documenting ulcer-free survival. METHODS: All referrals to a specialist diabetic foot clinic over a 31-month period were analysed and outcomes were determined after a minimum follow-up of 6 months. RESULTS: Three hundred and seventy patients were referred with a total of 1031 ulcers. One hundred and twenty-one (32.7%) never became ulcer free: 56 (46.3% of 121) remained unhealed, the ulcers of 12 (9.9% of 121) had been resolved by amputation, two remained unhealed after amputation (1.7% of 121) and 51 (13.8% of 370) had died. Two hundred and thirty-one (62.4% of 370) became ulcer free at some stage. Five of these were excluded because of an earlier amputation. Ninety-one of the remaining 226 (40.3%) developed a recurrent or new ulcer after a median 126 days. Of the 135 who did not have a recurrence, 133 (58.8% of 226; 35.9% of 370) survived ulcer free and with limbs intact, while two died. Outcome was unknown in 18 (4.9%). Those who never became ulcer free were older (P < 0.001) and with a greater prevalence of ischaemia (P < 0.001). Those who healed but went on to suffer a new ulcer had a greater prevalence of neuropathy (P = 0.027) than those who remained ulcer free. CONCLUSIONS: The use of ulcer-free survival can be used as an indication of the effectiveness of foot ulcer management. It could be adopted as a measure to compare performance between different specialist units.     

Outcome of diabetic foot ulcer admissions at the medical wards of University of Nigeria Teaching Hospital Enugu,Nigeria

Diabetic foot ulcer (DFU) is associated with a high rate of morbidity, prolonged hospital stay, and serious complications including limb amputation. The objective of this study was to determine the outcome of DFU among medical inpatients in the University of Nigeria Teaching Hospital Enugu, Nigeria. Data from case records of diabetes-related admissions into the medical wards of the University of Nigeria Teaching Hospital Enugu (UNTH) between January 2009 and December 2012 were analyzed. Statistical analysis was done using SPSS v17. Out of 726 diabetes mellitus (DM)-related admissions (59.1 % males, 40.9 % females), DFU accounted for 119 (16.4 %), of which 65.5 % were males and 34.5 % were females. The mean duration of diabetes in DFU patients was 7.2?±?5.8 years, while the median (interquartile range) duration of the ulcer before the presentation was 24 (14–60)?days. The mean age of patients with DFU was 55.2?±?13.2 years, while the duration of hospital stay ranged from 2 to 98 days, median (interquartile range (IQR)) of 16 (9.8–30.3)?days. Out of the 119 DFU admissions, 88 (73.9 %) were discharged, 15 (12.6 %) died, while 16 (13.5 %) discharged themselves against medical advice (DAMA). Of those who were discharged, about 75 % were discharged with non-healed ulcers either for outpatient care or to surgical units. The most common Wagner grade of ulcer was grade 3 (41.5 %). Risk factors for ulceration were peripheral vascular disease in 47.1 % and peripheral neuropathy in 57.6 %. Mortality due to DFU accounted for 10.6 % of all diabetes mortality. Diabetic foot ulcer was a common reason for admission and characterized by late presentation and advanced ulcer stage. Diabetes foot ulcers admitted and managed in the medical wards were associated with poor outcome.     

Screening diabetic patients at risk for foot ulceration. A multi-centre hospital-based study in France

BACKGROUND: To determine the prevalence of risk factors for diabetic foot ulceration in diabetic patients free of active pedal ulceration in a hospital setting. METHODS: In sixteen French diabetology centres, a survey was conducted on a given day in all diabetic people attending the units, both as in- or out-patients. RESULTS: 664 patients were evaluated: 105 had an active foot ulcer and were excluded from the analysis as were four other patients due to lack of reliable data. From the 555 assessable patients, 40 (7.2%) had a history of foot ulcer or lower-limb amputation. Sensory neuropathy with loss of protective sensation, as measured by the 5.07 (10 g) Semmes-Weinstein monofilament testing, was present in 27.1% of patients, whereas 17% had a peripheral arterial disease mainly based on the clinical examination. On addition, foot deformities were found in 117 patients (21.1%). According to the classification system of the International Working Group on the Diabetic Foot, 72.8% of patients were at low-risk for pedal ulceration (grade 0) and 17,5% were in the higher-risk groups (grade 2 & 3). If patients with isolated peripheral arterial disease were considered as a separate risk group (as was those with isolated neuropathy), percentage of low-risk patients decreased to 65.6%. There was a clear trend between the increasing severity of the staging and age, duration of diabetes, prevalence of nephropathy and retinopathy. CONCLUSIONS: Prevalence of risk factors for foot ulceration is rather high in a hospital-based diabetic population, emphasising the need for implementing screening and preventive strategies to decrease the burden of diabetic foot problems and to improve the quality of life for people with diabetes.     

Rodent bites on the feet of diabetes patients in Tanzania.

AIM: To characterize the epidemiology of rodent bite foot injuries in patients presenting to a diabetes clinic in Tanzania. METHODS: During July 1998-September 2003, all adult diabetes patients presenting with rodent bite injuries were identified. Follow-up included antimicrobial therapy and surgery, where appropriate. RESULTS: All 34 patients with rodent bites had Type 2 diabetes and peripheral neuropathy. Median age was 55.5 years; 62% were male. All bites occurred during sleep. The median time between acquiring the bite and presentation to MNH was 7 (range: 1-17) days. Patients who delayed seeking medical attention were significantly more likely to develop gangrene. Seventeen patients underwent minor or major amputation. Complete healing occurred in 30 (88%) patients; four patients died. CONCLUSION: Diabetes patients with peripheral neuropathy are at increased risk of bite injuries in areas with large rodent populations. Preventive efforts should include covering the feet at bedtime, and daily feet examination by patient or relatives.     

The Prevalence of Foot Ulceration and its Correlates in Type 2 Diabetic Patients: a Population-based Study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34–90) years, diabetes duration 7.4 (0–50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or ≥ 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3–44.9%) and the prevalence of PVD, 11% (9.1–13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.     

Clinical profile of diabetic foot infections in south India--a retrospective study.

AIMS: The aim of the study was to determine the profile of diabetes foot infections in south Indian diabetic subjects. The causative factors for delayed wound healing and the recurrence of infection were also studied. METHODS: During a period of 6 months, 374 patients who had undergone some surgical procedure for foot infection were available for follow-up (M:F 227:147, mean age 54.9 +/- 9.4 years, diabetes duration 10.9 +/- 7.7 years). All of them had records of clinical and treatment details, laboratory data including biothesiometry, Doppler tests and electrocardiogram (ECG) records. Foot ulcers were classified according to Wagner's classification. RESULTS: Majority of the patients had grade II and III ulcers (50% and 26.5%, respectively), grade IV was seen in another 21.9%. The median healing time was 44 days. Recurrence of infection which occurred in 53% was more common in patients with neuropathy and peripheral vascular disease (PVD). CONCLUSIONS: Recurrence of foot infection was common among south Indian Type 2 diabetic subjects and was related to the presence of PVD and neuropathy. There is also a need for improvement in footwear and foot care education.     

A proof‐of‐concept study of the effectiveness of a removable device for offloading in patients with neuropathic ulceration of the foot: the Ransart boot

Aim To undertake a proof‐of‐concept study to determine whether a removable offloading device (the Ransart boot) for the management of diabetic foot ulcers (DFU) was as effective as reports of non‐removable devices. Research design and methods This observational study used the Ransart boot for patients with DFU, in seven specialist centres. If a patient had two or more ulcers, one was selected as the index ulcer. Ulcers were classified by the University of Texas (UT) system. Results There were 135 patients (mean age 60.3 ± 11.4 years); 96 (71.1%) male. Median ulcer duration at presentation was 90 [interquartile range (IQR) 30–1825] days. Seven were lost to follow‐up, seven developed other major illnesses and four died; outcomes were documented in the remaining 117. Eighty‐two (70.1% of 117) healed, after a median (IQR) 60 (43–99) days, while 22 (18.8%) ulcers were resolved by amputation (one major). The remaining 13 (11.1%) patients were judged non‐compliant. There was a close correlation between ulcer classification at baseline and both time to healing (P < 0.001 χ²‐test) and amputation (P < 0.001; Spearman’s rank correlation coefficient). There was a positive correlation between ulcer duration at presentation and time to healing (P < 0.02), UT class (P < 0.01), glycated haemoglobin (P < 0.02) and amputation (P < 0.04). Conclusions Time to healing and incidence of amputation were comparable with those previously reported for non‐removable devices. Given that a removable device is much more acceptable to the patient, the effectiveness, cost and acceptability of the removable devices, such as the Ransart boot, need to be compared with a non‐removable device in a randomized trial.     

Magnitude of foot problems in diabetes in the developing world: a study of 1044 patients

Aim To gain insight into the prevalence of peripheral neuropathy, foot care practices, foot at risk and foot ulcers in patients with diabetes mellitus at a tertiary care centre. Methods A prospective case study involving 1044 patients with diabetes mellitus attending the diabetes clinic of a tertiary care centre in north India from January 2007 to May 2008. All subjects underwent a detailed clinical assessment including vibration perception threshold (VPT) and ankle brachial pressure index (ABI), along with metabolic parameters, and were categorized into ulcer, foot at risk and patients with no risk factors. Foot care practices were assessed with a questionnaire. Peripheral neuropathy was defined as VPT score ≥ 25 V. Peripheral vascular disease (PVD) was defined as ABI < 0.9. One hundred and forty‐nine patients with foot at risk were followed up for 9.0 ± 2.3 months (range 5–13 months). Results The prevalence of peripheral neuropathy was 34.9% and of PVD 12.6%. Two thirds of the patients were at risk for foot ulceration; 9% had an ulcer and 20.2% of them required amputation. Correct foot care practices were followed by 214 (20.5%) subjects of the whole study population and by only 135 (19.3%) of the patients with foot at risk. Improvement in glycaemic control in the patients on follow‐up was associated with improvement or stabilization of VPT score. Five (3.4%) patients developed new ulcers on follow‐up. Conclusion The high prevalence of neuropathy and PVD, coexisting with poor adherence to foot care practices predisposes to foot problems in people with diabetes in our study population.