Clinical outcomes of toe amputation in patients with type 2 diabetes in Tianjin,China

The aim of this study is to determine the predictors for reulceration, reamputation and mortality in patients with diabetes following toe amputation, and the impact of activities of daily living on clinical outcomes. This prospective cohort study included 245 patients who had undergone toe amputation (202 healing and 43 non‐healing) and was followed for a 5‐year period. Data regarding new foot ulceration, reamputation and mortality were recorded, and the patients' activities of daily living were evaluated. The rate of wound healing was 82·4%. The rate of follow‐up in the healed group was 91·6%. In years 1, 3 and 5, the cumulative incidence of patients who developed a new foot ulcer was 27·3%, 57·2% and 76·4%, respectively, leading to reamputation in 12·5%, 22·3% and 47·1%, respectively. The cumulative mortality was 5·8%, 15·1% and 32·7% at 1, 3 and 5 years, respectively. Multivariate analysis showed that GHbA1c > 9% (75 mmol/mol) was identified as an independent predictor of impaired wound healing, reulceration and reamputation. An age of >70 years was identified as an independent predictor of reamputation, mortality and impairment of activities of daily living. Despite a satisfactory initial healing rate after the first toe amputation, with the extension course after the toe amputation, the long‐term outcomes are not optimistic. In developing countries like China, taking measures to prevent reulceration and reamputation is very important for patients with diabetic foot minor amputations, especially following toe amputation.     

Amputations and foot‐related hospitalisations disproportionately affect dialysis patients

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD‐9 250.X), ulceration (ICD‐9 707·10, 707·14 and 707·15) and dialysis (CPT 90935–90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow‐up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person‐years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P < 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P < 0·001); however, there were more foot‐related hospital admissions in the dialysis group (32·9% versus 14·0%, P < 0·001) during the 30‐month evaluation period. The incidence of ulcers, amputations and all‐cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot‐related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high‐risk group.     

High probability of healing without amputation of plantar forefoot ulcers in patients with diabetes

Diabetic foot ulcer is an important entity which in many cases is the first serious complication in diabetes. Although a plantar forefoot location is common, there are few studies on larger cohorts and in such studies there is often a combination of various types of ulcer and ulcer locations. The purpose of this study is to discern the outcome of plantar forefoot ulcers and their specific characteristics in a large cohort. All patients (n = 770), presenting with a plantar forefoot ulcer at a multidisciplinary diabetes foot clinic from January 1, 1983 to December 31, 2012 were considered for the study. Seven hundred one patients (median age 67 [22–95]) fulfilled the inclusion criteria and were followed according to a preset protocol until final outcome (healing or death). Severe peripheral vascular disease was present in 26% of the patients and 14% had evidence of deep infection upon arrival at the foot clinic. Fifty‐five percent (385/701) of the patients healed without foot surgery, 25% (173/701) healed after major debridement, 9% (60/701) healed after minor or major amputation and 12% (83/701) died unhealed. Median healing time was 17 weeks. An ulcer classified as Wagner grade 1 or 2 at inclusion and independent living were factors associated with a higher healing rate. Seventy‐nine percent of 701 patients with diabetes and a plantar forefoot ulcer treated at a multidisciplinary diabetes foot clinic healed without amputation. For one third some form of foot surgery was needed to achieve healing.     

Heel ulcers do heal in patients with diabetes

A heel ulcer is considered to be a serious complication in patients with diabetes, and there is limited information regarding outcome. In most of the literature, a poor prognosis is described. The aim of this study was to investigate a large cohort of ulcers located in the heel in patients with diabetes. Seven hundred and sixty‐eight patients [median age 73 (17–98)], presenting with a heel ulcer at a multidisciplinary diabetes foot clinic, fulfilled the inclusion criteria and were followed‐up until final outcome. Fifty‐eight per cent of the patients healed primarily; 7% healed after major debridement; 9% healed after amputation and 25% died unhealed. Median healing time was 17 weeks. Ulcer progression was seen in 19% of patients. Thirty‐one percent of patients had severe peripheral vascular disease. A creatinine level below 91 µmol/l was related to a higher probability for healing without major debridement or amputation, whereas vascular surgery, nephropathy and oedema were related to a lower probability for healing without major debridement or amputation. Two thirds of heel ulcers do heal in patients with diabetes despite patients being elderly and with extensive comorbidity. The extent of peripheral vascular disease, nephropathy, oedema and decreased renal function are important factors influencing outcome.     

Risk factors for recurrence of diabetic foot ulcers: prospective follow‐up analysis in the Eurodiale subgroup

Few studies have examined factors associated with diabetic foot ulcer (DFU) recurrence. Using data from patients enrolled in the prospective Eurodiale DFU study, we investigated the frequency of and risk factors for DFU recurrence after healing during a 3‐year follow‐up period. At our site, 93 Eurodiale‐enrolled patients had a healed DFU. Among these, 14 were not alive; of the remaining 79 patients we enrolled 73 in this study. On entry to the Eurodiale study, we assessed demographic factors (age, sex and distance from hospital); diabetes‐related factors [duration, and glycated haemoglobin (HbA1c) levels]; comorbidities (obesity, renal failure, smoking and alcohol abuse) and DFU‐related factors [peripheral arterial disease, ulcer infection, C‐reactive protein (CRP) and; foot deformities]. During the 3‐year follow‐up period, a DFU had recurred in 42 patients (57·5%). By stepwise logistic regression of findings at initial DFU presentation, the significant independent predictors for recurrence were plantar ulcer location [odds ratio (OR) 8·62, 95% confidence interval (CI) 2·2–33·2]; presence of osteomyelitis (OR 5·17, 95% CI 1·4–18·7); HbA1c > 7·5% ([DCCT], OR 4·07, 95% CI 1·1–15·6) and CRP > 5 mg/l (OR 4·27, 95% CI 1·2–15·7). In these patients with a healed DFU, the majority had a recurrence of DFU during a 3‐year follow‐up period, despite intensive foot care. The findings at diagnosis of the initial DFU were independent risk factors associated with ulcer recurrence (plantar location, bone infection, poor diabetes control and elevated CRP) and define those at high risk for recurrence, but may be amenable to targeted interventions.     

Prevalence of foot ulcers in dialysis‐dependent patients

Hemodialysis patients are at high risk for foot ulceration. The aim of this prospective study was to describe the prevalence and risk factors for foot ulcers in hemodialysis‐dependent patients. From 2012 until 2015, all hemodialysis patients (n = 66) above18 years of age, treated at the Alrijne Hospital (Leiderdorp, the Netherlands), were included. Demographics and medical history were collected and the quality of life was measured. Data were collected on common risk factors for foot ulceration: peripheral arterial disease, peripheral neuropathy with or without foot deformities, diabetes mellitus (DM), hypertension, smoking, previous foot ulcer, edema, pedicure attendance, and orthopedic footwear. Sixty‐six hemodialysis patients were evaluated; the prevalence of foot ulcer was 21/66 (31.8%). Risk factors were history of foot ulceration in 27/66 (40.9%), ankle‐brachial index (ABI) <0.9, and toe pressure < 80 mmHg in 38/66 (57.6%). The percentage of DM in the group of foot‐ulcers was higher 13/21 (61.9%) vs. 20/45 (44.4%) in the non‐ulcer group, this was not significant (p = 0.183). No differences were found in ABI, toe pressure, peripheral neuropathy and foot deformity, between the DM and non DM group. The mortality between ulcer vs. no ulcer was significant different: 13/21 (61.9%) vs. 11/45 (24.4%) (p = 0.003). Approximately, one‐third of hemodialysis patient have a foot ulcer 21/66 (32%). Arterial insufficiency is associated with an increased risk of foot ulcers. In patients with a foot ulcer, survival is significantly lower than in patients without a foot ulcer; interventions to reduce foot ulceration should be implemented for all hemodialysis patients and include frequent inspection, and prompt treatment. Further research should focus on the prevention of foot ulcers in dialysis‐dependent patients.     

Podiatrist care and outcomes for patients with diabetes and foot ulcer

We examined whether outcomes of care (amputation and hospitalisation) among patients with diabetes and foot ulcer differ between those who received pre‐ulcer care from podiatrists and those who did not. Adult patients with diabetes and a diagnosis of a diabetic foot ulcer were found in the MarketScan Databases, 2005–2008. Multivariate Cox proportional hazard models estimated the hazard of amputation and hospitalisation. Logistic regression estimated the likelihood of these events. Propensity score weighting and regression adjustment were used to adjust for potentially different characteristics of patients who did and did not receive podiatric care. The sample included 27 545 patients aged greater than 65+ years (Medicare‐eligible patients with employer‐sponsored supplemental insurance) and 20 208 patients aged lesser than 65 years (non Medicare‐eligible commercially insured patients). Care by podiatrists in the year prior to a diabetic foot ulcer was associated with a lower hazard of lower extremity amputation, major amputation and hospitalisations in both non Medicare‐eligible commercially insured and Medicare‐eligible patient populations. Systematic differences between patients with diabetes and foot ulcer, receiving and not receiving care from podiatrists were also observed; specifically, patients with diabetes receiving care from podiatrists tend to be older and sicker.     

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.     

Cilostazol prevents foot ulcers in diabetic patients with peripheral vascular disease

Diabetic patients are at high risk of foot ulcerations that may lead to limb amputations with important socio‐economic impact. Peripheral vascular disease may be frequently associated in diabetes mellitus type II with its main symptom, intermittent claudication. Many studies reported the known efficacy of cilostazol in treating vascular claudication. Metalloproteinase‐9 (MMP‐9) seems to be a biochemical marker implicated in chronic wounds and in particular in diabetic foot ulcers. Cilostazol appears to have a lowering effect on MMP‐9 levels and this may suggest a beneficial effect in order to prevent or retard the onset of foot ulcer in diabetic patients. In our study, two groups of diabetic patients with peripheral vascular disease were divided into two groups according to the presence of claudication in order to receive cilostazol. Group A (31 patients without claudication) were not eligible to receive cilostazol whereas Group B (47 patients with claudication) received cilostazol administration for 24 weeks (100 mg orally twice daily). Median follow up was of 16 months. During the follow up, 4·25% of patients of Group B and 35·48% of patients of Group A (P < 0·01) showed onset of foot ulceration. Although further randomised and controlled studies are required cilostazol seems to show beneficial effects for primary prevention of diabetic foot ulcers.     

Hallux Ulceration in Diabetic Patients

We undertook a prospective cohort study to assess risk factors associated with hallux ulceration, and to determine the incidence of healing or amputation, in consecutive patients with diabetes mellitus who were treated over the observation period extending from September 2004 to March 2005, at the Jabir Abu Eliz Diabetic Centre, Khartoum City, Sudan. There were 122 diabetic patients in the cohort (92 males and 30 females) with an overall mean age of 58 ± 9 years. Fifty-three percent of patients had complete healing within 8 weeks and 43% healed within 20 weeks. The overall mean time to healing was 16 ± 8 weeks. In 32 (26.2%) patients, osteomyelitic bone was removed, leaving a healed and boneless hallux. The hallux was amputated in 17 (13.9%) patients; in 2 (1.6%) patients it was followed by forefoot amputation and in 7 (5.7%) patients by below-the-knee amputation. In 90 (73.8%) patients the initial lesion was a blister. In conclusion, hallux ulceration is common in patients with diabetes mellitus and is usually preceded by a blister. Neuropathy, foot deformity, and wearing new shoes are common causative factors; and ischemia, osteomyelitis, any form of wound infection, and the size of the ulcer are main outcome determinants. Complete healing occurred in 103 (85%) of diabetic patients with a hallux ulcer. Vascular intervention is important relative to limb salvage when ischemia is the main cause of the ulcer.     

Total-contact casting as an adjunct to promote healing of pressure ulcers in amputees

Partial foot amputations have become increasingly prevalent among long-lived diabetic patients. These patients have lower extremity neuropathy and are prone to ulceration at their amputation site. These ulcers are difficult to heal, and they place a significant financial and resource burden on the healthcare system. We examined the efficacy of total-contact casts (TCC) in diabetic amputees with nonhealing partial foot amputation site neuropathic ulcers. Data were collected retrospectively on all patients with amputations who were treated with a total-contact cast between December 2000 and December 2003. Seventeen patients (13 men, 4 women) with amputation site ulceration were identified. All patients were diagnosed with neuropathy secondary to diabetes and none had wound healing compromised by ischemia. The initial ulcer averaged 1,169 mm(2) with a depth of 2.77 mm. Patients were treated with an average of 7.9 cast applications over 8.4 weeks; 47% (8/17) of ulcers healed, but 29% (5/17) of patients were unable to complete their recommended treatment course secondary to complications from the TCC. Of the patients who were able to complete their treatment course, the healing rate was 66.7% (8/12). The recurrence rate for healed ulcers was 63% (5/8). Partial foot amputations with neuropathic ulcers present a very difficult problem to the vascular surgeon. Patient compliance and underlying medical comorbidities limit the success rate. In patients who can complete a TCC treatment course, good short term results can be expected. However, recurrence rates are high following discontinuation of mechanical TCC off-loading.     

Non traumatic lower extremity amputations in younger patients: an 11‐year retrospective study

The purpose of this study was to assess morbidity and mortality in patients undergoing non traumatic lower extremity amputations ≤65 years to identify the specific needs of these younger patients. A retrospective study was conducted to determine the demographics, comorbidity and mortality with below‐knee amputations and above‐knee amputations from 1998 to 2008. A total of 203 amputations were performed on 176 patients who were ≤65 years. Major comorbidities and associated physical findings were peripheral vascular disease, diabetes, pain, gangrene, hypertension, ulcer, local wound infection and hypercholesterolemia. Compared to patients who were not deceased post‐amputation, those deceased had a higher prevalence of diabetes, renal failure, coronary artery disease (CAD) and sepsis. Significant predictors of mortality were renal failure (hazard ratio [HR] = 4·19; 95% CI 1·96–8·93), CAD (HR = 3·33; 95% CI 1·42–7·81) and amputation site (above‐knee) (HR = 3·26; 95% CI 1·51–7·04). This study showed that younger patients may benefit from an interdisciplinary approach in treating local foot ulcers aggressively and optimising their cardiovascular, renal and diabetic risk factors.     

Validation of an algorithm to predict reulceration in amputation patients with diabetes

The aim of this article was to assess the ability to predict reulceration in people with diabetes and a history of minor amputation according to the formula proposed by Miller et al. A retrospective study was performed on 156 consecutive records of patients with a recent history of simple or multiple forefoot amputation. The sample was divided according to Miller's formula into patients at low risk of reulceration and those at high risk; those were further divided into two subgroups according to whether or not the first segment of the forefoot had been amputated. Forty‐eight (47·1%) individuals suffered forefoot reulceration, showing a median reulceration‐free survival time of 8 months [interquartile range (IR) 3·6–14·8]. Nephropathy (P = 0.005) and Miller's formula (P = 0.028) were risk factors for reulceration‐free survival time in the univariate analysis. The pattern relating to the first segment amputated [hazard ratio (HR) 2·853; P = 0·004; 95% confidence interval (CI) 1·391–5·849] and nephropathy (HR 2·468; P = 0.004; 95% CI 1.328–4.587) showed a significant hazard ratio in the multivariate Cox model. Participants with first segment amputation and one other amputation showed an association with the probability of reulceration in comparison with any other specific type of minor amputation.     

Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team

A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes‐related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty‐three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below‐knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.     

A cohort study of diabetic patients and diabetic foot ulceration patients in China

To determine the annual incidence and clinically relevant risk factors for foot ulceration in a large cohort study of diabetic foot ulcer (DFU) patients and diabetes mellitus (DM) patients in China. To investigate a cohort of 1,333 patients comprising 452 DFU patients and 881 DM patients, who underwent foot screening, physical examination, and laboratory tests in eight hospitals. The patients were assessed at baseline in terms of their demographic information, medical and social history, peripheral neuropathy disease (PND) screening, periphery artery disease (PAD) screening, assessment of nutritional status, and diabetic control. One year later, the patients were followed up to determine the incidence of new foot ulcers, amputation, and mortality. By univariate analysis, statistically significant differences were found in age, location, gender, living alone (yes/no), occupation, smoking, hypertension, PND, PAD, nephropathy, retinopathy, cataracts, duration of diabetes, Glycosylated hemoglobin A (HbA1c), fasting plasma glucose level, postprandial blood glucose level, insulin level, blood urea nitrogen, creatinine, cholesterol, triglyeride, high density lipoprotein (HDL), serum albumin, white blood cell, and body mass index. A binary logistic regression model was used to examine which of these risk factors were independent risk factors for foot ulceration. A total of 687 (51.5%) of the 1,333 patients were followed up for an average of 12 months; there were 458 DM patients and 229 DFU patients. A total of 46 patients died during the follow‐up period; 13 were DM patients, and 33 were DFU patients. Of the 641 patients, 445 (69.4%) patients were DM patients, and 196 (30.6%) were DFU patients. At follow‐up, 36/445 DM patients (8.1%), and 62/196 DFU patients (31.6%), developed new ulcers; 10/196 DFU patients underwent an amputation. The annual incidence of ulceration for DM patients and amputation for DFU patients were 8.1 and 5.1%, respectively. The annual mortality of the DM patients and DMF patients were 2.8 and 14.4%, respectively. A binary logistic regression model was used to examine which risk factors were independent risk factors for foot ulceration during the follow‐up period, and the final results showed that nephropathy (odds ratio 2.32), insulin level (odds ratio 3.136, 2.629), and decreased HDL (odds ratio 0.427) were associated with increased risks for foot ulceration. Complications of diabetes affecting the feet represent a serious problem in China. The incidence of foot ulcers and amputation are much higher than that of Western countries. More intensive surveillance and aggressive care following a diagnosis of DFU and earlier referral to specialty care might improve the patient outcome.     

Temporal association between the incidence of foot ulceration and the start of dialysis in diabetes mellitus.

BACKGROUND: The aim of this study was to seek a temporal association between the start of renal replacement therapy (RRT) and the first recorded foot ulcer in diabetes. METHODS: Details of all patients with diabetes who had received RRT were extracted from the renal database and were cross-checked with the database held in the specialist foot clinic. The date of onset of first registered foot ulcer was taken and compared with the date of onset of RRT. The self-controlled case-series method was used to establish any significant temporal association between the start of RRT and first recorded foot ulcer in diabetes. RESULTS: Of 466 patients with diabetes dialysed at our hospital since 1976, 94 (20.2%) were recorded as having at least one foot ulcer, with 15 of these undergoing major amputation. Incidence ratios (IRs) were calculated for 90 patients in whom complete data were available. A close temporal association was observed between the start of RRT and the first recorded foot ulceration: IR (95% CI) in the first and between the second and fifth years of dialysis were 3.35 (95% CI: 1.59-7.04), and 4.56 (2.19-9.50), respectively, relative to the time before dialysis. The IR for major amputation was 31.98 (2.09-490.3) in the first year and 34.01 (1.74-666.2) in the second to fifth years. CONCLUSION: These results reveal a close relationship between the onset of RRT in diabetes and the onset of foot ulceration, and confirm the high incidence of amputation in those on dialysis. Urgent steps should be taken to coordinate all aspects of diabetes foot care before and after the start of RRT.     

Heel overload associated with heel cord insufficiency

BACKGROUND: Heel cord lengthening is a common component of foot and ankle surgery. If the tendon is anatomically or functionally over lengthened patients may develop plantarflexion weakness and heel overload problems such as symptomatic plantar heel callosities and heel ulceration. METHODS: Nine patients who developed heel overload or heel ulcer after a heel cord lengthening or an irreparable rupture were identified. Initial foot injury, risk factors, treatment, and followup were reviewed. RESULTS: Five of the nine patients had diabetes and an insensate heel. The ulcer healed in two of five patients with a dorsiflexion stop brace, two with a tendon transfer, and one required a below knee amputation. There were four patients with heel overload with normal sensation and no diabetes. One improved with strengthening exercises, two with tendon transfer, and one required a below knee amputation. CONCLUSIONS: Heel cord insufficiency can lead to an overload callus or a heel ulcer. Patients with diabetes and an insensate heel are at highest risk, but this problem also can occur in patients with normal sensation. Obesity and ipsilateral first toe amputation also may be risk factors.     

Foot complications in people with diabetes

Foot complications are the most common cause of hospital admission of people with diabetes and a frequent cause of amputation. Neuropathy and peripheral arterial disease make the foot particularly vulnerable to ulceration, but infection is often the pathology precipitating presentation. Recognition of the patient at risk of ulceration may allow interventions to prevent the development of foot complications. When complications do occur, urgent treatment is required to prevent limb loss; the infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours after presentation. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputations in some European countries.     

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.