Clinical Evidence Handbook

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Diabetes: Foot Ulcers and Amputations



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Am Fam Physician. 2009 Oct 15;80(8):789-790.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 785.

Diabetic foot ulceration is full-thickness penetration of the dermis of the foot in a person with diabetes. Severity is classified as Grade 1 through 5 using the Wagner system.

  • The annual incidence of ulcers among persons with diabetes is 2.5 to 10.7 percent in resource-rich countries, and the annual incidence of amputation for any reason is 0.25 to 1.8 percent.

  • For persons with healed diabetic foot ulcers, the five-year cumulative rate of ulcer recurrence is 66 percent and of amputation is 12 percent.

The most effective preventive measure for major amputation seems to be screening and referral to a foot care clinic if high-risk features are present.

  • Other interventions for reducing the risk of foot ulcers include wearing therapeutic footwear and increasing patient education for prevention, but we did not find sufficient evidence to ascertain the effectiveness of these treatments.

Pressure off-loading with total-contact casting or nonremovable fiberglass casts successfully improves healing of ulcers.

  • Removable cast walkers that are rendered irremovable seem equally effective, but have the added benefit of requiring less technical expertise for fitting.

  • We do not know whether pressure offloading with felted foam or pressure-relief half shoe is effective in treating diabetic foot ulcers.

Human skin equivalent (applied weekly for a maximum of five weeks) seems to promote ulcer healing more effectively than saline moistened gauze.

  • Human cultured dermis does not seem to be effective at promoting healing.

Topical growth factors seem to increase healing rates, but there has been little long-term follow-up of persons treated with these factors.

Systemic hyperbaric oxygen seems to be effective in treating persons with severely infected ulcers, although it is unclear whether it is useful in persons with non-infected, nonischemic ulcers.

We do not know whether debridement or wound dressings are effective in healing ulcers.

  • However, debridement with hydrogel and dimethyl sulfoxide wound dressings seems to promote ulcer healing.

  • Debridement and wound dressings have been included together because the exact mechanism of the treatment can be unclear (e.g., hydrogel).

Clinical Questions

What are the effects of interventions to prevent foot ulcers and amputations in persons with diabetes?

Likely to be beneficial

Screening and referral to foot care clinics

Unknown effectiveness

Education

Therapeutic footwear

What are the effects of treatments in persons with diabetes with foot ulceration?

Likely to be beneficial

Human skin equivalent

Pressure off-loading with total-contact or nonremovable cast for plantar ulcers

Systemic hyperbaric oxygen (for infected ulcers)

Topical growth factors

Unknown effectiveness

Debridement or wound dressings

Pressure off-loading with felted foam or pressure-relief half shoe

Systemic hyperbaric oxygen (for noninfected, nonischemic ulcers)

Unlikely to be beneficial

Human cultured dermis

Clinical Questions

View Table

Clinical Questions

What are the effects of interventions to prevent foot ulcers and amputations in persons with diabetes?

Likely to be beneficial

Screening and referral to foot care clinics

Unknown effectiveness

Education

Therapeutic footwear

What are the effects of treatments in persons with diabetes with foot ulceration?

Likely to be beneficial

Human skin equivalent

Pressure off-loading with total-contact or nonremovable cast for plantar ulcers

Systemic hyperbaric oxygen (for infected ulcers)

Topical growth factors

Unknown effectiveness

Debridement or wound dressings

Pressure off-loading with felted foam or pressure-relief half shoe

Systemic hyperbaric oxygen (for noninfected, nonischemic ulcers)

Unlikely to be beneficial

Human cultured dermis

Definition

Diabetic foot ulceration is full-thickness penetration of the dermis of the foot in a person with diabetes. Ulcer severity is often classified using the Wagner system. Grade 1 ulcers are superficial ulcers involving the full skin thickness, but no underlying tissues. Grade 2 ulcers are deeper, penetrating down to ligaments and muscle, but not involving bone or abscess formation. Grade 3 ulcers are deep ulcers with cellulitis or abscess formation, often complicated with osteomyelitis. Ulcers with localized gangrene are classified as Grade 4, and those with extensive gangrene involving the entire foot are classified as Grade 5.

Incidence

Studies conducted in Australia, Finland, the United Kingdom, and the United States have reported the annual incidence of foot ulcers among persons with diabetes as 2.5 to 10.7 percent, and the annual incidence of amputation for any reason as 0.25 to 1.8 percent.

Etiology

Long-term risk factors for foot ulcers and amputation include duration of diabetes, poor glycemic control, microvascular complications (retinopathy, nephropathy, and neuropathy), peripheral vascular disease, foot deformities, and previous foot ulceration or amputation. Strong predictors of foot ulceration are altered foot sensation, foot deformities, and previous foot ulcer or amputation of the other foot (altered sensation [relative risk (RR) = 2.2; 95% confidence interval (CI), 1.5 to 3.1]; foot deformity [RR = 3.5; 95% CI, 1.2 to 9.9]; previous foot ulcer [RR = 1.6; 95% CI, 1.2 to 2.3]; previous amputation [RR = 2.8; 95% CI, 1.8 to 4.3]).

Prognosis

In persons with diabetes, foot ulcers often coexist with vascular insufficiency (although foot ulcers can occur in persons with no vascular insufficiency) and may be complicated by infection. Amputation is indicated if disease is severe or does not improve with conservative treatment. In addition to affecting quality of life, these complications of diabetes account for a large proportion of diabetes-related health care costs. For persons with healed diabetic foot ulcers, the five-year cumulative rate of ulcer recurrence is 66 percent and of amputation is 12 percent. Severe infected foot ulcers are associated with an increased risk of mortality.

Author disclosure: Nothing to disclose.


search date: November 2007

Adapted with permission from Hunt D. Diabetes: foot ulcers and amputations. Clin Evid Handbook. June 2009:124–125. Please visit http://www.clinicalevidence.bmj.com for full text and references.

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.



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