Diabetic Foot Ulcers: 10 Facts You Should Know

Tony L. Weaver, DO
Edited by Paul M. Graham, DO

According to 2016 data from the World Health Organization (WHO), approximately 422 million adults have been diagnosed with diabetes mellitus worldwide. Diabetic foot ulcers are a source of significant morbidity and a common reason for hospital admissions. In this article, we will discuss 10 important facts about diabetic foot ulcers that every diabetic patient should be aware of.

 

1. Diabetic foot ulcers are the most common reason for hospitalization among diabetics. 

In 2012, Mississippi ranked second in the nation for overall diabetes prevalence, with over 276,000 adult Mississippians having type 2 diabetes (over 12.5% of the adult population)¹ Diabetic Foot Ulcers (DFU) are a source of considerable morbidity and are the most common cause for diabetes related hospital admissions. As many as 25% of all hospitalizations in diabetic patients are related to diabetic foot ulcers (DFU). ² Among patients greater than 20 years old, DFU account for two-thirds of all non-traumatic amputations.

2. Diabetic Foot Ulcers are caused by diabetes and its many comorbid conditions. 

Several other conditions contribute to the formation of DFU’s. Mechanical changes in the conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease are all common sources of foot pathology in this population. These all occur with a much higher frequency and intensity among diabetics. In particular, diabetic peripheral neuropathy is present in 60% of diabetic persons and 80% of diabetic persons with foot ulcers. This confers the greatest risk of foot ulceration; microvascular disease and suboptimal glycemic control also contribute. These factors must be addressed to optimize care.

3. Not all Diabetic Ulcers are the same.

In general, DFU can be classified on multiple different levels; they can be differentiated based on wound depth and the presence of infection. Treatment protocols differ based on the classification of the ulcer. There are several classification systems to help determine the extent of disease and direct treatment plans. The University of Texas (UT) classification (a well validated staging and grading system) takes into account depth, infection and ischemia status.³ The Wagner classification, threatened limb classification and PEDIS (perfusion, extent, depth, infection, and sensation) system have all been used, but are less practical than the UT model. The UT model has the added benefit of being easy to use and is a better predictor of the overall outcome.

4. Wound Care is complex and requires a combination of medical and surgical therapy.

The prevention and treatment of DFUs requires the use of multidisciplinary therapy. Medical management includes tight glycemic control, infection treatment with targeted antibiotic therapy, and strict comorbidity management.  The surgical management includes wound debridement to remove necrotic tissue, specimen collection for culture and biopsy data, and optimization of blood flow through blood vessel stenting or bypass surgery when necessary. Therapeutic strategies such as wound care and off loading of weight are useful to prevent pressure injuries and tissue loss .⁵

5. Wound care centers are speciality centers designed to reduce complications, indirectly lowering healthcare cost.

Referral to specialist has been linked to reduced hospitalizations, fewer amputations, and reduced healthcare costs. Prompt referral can lead to quicker and superior treatment.

6. Diabetic foot wound care is ultimately in the patient’s hands.

Patient compliance makes a big difference when it comes to healthcare.  Compliance with wound care, diabetes control, and therapy is essential to wound healing and limb preservation. Patients should conduct daily self foot examinations, avoid walking barefoot, practice good hygiene, and visit a medical professional for nail and callus care^5-7

7. There are specific strategies that your doctor can use to help.

All diabetic patients should have an annual lower leg and foot examination by a trained wound care professional. This increases the providers’ awareness of potential future complications and provides an excellent opportunity for patient education. Multiple modalities such as bedside examinations, ultrasounds, neurological studies, and specialty referrals should be used to provide a comprehensive evaluation.

8. Strict glucose control is one of the most important factors in wound healing as well as preventing, treating and overcoming wound infections.

Ideal glycemic control is a hemoglobin A1c < 7%. Combining this goal with additional strategies has proven to minimize the incidence of DFUs and infections, with a reduction in the risk of amputation and tissue loss. ⁶

9. Protection is prevention.

The use of custom therapeutic footwear in high-risk diabetic patients, including those with neuropathy, foot deformities, or previous amputations, prevents further tissue loss. This includes patients with DFU’s on the soles of their feet. Total contact cast or irremovable fixed ankle walking boots such as those in Figure 2 prove to be a great strategy for treatment and prevention of DFU. ⁶

10. Timing is important.

The degree of improvement over a 4-week period is a predictor of the long-term healing. The surface area of a diabetic foot ulcer should decrease in size at a rate of about 1 to 2 percent per day. Thus, appropriate local wound care should achieve a greater than 40 to 50 percent surface area reduction or reduction of ulcer depth by 4 weeks. Ulcers that do not improve should be reevaluated for ongoing malignancy, soft tissue infection or osteomyelitis, impaired extremity blood flow, and most commonly, the need for more effective off-loading or surgical debridement. ⁷

Table 1.  University of Texas (UT) Wound Classification System
Stage A	No infection or Ischemia
Stage B	Infection Present
Stage C	Ischemia Present
Stage D	Infection and Ischemia
Grade 0	Epithelialized
Grade 1	Superficial Wound
Grade 2	Wound Penetrates Tendon or Capsule
Grade 3	Wound Penetrates to bone or joint
*Adapted from Oyibo et al.

References:

1. Mississippi Department of Health Diabetes in Mississippi. http://msdh.ms.gov/msdhsite/_static/43,0,296.html
2. American Diabetes Association: Statistics about diabetes: diabetes from the national diabetes statistics report, 2014 (released 06/10/14). http://www.diabetes.org/diabetes-basics/statistics/ (Accessed on August 12, 2016).
3. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ, A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001;24(1):84.
4. Armstrong DG, Lavery LA, Nixon BP, Boulton AJ: It’s not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis 39:S92-S99, 2004
5. Amputation and diabetes: How to protect your feet. (2014, September 26). Retrieved from http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/amputation-and-diabetes/art-20048262
6. Hingorani, A., LaMuraglia, G. M., & Henke, P. (2015, October 8). The manaement of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Pediatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery, 63, 1S-20S
7. Sheehan P, Jones P, Giurini JM, Caselli A, Veves A, Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Plast Reconstr Surg. 2006;117(7 Suppl):239S.
8. Gregg EW, Sorlie P, Paulose-Ram R, Gu Q, Eberhardt MS, Wolz M, Burt V, Curtin L, Engelgau M, Geiss L, 1999-2000 National Health and Nutrition Examination Survey. Diabetes Care. 2004;27(7):1591.
9. Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, Wagner EH Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382.
10. Amin N, Doupis J. Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities. World J Diabetes. 2016 Apr 10. 7 (7):153-64.
11. Naves CC. The Diabetic Foot: A Historical Overview and Gaps in Current Treatment. Adv Wound Care (New Rochelle). 2016 May 1. 5 (5):191-197.
12. Wrobel JS, Charns MP, Diehr P, Robbins JM, Reiber GE, Bonacker KM, Haas LB, Pogach L. The relationship between provider coordination and diabetes-related foot outcomes. Diabetes Care. 2003;26(11):3042.

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