Elsevier

The Lancet

Volume 361, Issue 9368, 3 May 2003, Pages 1545-1551
The Lancet

Review
Diabetic foot ulcers

https://doi.org/10.1016/S0140-6736(03)13169-8Get rights and content

Summary

Ulceration of the foot in diabetes is common and disabling and frequently leads to amputation of the leg. Mortality is high and healed ulcers often recur. The pathogenesis of foot ulceration is complex, clinical presentation variable, and management requires early expert assessment. Interventions should be directed at infection, peripheral ischaemia, and abnormal pressure loading caused by peripheral neuropathy and limited joint mobility. Despite treatment, ulcers readily become chronic wounds. Diabetic foot ulcers have been neglected in health-care research and planning, and clinical practice is based more on opinion than scientific fact. Furthermore, the pathological processes are poorly understood and poorly taught and communication between the many specialties involved is disjointed and insensitive to the needs of patients.

Published online Feb 25,2003 http://image.thelancet.com/extras/02art6190web.pdf

Section snippets

Incidence and prevalence

Although accurate figures are difficult to obtain for the prevalence or incidence of foot ulcers, the results of cross-sectional community surveys in the UK showed that 5·3% (type 2)1 and 7·4% (type 1 and 2 combined)2 of people with diabetes had a history of active or previous foot ulcer. The lifetime risk for any diabetic patient is up to 15%.3 Ramsey and colleagues4 noted a cumulative 3-year incidence of 5·8% in diabetic patients in the USA, but this value was based on hospital discharge

Predisposing and precipitating factors

Many overlapping factors lead to foot ulceration;31, 32, 33, 34, 35 they put the foot at risk, precipitate a break in the skin, or impair healing. The peripheral neuropathy of diabetes results in abnormal forces being applied to the foot, which diabetic ischaemia renders the skin less able to withstand. Other complications contributing to the onset of ulceration include poor vision, limited joint mobility, and the consequences of cardiovascular and cerebrovascular disease. However, the most

Failure to heal

Bacterial infection, tissue ischaemia, continuing trauma, and poor management cause diabetic foot ulcers to heal slowly and transform readily into chronic wounds.

Biology of the chronic wound

Wound healing involves a cascade of interacting phases of haemostasis, inflammation, proliferation, epithelialisation, and scar maturation, which can be affected by diabetes and its complications.50, 51, 52 Impairment of leucocyte function and proliferation occur in hyperglycaemia,53, 54 but the overall effect of the disease on healing is complex. The benefit of good blood glucose control has not been assessed, but is likely to be important, even though the rate of healing of neuropathic ulcers

Classification of foot ulcers

There is no widely accepted method for classifying or even describing foot ulcers.56, 57 Non-specialists commonly refer to all ulcers as diabetic foot. Two international working parties are trying to define a system of describing individual ulcers to improve communication and develop a classification for audit and research.14, 58 Without classification, selection of comparable populations for urgently needed multicentre trials will be impossible.

Principles of management

The first principle is to treat any infection; the second is to establish whether any associated ischaemia is amenable to revascularisation; the third is to keep forces applied to the ulcerated part to a minimum; and the fourth is to improve the condition of the wound or ulcer by wound-bed preparation, topical applications, and removal of callus. Once the wound has healed, attention can be turned to the prevention of ulcer recurrence.

Prevention

Primary prevention is the aim of diabetes management, but secondary prevention is the goal of good foot-ulcer care. The recurrence rate is high13 and ulcer healing should be followed by a well coordinated programme of secondary prevention. Sadly, this approach is beyond the capacity of health services in most countries. Surgery to correct deformities and abnormalities of posture, gait, and load-bearing74 (eg, lengthening the achilles tendon) has a place in both primary and secondary prevention,

Structure of care

Successful management of diabetic foot ulcers requires close collaboration between many different groups in primary care and in the hospital service, and this collaboration might not be easy to establish while traditional barriers between health-care professionals remain in place. Supervision is also made difficult by the frequent coincidence of both social and medical problems, when the patient may be looked after by independent teams of professional carers. The needs and wishes of the patient

Assessing effectiveness of care

The effectivenesss of recommended practice needs rigorous assessment, and for that more meaningful measurements have to be available. A reduction in major amputations has been reported by some specialist units, 29, 71, 116, 117, 118 including those serving an entire community where altered referral practice is not an issue. In some cases, however, the initial rate was rather 71, 116 Other studies record no change in incidence of amputation,119, 120, 121 or even an increase.122, 123 However, as

Conclusions

Investment is urgently needed for basic research into the pathophysiology of chronic wounds. Clinical management lacks a scientific basis and is determined by personal preference and the availability of local expertise and facilities. Therefore, clinicians should identify differences between centres, and undertake robust clinical trials of management, using appropriate end-points. Speedy and effective care will be possible only with effective communication and collaboration between all relevant

Search strategy and selection criteria

The authors based the review on personal knowledge of the subject, supplemented by information derived from comprehensive reviews of the different aspects of the subject area. This information was crosschecked with repeated searches on PubMed for articles recently published using the following index terms: diabetes, foot ulcer, amputation, vascular surgery, neuropathy, osteomyelitis, Charcot.

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