2000 Jun 10;320(7249):1589-91[Texto
of arterial and venous disease. Ulcerated lower limb.
NJ, Donnelly R
of Nottingham, UK.
Med 1999 Oct;16(10):799-800
foot disease--where is the evidence?
Comment on: Diabet Med 1999 Oct;16(10):801-12
Care 1999 Aug;22(8):1354-60
Development Conference on Diabetic Foot Wound Care: 7-8 April 1999,Boston,
Massachusetts. American Diabetes Association.
Diabetes Association, Alexandria, VA 22314, USA.
Consensus development conference
1999 Jul 31;319(7205):318 [Texto
of lower limb amputation in diabetic patients. Particular attention should
be paid to dominant foot at regular review.
PM, Williams C, Page MD, Alcolado JC
Comment on: BMJ 1999 Feb 6;318(7180):367
Med 1999 Jul;106(1):97-102 [Texto
wound care in diabetic foot complications. Aggressive risk management and
ulcer treatment to avoid amputation.
Podiatry Associates, Florence, South Carolina 29505, USA.firstname.lastname@example.org
to prevent and treat lower extremity amputation in patients with diabetes
vary from simple foot inspection to complicated vascular and
reconstructive surgery. Early identification of risk factors, careful and
regular evaluation, and aggressive treatment in a multidisciplinary team
approach prevent amputation in most cases of diabetic foot ulcer. Suitable
treatment of these ulcers consists of minimizing pressure, resolving
infection, correcting ischemia, and maintaining a warm, moist, clean
environment to enhance wound healing. Success in these efforts not only
preserves quality of life for diabetic patients but also saves money for
the healthcare system.
Comment in: Postgrad Med 1999 Nov;106(6):27
Med 1999 Jul;106(1):85-6, 89-94 [Texto
therapy for diabetic foot infections. A practical approach.
of the diabetic foot is a common problem in clinical practice and is
associated with significant morbidity. Optimal management requires a
multidisciplinary approach. Aggressive surgical debridement and wound
management, carefully chosen antimicrobial therapy, and modification of
host factors (i.e., hyperglycemia, concomitant arterial insufficiency) are
all equally important for a successful outcome. Empirical antibiotic
selection should be followed by culture-guided definitive therapy.
Med 1999 Jul;106(1):74-8, 83 [Texto
diabetic foot complications. Tight glucose control and patient education
are the keys.
JL Division of Endocrinology, Carolina Health Care, Florence, SC 29501,
disease is a common complication of diabetes that can have tragic
consequences. Tight glucose control can reduce microvascular diabetic
complications, including peripheral sensory neuropathy and thus
development of foot ulcers. Patient education is essential for risk-factor
reduction and early recognition of foot complications. Awareness and
training of healthcare providers in diagnosing and treating diabetic foot
disease are paramount and may begin with such simple measures as adding a
wall poster or chart reminder to conduct foot examinations in all diabetic
patients at every office visit.
Care 1999 May;22(5):692-5
of diabetic neuropathic foot ulcers receiving standard treatment. A
DJ, Kantor J, Berlin JA
of Dermatology, University of Pennsylvania School of Medicine,
Philadelphia 19104, USA. email@example.com
The aim of the study was to determine the percentage of individuals with
neuropathic diabetic foot ulcers receiving good wound care who heal within
a defined period of time. RESEARCH DESIGN AND METHODS: We conducted a
systematic review of the control groups of clinical trials that evaluated
a treatment for diabetic neuropathic foot ulcers. The meta-analytic
techniques used include an estimation of the weighted mean percentage
healed by end point, an evaluation of the homogeneity of trials, and an
estimate of the 95% CI of the grouped data. Grouped-data univariate and
multivariate logistic regression was conducted to assess the impact of
mean age, ulcer size, and duration on the percentage of ulcers healed at
end point. RESULTS: We found a total of 10 control groups meeting our
criteria. Six control groups used 20 weeks as the end point for healing or
nonhealing. For the six control arms with a 20-week end point, we found a
weighted mean healing rate of 30.9% (95% CI 26.6-35.1). A similar analysis
for the four 12-week arms found a mean healing rate of 24.2% (19.5-28.8).
We failed to detect any statistically significant heterogeneity for either
the 20-week or the 12-week trials. CONCLUSIONS: After 20 weeks of good
wound care, approximately 31% of diabetic neuropathic ulcers heal.
Similarly, after 12 weeks of good care, approximately 24% of neuropathic
ulcers attain complete healing. Further patient-level analyses are
necessary to definitively determine the associations of age, wound size,
and wound duration with likelihood of healing.
J Surg 1998 Aug;176(2A Suppl):11S-19S
development and complications of diabetic foot ulcers.
Wrexham Maelor Hospital, Clwyd, United Kingdom.
and ischemia, two common complications of diabetes mellitus, are the
primary underlying risk factors for the development of foot ulcers and
their complications. The presence of symmetric distal polyneuropathy,
encompassing motor, sensory, and autonomic involvement, is one of the most
important factors in the development of diabetic foot ulcers. Perhaps one
third of diabetic foot ulcers have a mixed neuropathic and ischemic
etiology. Although neuropathy and ischemia are the primary predisposing
factors in the formation of diabetic foot ulcers, an initiating factor,
such as physical or mechanical stress, is required for an ulcer to
develop. Ischemic ulcers develop as a result of low perfusion pressure in
a foot with inadequate blood supply, whereas neuropathic ulcers result
from higher pressures in a foot with adequate blood supply but loss of
protective sensation. In addition to increasing the risk of ulceration,
diabetes mellitus also increases the risk of infection by impairing the
body's ability to eliminate bacteria. The processes by which ulcers
develop are reviewed here.
J Surg 1998 Aug;176(2A Suppl):5S-10S
burden of diabetic foot ulcers.
GE, Lipsky BA, Gibbons GW
of Epidemiology and Health Services, University of Washington, VA Puget
Sound Health Care System, Seattle 98108, USA.
extremity ulcers represent a major concern for patients with diabetes and
for those who treat them, from both a quality of life and an economic
standpoint. Studies to evaluate quality of life have shown that patients
with foot ulcers have decreased physical, emotional, and social function.
Analyses of economic impact have shown (1) the majority of costs occur in
the inpatient setting, (2) a lack of financial benefit when comparing
primary amputation with an aggressive approach to limb salvaging including
vascular reconstruction, and (3) private insurance provides greater
reimbursement for inpatient care than does Medicare. Results of etiologic
studies suggest that hyperglycemia induces diabetes-related complications
through sorbitol accumulation and protein glycation, and the resultant
nerve damage manifests as peripheral neuropathy, which predisposes to
ulcer development. Patients with diabetes also have an increased incidence
of peripheral vascular disease, impaired wound healing, and decreased
ability to fight infection. In light of these factors, it is sometimes
difficult to determine the optimal course for patient management. This
review is aimed at helping healthcare providers make better decisions
about treatment, resource use, and strategies for future foot ulcer
Clin North Am 1998 Dec;33(4):629-41
amputations in the diabetic population.
Care Division, Yale University School of Nursing, New Haven, Connecticut
than 50% of all lower extremity amputations occur in patients with
diabetes. This phenomenon is largely preventable through risk factor
reduction and proper foot care education. In cases where lower extremity
injury or infection are present prompt and aggressive care can preserve
the limb. New techniques for revascularization to ulcerated areas of the
foot are promoting wound healing and improving long term outcomes.
Clin North Am 1998 Jul;82(4):949-71
problems in diabetes.
of Orthopaedic Surgery, Lahey Clinic, Burlington, Massachusetts, USA.
and care of diabetic foot complications continue to represent a major
challenge to the treating clinician. Neuropathy, infection, deformity, and
vascular insufficiency threaten the diabetic foot and the overall
functional well being of the diabetic patient. Although foot problems in
diabetes cannot be eradicated completely, the opportunity exists to
diagnose and manage diabetic foot conditions effectively, to educate and
motivate patients to care for their feet, to minimize complications, and
to decrease health care costs.
Fam Physician 1998 Jun;57(11):2705-10 [Texto
Charcot foot in diabetes: six key points.
GM, Ulbrecht J, Cavanagh PR, Juliano P
of General Internal Medicine, Pennsylvania State University College of
Medicine, Milton S. Hershey Medical Center, Hershey, Pa., USA.
Charcot foot commonly goes unrecognized, particularly in the acute phase,
until severe complications occur. Early recognition and diagnosis,
immediate immobilization and a lifelong program of preventive care can
minimize the morbidity associated with this potentially devastating
complication of diabetic neuropathy. If unrecognized or improperly
managed, the Charcot foot can have disastrous consequences, including
amputation. The acute Charcot foot is usually painless and may mimic
cellulitis or deep venous thrombosis. Although the initial radiograph may
be normal, making diagnosis difficult, immediate detection and
immobilization of the foot are essential in the management of the Charcot
foot. A lifelong program of patient education, protective footwear and
routine foot care is required to prevent complications such as foot
Fam Physician 1998 Mar 15;57(6):1325-32, 1337-8 [Texto
foot ulcers: prevention, diagnosis and classification.
DG, Lavery LA
of Orthopaedics, University of Texas Health Science Center at San Antonio,
ulcers are the most common foot injuries leading to lower extremity
amputation. Family physicians have a pivotal role in the prevention or
early diagnosis of diabetic foot complications. Management of the diabetic
foot requires a thorough knowledge of the major risk factors for
amputation, frequent routine evaluation and meticulous preventive
maintenance. The most common risk factors for ulcer formation include
diabetic neuropathy, structural foot deformity and peripheral arterial
occlusive disease. A careful physical examination, buttressed by
monofilament testing for neuropathy and noninvasive testing for arterial
insufficiency, can identify patients at risk for foot ulcers and
appropriately classify patients who already have ulcers or other diabetic
foot complications. Patient education regarding foot hygiene, nail care
and proper footwear is crucial to reducing the risk of an injury that can
lead to ulcer formation. Adherence to a systematic regimen of diagnosis
and classification can improve communication between family physicians and
diabetes subspecialists and facilitate appropriate treatment of
complications. This team approach may ultimately lead to a reduction in
lower extremity amputations
related to diabetes.
Infect Dis 1997 Dec;25(6):1318-26
of the foot in diabetic patients.
Internal Medicine Clinic, Veterans Affairs Puget Sound Health Care System,
Seattle, Washington 98108-1532, USA.
of the foot, a common and serious problem in diabetic patients, results
from diabetes complications, especially peripheral neuropathy. Infection
generally develops by spread of contiguous soft-tissue infection to
underlying bone. The major diagnostic difficulty in diabetic patients is
distinguishing bone infection from noninfectious neuropathic bony lesions.
Certain clinical signs suggest osteomyelitis, but imaging tests are
usually needed. The 111In-labeled leukocyte scan and magnetic resonance
imaging are the most diagnostically useful. Staphylococcus aureus is the
most common etiologic agent, followed by other aerobic gram-positive
cocci. Aerobic gram-negative bacilli and anaerobes are occasionally
isolated, often in mixed infections. Antimicrobial therapy is best
directed by cultures of the infected bone, obtained percutaneously or at
surgery. Antibiotic therapy should usually be given parenterally, at least
initially, and continued for at least 6 weeks. Surgical debridement or
resection of the infected bone, when feasible, improves the outcome. With
appropriate therapy most cases of osteomyelitis can be successfully
Fam Physician 1997 Nov 15;56(8):2021-8, 2033-4 [Texto
on the care of diabetic nephropathy, retinopathy and foot disease.
RJ, Hagen MD
State University Medical Center, New Orleans, USA.
mellitus is a common disease frequently managed by family physicians.
Because of its high prevalence and associated comorbidity, diabetes
mellitus has received a great deal of attention from several specialty
organizations. The American Diabetes Association, the American Board of
Family Practice and the Centers for Disease Control and Prevention have
published specific practice guidelines and recommendations for the care of
diabetic patients. These recommendations include annual comprehensive foot
examinations, yearly ophthalmologic screening for retinopathy, and
urinalysis for microalbuminuria. The use of angiotensin converting enzyme
inhibitors is advocated for the majority of diabetic patients with
proteinuria or hypertension. Based on recent evidence, improved glycemic
control is also increasingly advocated. Compliance with practice
guidelines by primary care physicians has historically been poor.
Mechanisms such as the use of patient problem lists and diabetic flow
sheets can serve as reminders to physicians and can facilitate closer
adherence to practice guidelines.
Fam Physician 1997 Jul;56(1):195-202
infections in patients with diabetes.
GM, Joshi N, Weitekamp MR
S. Hershey Medical Center, Hershey, Pennsylvania, USA.
combination of sensory neuropathy, ischemia and direct adverse effect on
host defense mechanisms makes patients with diabetes vulnerable to foot
infections. A high degree of clinical suspicion and vigilance is necessary
for early diagnosis of soft tissue infections and their differentiation
from noninfected ulcers. Diagnosis and assessment depend primarily on
clinical history and physical examination, although radiographs, scans and
laboratory tests may also provide useful clinical data. The ability to
detect bone in the base of an ulcer with a blunt sterile probe may be
particularly useful in assisting the recognition of osteomyelitis. Most
non-limb-threatening infections are caused by Gram-positive cocci, but
more serious infections are often polymicrobial. Effective treatment is
based on a comprehensive strategy of wound care, avoidance of weight
bearing, optimal metabolic control, appropriate antibiotic use and,
possibly, surgical intervention.