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Preventing Preventable Diabetes Foot Disease
Part 1: The Problem

Well, my friends, it’s a Friday night at 5:00 PM. I was about to go home after clinic when one of my residents called me with a new patient consultation at the hospital: a septic diabetic patient with an abscess. Isn’t that always the way it goes? When I was a student, one of my very astute attendings made the comment “pus doesn’t take a holiday.” Tonight it seemed that for this patient situation, pus actually did take a holiday and decided to come back just at the right time – on Friday night at 5:00 PM. Unfortunately for my patient, this needed to go to the operating room.

It’s tough to have an emergent case at just the wrong time, but this situation is much sadder than my inconvenience. In reality, my poor patient’s dilemma demonstrates how unnecessary diabetic foot infections are. The vast majority of diabetic foot infections are the result of chronic, low-grade issues that could have been avoided with appropriate preventative care. Take a look at my patient’s clinical images below.

You’ll note the dry gangrenous fifth toe with the associated erythema and ascending lymphangitis plantarly, along with the hemorrhagic bulla. Take a look at the radiographs and CT scan. To be clear, I didn’t order the CT myself. That was ordered by someone else, and my resident didn’t have the opportunity to cancel the order. However, it’s interesting for our sake to demonstrate the soft tissue emphysema.

Now, what’s important for our discussion is that the clinical picture I’m attempting to paint for you is one of a chronic process that became acute.

And, again, it was entirely preventable.

Let’s take a step back and consider some of the well-known statistics on the diabetic foot.

Between 15% and 25% of diabetics will develop a foot ulcer at some time.
Two-6% of diabetics develop a wound yearly.¹
Eighty-four (84%) of nontraumatic limb amputations in diabetes are preceded by an ulcer.²
The odds ratio for amputation after the index ulceration is 5.7.³
Thirty-four (34%) of patients develop a new ulcer within one year of healing their first ulcer (70% at 5 years).⁴
There is a 50% risk of contralateral foot ulcer after a major limb amputation and 50% contralateral limb amputation within 2-5 years.⁵
The survival rate after a major limb amputation is 50% after three years and 40% after five years.⁶

To put these stats in perspective: the odds are simply terrible.

Is that enough perspective for you?

If you’re a diabetic and you get an ulcer, you’re highly likely to have a future one. If you ulcerate, you’re much more likely to have a major limb amputation. If that occurs, your life expectancy is much lower (not because of the amputation itself – we don’t have proof of that yet – but due to the associated cardiac comorbidities). Not good.

Another statistic pertinent to our discussion is that lower extremity infection is the most common reason for a diabetic to be admitted to a hospital. We’re also well aware that contiguous spread (normal bacterial skin flora spreading to the deep tissues through an opening in the skin) is the manner in which these infections occur. Diabetics rarely get hematogenous spread infections to the feet (luckily for us!).

With this entire picture in mind, one can understand my frustration with situations like my patient’s. This is an entirely preventable situation, yet one in which the medical community has such an incredibly difficult time preventing. There are a number of locations in the process in which WE MAY EFFECTIVELY INTERVENE:

Diabetic Foot Complication Disease Progression Line

Prevent the diabetes > halt the neuropathy > prevent the ulcer > stop the infection > limit the amputation > target limited foot amputations > active rehab after a major limb amputation.

I used a greater-than symbol between each step, because the earlier in the disease line we intervene, the more effective we are. The converse of this is also true: the later that we intervene, the less effective we are. Preventing a foot amputation is less effective overall than preventing the ulcer in the first place.

If the problem is almost 100% preventable, then how do we accomplish that goal? How do we stop our diabetic patients from becoming one of those grisly statistics? That, colleagues, will be the topic of next week’s issue. Until then, I hope your patients can stay out of the hospital, unlike mine.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References

Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382-387.

Pecoraro RE, Reiber GE, Burgess EM. Pathways to Diabetic Limb Amputation: Basis for Prevention. Diabetes Care. 1990;13(5):513-521.

Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care. 1999;22(7):1029-1035.

Apelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med. 1993;233(6):485-491.

Larsson J, Agardh CD, Apelqvist J, Stenström A. Long-term prognosis after healed amputation in patients with diabetes. Clin Orthop Relat Res. 1998;350:149-158.

Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26(2): 491-494.

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