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CLINICIAN’S CORNER
Preventing Foot Ulcers in Patients With Diabetes
Nalini Singh, MD;
David G. Armstrong, DPM, MSc, PhD;
Benjamin A. Lipsky, MD
JAMA. 2005;293:217-228.
ABSTRACT
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Context Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0% to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently become infected, cause great morbidity, engender considerable financial costs, and are the usual first step to lower extremity amputation.
Objective To systematically review the evidence on the efficacy of methods advocated for preventing diabetic foot ulcers in the primary care setting.
Data Sources, Study Selection, and Data Extraction The EBSCO, MEDLINE, and the National Guideline Clearinghouse databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles were also searched, along with the Cochrane Library and relevant Web sites. We reviewed the retrieved literature for pertinent information, paying particular attention to prospective cohort studies and randomized clinical trials.
Data Synthesis Prevention of diabetic foot ulcers begins with screening for loss of protective sensation, which is best accomplished in the primary care setting with a brief history and the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy with biothesiometry, measure plantar foot pressure, and assess lower extremity vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify patients based on risk and to determine the type of intervention. Educating patients about proper foot care and periodic foot examinations are effective interventions to prevent ulceration. Other possibly effective clinical interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, debridement of calluses, and certain types of prophylactic foot surgery. The value of various types of prescription footwear for ulcer prevention is not clear.
Conclusions Substantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration. These patients might benefit from certain prophylactic interventions, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical interventions.
INTRODUCTION
Among persons diagnosed as having diabetes mellitus, the lifetime risk of developing a foot ulcer is estimated to be 15%.1 Based on recent studies, the annual population-based incidence ranges from 1.0% to 4.1%2 and the prevalence ranges from 4% to 10%, which suggests that the lifetime incidence may be as high as 25%.3-4 Lower extremity disease, including peripheral arterial disease, peripheral neuropathy, foot ulceration, or lower extremity amputation, is twice as common in diabetic persons compared with nondiabetic persons and it affects 30% of diabetic persons who are older than 40 years.5 Foot ulcers cause substantial emotional, physical, productivity, and financial losses.6-9 The estimated costs of treating a diabetic foot ulcer were $28 000 in a 1999 US study,10 and $18 000 (with no amputation) and $34 000 (with amputation) in a 2000 Swedish study.11
The most costly and feared consequence of a foot ulcer is limb amputation, which occurs 10 to 30 times more often in diabetic persons than in the general population.12-13 Diabetes underlies up to 8 of 10 nontraumatic amputations, of which 85% follow a foot ulcer.1, 3, 14 The age-adjusted annual incidence for nontraumatic lower limb amputations in diabetic persons ranges from 2.1 to 13.7 per 1000 persons.2 Mortality following amputation ranges from 13% to 40% at 1 year, 35% to 65% at 3 years, and 39% to 80% at 5 years—worse than for most malignancies.2
In light of the enormous disease burden of diabetic foot ulcers, it is crucial to know if they are preventable. This review summarizes and critically evaluates evidence on the efficacy of identifying diabetic persons at high risk for foot ulcers and of interventions designed to prevent them.
METHODS
Assisted by a medical librarian, we conducted a systematic literature search using the EBSCO (EBSCO Information Services, Birmingham, Ala), MEDLINE, and the National Guideline Clearinghouse databases for articles published between January 1980 and April 2004 and used the following phrases: diabetes or diabetic, foot ulcer or infection, and prevention or preventing. The EBSCO database includes the American Medical Association Collection, Comprehensive Biomedical Reference Collection, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effectiveness, Health Business Fulltext Elite, International Pharmaceutical Abstracts, Comprehensive Nursing and Allied Health Collection, and the American Medical Association’s Archive. We also searched (1) the bibliography of each identified article; (2) the National Guideline Clearinghouse Web site (http://www.guidelines.gov); (3) an extensive printed diabetic foot reference collection15; and (4) several Web sites specializing in issues related to the diabetic foot.
This search identified 165 articles that addressed preventing diabetic foot ulcers, including 22 randomized controlled studies, most of which measured changes in the rates of foot ulceration and amputations related to various interventions. For topics on which there were only a few randomized controlled studies, we focused on selected case-control and cohort studies.
Pathophysiology of Diabetic Foot Ulcers
Causative Factors. The causal pathways leading to foot ulceration include several component causes, the most important of which is peripheral neuropathy.16 This is present to some degree in more than 50% of diabetic persons older than 60 years.17 Peripheral neuropathy must usually be profound before leading to loss of protective sensation; the consequent vulnerability to physical and thermal trauma increases the risk of foot ulceration 7-fold.18-19 A second causative factor in foot ulceration is excessive plantar pressure.20 This is related to both limited joint mobility (at the ankle, subtalar, and first metatarsophalangeal joints) and to foot deformities.21-23 In one study of patients with peripheral neuropathy, 28% with high plantar pressure developed a foot ulcer during a 2.5-year follow-up compared with none with normal pressure.24 A third component cause is trauma, especially when repetitive. Among 669 persons with a foot ulcer, 21% were attributed to rubbing from footwear, 11% were linked to injuries (mostly falls), 4% to cellulitis complicating tinea pedis, and 4% to self-inflicted trauma (eg, cutting toenails).25 Persons who had a previous foot ulceration could withstand fewer cycles of stress to their feet before an ulcer recurred.26
Contributory Factors. Once a foot ulcer develops, several factors may contribute to adverse outcomes. The most important is atherosclerotic peripheral vascular disease, which is twice as common in persons with diabetes as in persons without diabetes5 and particularly affects the femoropopliteal and smaller vessels below the knee, while frequently sparing the pedal vessels.27 Diabetes is also associated with several intrinsic wound-healing disturbances, including impaired collagen cross-linking and matrix metalloproteinase function,27-28 and immunologic perturbations, especially in polymorphonuclear leukocyte function.29-30 Furthermore, persons with diabetes have a higher rate of onychomycosis and toe-web tinea infections that can lead to skin disruption.31-34
Having a foot ulcer dramatically worsens physical, psychological, and social quality of life.6-8,35-36 The obesity and poor vision that are associated with diabetes may also impair self-care. Optimal prevention (and treatment) outcomes require both a motivated patient and an effective medical care system.
Screening to Identify Patients at Risk for Diabetic Foot Ulcers
Preventing foot complications begins with identifying those at risk. Primary care clinicians should inquire about factors known to be associated with foot ulcers, namely, previous foot ulceration (relative risk [RR], 1.6; 95% confidence interval [CI], 1.2-2.3; P = .004),37 prior lower extremity amputation (RR, 2.8; 95% CI, 1.8-4.3; P<.001),37 long duration (>10 years) of having diabetes (odds ratio [OR], 3.0; P<.04),38 poor glycemic control (glycosylated hemoglobin >9%; OR, 3.2; P<.03),38 and impaired vision (acuity <20/40; RR, 1.9; 95% CI, 1.4-2.6; P<.001).37 Clinicians should also examine the feet for structural abnormalities (eg, calluses, hammer or claw toes, flat feet, bunions), reduced joint mobility, dry or fissured skin, tinea, or onychomycosis,39-40 and also inspect footwear to ensure proper fit.
Screening for Loss of Protective Sensation. Nerve conduction studies are generally considered the criterion standard for diagnosing peripheral neuropathy. They are less useful in screening for loss of protective sensation (ie, degree of neuropathy beyond which the patient has a measurably increased risk for diabetic foot ulceration),41 and are not widely available.
Monofilament. The most frequently used instrument for detecting neuropathy is the nylon Semmes-Weinstein monofilament.42 Inability to perceive the 10g of force a 5.07 monofilament applies is associated with clinically significant large-fiber neuropathy (Figure). In 3 prospective studies, the Semmes-Weinstein monofilament identified persons at increased risk of foot ulceration with a sensitivity of 66% to 91%, a specificity of 34% to 86%, a positive predictive value of 18% to 39%, and a negative predictive value of 94% to 95%.37, 45-46 Certain brands of monofilaments are more accurate than others47 and they should not be used on more than 10 patients without a recovery period of 24 hours.42, 47
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Figure. Monofilament Test for Light Touch Sensation
The 5.07 Semmes-Weinstein monofilament consists of a plastic handle supporting a nylon filament. The filament is placed perpendicular to the skin, and pressure is applied until the filament buckles. The filament is held in place for approximately 1 second, then released. Inability to perceive the 10g of force it applies is associated with clinically significant large-fiber neuropathy.42-43 Testing 10 sites (as shown) evaluates all dermatomes of the foot and may improve the sensitivity and specificity compared with testing a single site.44
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While authorities recommend testing 8 to 10 anatomic sites, testing just 4 plantar sites on the forefoot (great toe and base of first, third, and fifth metatarsals) identifies 90% of patients with an insensate site.48 Most consider a lack of perception at any site(s) to be abnormal, but as the threshold for an abnormal test is raised from 1 to 4 insensate sites, the sensitivity remains higher than 90% while the specificity improves from 60% to 80%.44 Asking the patient to say "yes" or "no" when asked if he/she believes the Semmes-Weinstein monofilament is being applied is equally accurate and quicker than the "forced-choice" method (asking the patient to correctly identify whether it was at time "A" or "B" that the monofilament was applied).49
Biothesiometer. A biothesiometer (Xilas Medical, San Antonio, Tex) is a handheld device that assesses vibration-perception threshold.50 A rubber tactor is applied to the distal aspect of the toe and the amplitude is increased to a maximum of 100 V (converted from microns).41, 46 In one study, a vibration-perception threshold of more than 25 V had a sensitivity of 83%, a specificity of 63%, a positive likelihood ratio of 2.2 (95% CI, 1.8-2.5), and a negative likelihood ratio of 0.27 (95% CI, 0.14-0.48) for predicting a foot ulceration over 4 years.19, 51 A case-control study with 255 diabetic persons found that having either abnormal Semmes-Weinstein monofilament perception or a vibration-perception threshold of more than 25 V predicted foot ulceration with a sensitivity of 100% and a specificity of 77%.43
Tuning Fork. The tuning fork provides an easy and inexpensive test of vibratory sensation. With a conventional fork, an abnormal response occurs when the patient loses vibratory sensation while the examiner still perceives it.37 With a graduated (Rydel-Seiffer) fork (Gebrueder Martin, Tuttlingen, Germany), persons indicate first loss of vibration at the plantar hallux as the intersection of 2 virtual triangles moves on a scale exponentially from 0 to 8 in a mean (SD) of 39.8 (1) seconds.52 This test correlates more strongly with biothesiometer results (r, –0.90; P<.001)53 than the conventional tuning fork,54 but the latter predicted foot ulceration in 2 studies.37, 55 Tuning fork results are less predictive of ulceration than results from using the monofilament.37
Screening for Patients With Elevated Plantar Pressure. Devices identifying high plantar pressure include mats to measure barefoot plantar load distribution and transducers distributed in a removable shoe insole to measure pressure inside footwear.56 The numerical values generated are often device-specific and cannot easily be compared. There is no generally accepted plantar pressure level associated with an increased risk of diabetic foot ulceration. In case-control studies using the EMED pressure platform system (Novell, Minneapolis, Minn), a peak barefoot dynamic pressure of 70 N/cm2 had a sensitivity of 70.0% and a specificity of 65.1%, while a cutoff of 87.5 N/cm2 had a sensitivity of 64%, a specificity of 46%, a positive predictive value of 17%, and a negative predictive value of 90% (Table 1).57-58
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Table 1. Screening Methods to Identify Persons With Diabetes at Increased Risk for Foot Ulceration
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Screening for Peripheral Vascular Disease. Peripheral vascular disease is most easily detected by the ankle-brachial index (ABI), which is the ratio of systolic blood pressure in the ankle to that in the brachial artery. An ABI of 0.90 or less suggests peripheral vascular disease, while higher than 1.1 may represent a falsely elevated pressure caused by medial arterial calcinosis.59 This test is easily performed, objective, and reproducible.59 One large study found that the ABI was strongly related to the risk of foot ulceration (0.3 higher ABI is associated with an RR of 0.83; 95% CI, 0.73-0.96; P = .01).37
Arterial oxygen supply can also be measured by transcutaneous oximetry.59 A transcutaneous oxygen tension higher than 30 mm Hg correlates with a high likelihood of wound healing.59 Transcutaneous oxygen tension is also inversely associated with the risk of foot ulceration (15 mm Hg higher dorsal foot transcutaneous oxygen tension is associated with an RR of 0.80; 95% CI, 0.69-0.93; P = .004).37 Because accurately measuring transcutaneous oxygen tension requires expensive equipment and a trained technician, it is not routinely used.
Educational Interventions to Prevent Foot Ulceration
Patient Education. Most patient education studies emphasize foot care, but have been short-term and have measured changes in behavior and cognition rather than the incidence of relevant clinical outcomes such as ulceration. Patient education formats have included lectures, hands-on workshops, skills exercises, behavioral modification programs, and telephone reminders (Table 2).
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Table 2. Studies of Patient Education Programs Directed at Improving Foot Care in Persons With Diabetes
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Two recent reviews concluded that patient education improves short-term knowledge and may modestly reduce risk of foot ulcerations and amputations.51, 67 Larger randomized clinical trials are needed to assess which patient education formats are the most effective, how often periodic reinforcement is required, and the long-term effectiveness of various programs.
Physician Education. Health care organizations have used various strategies to improve clinicians’ performance with patient education.68-69 In one strategy, a computerized registry reminded physicians to enter the patient’s risk status for lower extremity amputation. After 28 months, the percentage of patients who had received foot screening and risk assessment increased from 15% to 76%.68 Project LEAP (Lower-Extremity Amputation Prevention), developed by the US Department of Health and Human Services, is a 1-day workshop on diabetes foot care. When given to 560 clinicians from 85 organizations, it improved the rate of documenting foot care education from a baseline of 38% to 62% after 9 months.70 More importantly, appropriate foot care self-management increased from 32% to 48%, and there was a trend toward reduced lower extremity amputations.70
Another approach is implementing foot care clinical practice guidelines. An Indian Health Service diabetes program observed 669 patients during a standard care period (1986-1989) with routine foot screening; a public health period (1990-1993) with an annual foot examination and initial risk stratification to give those at high-risk special interventions; and a staged diabetes management period (1994-1996) during which clinicians used clinical practice guidelines.71 The average lower-extremity amputation incidence per 1000 diabetic person-years was 29 during the standard care period, 21 during public health, and 15 during staged management. The overall reduction in lower extremity amputation was 48% (P = .02), and the incidence of first amputation decreased from 21 per 1000 to 6 per 1000 from the first to the third period (P<.001).71
Clinical Practice Guidelines on the Diabetic Foot. Published guidelines72-77 uniformly recommend that all diabetic persons have an annual foot examination that includes assessing for anatomic deformities, skin breaks, nail disorders, loss of protective sensation, diminished arterial supply, and improper footwear. The clinician should then assign the patient to a risk category by using any of several systems. The recommended interventions for various risk groups differ slightly among the guidelines, but persons at higher risk for foot ulceration should have more frequent foot examinations.72-77 (Table 3)
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Table 3. Summary of Available Recommendations From Professional Organizations on Screening to Prevent Diabetic Foot Ulcers in Persons With Diabetes*
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Clinical Interventions to Prevent Foot Ulceration
Optimizing Glycemic Control. The Diabetes Complications and Control Trial reported a 57% reduction in the incidence of clinical neuropathy in patients managed with intensive compared with conventional glycemic treatment.78 In the United Kingdom Prospective Diabetes Study, a 1% mean reduction in hemoglobin A1c was associated with a 25% reduction in microvascular complications, including neuropathy. There was also a nonsignificant reduction in amputations (by 36%) in the intensive compared with the conventional treatment group.79
Smoking Cessation. Some but not all studies have found a direct causal association between tobacco use and foot ulceration or amputation.37 A case-control study of diabetic persons in the United Kingdom found the lower risk of leg amputation in those of South Asian compared with European ancestry (OR, 0.26; 95% CI, 0.11-0.65; P = .004) partly attributable to their lower rates of smoking (31% vs 57%; P = .03).80 Similarly, a cross-sectional study of 1142 patients with type 2 diabetes in Jordan found smoking to be a strong predictor of amputation.81
Foot Examination by a Clinician. Foot examinations did not significantly reduce amputations among 244 diabetic patients in 1 case-control study (OR, 0.55; 95% CI, 0.2-1.7; P = .31).82 These results may reflect the study’s limited sample size, high rates of foot examination in both case and control patients, different degree of risk between the groups, as well as the unusually high rates of diabetes and amputations among the Pima Indian population studied.83 Another randomized study of diabetic persons (N = 91) with a previous foot ulceration found a significantly reduced risk for ulceration recurrence (RR, 0.52; 95% CI, 0.29-0.93; P = .03) at 1 year for those who received routine podiatric care.84 Thus, screening foot examinations are unlikely to reduce the incidence of foot complications unless they eventuate in appropriate specialist referrals (eg, for intensive podiatric care and customized footwear; Table 4).
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Table 4. Prevention of Foot Ulceration in Persons With Diabetes: Recommended Management Based on Results of Clinical Evaluation
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Custom Footwear and Orthotics. Prescription shoes for high-risk patients should reduce areas of high plantar pressure and friction and accommodate foot deformities (eg, with a deep, wide toe box and ample padding).85 Similarly, shoe inserts should cushion the plantar surface and redistribute pressure over a greater surface area.85 Clinical data supporting the benefits of prescription footwear are surprisingly meager. In the largest of several studies, 400 persons with a history of a foot ulcer (but without a severe deformity) were randomized to receive extradeep, extrawide therapeutic shoes with customized neoprene-covered cork inserts; therapeutic shoes with nylon-covered polyurethane inserts; or instructed to wear usual footwear.86 Persons assigned to therapeutic shoes had a similar incidence of foot ulcer recurrence as controls.86 These surprising findings may have resulted from excluding patients with severe foot deformities, a person’s low baseline prevalence (58%) of "foot insensitivity,"87 and defining a foot ulcer as existing for 30 days or longer. This and other studies suggest that patients at low risk for foot complications may safely wear well-fitting, good-quality over-the-counter athletic or walking shoes, whereas those with neuropathy and foot deformities may benefit from custom shoes (Table 5). Larger randomized studies should explore which type of therapeutic footwear (including stockings) may best reduce ulceration in patients with neuropathy and deformities and whether patients with only neuropathy require prescription footwear.
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Table 5. Studies of Therapeutic Footwear Directed at Preventing Foot Ulceration in Persons With Diabetes
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Debridement of Calluses. Calluses (hyperkeratotic lesions caused by pressure) further increase pressure, which is a component cause of ulceration. Because debriding hyperkeratoses can reduce peak plantar pressure by 26%,91 this should be routinely provided by trained personnel. Wearing proper footwear may not only prevent but also reduce development of calluses. Among 78 diabetic persons, the mean size of plantar calluses decreased in direct proportion with the amount of time spent wearing running shoes.92 Similarly, among high-risk persons, those who visited podiatrists most frequently (every 3-4 weeks) had the lowest mean plantar pressure before and after callus removal.93 The optimal frequency of podiatric evaluation and management is uncertain.
Foot Specialist and Multidisciplinary Team Care. A few studies have assessed the role of foot specialist care as the main intervention in preventing diabetic foot ulcers.84, 94 Among 91 diabetic persons with a healed foot ulcer, there were 20 ulcer recurrences in those randomized to podiatric care and 32 in the control group after a median follow-up of 386 days (RR, 0.52; 95% CI, 0.30-0.93; P = .03).84 In another trial of diabetic persons with neuropathy, 235 were randomized to receive podiatric care at least twice a year and 263 to receive no podiatric treatment.95 During the study period ( 3 years), there was no difference in the incidence of foot ulcers, but the podiatric care group had fewer deep ulcers (6 vs 12), infected ulcers (1 vs 10; P<.01), and hospital admission days (24 vs 346; P<.01).95
Other studies have used multidisciplinary (eg, podiatrists, internists, surgeons, nurses, dieticians, social workers) care teams. In one study, 341 diabetic persons were examined to categorize baseline risk,96 initiate appropriate education and interventions, and schedule follow-up foot examinations and podiatric care.97 After 3 years, the incidence of lower-extremity amputation was only 1.1 per 1000 persons per year. Among high-risk persons, those who missed more than 50% of their appointments with the team were 54 times more likely to develop an ulcer and 20 times more likely to require an amputation than those who kept most appointments.97
Prophylactic Foot Surgeries. A dramatically increased interest in reconstructive surgery has occurred in the past 2 decades.72, 98-113 One proposed classification system divides nonvascular foot surgery into elective (to alleviate pain), prophylactic (to reduce risk of ulceration), curative (to heal an open wound), and emergent (to help control a limb-threatening infection).114 Only a few small studies have reported long-term outcomes for prophylactic procedures, generally aimed at correcting deformities that increase plantar pressure (Table 6). For example, a short Achilles tendon leads to increased pull on the calcaneus, elevated plantar-flexory movement about the ankle, and subsequent elevated forefoot plantar pressure; this may be improved by tendon lengthening. Preventing foot ulcers in patients with Charcot arthropathy usually requires an expert pedorthist and potentially a foot surgeon. In this condition, some advocate surgical options including removal of osseous prominences and reconstruction of the deformed foot or ankle, but controlled trials are lacking.103, 120
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Table 6. Studies of Prophylactic Foot Surgeries Directed at Preventing Foot Ulceration in Persons With Diabetes
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Revascularization Surgery. Vascular surgeons have developed techniques (eg, bypass grafts from femoral to pedal arteries and peripheral angioplasty) to improve blood flow to an ischemic foot. While these procedures help heal ischemic ulcers, no prospective study shows that they reduce foot ulceration.121 The reported effect of revascularization procedures on the incidence and site of amputations varies, but most recent studies suggest benefits.122-124
Cost-Effectiveness. A recent cost of illness model, based on published data about diabetic complications and the value of health resources from numerous sources found that the mean annual cost of treatment in 2001 was $9306 for an uninfected diabetic foot ulcer, $24 582 for an infected foot ulcer, and $45 579 for a foot ulcer with osteomyelitis.125 Another review compiled cost data from 1990 to 1997 from 7 studies—4 conducted in the United States and 3 in other countries.126 After inflation adjustment and currency conversion, the cost of treating foot ulcers not requiring amputation ranged from $993 to $17 519, and approached $30 724 in 1 study that spanned 2 years after diagnosis.
A few groups have modeled cost-utility analyses for strategies to prevent foot ulcers. A Markov model from Sweden of intensive prevention (patient education, use of appropriate footwear, and access to therapeutic foot care) for high-risk patients was cost-effective if the incidence of foot ulcers and lower extremity amputations was reduced by 25%.127 A similar model for patients with newly diagnosed type 2 diabetes found that implementing a guideline-based foot program that included intensive glycemic control, regular foot examinations, risk stratification, patient education, clinician education, and multidisciplinary foot care increased life expectancy and quality-adjusted life-years and reduced the incidence of foot complications.128 The cost of achieving a 10% reduction in the incidence of foot lesions was less than $25 000 per quality-adjusted life-year gained.128
CONCLUSIONS
Diabetes confers a dramatically increased risk of foot ulceration, but available evidence suggests that this risk may be reduced to some degree by appropriate screening and intervention measures. Clinicians should screen all patients with diabetes to identify those at risk for foot ulceration. This includes reviewing relevant past history, identifying any current foot deformities, and especially assessing for loss of protective sensation with a monofilament. Other helpful screening methods include assessing for peripheral vascular disease by measuring ABIs, ensuring that the patient is wearing appropriate footwear, and checking for high plantar pressure when possible.
Screening allows the clinician to assign the patient to a risk category that dictates both the type and frequency of foot interventions needed. Effective interventions include patient (and clinician) education. Possibly effective interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, and debridement of calluses. The value of prescription footwear for ulcer prevention is unclear. In selected cases, evaluation for surgical procedures may be indicated. Each of these interventions, when used appropriately, may reduce the risk of foot ulceration and its devastating consequences.
AUTHOR INFORMATION
Corresponding Author: Nalini Singh, MD, VA Puget Sound Healthcare System, Mailcode: S-111-ENDO, 1660 S Columbian Way, Seattle, WA 98108 (Nalini.Singh2{at}med.va.gov).
Author Contributions: All of the authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis except for the few cases mentioned in the tables.
Study concept and design: Singh, Armstrong, Lipsky.
Acquisition of data: Singh, Lipsky.
Analysis and interpretation of data: Singh, Lipsky.
Drafting of the manuscript: Singh, Armstrong, Lipsky.
Critical revision of the manuscript for important intellectual content: Singh, Armstrong, Lipsky.
Statistical analysis: Singh.
Administrative, technical, or material support: Singh, Armstrong, Lipsky.
Study supervision: Lipsky.
Role of the Sponsor: There was no sponsor for this study and no agency or company reviewed the manuscript.
Acknowledgment: We thank VA Puget Sound Healthcare System employees Ted Hamilton, MLIS, for his invaluable assistance with the literature searches, and Christopher Pacheco for providing the initial version of the monofilament figure. We also thank Edward J. Boyko, MD, MPH, for his time and expertise in calculating measures of effect in the tables.
Financial Disclosure: Dr Armstrong has participated in research funded by the National Institutes of Health using devices manufactured by Xilas Medical Inc (makers of the biothesiometer).
We encourage authors to submit papers for consideration as a "Clinical Review." Please contact Michael S. Lauer, MD, at lauerm{at}ccf.org.
Author Affiliations: Department of Medicine, Divisions of Endocrinology and Metabolism (Dr Singh) and General Internal Medicine and Infectious Diseases (Dr Lipsky),Veterans Affairs Puget Sound Healthcare System and University of Washington School of Medicine, Seattle (Drs Singh and Lipsky); and Center for Lower Extremity Ambulatory Research, Dr William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, Chicago, Ill (Dr Armstrong).
REFERENCES
| |
1. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med. 1996;13(suppl 1):S6-S11.
PUBMED
2. Reiber GE. Epidemiology of foot ulcers and amputations in the diabetic foot. In: Bowker JH, Pfeifer MA, eds. The Diabetic Foot. St Louis, Mo: Mosby; 2001:13-32.
3. International Working Group on the Diabetic Foot. Epidemiology of diabetic foot infections in a population-based cohort. Paper presented at: International Consensus on the Diabetic Foot; May 22-24, 2003; Noordwijkerhout, the Netherlands.
4. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort. Diabetes Care. 2003;26:1435-1438.
FREE FULL TEXT
5. Gregg EW, Sorlie P, Paulose-Ram R, et al. Prevalence of lower-extremity disease in the US adult population  40 years of age with and without diabetes: 1999-2000 National Health and Nutrition Examination Survey. Diabetes Care. 2004;27:1591-1597.
FREE FULL TEXT
6. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res Rev. 2001;17:246-249.
FULL TEXT
|
ISI
| PUBMED
7. Meijer JW, Trip J, Jaegers SM, et al. Quality of life in patients with diabetic foot ulcers. Disabil Rehabil. 2001;23:336-340.
FULL TEXT
|
ISI
| PUBMED
8. Vileikyte L, Boulton AJM. Psychological/behavioral issues in diabetic neuropathic foot ulceration. Wounds. 2000;12(6 suppl B):43B-47B.
9. Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice: neuropathic diabetic foot ulcers. N Engl J Med. 2004;351:48-55.
FREE FULL TEXT
10. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22:382-387.
ABSTRACT
11. Tennvall GR, Apelqvist J, Eneroth M. Costs of deep foot infections in patients with diabetes mellitus. Pharmacoeconomics. 2000;18:225-238.
FULL TEXT
|
ISI
| PUBMED
12. Siitonen OI, Niskanen LK, Laakso M, Siitonen JT, Pyorala K. Lower-extremity amputations in diabetic and nondiabetic patients: a population-based study in eastern Finland. Diabetes Care. 1993;16:16-20.
ABSTRACT
13. Trautner C, Haastert B, Giani G, Berger M. Incidence of lower limb amputations and diabetes. Diabetes Care. 1996;19:1006-1009.
ABSTRACT
14. Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC. Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. South Med J. 1997;90:384-389.
ISI
| PUBMED
15. Cavanagh PR, Boone EY, Plummer DL. The Foot in Diabetes: A Bibliography. College Station: Pennsylvania State University; 2000.
16. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13:513-521.
ABSTRACT
17. Young MJ, Boulton AJ, MacLeod AF, Williams DR, Sonksen PH. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia. 1993;36:150-154.
FULL TEXT
|
ISI
| PUBMED
18. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22:157-162.
FREE FULL TEXT
19. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds: a prospective study. Diabetes Care. 1994;17:557-560.
ABSTRACT
20. Sanders LJ. Diabetes mellitus: prevention of amputation. J Am Podiatr Med Assoc. 1994;84:322-328.
ABSTRACT
21. Zimny S, Schatz H, Pfohl M. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care. 2004;27:942-946.
FREE FULL TEXT
22. Fernando DJ, Masson EA, Veves A, Boulton AJ. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care. 1991;14:8-11.
ABSTRACT
23. Mueller MJ, Hastings M, Commean PK, et al. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech. 2003;36:1009-1017.
FULL TEXT
|
ISI
| PUBMED
24. Veves A, Murray HJ, Young MJ, Boulton AJ. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia. 1992;35:660-663.
FULL TEXT
|
ISI
| PUBMED
25. Macfarlane RM, Jeffcoate WJ. Factors contributing to the presentation of diabetic foot ulcers. Diabet Med. 1997;14:867-870.
FULL TEXT
|
ISI
| PUBMED
26. Maluf KS, Mueller MJ. Novel Award 2002: comparison of physical activity and cumulative plantar tissue stress among subjects with and without diabetes mellitus and a history of recurrent plantar ulcers. Clin Biomech (Bristol, Avon). 2003;18:567-575.
27. American Diabetes Association. Consensus Development Conference on Diabetic Foot Wound Care. Diabetes Care. 1999;22:1354.
PUBMED
28. Lobmann R, Ambrosch A, Schultz G, Waldmann K, Schiweck S, Lehnert H. Expression of matrix-metalloproteinases and their inhibitors in the wounds of diabetic and non-diabetic patients. Diabetologia. 2002;45:1011-1016.
FULL TEXT
|
ISI
| PUBMED
29. Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol. 1999;26:259-265.
FULL TEXT
|
ISI
| PUBMED
30. Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes mellitus. N Engl J Med. 1999;341:1906-1912.
FREE FULL TEXT
31. Mayser P, Hensel J, Thoma W, et al. Prevalence of fungal foot infections in patients with diabetes mellitus type 1: underestimation of moccasin-type tinea. Exp Clin Endocrinol Diabetes. 2004;112:264-268.
FULL TEXT
|
ISI
| PUBMED
32. Anarella JJ, Toth C, DeBello JA. Preventing complications in the diabetic patient with toenail onychomycosis. J Am Podiatr Med Assoc. 2001;91:325-328.
FREE FULL TEXT
33. Gupta AK, Humke S. The prevalence and management of onychomycosis in diabetic patients. Eur J Dermatol. 2000;10:379-384.
ISI
| PUBMED
34. Chincholikar DA, Pal RB. Study of fungal and bacterial infections of the diabetic foot. Indian J Pathol Microbiol. 2002;45:15-22.
PUBMED
35. Ragnarson Tennvall G, Apelqvist J. Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes Complications. 2000;14:235-241.
FULL TEXT
|
ISI
| PUBMED
36. Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and care givers. Qual Life Res. 1998;7:365-372.
ISI
| PUBMED
37. Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer: the Seattle Diabetic Foot Study. Diabetes Care. 1999;22:1036-1042.
FREE FULL TEXT
38. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med. 1998;158:157-162.
FREE FULL TEXT
39. Altman MI, Altman KS. The podiatric assessment of the diabetic lower extremity: special considerations. Wounds. 2000;12(6 suppl B):64B-71B.
40. Boike AM, Hall JO. A practical guide for examining and treating the diabetic foot. Cleve Clin J Med. 2002;69:342-348.
FREE FULL TEXT
41. Armstrong DG. Loss of protective sensation: a practical evidence-based definition. J Foot Ankle Surg. 1999;38:79-80.
PUBMED
42. Armstrong DG. The 10-g monofilament: the diagnostic divining rod for the diabetic foot? Diabetes Care. 2000;23:887.
ISI
| PUBMED
43. Perkins BA, Olaleye D, Zinman B, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care. 2001;24:250-256.
FREE FULL TEXT
44. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med. 1998;158:289-292.
FREE FULL TEXT
45. Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at risk for lower extremity amputation in a primary health care setting. Diabetes Care. 1992;15:1386-1389.
ABSTRACT
46. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify the at risk patients for developing diabetic foot ulcers in a prospective multicenter trial. Diabetes Care. 2000;23:606-611.
FREE FULL TEXT
47. Booth J, Young MJ. Differences in the performance of commercially available 10-g monofilaments. Diabetes Care. 2000;23:984-988.
ABSTRACT
48. Smieja M, Hunt DL, Edelman D, et al, International Cooperative Group for Clinical Examination Research. Clinical examination for the detection of protective sensation in the feet of diabetic patients. J Gen Intern Med. 1999;14:418-424.
FULL TEXT
|
ISI
| PUBMED
49. Gerr FE, Letz R. Reliability of a widely used test of peripheral cutaneous vibration sensitivity and a comparison of two testing protocols. Br J Ind Med. 1988;45:635-639.
ISI
| PUBMED
50. Rosenblum BI. Identifying the patient at risk of foot ulceration. Wounds. 2000;12(6 suppl B):7B-11B.
51. Mason J, O'Keeffe C, Hutchinson A, McIntosh A, Young R, Booth A. A systematic review of foot ulcer in patients with type 2 diabetes mellitus, II: treatment. Diabet Med. 1999;16:889-909.
FULL TEXT
|
ISI
| PUBMED
52. Thivolet C, el Farkh J, Petiot A, Simonet C, Tourniaire J. Measuring vibration sensations with graduated tuning fork: simple and reliable means to detect diabetic patients at risk of neuropathic foot ulceration. Diabetes Care. 1990;13:1077-1080.
ABSTRACT
53. Liniger C, Albeanu A, Bloise D, Assal JP. The tuning fork revisited. Diabet Med. 1990;7:859-864.
ISI
| PUBMED
54. Gin H, Rigalleau V, Baillet L, Rabemanantsoa C. Comparison between monofilament, tuning fork and vibration perception tests for screening patients at risk of foot complication. Diabetes Metab. 2002;28:457-461.
ISI
| PUBMED
55. Coppini DV, Young PJ, Weng C, Macleod AF, Sonksen PH. Outcome on diabetic foot complications in relation to clinical examination and quantitative sensory testing: a case-control study. Diabet Med. 1998;15:765-771.
FULL TEXT
|
ISI
| PUBMED
56. Pitei DL, Edmonds ME. Foot pressure measurements. Wounds. 2000;12(6 suppl B):19B-29B.
57. Armstrong DG, Peters EJ, Athanasiou KA, Lavery LA. Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg. 1998;37:303-307.
PUBMED
58. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell JL, Boulton AJM. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26:1069-1073.
FREE FULL TEXT
59. American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care. 2003;26:3333-3341.
FREE FULL TEXT
60. Kruger S, Guthrie D. Foot care: knowledge retention and self-care practices. Diabetes Educ. 1992;18:487-490.
61. Mazzuca SA, Moorman NH, Wheeler ML, et al. The diabetes education study: a controlled trial of the effects of diabetes patient education. Diabetes Care. 1986;9:1-10.
ABSTRACT
62. Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ. Intensive education improves knowledge, compliance, and foot problems in type 2 diabetes. Diabet Med. 1991;8:111-117.
ISI
| PUBMED
63. Bloomgarden ZT, Karmally W, Metzger MJ, et al. Randomized, controlled trial of diabetic patient education: improved knowledge without improved metabolic status. Diabetes Care. 1987;10:263-272.
ABSTRACT
64. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non–insulin-dependent diabetes mellitus: a randomized, controlled trial. Ann Intern Med. 1993;119:36-41.
FREE FULL TEXT
65. Pieber TR, Holler A, Siebenhofer A, et al. Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria. Diabet Med. 1995;12:349-354.
ISI
| PUBMED
66. Malone JM, Snyder M, Anderson G, Bernhard VM, Holloway GA Jr, Bunt TJ. Prevention of amputation by diabetic education. Am J Surg. 1989;158:520-523.
FULL TEXT
|
ISI
| PUBMED
67. Valk GD, Kriegsman DM, Assendelft WJ. Patient education for preventing diabetic foot ulceration: a systematic review. Endocrinol Metab Clin North Am. 2002;31:633-658.
FULL TEXT
|
ISI
| PUBMED
68. Khoury A, Landers P, Roth M, et al. Computer-supported identification and intervention for diabetic patients at risk for amputation. MD Comput. 1998;15:307-310.
PUBMED
69. Wheatley C. Audit protocol: part one: prevention of diabetic foot ulcers—the non-complicated foot. J Clin Govern. 2001;9:93-100.
70. Bruckner M, Mangan M, Godin S, Pogach L. Project LEAP of New Jersey: lower extremity amputation prevention in persons with type 2 diabetes. Am J Manag Care. 1999;5:609-616.
ISI
| PUBMED
71. Rith-Najarian S, Branchaud C, Beaulieu O, Gohdes D, Simonson G, Mazze R. Reducing lower-extremity amputations due to diabetes: application of the staged diabetes management approach in a primary care setting. J Fam Pract. 1998;47:127-132.
ISI
| PUBMED
72. Frykberg RG, Armstrong DG, Giurini JM, et al. Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg. 2000;39:S2-S60.
73. Hutchinson A, McIntosh A, Feder G, Home PD, Young R. Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems. London, England: Royal College of General Practitioners; 2000.
74. International Consensus on the Diabetic Foot: Practical Guidelines [book on CD-ROM]. Noordwijkerhout, the Netherlands: International Working Group on the Diabetic Foot; 1999.
75. Supplement to the International Consensus on the Diabetic Foot: Practical Guidelines [book on CD-ROM]. Noordwijkerhout, the Netherlands: International Working Group on the Diabetic Foot; 2003.
76. US Veterans Health Administration/Department of Defense. Clinical Practice Guidelines: Diabetes Mellitus Algorithms—Module F: Foot Care. Washingon, DC: Veterans Health Administration; 2003.
77. American Diabetes Association. Preventative foot care in people with diabetes. Diabetes Care. 2004;27(suppl 1):S31-S32.
78. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.
FREE FULL TEXT
79. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet. 1998;352:854-865.
FULL TEXT
|
ISI
| PUBMED
80. Chaturvedi N, Abbott CA, Whalley A, Widdows P, Leggetter SY, Boulton AJ. Risk of diabetes-related amputation in South Asians vs Europeans in the UK. Diabet Med. 2002;19:99-104.
FULL TEXT
|
ISI
| PUBMED
81. Jbour AS, Jarrah NS, Radaideh AM, et al. Prevalence and predictors of diabetic foot syndrome in type 2 diabetes mellitus in Jordan. Saudi Med J. 2003;24:761-764.
ISI
| PUBMED
82. Mayfield JA, Reiber GE, Nelson RG, Greene T. Do foot examinations reduce the risk of diabetic amputation? J Fam Pract. 2000;49:499-504.
ISI
| PUBMED
83. Ganiats TG. Judging the evidence for interventions: asking the right questions about foot examinations for patients with diabetes. J Fam Pract. 2000;49:505-506.
ISI
| PUBMED
84. Plank J, Haas W, Rakovac I, et al. Evaluation of the impact of chiropodist care in the secondary prevention of foot ulcerations in diabetic subjects. Diabetes Care. 2003;26:1691-1695.
FREE FULL TEXT
85. Tyrrell W. Orthotic intervention in patients with diabetic foot ulceration. J Wound Care. 1999;8:530-532.
PUBMED
86. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002;287:2552-2558.
FREE FULL TEXT
87. Cavanagh PR, Boulton AJ, Sheehan P, Ulbrecht JS, Caputo GM, Armstrong DG. Therapeutic footwear in patients with diabetes. JAMA. 2002;288:1231.
FREE FULL TEXT
88. Colagiuri S, Marsden LL, Naidu V, Taylor L. The use of orthotic devices to correct plantar callus in people with diabetes. Diabetes Res Clin Pract. 1995;28:29-34.
FULL TEXT
|
ISI
| PUBMED
89. Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care. 1995;18:1376-1378.
ABSTRACT
90. Busch K, Chantelau E. Effectiveness of a new brand of stock "diabetic" shoes to protect against diabetic foot ulcer relapse: a prospective cohort study. Diabet Med. 2003;20:665-669.
FULL TEXT
|
ISI
| PUBMED
91. Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJ. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet Med. 1992;9:55-57.
ISI
| PUBMED
92. Soulier SM, Godsey C, Asay ED, Perrotta DM. The prevention of plantar ulceration in the diabetic foot through the use of running shoes. Diabetes Educ. 1987;13:130-132.
93. Pitei DL, Foster A, Edmonds M. The effect of regular callus removal on foot pressures. J Foot Ankle Surg. 1999;38:251-255.
PUBMED
94. Ronnemaa T, Hamalainen H, Toikka T, Liukkonen I. Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care. 1997;20:1833-1837.
ABSTRACT
95. van Putten M, Schaper NC. The preventive value of podiatry for the diabetic foot at risk for ulceration. Paper presented at: International Consensus on the Diabetic Foot; May 22-24, 2003; Noordwijkerhout, the Netherlands.
96. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system: the contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21:855-859.
ABSTRACT
97. Armstrong DG, Harkless LB. Outcomes of preventative care in a diabetic foot specialty clinic. J Foot Ankle Surg. 1998;37:460-466.
PUBMED
98. Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle. 1981;2:64-122.
PUBMED
99. Armstrong DG, Lavery LA, Stern S, Harkless LB. Is prophylactic diabetic foot surgery dangerous? J Foot Ankle Surg. 1996;35:585-589.
PUBMED
100. Armstrong DG, Stacpoole-Shea S, Nguyen HC, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am. 1999;81A:535-538.
101. Gudas CJ. Prophylactic surgery in the diabetic foot. Clin Podiatr Med Surg. 1987;4:445-458.
PUBMED
102. Catanzariti AR, Blitch EL, Karlock LG. Elective foot and ankle surgery in the diabetic patient. J Foot Ankle Surg. 1995;34:23-41.
PUBMED
103. Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot. J Bone Joint Surg Am. 2000;82-A:939-950.
FREE FULL TEXT
104. Rosenblum BI, Giurini JM, Chrzan JS, Habershaw GM. Preventing loss of the great toe with the hallux interphalangeal arthroplasty. J Foot Ankle Surg. 1994;33:557-566.
PUBMED
105. Wieman TJ, Mercke YK, Cerrito PB, Taber SW. Resection of the metatarsal head for diabetic foot ulcers. Am J Surg. 1998;176:436-441.
FULL TEXT
|
ISI
| PUBMED
106. Giurini JM, Basile P, Chrzan JS, Habershaw GM, Rosenblum BI. Panmetatarsal head resection: a viable alternative to the transmetatarsal amputation. J Am Podiatr Med Assoc. 1993;83:101-107.
ABSTRACT
107. Barry DC, Sabacinski KA, Habershaw GM, Giurini JM, Chrzan JS. Tendo Achillis procedures for chronic ulcerations in diabetic patients with transmetatarsal amputations. J Am Podiatr Med Assoc. 1993;83:96-100.
ABSTRACT
108. Giurini JM, Chrzan JS, Gibbons GW, Habershaw GM. Sesamoidectomy for the treatment of chronic neuropathic ulcerations. J Am Podiatr Med Assoc. 1991;81:167-173.
ABSTRACT
109. Fleischli JE, Anderson RB, Davis WH. Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int. 1999;20:80-85.
ISI
| PUBMED
110. Blume PA, Paragas LK, Sumpio BE, Attinger CE. Single-stage surgical treatment of noninfected diabetic foot ulcers. Plast Reconstr Surg. 2002;109:601-609.
ISI
| PUBMED
111. Armstrong DG, Todd WF, Lavery LA, Harkless LB. The natural history of acute Charcot’s arthropathy in a diabetic foot specialty clinic. Diabet Med. 1997;14:357-363.
FULL TEXT
|
ISI
| PUBMED
112. Ha Van G, Siney H, Danan JP, Sachon C, Grimaldi A. Treatment of osteomyelitis in the diabetic foot: contribution of conservative surgery. Diabetes Care. 1996;19:1257-1260.
ABSTRACT
113. Scher KS, Steele FJ. The septic foot in patients with diabetes. Surgery. 1988;104:661-666.
ISI
| PUBMED
114. Armstrong DG, Frykberg RG. Classification of diabetic foot surgery: toward a rational definition. Diabet Med. 2003;20:329-331.
FULL TEXT
|
ISI
| PUBMED
115. Lin SS, Lee TH, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-achilles lengthening and total contact casting. Orthopedics. 1996;19:465-475.
ISI
| PUBMED
116. Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of achilles tendon lengthening on neuropathic plantar ulcers: a randomized clinical trial. J Bone Joint Surg Am. 2003;85-A:1436-1445.
FREE FULL TEXT
117. Mueller MJ, Sinacore DR, Hastings MK, Lott DJ, Strube MJ, Johnson JE. Impact of achilles tendon lengthening on functional limitations and perceived disability in people with a neuropathic plantar ulcer. Diabetes Care. 2004;27:1559-1564.
FREE FULL TEXT
118. Piaggesi A, Schipani E, Campi F, et al. Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. Diabet Med. 1998;15:412-417.
FULL TEXT
|
ISI
| PUBMED
119. Armstrong DG, Lavery LA, Vazquez JR, et al. Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in persons with diabetes. Diabetes Care. 2003;26:3284-3287.
FREE FULL TEXT
120. Wang JC, Le AW, Tsukuda RK. A new technique for Charcot’s foot reconstruction. J Am Podiatr Med Assoc. 2002;92:429-436.
FREE FULL TEXT
121. Feinglass J, Brown JL, LoSasso A, et al. Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996. Am J Public Health. 1999;89:1222-1227.
FREE FULL TEXT
122. Sumpio BE, Lee T, Blume PA. Vascular evaluation and arterial reconstruction of the diabetic foot. Clin Podiatr Med Surg. 2003;20:689-708.
FULL TEXT
| PUBMED
123. Faglia E, Mantero M, Caminiti M, et al. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med. 2002;252:225-232.
FULL TEXT
|
ISI
| PUBMED
124. Rauwerda JA. Surgical treatment of the infected diabetic foot. Diabetes Metab Res Rev. 2004;20(suppl 1):S41-S44.
FULL TEXT
| PUBMED
125. Gordois A, Scuffham P, Shearer A, Oglesby A, Tobian JA. The health care costs of diabetic peripheral neuropathy in the US. Diabetes Care. 2003;26:1790-1795.
FREE FULL TEXT
126. Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis. 2004;39(suppl 2):S132-S139.
FULL TEXT
| PUBMED
127. Ragnarson Tennvall G, Apelqvist J. Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations. Diabetologia. 2001;44:2077-2087.
FULL TEXT
|
ISI
| PUBMED
128. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.
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Diabetes Care 2005;28:2896-2900.
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Recent advances in the diagnosis and management of diabetic neuropathy
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Beckley
DOC News 2005;2:10-11.
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