|ISSN No. 1606-7754 Vol.11 No.3 December 2003|
Prevention of diabetic foot ulcers: Holy grail of foot clinics
H Rathur, S M Rajbhandari
Lancashire Teaching Hospital (Chorley & South Ribble), UK
Diabetic foot ulcer is a common and debilitating complication of diabetes. Often this is preventable by regular screening and addressing risk factors such as regular podiatry, good foot wear and early consultation with health care professionals. General measures such as good glycaemic control, prevention of cardiovascular risk factors and prevention of deformity should be aimed during the early stages of the disease. Diabetic subjects should be encouraged to actively participate in their foot care. Prevention of foot ulcers will reduce the rate of amputation, which is common in diabetic subjects.
Keywords : Diabetic foot ulcer, prevention, chronic complication.
Diabetic foot ulcer (DFU) is one of the common but often neglected complications of diabetes (Figure 1). There is no doubt that people with DFU have considerable mortality and morbidity. The risk of death for those with foot ulcers is 12.1 per 100 person-years of follow-up compared with 5.1 in those without foot ulcers.1 Similarly the risk for amputation in patients with diabetes is 15 times greater than for the non-diabetic population and the majority of amputations are preceded by DFU. In addition to increased morbidity and mortality, subjects with DFU have a poorer quality of life in comparison to those without ulcers.2 The annual incidence of DFU is 2.5% and it is estimated that 15% of all diabetics are affected by diabetic foot ulcers during their lifetime causing a considerable financial burden on health care providers. In the UK alone it has been estimated that 1.25 million hospital bed-days per year at a cost of £220 million are required to treat diabetic foot problems.3 This figure does not include the whole cost, as there are almost seven times as many patients in the community as in the hospital.4 Similarly, in the USA, 15% of total admissions for people with diabetes during a two year period were related to foot problems which accounted for 23% of the total hospital days. Direct hospital costs for the treatment of diabetic foot infections exceed $200 million per year and that for amputation related to diabetes exceed $350 million annually.5
Despite this, DFU is often neglected by the mainstream medical specialities. One of the main reasons for this is the absence of coherent management policy of this disorder as various specialists such as podiatrists, vascular surgeons, orthopaedic surgeons, diabetologists, district nurses etc are involved in the management of DFU. More recently there has been increasing recognition of the problems caused by this condition and multidisciplinary foot clinics have been introduced in various parts of the world. Multidisciplinary care of foot ulcers can reduce the rate of amputation by as much as 50%.6,7 With increasing recognition of the importance of this condition, the attention has now been focused on the prevention of this complication. In the UK, the National Service Framework of Diabetes8 has reiterated the importance of regular surveillance for the long-term complications of diabetes including that of diabetic foot problems and the key interventions planned are given in Table 1.
DFU is a preventable condition if high risk individuals are identified by appropriate screening programmes and are given appropriate foot care education. Similarly, if various chronic complications of diabetes such as neuropathy, peripheral vascular disease and foot deformities are prevented, it may be possible to prevent the development of DFU and its consequences. There have been exciting developments in this field and various new studies and observations are detailed below.